Retooling the Nation’s First Long Term Care Insurance Program

Washington State delays start of groundbreaking health benefit

Seventy percent of Americans who turn 65 need long term care at some point, but the nation has no program in place to help pay for that. Families can be bankrupted by the expense. In 2019, the state of Washington passed a law establishing a state-wide program, which could become a model for the country. It hasn’t started yet and is currently being retooled. In this article written for Kaiser Health News, journalist Michelle Andrews describes the law as it stands and the changes under consideration. Her story was posted on the KHN website on April 18, 2022. It also ran on NPR. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues. 

Patricia Keys, 71 and a stroke survivor, needs help with many everyday activities, such as dressing and bathing. Her daughter Christina, who lives near her mom in Vancouver, WA, cares for her in the evenings and pays about $3,000 a month for help from other caregivers.

Christina Keys, 53, was thrilled three years ago when Washington state passed a first-in-the-nation law that created a long term care benefit for residents who paid into a state fund. She hoped it would be a resource for others facing similar challenges.

The benefit, which has a lifetime limit of $36,500, would have made a big difference during the first year after her mom’s stroke, Keys said. Her mom needed a ramp built and other modifications made to her house, as well as a wheelchair and hospital bed. The extra money might also have made it easier for Keys to hire caregivers. Instead, she gave up her technology sales job to look after her mom.

“People are under this cloud of delusion that between your insurance and your retirement [income] you’re going to be fine,” she said. “They don’t understand all the things that insurance doesn’t cover.”

But relief for Washington families will have to wait. The WA Cares Fund,  which was set to begin collecting money for the program with a mandatory payroll tax on workers in January [2022] has been delayed while lawmakers made adjustments during the current legislative session. Payroll deductions will start in July 2023, and benefits will become available in July 2026.

Other states are watching Washington closely as they weigh offering coverage for their own residents. In California, a task force is examining how to design and implement a long term care program, according to the National Conference of State Legislatures. Illinois and Michigan are also studying the issue, according to the NCSL.

Supporters of the Washington program say it just needed fine-tuning and note that social programs like Medicare and the Affordable Care Act also underwent tweaking. The program’s long-term solvency, however, is in doubt and the cost to workers who buy into the program is in question.

We don’t have a solution at the federal level, so states are taking it on themselves to experiment with solutions.

—Bonnie Burns

What’s not in doubt is that it is critically important to address long term care needs. About 70 percent of people who turn 65 will require some type of long term care services. Many will need help such as an at-home assistant, while others could face a stay in a nursing home, which on average costs more than $90,000 a year. But many don’t have good options to cover the expense. Medicare’s coverage is very limited, while Medicaid generally requires people to impoverish themselves before it picks up the tab. Private long term care insurance policies are unaffordable for most people.

The upshot: many people rely on unpaid family members to help them with medical care, as well as everyday activities like bathing and dressing.

The problem is getting much worse. The number of people 85 and older is projected to more than double within the next 20 years, while the number of Americans living with Alzheimer’s disease and related dementias is expected to double as well, to 13 million. 

The federal Community Living Assistance Services and Supports Act (CLASS Act), which was part of the Affordable Care Act, created a voluntary long term care buy-in program, but it was never implemented because of concerns it wouldn’t be financially sound. Since then, policymakers in Washington, DC, have had little appetite for addressing the problem.

“We don’t have a solution at the federal level, so states are taking it on themselves to experiment with solutions,” said Bonnie Burns, a consultant for California Health Advocates and an expert on long term care who was appointed to a Washington state committee to help develop a supplemental long term care insurance product to be offered alongside the state benefit.

The Washington state program’s maximum benefit is intended to cover a year’s worth of home care at 20 hours a week, said program director Benjamin Veghte, PhD.

Although wealthy people likely can afford to pay for their care and the poorest families qualify for Medicaid, middle-class families might burn through their savings trying to cover such bills.

Many employers are now offering their workers the opportunity to buy a private long term care plan.

“It doesn’t solve all the problems, but with a modest premium and a modest benefit it eases the problem for families,” Veghte said. It could also give some families time so that “maybe they can develop a plan” for long term care needs after their benefits expire, he added.

Although the law passed in 2019, it remained below many people’s radars until the mandatory payroll deduction approached. Workers faced a tax of 0.58 percent per $100 of income. For someone earning $52,000 annually, the deduction would equal $302 a year, according to state estimates. As people realized they were about to have to start paying into the program, some pushed back.

Workers could get an exemption if they had private long term care insurance, and thousands of people scrambled for that coverage before the Nov. 1, 2021, opt-out deadline. Many of the state’s employers quickly offered workers the opportunity to buy private plans.

Because withholding for the benefit isn’t capped based on income, wealthier people may be better off with private long term care insurance, if they can pass the insurer’s medical evaluation.

“We did have a good number of higher-earning, younger folks who wanted to buy a policy,” said Gary Brooks, a certified financial planner who is co-owner of BHJ Wealth Advisors in Gig Harbor, WA.

By last month, 473,000 workers had taken the one-time offer to opt out of the program.

Other people raised objections because they would have to pay into the system but wouldn’t benefit. These included people who work in Washington but live in a neighboring state, the spouses of service members who are unlikely to make Washington a permanent home, people planning to retire before the three years needed to qualify for benefits, and some workers on temporary visas. The commission overseeing the long term care program has estimated that the number of people from these groups eligible to opt out is about 264,000.

We know that as the first state to do this that it may not be perfect going out of the gate.

—Jessica Gomez

In January, Gov. Jay Inslee signed legislation that addressed many of these issues. It allows certain groups to opt out and people nearing retirement to receive partial benefits based on the number of years they paid into the program.

One other group—those who plan to retire elsewhere—hasn’t been addressed, but the state is developing recommendations for the legislature, Veghte said. According to current actuarial projections, 3.1 million workers will begin paying into the program next year, out of a total of 3.6 million, Veghte said.

Some critics are concerned that allowing more people to opt out of the program puts it on increasingly precarious financial footing.

“The solvency issue just gets greater and greater,” said Richard Birmingham, a partner at Davis Wright Tremaine in Seattle who is representing employers and workers in a class-action lawsuit that claims the law violates federal and state statutes governing employee benefit plans. “Any change they make further increases the cost.”

Supporters are sponsoring a ballot initiative that they believe would help bolster the program’s assets by allowing program funds to be invested in a diversified portfolio rather than fixed-income investments. That initiative “probably will eventually” pass, Veghte said, even though it failed in 2020.

Although the program delay isn’t ideal for the thousands of people who could benefit from the new program in the short term, consumer advocates are taking it in stride.

“We know that as the first state to do this that it may not be perfect going out of the gate,” said Jessica Gomez, coalition manager of Washingtonians for a Responsible Future, which represents community groups for aging and disability populations. “It may have to be fixed, but we’ll fix the problems and go forward.”

Advance Care Planning for Guns

Ensuring that they remain in safe hands, whatever happens to their owners

What happens to gun-owners’ guns if they develop dementia or when they die? Journalist Judith Graham describes the problems that can develop and a way to plan ahead, so that the guns are safely transferred to others, according to their owners’ wishes. She wrote her article for Kaiser Health News, and it was posted on the KHN website on April 27, 2022. Her story also ran on U.S. News & World Report. 

Kerri Raissian didn’t know what to do about her father’s guns when he died of COVID-19 in December at age 86 and left her executor of his estate.

Her father, Max McGaughey, hadn’t left a complete list of his firearms and where they were stored, and he hadn’t prepared a realistic plan for responsibly transferring them to family members.

What’s more, McGaughey had lived alone for at least a year at his home in Weimar, TX, after being diagnosed with dementia in October 2020—a situation Raissian realized was potentially unsafe but didn’t know how to address.

Now, a new tool can help gun owners and family members plan ahead for safe firearm use and transfers in the event of disability or death: the Firearm Life Plan, created by researchers at the University of Colorado and the Rocky Mountain Regional VA Medical Center in Denver.

Think of it as advance care planning for guns—a way for someone to describe what they want to have happen to their firearms should they die or become physically or cognitively disabled and unable to use them responsibly.

The goal is to prevent accidental injuries that can result if older gun owners forget to store firearms safely, their hearing and vision are impaired, they become seriously depressed or a medical condition such as arthritis prevents them from handling firearms adeptly. Another goal is to ensure that firearms are transferred safely to responsible new owners when the need arises.

As many as 60 percent of people who are struggling with dementia live in homes that have firearms. 

This is a real concern because 42 percent of Americans 65 and older live in households with guns, according to the Pew Research Center, and more than 100 people die of firearm injuries in the United States each day. Among adults ages 50 and older, 84 percent of firearm-related deaths are suicides.

The Firearm Life Plan has four parts. First, there’s a list of warning signs (physical, cognitive, behavioral and emotional) that might cause a gun owner to use a gun inappropriately. Among them are symptoms associated with dementia, whose dangerous nexus with firearm ownership was the topic of a KHN investigation in 2018.

Up to 60 percent of people with dementia live in homes with a firearm, according to an overview of gun-related injury and death published in 2019.

The Firearm Life Plan kit stresses personal responsibility, safety and the importance of being prepared, themes that older owners and family members emphasized in focus groups conducted by researchers.

Key messages for owners are “this is your decision” and “it’s voluntary,” said Emmy Betz, MD, co-founder of the Colorado Firearm Safety Coalition and a University of Colorado researcher who led the project. Also, the kit notes that people’s plans may change over time, and the worksheets gun owners fill out are not legally binding.

“We talk a lot about safe gun storage. This really challenges us to make sure that guns are handled appropriately when an owner dies or experiences health declines,” said Cassandra Crifasi, director of research and policy at the Center for Gun Violence Solutions at the Johns Hopkins Bloomberg School of Public Health.

A second part of the guide features conversation prompts for family members and friends who might be concerned about an older gun owner and for older adults who recognize the value of planning ahead. Among them: 

“You always taught me about firearm safety. That’s why I wanted to talk about some changes I’ve noticed lately.”

“Do you think it’s time to have someone give you an honest assessment about how you’re handling your firearms these days?”

“If I’m ever incapacitated or die, I need to make sure my firearms are taken proper care of. Having a conversation about what to do is important to me.”

Conversations of this sort are bound to be difficult since they touch on fundamental issues of identity, autonomy, safety and mortality.

“I’ve seen several people that I’ve really been worried about and had conversations with a couple of them that haven’t gone particularly well,” said Richard Abramson, founder of Colorado’s Centennial Gun Club and a former board member of NSSF, a firearm industry trade group.

“In my opinion, it’s much harder to get someone to relinquish their firearms than their car keys because of this strong feeling that I need to protect myself and my loved ones,” he added.

“I would ask ‘Who is the person you trust the most to come to you and tell you you’re beginning to lose it?’” said Michael Victoroff, MD, 72, a physician who is a competitive shooter and firearms safety instructor. “You’ve got to tell that person you want him to be straight with you when the time comes, even though it’s a horrible thing to talk about.”

The third piece of the Firearm Life Plan is the most straightforward. It calls for people to create an inventory of their firearms, where they’re stored (including codes to lockboxes, storage sheds and gun safes), who should get the firearms when the owner dies or is willing to relinquish them and when transfers should occur.

Some gun owners have so many guns that they aren’t sure just how many they own. 

Khalil Spencer, 68, a retired scientist from Los Alamos National Laboratory and a member of the board of directors of the Los Alamos Sportsmen’s Club, is among the legions of gun owners who haven’t assembled this kind of information. When I asked him how many guns he had, he responded, “At least a dozen, I’ve lost track.”

In some ways Spencer is well prepared: after a “mini-stroke” eight years ago, he talked to his family and asked a former colleague to help his wife dispose of his firearms should he become incapacitated or die. Spencer wants the colleague to take some guns, give others to Spencer’s two younger brothers and sell whatever is left behind.

Still, Spencer acknowledged, he hasn’t inventoried his firearms or included plans for them in his will. “At this point, it’s all been done verbally and via email,” he told me.

Similarly, David Yamane, 53, a professor of sociology at Wake Forest University who has written extensively about America’s gun culture, hadn’t thought about describing what should happen to his guns in his will before he reviewed the Firearm Life Plan. Altogether, he and his wife have 18 firearms.

Because gun owners care deeply about personal protection (two-thirds of owners cite this as a major reason for having firearms), it might be hard for them to give up guns as they grow older, Yamane said. “There would have to be some way of compensating for that feeling of vulnerability,” he suggested. Possibilities include installing a home alarm system, buying a dog and moving in with someone else or to a senior living complex.

Barriers to using the plan might also arise because gun owners are “incredibly resistant to being told they shouldn’t be doing what they’re doing,” Victoroff said. He plans to transfer ownership of all his firearms to a “gun trust” and name himself, his wife, and his children as joint trustees with equal rights. Altogether, Victoroff estimates he owns “more than 20, less than 30” firearms.

The fourth component of the guide is a “legacy” section that asks gun owners to share memories and stories about their firearms and what they’ve meant to them.

“This becomes a plan for transferring family knowledge, and I think that’s really lovely,” said Raissian, a third-generation Texan who now researches gun violence prevention at the University of Connecticut. “Some of the guns in my dad’s estate are my grandfather’s, and I’m pretty sure Dad would have told me the stories if I’d asked, which I didn’t, unfortunately.”

As for disseminating the Firearm Life Plan, Betz hopes that gun shops, shooting ranges, gun industry groups and aging organizations will make copies available. She’s in discussion with several groups, but none have publicly endorsed the plan yet. 

Top Experts Question the Value of Advance Care Planning

A controversy has developed over end-of-life care

Some medical experts have begun to question whether it’s a good idea to draw up a document specifying what kind of care you want if you’re seriously ill and can’t speak for yourself. Others are pushing back. Kaiser Health News (KHN) columnist Judith Graham considers both sides of the controversy in this article, which was posted on KHN’s website on January 6, 2022.

For decades, Americans have been urged to fill out documents specifying their end-of-life wishes before becoming terminally ill—living wills, do-not-resuscitate orders and other written materials expressing treatment preferences.

Now, a group of prominent experts is saying those efforts should stop because they haven’t improved end-of-life care.

“Decades of research demonstrate advance care planning doesn’t work. We need a new paradigm,” said R. Sean Morrison, MD, chair of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York and a coauthor of a recent opinion piece advancing this argument in JAMA.

“A great deal of time, effort, money, blood, sweat and tears have gone into increasing the prevalence of advance care planning, but the evidence is clear: it doesn’t achieve the results that we hoped it would,” said Diane Meier, MD, founder of the Center to Advance Palliative Care, a professor at Mount Sinai and coauthor of the opinion piece. Notably, advance care planning has not been shown to ensure that people receive care consistent with their stated preferences—a major objective.

“We’re saying stop trying to anticipate the care you might want in hypothetical future scenarios,” said James Tulsky, MD, who is chair of the department of psychosocial oncology and palliative care at the Dana-Farber Cancer Institute in Boston and collaborated on the article. “Many highly educated people think documents prepared years in advance will protect them if they become incapacitated. They won’t.”

The reasons are varied and documented in dozens of research studies. People’s preferences change as their health status shifts; forms offer vague and sometimes conflicting goals for end-of-life care; families, surrogates and clinicians often disagree with a patient’s stated preferences; documents aren’t readily available when decisions need to be made; and services that could support a patient’s wishes—such as receiving treatment at home—simply aren’t available.

Already, the priority is to help seriously ill people make complicated decisions.

But this critique of advance care planning is highly controversial and has received considerable pushback.

Advance care planning has evolved significantly in the past decade and the focus today is on conversations between patients and clinicians about patients’ goals and values, not about completing documents, said Rebecca Sudore, MD, a professor of geriatrics and director of the Innovation and Implementation Center in Aging and Palliative Care at the University of California-San Francisco. This progress shouldn’t be discounted, she said.

Also, anticipating what people want at the end of their lives is no longer the primary objective. Instead, helping people make complicated decisions when they become seriously ill has become an increasingly important priority.

When people with serious illnesses have conversations of this kind, “our research shows they experience less anxiety, more control over their care, are better prepared for the future and are better able to communicate with their families and clinicians,” said Jo Paladino, MD, associate director of research and implementation for the Serious Illness Care Program at Ariadne Labs, a research partnership between Harvard and Brigham and Women’s Hospital in Boston.

Advance care planning “may not be helpful for making specific treatment decisions or guiding future care for most of us, but it can bring us peace of mind and help prepare us for making those decisions when the time comes,” said J. Randall Curtis, MD, 61, director of the Cambia Palliative Care Center of Excellence at the University of Washington.

Curtis and I communicated by email because he can no longer speak easily after being diagnosed with amyotrophic lateral sclerosis, an incurable neurologic condition, early in 2021. Since his diagnosis, Curtis has had numerous conversations about his goals, values and wishes for the future with his wife and palliative care specialists.

“I have not made very many specific decisions yet, but I feel like these discussions bring me comfort and prepare me for making decisions later,” he told me. Assessments of advance care planning’s effectiveness should take into account these deeply meaningful “unmeasurable benefits,” Curtis wrote recently in JAMA in a piece about his experiences.

Only 37 percent of adults have advance directives.

The emphasis on documenting end-of-life wishes dates to a seminal legal case, Cruzan v. Director, Missouri Department of Health, decided by the Supreme Court in June 1990. Nancy Cruzan was 25 when her car skidded off a highway and she sustained a severe brain injury that left her permanently unconscious. After several years, her parents petitioned to have her feeding tube removed. The hospital refused. In a 5-4 decision, the Supreme Court upheld the hospital’s right to do so, citing the need for “clear and convincing evidence” of an incapacitated person’s wishes.

Later that year, Congress passed the Patient Self-Determination Act, which requires hospitals, nursing homes, home health agencies, health maintenance organizations and hospices to ask whether a person has a written “advance directive” and, if so, to follow those directives to the extent possible. These documents are meant to go into effect when someone is terminally ill and has lost the capacity to make decisions.

But too often this became a “check-box” exercise, unaccompanied by in-depth discussions about a patient’s prognosis, the ways that future medical decisions might affect a patient’s quality of life, and without a realistic plan for implementing a patient’s wishes, said Meier, of Mount Sinai.

She noted that only 37 percent of adults have completed written advance directives—in her view, a sign of uncertainty about their value.

Other problems can compromise the usefulness of these documents. A patient’s preferences may be inconsistent or difficult to apply in real-life situations, leaving medical providers without clear guidance, said Scott Halpern, MD, a professor at the University of Pennsylvania Perelman School of Medicine, who studies end-of-life and palliative care.

For instance, an older woman may indicate she wants to live as long as possible and yet also avoid pain and suffering. Or an older man may state a clear preference for refusing mechanical ventilation but leave open the question of whether other types of breathing support are acceptable.

“Rather than asking patients to make decisions about hypothetical scenarios in the future, we should be focused on helping them make difficult decisions in the moment,” when actual medical circumstances require attention, said Morrison, of Mount Sinai.

There’s strong support for naming a health care surrogate or proxy to make decisions on your behalf. 

Also, determining when the end of life is at hand and when treatment might postpone that eventuality can be difficult.

Morrison spoke of his alarm early in the pandemic when older adults with COVID-19 would go to emergency rooms, and medical providers would implement their advance directives (for instance, no CPR or mechanical ventilation) because of an assumption that the virus was “universally fatal” to seniors. He said he and his colleagues witnessed this happen repeatedly.

“What didn’t happen was an informed conversation about the likely outcome of developing COVID and the possibilities of recovery,” even though most older adults ended up surviving, he said.

For all the controversy over written directives, there is strong support among experts for another component of advance care planning—naming a health care surrogate or proxy to make decisions on your behalf should you become incapacitated. Typically, this involves filling out a health care power-of-attorney form. 

“This won’t always be your spouse or your child or another family member: it should be someone you trust to do the right thing for you in difficult circumstances,” said Tulsky, who cochairs a roundtable on care for people with serious illnesses for the National Academies of Sciences, Engineering and Medicine.

“Talk to your surrogate about what matters most to you,” he urged, and update that person whenever your circumstances or preferences change.

Most people want their surrogates to be able to respond to unforeseen circumstances and have leeway in decision-making while respecting their core goals and values, Sudore said.

Among tools that can help patients and families are Sudore’s Prepare for Your Care program; materials from the Conversation Project, Respecting Choices and Caring Conversations; and videos about health care decisions at ACP Decisions

The Centers for Disease Control and Prevention also has a comprehensive list of resources

Smashing Stereotypes on Social Media

Older social media stars are disproving ageist stereotypes, while making intergenerational connections

When she retired 15 years ago, Tzipporah “Zippy” Sandler was floundering and unsure what was next. Then a tech-savvy friend suggested she start a blog and even offered to build it for her.

“I didn’t even know what a blog was, but I said, ‘Yeah, why not?’” Sandler said. 

Sandler’s blog, Champagne Living, focused on affordable travel and lifestyle and soon expanded to social media. Now, at age 68, she’s a top-ranked social media influencer, with more than 34,000 followers on her Instagram account (“Zipporahs”), YouTube channel, a weekly show livestreamed via Facebook, and her blog, which attracts more than 315,000 unique visitors monthly. 

In search of her next post, she’s done everything from riding a luxury train through the Canadian Rockies to hang gliding off a cliff in the Outer Banks in North Carolina.

“It makes me feel young,” said Sandler. “I’m checking things off my bucket list.” 

Sandler is also making money. Companies pay her to serve as a “brand ambassador,” to try their products or experiences and post about them on social media feeds. The hang-gliding escapade, for example, was sponsored by a convention and visitors bureau. 

Sandler is one of a small but increasingly visible number of older adults who’ve become social media stars, with thousands, even millions, of followers on Instagram, Twitter, Facebook, TikTok, YouTube and other platforms, often in tandem with podcasts, websites and blogs. These “granfluencers” share photos of fashionable looks, or tips and ideas on fitness, food, travel, crafts and other areas. In a media landscape that often ignores people over 60, older social media stars are boosting the presence of older adults, smashing stereotypes, sometimes making money and, often, engaging younger people as well as their peers.

Among the most well-known are George Takei, 84, whose Facebook profile is followed by more than nine million people, many of them too young to recognize Takei as the actor who played Hikaru Sulu on the TV series Star Trek; fashion icon Iris Apfel, 100, who models flamboyant outfits on Instagram for two million plus followers; Helen Elam, 93, whose “Baddiewinkle” Instagram account has 3.3 million followers; and the “Old Gays”—four gay men, in their 60s and 70s, with more than six million followers on TikTok.

Staying Engaged

For many older adults—famous and not—social media offer a way to stay connected to the wider world. 

Social media extended Linda Rodin’s 40-year career as a fashion stylist, beauty industry entrepreneur and model. More than 300,000 people follow her Instagram page, “LindaandWinks,” which features stylized photos of Rodin, 74, often posed with her poodle, Winky, street scenes from New York and pictures of objects that catch her eye.  

“It started out as a photo diary—just a funny record of me and my dog,” she said. But the chic Rodin, who sports silver hair and statement eyeglasses and mostly poses in her own clothes, draws followers of all ages. One 30-something called Rodin “my soulmate in fashion.” Another commented, “Turned 60 recently and inspired by you and Winks. Keep up the good work.” 

“I got a lot of comments from younger women who say, ‘I want to grow up to look like you,’” she said. 

Barbara Weibel, 69, has been able to finance her nomadic lifestyle thanks to social media. Fifteen years ago, she left the corporate world and hit the road, writing about her travels on a blog called Hole in the Donut. Bolstered by years of corporate computer experience, she taught herself to use social media platforms as they emerged. Although she lost some traffic when the pandemic paused her travels, she still has almost 9,000 Facebook followers, 6,000 following her YouTube channel, and thousands of loyal blog subscribers, many who’ve been with her since the beginning. 

Weibel says followers tell her that her blog gave them confidence to travel solo and independently, without packaged tours.  

“I get a lot of emails from single women who say, ‘You made me believe it’s okay to travel solo,’ or ‘You’ve given me hope; you did it at age 54,’” she said. “I’ve encouraged people to travel independently and to not be afraid.”  

Though about half of adults over 65 use Facebook, older people are relatively rare on Instagram and TikTok. 

For Steve Austin, 83, social media brought millions of friends to his apartment, where he lives alone, in Dallas, TX. He couldn’t go out during the pandemic, but with 1.7 million people following his TikTok account, “Old Man Steve,” he wasn’t lonely. Austin creates two to four short videos a day, showing himself dancing or performing silly magic tricks, always wearing his signature hats. Austin started posting on TikTok in 2019 at the urging of his nephew; many of his fans are young people, who send gifts, cards and hats from as far away as Brazil, India and Ireland. 

“They tell me they want me to be their grandpa, or I remind them of their grandpa,” he said. “I think I come across as a regular guy having a good time. I’m told I seem honest and trustworthy.”

It’s no surprise that older people attract younger followers on social media, especially on platforms like TikTok or Instagram. Pew Research reports that about 50 percent of adults over 65 use Facebook, but only 11 percent are on Instagram and only 4 percent on TikTok.

While older adults can make money and have fun on social media, maintaining a large following isn’t easy. New content must be posted regularly. They must understand Google’s ranking system to drive traffic. They must master the platforms they’re on but stay nimble. Today’s hot social media platform may be tomorrow’s has-been. (Remember MySpace?)

Dennis Littley, 68, learned that lesson. A former culinary director and teacher at a Catholic girls’ high school, he started a blog to share his recipes for “restaurant-style” dishes with students and staff. Ask Chef Dennis eventually garnered a following of more than a million people on Google+, a social networking platform launched in 2011. Then, with little warning, Google shut down the platform in 2019. 

“That hurt,” he said. But Littley, who’s always been tech-savvy, pivoted and rebuilt. Now he has 800,000 followers on Facebook and 53,000 on Instagram, and his blog attracts nine million visitors annually. 

“I’ve always gone after whatever new social media was out there and learned how to use it properly,” he said. 

Marketing Boon 

Older adults with large followings on social media created a new avenue for brands looking to grow their customer bases, according to Joe Sinkwitz, CEO of Intellifluence, an influencer marketing network. 

“Peer influence is usually the most powerful driver when reaching specific demographics,” Sinkwitz said. “Getting more older voices is absolutely vital for companies looking to reach that key demographic.” 

Older adults represent a massive market, Sinkwitz added. Women 50 and older handle 27 percent of all consumer spending, according to the US Government Consumer Expenditure Survey. “They are the healthiest, wealthiest and most active generation in history, have over $15 trillion in purchasing power, and control 95 percent of household purchasing decisions and 80 percent of luxury travel purchases,” Forbes reports.

Social media also connects people with similar interests in a way that wasn’t possible before, according to digital media expert Dale Blasingame, assistant professor of practice in the School of Journalism and Mass Communication at Texas State University in San Marcos, TX. Digital media “has fundamentally changed the way we consume media,” he said. “It’s no longer all about ‘the hits.’” 

Just 30 years ago, a few television networks decided what shows viewers watched and a handful of radio stations determined what songs became the Top 10 hits. Today, consumers have unlimited choices. Through social media, consumers can find content related to even the most obscure interests, and older adults with experience or accumulated wisdom in niche areas can get “discovered.” 

Timothy Rowett, 79, quietly collected vintage toys, novelties and puzzles for 50 years; then he started creating short videos demonstrating his toys. Now he’s a You Tube hit, with more than two million followers. 

One woman’s videos on YouTube transformed her town into “the Disneyland of quilting.”

Similarly, Jenny Doan, 64, leveraged her sewing skills to tap into a worldwide market of quilting enthusiasts. Her family launched the Missouri Star Quilt Company, a small retail operation in Hamilton, MO, in 2009. Business was slow at first, so her son suggested she try creating video tutorials on quilting techniques. She did all the talking and demonstrating; he ran the camera and set up the YouTube account. Not only did Doan become a YouTube star with more than 800,000 subscribers, the business flourished, transforming Hamilton from a sleepy farming community into “the Disneyland of quilting.” Quilters come from around the world to shop at Missouri Star Quilt’s 13 retail stores, take quilting classes and, they hope, catch a glimpse of Jenny Doan, the quilting maven.

Even in fashion, a notoriously youth-oriented field, older people on social media have a unique niche, according to the New York Times: “They’ve already seen the trends, chased the goods and graduated into freedom.”

Sandler thinks she appeals to older people because she’s real and relatable. Followers see a woman with gray hair and a few wrinkles. She’s not following the lead of many young social media influencers, who use Instagram’s photo filters to make their skin smoother, lashes longer and lips fuller.  

“I’m just not going to do that,” she said. “Because this is reality. I think my followers are feeling the same way and they want that connection.” 

Likewise, Rodin’s followers seem to find her relatable and inspirational. She’s never had cosmetic surgery. She wears funky glasses, not as a gimmick but because “without them, I’m blind as a bat.” Instead of chasing after new trends, she poses in outfits assembled from her own closet.

But Rodin says Instagram is mostly something she does for herself—a  way to stay creatively engaged. 

“I do this for my own pleasure,” she said, “It keeps me on my toes. It’s a way for me to be artful.” 

COVID Spotlights the Ageism in Health Care

Death toll among older people shows urgent need for changes

The staggering death toll among older people who have contracted COVID has many more people, worldwide, thinking about what needs to change in medical care and elsewhere. In this article for Kaiser Health News, journalist Judith Graham reports on new health care strategies being adopted in the United States. Her piece was posted on KHN’s website on November 5, 2021.

Earlier this year, the World Health Organization announced a global campaign to combat ageism—discrimination against older adults that is pervasive and harmful but often unrecognized. 

“We must change the narrative around age and ageing” and “adopt strategies to counter” ageist attitudes and behaviors, WHO concluded in a major report accompanying the campaign.

Several strategies WHO endorsed—educating people about ageism, fostering intergenerational contacts, and changing policies and laws to promote age equity—are being tried in the United States. But a greater sense of urgency is needed in light of the coronavirus pandemic’s shocking death toll, including more than 500,000 older Americans, experts suggest.

“COVID hit us over the head with a two-by-four, [showing that] you can’t keep doing the same thing over and over again and expect different results” for seniors, Jess Maurer, executive director of the Maine Council on Aging, said in an October webinar on ageism in health care, sponsored by KHN and the John A. Hartford Foundation. “You have to address the root cause—and the root cause here is ageism.”

Some experts believe there’s a unique opportunity to confront this concern because of what the country has been through. Here are some examples of what’s being done, particularly in health care settings.

Distinguishing old age from disease. In October, a group of experts from the United States, Canada, India, Portugal, Switzerland and the United Kingdom called for old age to be removed as one of the causes and symptoms of disease in the 11th revision of the International Classification of Diseases, a global resource used to standardize health data worldwide.

Aging is a normal process, and equating old age with disease “is potentially detrimental,” the experts wrote in the Lancet. Doing so could result in inadequate clinical evaluation and care and an increase in “societal marginalisation and discrimination” against older adults, they warn.

Identifying ageist beliefs and language. Groundbreaking research published in 2015 by the FrameWorks Institute, an organization that studies social issues, showed that many people associate aging with deterioration, dependency and decline—a stereotype that almost surely contributed to policies that harmed older adults during the pandemic. By contrast, experts understand that older adults vary widely in their abilities and that a significant number are healthy, independent and capable of contributing to society.

Using this and subsequent research, the Reframing Aging Initiative, an effort to advance cultural change, has been working to shift how people think and talk about aging, training organizations across the country. Instead of expressing fatalism about aging (“a silver tsunami that will swamp society”), it emphasizes ingenuity, as in “we can solve any problem if we resolve to do so,” said Patricia D’Antonio, project director and vice president of policy and professional affairs at the Gerontological Society of America. Also, the initiative promotes justice as a value, as in “we should treat older adults as equals.”

Since it began, the American Medical Association, the American Psychological Association and the Associated Press have adopted bias-free language around aging, and communities in Colorado, New Hampshire, Massachusetts, Connecticut, New York and Texas have signed on as partners.

Tackling ageism at the grassroots level. In Colorado, Changing the Narrative, a strategic awareness campaign, has hosted more than 300 workshops educating the public about ageist language, beliefs and practices in the past three years. Now, it’s launching a campaign calling attention to ageism in health care, including a 15-minute video set to debut in November.

“Our goal is to teach people about the connections between ageism and poor health outcomes and to mobilize both older people and [health] professionals to advocate for better medical care,” said Janine Vanderburg, director of Changing the Narrative.

Faced with the pandemic’s horrific impact, the Maine Council on Aging earlier this year launched the Power in Aging Project, which is sponsoring a series of community conversations around ageism and asking organizations to take an “anti-ageism pledge.” 

The goal is to educate people about their own “age bias”—largely unconscious assumptions about aging—and help them understand “how age bias impacts everything around them,” said Maurer. For those interested in assessing their own age bias, a test from Harvard University’s Project Implicit is often recommended. (Sign in and choose the “age IAT” on the next page.)

Changing education for health professionals. Two years ago, Harvard Medical School began integrating education in geriatrics and palliative care throughout its curriculum, recognizing that it hadn’t been doing enough to prepare future physicians to care for seniors. Despite the rapid growth of the older population, only 55 percent of US medical schools required education in geriatrics in 2020, according to the latest data from the Association of American Medical Colleges.

Andrea Schwartz, MD, an assistant professor of medicine, directs Harvard’s effort, which teaches students about everything from the sites where older adults receive care (nursing homes, assisted living, home-based programs, community-based settings) to how to manage common geriatric syndromes such as falls and delirium. Also, students learn how to talk with older patients about what’s most important to them and what they most want from their care.

Schwartz also chaired a committee of the academic programs in geriatrics that recently published updated minimum competencies in geriatrics that any medical school graduate should have.

Altering professional requirements. Sharon Inouye, MD, also a professor of medicine at Harvard, suggests additional approaches that could push better care for older adults forward. When a physician seeks board certification in a specialty or doctors, nurses or pharmacists renew their licenses, they should be required to demonstrate training or competency in “the basics of geriatrics,” she said. And far more clinical trials should include a representative range of older adults to build a better evidence base for their care.

Inouye, a geriatrician, was particularly horrified during the pandemic when doctors and nurses failed to recognize that seniors with COVID-19 were presenting in hospital emergency rooms with “atypical” symptoms such as loss of appetite and delirium. Such “atypical” presentations are common in older adults, but instead of receiving COVID tests or treatment, these older adults were sent back to nursing homes or community settings where they helped spread infections, she said.

Bringing in geriatrics expertise. If there’s a silver lining to the pandemic, it’s that medical professionals and health system leaders observed firsthand the problems that ensued and realized that older adults needed special consideration.

“Everything that we as geriatricians have been trying to tell our colleagues suddenly came into sharp focus,” said Rosanne Leipzig, MD, a professor of geriatrics at the Icahn School of Medicine at Mount Sinai in New York City.

Now, more Mount Sinai surgeons are asking geriatricians to help them manage older surgical patients, and orthopedic specialists are discussing establishing a similar program. “I think the value of geriatrics has gone up as institutions see how we care for complicated older adults and how that care improves outcomes,” Leipzig said.

Building age-friendly health systems. “I believe we are at an inflection point,” said Terry Fulmer, president of the John A. Hartford Foundation, which is supporting the development of age-friendly health systems with the American Hospital Association, the Catholic Health Association of the United States and the Institute for Healthcare Improvement. (The John A. Hartford Foundation is a funder of KHN.)

More than 2,500 health systems, hospitals, medical clinics and other health care providers have joined this movement, which sets four priorities (“the 4Ms”) in caring for older adults: attending to their mobility, medications, mentation (cognition and mental health) and what matters most to them—the foundation for person-centered care.

Creating a standardized framework for improving care for seniors has helped health care providers and systems know how to proceed, even amid the enormous uncertainty of the past couple of years. “We thought [the pandemic] would slow us down, but what we found in most cases was the opposite—people could cling to the 4Ms to have a sense of mastery and accomplishment during a time of such chaos,” Fulmer said.

Keeping an Eye on Older Adults with a Camera or Sensors

Here’s what you can do if it’s not safe to leave an older person alone 

By monitoring older people who have dementia or other cognitive problems, the latest technology can make a huge difference for exhausted caregivers. In this article, journalist Sofie Kodner reports on some of what’s available and how it’s being used. Kodner is a writer with the Investigative Reporting Program (IRP) at the University of California-Berkeley Graduate School of Journalism. Kaiser Health News posted her article on November 23, 2021, and it also ran in the Washington Post. The IRP covered the story through a grant from the SCAN Foundation. 

In the middle of a rainy Michigan night, 88-year-old Dian Wurdock walked out the front door of her son’s home in Grand Rapids, MI, barefoot and coatless. Her destination was unknown even to herself. Wurdock was several years into a dementia diagnosis that turned out to be Alzheimer’s disease. By luck, her son woke up and found her before she stepped too far down the street. As the Alzheimer’s progressed, so did her wandering and with it, her children’s anxiety.

“I was losing it,” said her daughter, Deb Weathers-Jablonski. “I needed to keep her safe, especially at night.”

Weathers-Jablonski installed a monitoring system with nine motion sensors around the house—in her mother’s bedroom, the hallway, kitchen, living room, dining room and bathroom and near three doors that led outside. They connected to an app on her phone, which sent activity alerts and provided a log of her mother’s movements.

“When I went to bed at night, I didn’t have to guess what she was doing,” Weathers-Jablonski said. “I was actually able to get some sleep.”

New monitoring technology is helping family caregivers manage the relentless task of looking out for older adults with cognitive decline. Setting up an extensive monitoring system can be expensive—Weathers-Jablonski’s system from People Power Co. costs $299 for the hardware and $40 a month for use of the app. With scores of companies selling such gear, including SentryTell and Caregiver Smart Solutions, they are readily available to people who can pay out of pocket.

But that’s not an option for everyone. While the technology is in line with President Joe Biden’s plan to direct billions of dollars toward helping older and disabled Americans live more independently at home, the costs of such systems aren’t always covered by private insurers and rarely by Medicare or Medicaid.

Monitoring also raises ethical questions about privacy and quality of care. Still, the systems make it possible for many older people to stay in their home, which can cost them far less than institutional care. Living at home is what most people prefer, especially in light of the toll the COVID-19 pandemic took on nursing homes.

The new devices can use artificial intelligence to detect when something is wrong and make an emergency call—all, done automatically. 

Technology could help fill a huge gap in home care for the elderly. Paid caregivers are in short supply to meet the needs of the aging population, which is expected to more than double in coming decades. The shortage is fueled by low pay, meager benefits and high rates of burnout.

And for the nearly one in five US adults who are caregivers to a family member or friend over age 50, the gadgets have made a hard job just a little easier.

Passive surveillance systems are replacing the “I’ve fallen and I can’t get up” medical alert buttons. Using artificial intelligence, the new devices can automatically detect something is wrong and make an emergency call unasked. They also can monitor pill dispensers and kitchen appliances, using motion sensors, like EllieGrid and WallFlower. Some systems include wearable watches for fall detection, such as QMedic, or can track GPS location, like SmartSole’s shoe insoles. Others are video cameras that record. People use surveillance systems like Ring inside the home.

Some caregivers may be tempted to use technology to replace care, as researchers in England found in a recent study. A participant who had visited his father every weekend began visiting less often after his dad started wearing a fall detector around his wrist. Another participant believed her father was active around the house, as evidenced by activity sensor data. She later realized the app was showing not her father’s movement, but his dog’s. The monitoring system picked up the dog’s movements in the living room and logged it as activity.

Technology isn’t a substitute for face-to-face interaction, stressed Crista Barnett Nelson, executive director of Senior Advocacy Services, a nonprofit group that helps older adults and their families in the North Bay area outside San Francisco. “You can’t tell if someone has soiled their briefs with a camera. You can’t tell if they’re in pain, or if they just need an interaction,” she said.

In some instances, people being monitored changed their habits in response to technology. Clara Berridge, PhD, a professor of social work at the University of Washington who studies the use of technology in elder care, interviewed a woman who stopped her usual practice of falling asleep on the recliner because the technology would falsely alert her family that something was wrong, based on inactivity deemed abnormal by the system. Another senior reported rushing in the bathroom for fear an alert would go out if they took too long.

The technology presents another worry for those being monitored. “A caregiver is generally going to be really concerned about safety. Older adults are often very concerned about safety too, but they may also weigh privacy really heavily, or their sense of identity or dignity,” Berridge said.

The most compelling reason for using monitoring devices may be the relief caregivers feel. 

Charles Vergos, 92 and living in Las Vegas, is uncomfortable with video cameras in his house and wasn’t interested in wearing gadgets. But he liked the idea that someone would know if something went wrong while he was alone. His niece, who lives in Palo Alto, CA, suggested Vergos install a home sensor system so she could monitor him from afar.

“The first question I asked is, does it take pictures?” Vergos recalled. Because the sensors don’t have a video component, he was fine with them. “Actually, after you have them in the house for a while, you don’t even think about it,” Vergos said.

The sensors also have made conversations with his niece more convenient for him. She knows he likes to talk on the phone while he’s in his chair in the den, so she’ll check his activity on her iPad to determine whether it’s a good time to call.

People making audio and video recordings must abide by state privacy laws, which typically require the consent of the person being recorded. It’s not as clear, however, if consent is needed to collect the activity data that sensors gather. That falls into a gray area of the law, similar to data collected through internet browsing.

Then there is the problem of how to pay for it all. Medicaid, the federal-state health program for low-income people, does cover some passive monitoring for home care, but it’s not clear how many states have opted to pay for such service.

Some seniors also lack access to robust Internet broadband, putting much of the more sophisticated technology out of reach, noted Karen Lincoln, PhD, founder of Advocates for African American Elders at the University of Southern California.

The relief monitoring devices bring [to] caregivers may be the most compelling reason for their use. Delaine Whitehead, who lives in Orange County, CA, started taking medication for anxiety about a year after her husband, Walt, was diagnosed with Alzheimer’s.

Like Weathers-Jablonski, Whitehead sought technology to help, finding peace of mind in sensors installed on the toilets in her home.

Her husband often flushed too many times, causing the toilets to overflow. Before Whitehead installed the sensors in 2019, Walt had caused $8,000 worth of water damage in their bathroom. With the sensors, Whitehead received an alert on her phone when the water got too high.

“It did ease up a lot of my stress,” she said.

 

Saying a Wrenching Goodbye to My Longtime Primary Care Doctor

A foretaste of physician shortages to come as many older doctors begin to retire

Medical authorities are predicting a huge shortage of primary care physicians and specialists in the not-too-distant future, just as the population of older Americans is exploding. After losing her own doctor to retirement, journalist Judith Graham takes a broader look at the way medicine is changing. Kaiser Health News posted her article on the KHN website on October 12, 2021. The story also ran in the Washington Post. 

I hadn’t expected the tears.

My primary care doctor and I were saying goodbye after nearly 30 years together.

“You are a kind and a good person,” he told me after the physical exam, as we wished each other good luck and good health.

“I trust you completely—and always have,” I told him, my eyes overflowing.

“That means so much to me,” he responded, bowing his head.

Will I ever have another relationship like the one with this physician, who took time to ask me how I was doing each time he saw me? Who knew me from my first months as a young mother, when my thyroid went haywire, and who since oversaw all my medical concerns, both large and small?

It feels like an essential lifeline is being severed. I’ll miss him dearly.

This isn’t my story alone; many people in their 50s, 60s and 70s are similarly undergoing this kind of wrenching transition. A decade from now, at least 40 percent of the physician workforce will be 65 or older, according to data from the Association of American Medical Colleges (AAMC). If significant numbers of doctors retire, as expected, physician shortages will swell. Earlier this year, the AAMC projected an unmet need for up to 55,200 primary care physicians and 86,700 specialists by 2033, amid the rapid growth of the [older] population.

Stress from the COVID pandemic has made the outlook even worse, at least in the near term. When the Physicians Foundation, a nonprofit research organization, surveyed 2,504 doctors in May and June, 61 percent reported “often experiencing” burnout associated with financial and emotional strain. Two percent said they had retired because of the pandemic; another 2 percent had closed their practices.

Twenty-three percent of the doctors surveyed said they’d like to retire during the next year.

When doctor-patient relationships end, the patient’s medical issues can be overlooked.

Baby boomers, like me, whose medical needs are intensifying even as their longtime doctors bow out of practice, are most likely to be affected.

“There’s a lot of benefit to having someone who’s known your medical history for a long time,” especially for older adults, said Janis Orlowski, MD, AAMC’s chief health care officer. When relationships with physicians are disrupted, medical issues that need attention can be overlooked, and people can become less engaged in their care, said Gary Price, MD, president of the Physicians Foundation.

My doctor, who’s survived two bouts of cancer, didn’t mention the pandemic during our recent visit. Instead, he told me he [was] turning 75 a week before he closed the practice at the end of October. Having practiced medicine for 52 years, 40 as a solo practitioner, “it’s time for me to spend more time with family,” he explained.

An intensely private man who’s averse to publicity, he didn’t want his name used for this article. I know I’m lucky to have had a doctor I could rely on with complete confidence for so long. Many people don’t have this privilege because of where they live, their insurance coverage, differences in professional competence and other factors.

With a skeletal staff—his wife is the office manager—my doctor has been responsible for 3,000 patients, many of them for decades. One woman sobbed miserably during a recent visit, saying she couldn’t imagine starting over with another physician, he told me.

At one point, when my thyroid levels were out of control, I saw my physician monthly. After my second pregnancy, when this problem recurred, I brought the baby and her toddler brother in a double stroller into the exam room. One or the other would often cry sympathetically when he drew my blood.

I remember once asking when a medical issue I was having—the flu? a sore throat?—would resolve. He pointed upward and said, “Only Hashem knows.” A deeply religious man, he wasn’t afraid to acknowledge the body’s mysteries or the limits of medical knowledge.

“Give it a few days and see if you get better,” he frequently advised me. “Call if you get worse.”

Older people often have trouble finding a new doctor who is accepting patients. 

At each visit, my doctor would open a large folder and scribble notes by hand. My file is more than four inches thick. He never signed up for electronic medical records. He’s not monetizing his practice by selling it. For him, medicine was never about money.

“Do you know the profit margins this hospital makes?” he asked at our last visit, knowing my interest in health care policy and finance. “And how do you think they do it? They cut costs wherever they can and keep the nursing staff as small as possible.”

Before a physical exam, he’d tell a joke—a way to defuse tension and connect with a smile. “Do you know the one about …” he’d begin before placing his fingers on my throat (where the thyroid gland is located) and squeezing hard.

Which isn’t to say that my doctor was easygoing. He wasn’t. Once, he insisted I go to the emergency room after I returned from a long trip to South Asia with a very sore leg and strange pulsing sensations in my chest. An ultrasound was done and a blood clot, discovered.

The young doctors in the ER wanted to give me intravenous blood thinner and send me home with a prescription. My doctor would have nothing of it. I was to stay in the hospital overnight and be monitored every few hours, efficiency and financial considerations be damned. He was formidable and intransigent, and the younger physicians backed down.

At that last meeting, my doctor scribbled the names of two physicians on a small sheet of paper before we said our goodbyes. Both would take good care of me, he said. When I called, neither was accepting new patients. Often, I hear this from older friends: they can’t find physician practices that are taking new patients.

The transition to a new physician can be hard for patients and also for doctors. 

Price, who’s 68, went through this when his family physician announced she was retiring and met with him in January to work out who might take over his care. Price was admitted into the practice of a younger physician with a good reputation only because he asked a medical colleague to intervene on his behalf. Even then, the first available appointment was in June.

Orlowski had a similar experience two years ago when searching for a new primary care doctor for her elderly parents. “Most of the practices I contacted weren’t accepting new patients,” she told me. It took six months to find a physician willing to see her parents—again, with the help of medical colleagues.

I’m lucky. A friend of mine has a physician daughter, part of an all-women medical practice at a nearby university hospital. One of her colleagues had openings and I got on her schedule in December. My friend’s daughter recommends her highly.

Still, it will mean starting over, with all the dislocation that entails. And these transitions are hard for patients and doctors alike.

Several weeks ago, I received a letter from my doctor, likely his last communication, which I read with a lump in my throat.

“To my beloved patients,” he wrote. “I feel so grateful for the opportunity to treat you and develop relationships with you and your families that I will always treasure. … I bid you all adieu. I hope and pray for your good health. I will miss each and every one of you and express to you my appreciation for so many wonderful years of doing what I love, caring for and helping people.”

 

Getting Older with Grace—and Gratitude

Making it a habit to feel grateful can make you healthier and happier  

In a cruel twist of timing, Sally Magnuson’s husband of 55 years died of COVID-19 on February 10, 2021—the very day the couple was scheduled to get their first vaccines. Around the same time, Magnuson, 80, of Plano, TX, also contracted COVID; she spent weeks in the hospital and relied on supplemental oxygen for months afterward. 

Despite all that, she still starts each day with gratitude.

“I literally thank God daily for my life and for what I have,” said Magnuson. She recounted her blessings: she was hospitalized but never needed to be intubated; she had excellent medical care; she had the support of friends, who brought meals and flowers. 

She recalled the time her nurse asked her to call if she needed anything; the nurse was occupied with a patient who was dying that day. 

“I knew I was so much better off than that poor man,” Magnuson said. “Even with everything that’s happened, there’s a lot to be grateful for. I’m a lucky person.”

Today, Magnuson is on the mend and regaining strength. As a growing body of research suggests, her grateful spirit may have helped her get there. Gratitude can make people healthier, happier and more satisfied with life.  

Gratitude can help lower your blood pressure and improve immunity, and you’re less likely to become anxious or depressed. 

“Gratitude is literally one of the few things that can measurably change peoples’ lives,” wrote Robert Emmons, PhD, professor of psychology at the University of California at Davis and a leading expert on the science of gratitude. “Gratitude has one of the strongest links to mental health and satisfaction with life of any personality trait—more so than even optimism, hope or compassion.”

The long list of health benefits associated with gratitude includes lowered blood pressure, improved immune function and better sleep, as well as reduced risk for depression, anxiety and substance abuse. Heart patients who practice gratitude may recover more quickly. Grateful people also tend to have better habits: they exercise more, eat healthier and are less likely to smoke or abuse alcohol. 

Regulating one’s emotions is fundamental to increasing an older person’s number of healthy years, and gratitude aids in that, according to Daniel Levitin, PhD, author of Successful Aging: A Neuroscientist Explores the Power and Potential of Our Lives (2020).

“Gratitude causes us to focus on what’s good about our lives rather than what’s bad, shifting our outlook toward the positive,” he said.  

This research supports the wisdom that traditions have taught for thousands of years: gratitude works. All the world’s major religions teach the need for gratitude. It’s one of eight core teachings of yoga. Cicero called gratitude “not only the greatest of virtues, but the parent of all others.” 

Not-So-Secret Weapon

What exactly is gratitude? 

Psychological studies tend to compare groups of people who’ve completed some type of gratitude exercise—such as keeping a list of things they’re grateful for—to control groups that completed a similar but neutral exercise, such as writing down what they ate for breakfast. But gratitude has many facets. It can mean reflecting on good things in one’s life, expressing thanks to God or a higher power, expressing thanks to others or even receiving words of gratitude.  

“From the psychotherapeutic point of view, we tend to focus on the kind of gratitude that’s centered on appreciating one’s blessings and communicating to others the meaning and value they have for you in your life,” said Brian Carpenter, PhD, professor of psychological and brain sciences at Washington University in St. Louis, MO.

Experiencing gratitude does not mean glossing over real challenges that need acknowledgement and attention, Carpenter said, stressing that gratitude is a coping strategy that should be offered to—but not imposed upon—older adults. He cautioned that staying rigidly determined to focus gratefully on the positive, and willfully ignoring negatives, could veer into a form of denial.

But a sense of gratitude may be a particularly powerful tool for helping older adults face the challenges of aging. When confronted with illness or the need to depend on others for help, the choice to respond with gratitude can create a sense of control. 

Expressing gratitude can make you feel less helpless, more in control. 

M.K. Werner, 62, of Plano, TX, recognized that when she underwent treatment for cancer 11 years ago. While at the hospital, Werner resolved to thank every person who helped her along the way. 

“If someone came into my room to clean, I thanked them,” she said. “If someone put towels in the dispenser in my room, I thanked them. It became something I could do. I was completely powerless over what was happening with my body, but I could choose my attitude and how I treated people.”

Although it wasn’t her intent, Werner thinks her expressions of gratitude resulted in better, more attentive medical care. 

“Nurses would tell me they had asked for me, or they were happy to have me on their list of patients that day,” she said. “I think they knew I appreciated them.”

Barbara Morris of Surprise, AZ, also boosts her sense of agency by expressing gratitude. At age 93, she must rely on others to drive her and assist with other chores. Gratitude makes her feel less helpless. She says “Thank you” whenever she can. She assists helpful family members financially from time to time. And she loves to send flowers to people who’ve done something kind for her. 

“It not only makes them feel good, it makes me feel good,” she said.  

Older and More Grateful

The capacity for feeling and expressing gratitude seems to grow with age. One 2017 study reported that the experience of gratitude was greatest in older adults, compared to other age groups. Researchers speculate that older people may be more aware that time is limited, and that can lead to feelings of gratitude. 

Loss, an inevitable part of aging, can also heighten a sense of gratitude. 

“Ironically, tragedy often catapults people toward gratitude whereas constant good fortune can actually make it hard to feel grateful,” wrote Mary Pipher, PhD, in Women Rowing North: Navigating Life’s Currents and Flourishing as We Age (2019). “Privileged people may habituate to a comfortable, easy life.”

Jane Yancey, 81, of Plano, TX, connects her grateful spirit, in part, to losses she’s experienced in life. She grew up hearing her parents’ stories of sacrifice and hardship during the Great Depression. Her first husband was killed in a car accident; her parents took care of her one-year-old child while she worked. Then she met her second husband, who raised her daughter as his own. 

“I’m grateful I had a family to help me,” she said. “I’m grateful for my supportive husband. I’m thankful and grateful for every breath I take. I thank God for every day I’m still above the grass!” 

Yancey wonders if her children, now grown, will have the same capacity for gratitude, or will understand how fortunate they have been.

“I don’t know if it’s as easy to be grateful if you’ve never been without,” she said. 

Some say it becomes easier to practice gratitude as you grow older. 

Receiving expressions of gratitude can be life changing, said Benny Barrett, 72, a retired police officer in Dallas, TX. Years ago, Barrett arrested a young man and testified in the trial that resulted in a prison term. After he was released from prison, the young man asked to speak to Barrett. 

The young man’s message: thank you.

“He poured out his heart to me,” Barrett said. “He was grateful I’d taken him away from a bad situation and people who were a negative influence.” 

The encounter affected Barrett deeply. Going forward, he said he treated offenders with more empathy, as human beings with the potential for redemption.  

Older people may experience gratitude more consistently simply because they have more time. Christel Autuori, director of the Institute for Holistic Health Studies at Western Connecticut State University, teaches a gratitude practice to students as a stress management tool. The students are asked to write five things each morning for which they are grateful, and to keep them in mind throughout the day; students report this simple habit helps them stay more positive. 

College students tend to be wrapped up in themselves and their studies, Autuori said, but she thinks it’s easier to practice what she preaches as she gets older. For example, Autuori has lived in the same home in Connecticut for 40 years. It has a long driveway through the woods. When her children were young, she said, she’d power up that driveway with “blinders” on, never paying attention. 

“Now that my kids are out and on their own, I’m able to see the forest for the trees,” she said. “I take time every day to appreciate the beauty that has always been there.” 

Cultivating Gratitude 

A few months ago, while struggling with low-grade depression, Teri Ervin, 64, of Dallas, TX, decided to renew a daily practice of gratitude. Each day, before she gets out of bed, Ervin reads aloud a list of all that she’s thankful for—her health, her husband, her home. She tries to add a new item each day, perhaps related to her plans for the day. If she’s meeting a friend for lunch, for example, she expresses gratitude for that friendship. Over coffee, she writes about what makes her grateful, using a box of cards with written prompts. In just a few months, she already sees a change.

“I noticed a huge shift in many aspects of my internal life and my close relationships,” she said. “It makes life much easier.”

Simply choosing to be grateful isn’t enough to gain its benefits; most people need strategies to keep grateful thoughts alive. Author Emmons encourages people to adopt a gratitude practice, as Ervin did. That might take the form of journaling, writing letters to express gratitude to people who’ve been positive influences in one’s life, or even gratitude visits—meeting with a friend or acquaintance who was particularly helpful at some point. 

Gratitude can serve as an emotional signpost for older adults as they look back on their lives or embark on a new phase. In her practice as a retirement coach, Dorian Mintzer, PhD, 76, of Boston, MA, encourages her clients to start with gratitude as they begin to envision how they’d like to use their “bonus years” after leaving the workforce.

“When people take time to reflect back on their lives—the good, the bad and the ugly— they appreciate what they’ve come through, and they often feel gratitude,” she said. That, in turn, helps clarify what they want for the next phase of life. 

Carpenter, of Washington University, saw the power of gratitude in the case of a client who was struggling with depression. The man had chosen to make a major life transition in his mid-80s. A series of setbacks followed; the client began to question his choices and blame himself. 

“He wondered if his life would’ve been just fine had he just stayed put,” Carpenter said. “But he managed to work himself through that by adopting a stance of gratitude, by acknowledging that, despite the real adversity he was facing, he still had a lot to be thankful for.”

Sure enough, with time, the client’s depression began to lift. His optimistic spirit returned, and he was able to embrace life again. 

“For him, gratitude was really a lifeline,” said Carpenter. 

Minister for Older Adults Has Seen How Pervasive Ageism Is

She’s also seen the courage it takes to push back against it

In a wide-ranging interview, journalist Judith Graham asks the minister of older adults of a famous New York City church about her job and what it’s taught her about aging and older people. Graham wrote her piece for  Kaiser Health News, and KHN posted it on September 2, 2021. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues. 

Later life is a time of reassessment and reflection. What sense do we make of the lives we have lived? How do we come to terms with illness and death? What do we want to give to others as we grow older?

Lynn Casteel Harper, 41, has thought deeply about these and other spiritual questions. She’s the author of an acclaimed book on dementia and serves as the minister of older adults at Riverside Church in New York City, an interdenominational faith community known for its commitment to social justice. Most of the church’s 1,600 members are 65 and older.

Every Thursday from September to June, Harper runs programs for older adults that include Bible study, lunch, concerts, lectures, educational sessions and workshops or other forms of community-building. She also works with organizations throughout New York committed to dismantling ageism.

I spoke with Harper recently about the spiritual dimension of aging. Our conversation, below, has been edited for length and clarity.

Q: What does a minister of older adults do?

A large part of my job is presence and witness—being with people one-on-one in their homes, at the bedside in hospitals or nursing homes, or on the phone, these days on Zoom, and journeying with them through the critical junctures of their life.

Sometimes if people are going through really difficult experiences, especially medically, it’s easy for the story of the illness and the suffering to take over. Part of my role is to affirm the other dimensions. To say you are valuable despite your sickness and through your sickness. And to affirm that the community, the church is with you, and that doesn’t depend on your capacity or your abilities.

Q: Can you give me an example of someone who reached out to you?

I can think of one today—a congregant in her 70s who’s facing a surgery. She had a lot of fear leading up to the surgery and she felt there could be a possibility she wouldn’t make it through.

So, she invited me to her home, and we were able to spend an afternoon talking about experiences in her life, about the things that were important to her and the ways she’d like the church to be there for her in this time. And then we were able to spend some time in prayer.

Q: What kind of spiritual concerns do you find older congregants bringing to you?

One of the things, undeniably, is death and dying. I see a lot of older adults wanting to express their concerns and desires regarding that.

I can think of one woman who wanted to plan out her memorial service. It was really important for her to think about what would be special for the congregation and her family—a gift she wanted to leave behind.

I rarely encounter a fearfulness about what will happen when someone dies. It’s more about: What kind of care will I receive before I go? Who will care for me? I hear that especially from people who are aging solo. And I think the church has an opportunity to say we are a community that will continue to care for you.

Q: What other spiritual concerns regularly arise?

People are looking back on their lives and asking, “How do I make sense of the things that maybe I regret or maybe am proud or am ambivalent about? What do those experiences mean to me now and how do I want to live the rest of my life?”

We invite story sharing. For instance, we did a program where we asked people to share an important object from their home and talk about how you came to have it and why it’s important to you.

For another program, we asked, “What is a place that’s been important to you and why?” That ended up being a discussion about “thin places”—a Celtic concept—where it feels like the veil between this world and the next is very thin and where you feel a connection with the divine.

Q: Your work revolves around building community. Help me understand what that means.

That’s another theme of spirituality and aging. In middle life and earlier in life, we’re incentivized to be self-sufficient, to focus on what you can accomplish and build up in yourself. In later life, I see some of that shedding away and community becoming a really important value.

There are many types of communities. A faith community isn’t based on shared interests, like a knitting club or a sports team. It’s something deeper and wider. It’s a commitment to being with one another beyond an equal exchange—beyond your ability to pay or repay what I give to you in kind. It’s a commitment to going the extra mile with you, no matter what.

Q: How did the pandemic and spiritual concerns change or influence the nature of spiritual discussions?

Every Sunday, our congregation offers a moment of silence for the victims of COVID-19. And every Sunday, we list the names of congregants who are sick and who died, not only of COVID. It’s built into our practice to acknowledge sickness and death. And that became something even more needed.

As much as there was a lot of worry about isolation and our older adults, in many ways our ties with one another became stronger. I saw a tremendous amount of compassion—people extending themselves in very gracious ways. People asking, “Can I deliver groceries? Does anyone need a daily phone call? What can I do?”

Q: What about pandemic-related loss?

The grief has been heavy and will live with us for a while. I think that the ongoing work of the church now is to understand what to do in the wake of this pandemic. Because there have been multiple layers of loss—the loss of loved ones, the loss of mobility, the loss of other abilities. There have been significant changes for people, emotionally, mentally, financially or physically. Much of our work will be acknowledging that.

Q: What have you learned about aging through this work?

I’ve learned how real and pervasive ageism is. And I’ve been brought into the world of what ageism does, which is to bring shame in its wake. So that people, instead of moving toward community, if they feel like they’re compromised physically or in some other way, the temptation is to withdraw. I’m pained by that.

Q: What else have you learned?

How wildly creative and liberating aging can be. I’m around people who have all kinds of experience: all these years, all these tragedies and triumphs and everything in between. And I see them every day showing up. There’s this freedom of being without apology.

I’m so appreciative of the creativity. The honesty. And the real, radical attention they pay to each other and the world around them. I’m always remarking how many of our older adults pay attention to things that I hadn’t noticed.

Q: It sounds like a form of bravery.

Yes, that’s right. Courage. The courage to almost be countercultural. To say, even if the culture tells me I don’t have a place or I don’t really matter, I’m going to live in a way that pushes back against that. And I’m really going to see myself and others around me. So they’re not invisible, even if they’re invisible in a larger cultural sense.

Those of us who aren’t of advanced age yet, we often think we’re doing a favor by being around older people and listening to their stories. I don’t see it that way at all. It’s not charity to be around older adults. I am a better person, a better minister, our church is a better place because of our older members, not despite them.

It reflects poorly that our imagination is so stunted and limited when it comes to aging—that we can’t see all the gifts that are lost, all the creativity and the care and the relationships that are lost when we don’t interact with older adults. That’s a real spiritual deficit in our society.

The Surprising Importance of Casual Acquaintances

These low-key relationships have health benefits for older adults

Your undemanding, everyday connections with everyone from your neighbors to your local pharmacist—people you barely know—are important. Journalist Judith Graham explains how and why in this article she wrote for Kaiser Health News (KHN), which posted her piece online on August 2,2021. The story also ran on CNN. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues.

In May, Vincent Keenan traveled from Chicago to Charlottesville, VA, for a wedding—his first trip out of town since the start of the pandemic.

“Hi there!” he called out to customers at a gas station where he’d stopped on his way to the airport. “How’s your day going?” he said he asked the Transportation Security Administration agent who checked his ID. “Isn’t this wonderful?” he exclaimed to guests at the wedding, most of whom were strangers.

“I was striking up conversations with people I didn’t know everywhere I went,” said Keenan, 65, who retired in December as chief executive officer of the Illinois Academy of Family Physicians. “Even if they just grunted at me, it was a great day.”

It wasn’t only close friends Keenan missed seeing during 15 months of staying home and trying to avoid COVID-19. It was also dozens of casual acquaintances and people he ran into at social events, restaurants, church and other venues.

These relationships with people we hardly know or know only superficially are called “weak ties”—a broad and amorphous group that can include anyone from your neighbors or your pharmacist to members of your book group or fellow volunteers at a school.

Like Keenan, who admitted he’s an unabashed extrovert, many older adults are renewing these connections with pleasure after losing touch during the pandemic.

Feeling connected to other people, not just the people who are closest to you, turns out to be incredibly important.

—Gillian Sandstrom 

Casual relationships have several benefits, according to researchers who’ve studied them. These ties can cultivate a sense of belonging, provide bursts of positive energy, motivate us to engage in activities, and expose us to new information and opportunities—all, without the emotional challenges that often attend close relationships with family and friends.

Multiple studies have found that older adults with a broad array of “weak” as well as “close” ties enjoy better physical and psychological well-being and live longer than people with narrower, less diverse social networks. Also, older adults with broad, diverse social networks have more opportunities to develop new relationships when cherished friends or family members move away or die. 

“Feeling connected to other people, not just the people who are closest to you, turns out to be incredibly important,” said Gillian Sandstrom, a senior lecturer in the department of psychology at the University of Essex in England.

Sandstrom’s research has found that people who talk to more acquaintances daily tend to be happier than people who have fewer of these interactions. Even talking to strangers makes people feel less lonely and more trusting, she has discovered.

Claire Lomax, 76, of Oakland, CA, who’s unmarried, has made a practice of chatting with strangers all her life. Among her greatest pleasures in recent years was volunteering at the Oakland Police Department, where she would ask patrol officers about their families or what was happening at the station.

“I never wanted a man of my own, but I like to be around them,” she explained. “So, I got to have my guy buzz without any complications, and I felt recognized and appreciated,” Lomax told me. Since becoming fully vaccinated, she’s volunteering in person at the police stations again—a deep source of satisfaction.

In places like coffee shops and gyms, you can feel part of a community. 

Even people who describe themselves as introverts enjoy the positivity that casual interactions can engender.

“In fact, people are more likely to have purely positive experiences with weak ties” because emotional complications are absent, said Katherine Fiori, a prominent researcher and chair of the psychology department at Adelphi University in Garden City, NY.

Lynn Eggers, 75, a retired psychologist in Minneapolis, loved going to coffee shops and the gym before COVID hit. “In both places, you can be in a group and alone,” she told me. “You can choose to talk to someone or not. But you feel you’re part of the community.”

At a light-rail station, Eggers would strike up conversations with strangers: two police officers, who told her about growing up in Somalia, a working-class Texan, whose daughter won a scholarship to Harvard, a young Vietnamese woman whose parents worried she was abandoning her culture.

When Eggers stopped taking public transportation for fear of COVID, she missed “getting these glimpses into other ways of seeing the world.” Instead, she started chatting with neighbors in daily walks around her neighborhood—another way to feel connected.

Many people may have found that neighbors, mail carriers and delivery people became more important during the pandemic—simply because they were around when others were not, said Karen Fingerman, a professor of human ecology at the University of Texas-Austin. As pandemic restrictions lift, “the key is to get out in daily life again” and re-engage with a variety of people and activities, she recommended.

Helen Bartos, 69, a retired clinical psychologist, lives in a condominium community in Rochester, NY. “With COVID, a whole group of us started getting together outside,” she told me. “We’d bring out chairs and drinks, wear masks, and sit around and talk. It was very bonding. All of these people are neighbors; now I would call some of them friends.”

Ellie Mixter-Keller, 66, of Milwaukee, turned to social gatherings sponsored by the activity group Meetup six years ago after a divorce disrupted her life. “It was my salvation. It exposed me to a bunch of new people who I didn’t have to date or have to dinner,” she said. Now that she’s fully vaccinated, she’s busy almost every night of the week attending Meetup events and informal get-togethers arranged by people she’s met.

In some cases, varying views of COVID vaccines have made casual interactions more difficult. Patty Beemer, 61, of Hermosa Beach, CA, used to go swing-dancing two or three times a week before the pandemic. “It’d be 20 seconds of chitchat and just dance” before all those events were canceled, she said.

In the past several months, however, the swing-dance community in and around Los Angeles has split, with some events requiring proof of vaccination and others open to everyone.

“Before, everyone danced with everyone, without really thinking about it. Now, I don’t know if it’s going to be like that. I’m not sure how much mixing is going to happen,” Beemer said. “And that sense of shared humanity, which is so meaningful to all of us, may be harder to find.”

 

Older Women Face a Fashion Challenge

But it comes with a new freedom to wear what they like

On a shopping outing, Jane Bourland informed her granddaughter, “I can’t wear sleeveless. I can’t wear short. And I can’t wear low-cut.” Surveying the styles on the racks at the department store, her granddaughter quickly realized that didn’t leave many choices.  

For many older women, like Bourland, finding flattering, fashionable clothing options can be challenging. A growing number of retailers are vying for their dollars, but older shoppers still need resourcefulness, patience and savvy to look put-together. 

“The fashion industry is geared to young women who are a size 2,” said Jan Tuckwood, 65, a retired fashion editor. “You can find clothes that look great at any age, but you may need to look in new places.” 

While finding appealing clothes gets trickier, many women say they discover new freedom in clothing choices in later life. Nancy Shenker’s work uniform in the 1980s was nude hose and suits with big shoulder pads, following the power-dressing prescription in John Malloy’s 1975 bestseller, Dress for Success. Now, at 65, Shenker continues to work as a marketing consultant but feels freer to dress as she pleases. She wears an updated version of what she calls her “1970s hippie style”—flowy, bohemian tops, boots and hoop earrings. Several years ago, she made a best-dressed list in her hometown of Westchester, NY. 

“Finding my style again has been liberating,” she said. “Plus, as an older woman, I really don’t care what anyone else thinks.” 

Susan Jones Knape, 66, has read Vogue magazine cover to cover since she was a teenager. After starting her own business a few years ago, she too feels more freedom to follow fashion. 

“Before, I squashed my fashion sensibilities in the workplace,” she said. “I thought I would be taken less seriously if I looked fashion-forward. Now, I’m having more fun than ever. I don’t feel impeded by having to look a certain way.”  

The freedom that comes with older age was celebrated in the popular 1992 poem, Warning,” by Jenny Joseph, which reads in part, “When I am an old woman I shall wear purple / With a red hat that doesn’t go, and doesn’t suit me.” Joseph wrote that she will “make up for the sobriety of my youth,” when she no longer needs to worry about responsibilities or to “set a good example for the children.” 

The poem inspired the Red Hat Society, founded in 1998 for women 50 and up, which now boasts more than 20,000 members worldwide. But members say it’s more about socializing than daily fashion choices. The group meets for meals and outings, always sporting red hats and purple clothing. (Younger women were admitted in recent years, but they wear lavender and pink.)  

“It’s about growing older with fun and grace,” said Sandi Goldbach, who presides as “Queen” of a Dallas-area chapter. “When you’re young, you dress to impress. When you’re older, you have fewer opportunities to dress up and go out.” 

Youthquake’s Legacy 

Toni Thomas, 66, and her sister, Dollie Thomas, 63, remember the crisply ironed house dresses and aprons worn every day by their grandmother, who refused to wear pants most of her life. Similarly, their mother’s closet was filled with church dresses, each paired with carefully chosen matching accessories: a full slip, high-heeled shoes and jewelry. 

By contrast, the sisters enjoy much more freedom to dress comfortably and creatively.  Both retired, they’ve hung up the dark suits and blouses of their working days and now choose comfortable options like sneakers and leggings most days. But they still enjoy shopping, trying new fashions and looking fashion-forward. 

As women in their 60s, the Thomas sisters benefited from the fashion revolution of the 1960s, which Vogue dubbed the “Youthquake.” Fashion became more youth-oriented, more individualistic and less rule bound. Now, older women today feel more freedom than previous generations.  

“Prior to 1970, the industry would promote changes in fashion, especially skirt lengths, and most women who were tuned into fashion would adjust,” said Catherine Amoroso Leslie, a professor at the School of Fashion at Kent State University. 

In 1970, the fashion bible Women’s Wear Daily declared the miniskirt was dead and the midi was in—but consumers rebelled. They initially spurned the midi. Women started wearing pants in more and more settings. Gone was the annual ritual of taking up or letting down hemlines as fashion authorities decreed. New fashions originated in the streets of London and New York, rather than the ateliers of Paris. 

“It was the start of the consumer having more power in what the industry was producing,” Leslie said. “Women began making choices rather than blindly following dictates.” 

Perhaps reflecting that sensibility, many women interviewed for this story bristled at the notion of “age-appropriate” clothing. 

Sixty years ago, women didn’t feel the same pressure to look young.

“That implies there’s a rule book,” said Tuckwood, who edited fashion sections at the Denver Post and other newspapers. “It sounds like a way to put women in their place. I have long blond hair, almost to my waist. Some would say that’s not age appropriate. But when you reach a certain age, you can do whatever you want.”

Tuckwood prefers to think in terms of “body-appropriate” clothing, but that’s where clothing choices get more complicated. As they age, women tend to get rounder in the middle and flatter in the rear end. Skin gets wrinkly, making sleeveless tops or bare legs less appealing. Body parts sag; an older woman’s breasts aren’t perched as high as those of a young woman. Stiletto heels become a safety hazard as balance becomes more precarious. Even Knape—who’s still the same size she was in high school—avoids sleeveless tops. Shenker still wears short skirts, but only with black tights. 

Finding clothes that are body appropriate is something that Hilde Schwartz, 93, has contended with all her life. She sees maturity as an advantage because she benefits from the hard-earned wisdom from past mistakes. Schwartz, whose career included stints in retail and the apparel industry, recalled spending $500 in the 1980s on an expensive jumper in then-trendy Ultrasuede (a suede-like synthetic fabric) because “Everybody in my synagogue was wearing Ultrasuede back then.”

The fabric didn’t flatter Schwartz, who is short, full-busted and “on the chunky side.” From that and similar experiences, Schwartz says she honed a critical eye for what works and what doesn’t work for her body. 

“I learned that I don’t have to wear what everybody else does,” she said. “The older I get, the more I feel that way. With age, you gain a little acceptance and some smarts about what can and can’t be done.” 

Sixty years ago, women over 40 did follow more rigid prescriptions for dressing appropriately, according to Linda Przybyszewski, an associate professor of history at Notre Dame University and author of The Lost Art of Dress (2014). But that was viewed as a privilege, not a limitation. Women didn’t feel the same pressure to look young. Sophisticated styles were aimed for women 30 and older; older women disdained the idea of dressing like teens or young women. 

“Today, ‘matronly’ is the worst thing you can say about a look,” she said.  “But matron used to be a word that conferred respect and dignity. You might see a ‘Hats for Matrons’ section in the Sears and Roebuck catalog, with hats in colors and styles suitable for older women.” 

More Options

Many older shoppers find that a single trip to the nearest department store doesn’t work for finding clothes that are body appropriate. Sometimes, the process involves trial and error, a bit of persistence and a willingness to return garments that don’t work.

At the same time, shoppers have more options. Online shopping offers a wider range of choices in more sizes. TV shopping networks (and their online websites) show clothing on older models, often with explanations of what works for specific body types.

Discovering clothing brands that work for one’s body also helps. Leslie notes that clothing sizes aren’t standardized; each brand has its own sizing, tailored to a specific body type. Her mother finds that Jones New York clothing fits her well; she can order online knowing the garment will fit.  

On the plus side, more and more retailers are targeting older shoppers who are interested in fashion—and able to pay for it. Although statistics vary from year to year, shoppers ages 55-64 may spend as much or more than younger counterparts, with those 65-74 close behind. Brands like Chicos, Soma and Not Your Daughter’s Jeans have cropped up specifically to serve Boomer-aged shoppers. And when the youngest Boomers reached 40—the year most begin wearing reading glasses—retailers like Eyebobs (tagline, “Leading the Eyewear Rebellion”) answered with funky and fun styles. 

Leaving the Game

Combing the clothing at an estate sale, Leslie deduced that the home’s former resident had stopped buying new clothes around 1985. That’s not that uncommon, she believes. 

“At some point, some older women leave the fashion game,” she said. Health conditions, a lack of occasions to dress up, frustration with their aging looks or retirement are a few factors. Clothing spending decreases considerably among those 75 and up, when most people are retired. And some develop an inventory of timeless clothing. While she’s still teaching fashion history and forecasting to classrooms full of 20-somethings, and still very interested in fashion, Leslie, 65, says, “I’m almost exclusively shopping my own closet now. I’m finding new ways to combine clothing pieces I already own.”  

Laurie Joseph, 56, started leaving the game about 20 years ago, when an autoimmune condition made wearing cosmetics impossible. Before, she dressed up, put on makeup and did her hair every morning. When the health issues started, she began to simplify. 

“I wondered, ‘What’s the worst thing that can happen?’” she recalled. “And lo and behold, nothing bad happened when I stopped smearing chemicals on my face every day. I kept my job, I kept my husband and people kept talking to me.” 

Increasingly, her clothing choices became comfort focused. Joseph wore jeans, tops and sneakers to the office before the pandemic. Now that she’s working remotely as a graphic artist—and tackling a home remodeling project in her spare time—she spends her days in cut-offs and T-shirts.

“I think of myself as aggressively casual,” she said. “I’m kind of militant about it. If you show up in pearls, I may ask you to leave.” 

But at 93, Schwartz is still in the game, with no plans to quit. She follows style icon Iris Apfel, now 100, whose signature, big, round glasses are similar to the pair Schwartz has worn since the 1960s. Like Leslie, she shops from her closet but still spends a good bit of money on haircuts and color. 

“I’m still very fashion conscious,” she said. “If your health is in good shape and you still have all your marbles, fashion is a way to involve yourself in the world.” 

Tuckwood agrees.

“Paying attention to your image gives you self-confidence,” she said. “You can be comfortable, but you can have fun too. Why not have fun until the day you drop over?” 

‘They Treat Me Like I’m Old and Stupid’

Older people protest ageist incidents in medical care 

Ageism is all too common in medical settings, and it’s been escalating—and getting more attention—because of the pandemic. Journalist Judith Graham describes the problems older people are encountering in this article written for Kaiser Health News. KHN posted her story on October 20, 2021. It also ran on CNN.

Joanne Whitney, PharmD, 84, a retired associate clinical professor of pharmacy at the University of California-San Francisco, often feels devalued when interacting with health care providers.

There was the time several years ago when she told an emergency room doctor that the antibiotic he wanted to prescribe wouldn’t counteract the kind of urinary tract infection she had.

He wouldn’t listen, even when she mentioned her professional credentials. She asked to see someone else, to no avail. “I was ignored and finally I gave up,” said Whitney, who has survived lung cancer and cancer of the urethra and depends on a special catheter to drain urine from her bladder. (An outpatient renal service later changed the prescription.)

Then, earlier this year, Whitney landed in the same emergency room, screaming in pain, with another urinary tract infection and a severe anal fissure. When she asked for Dilaudid, a powerful narcotic that had helped her before, a young physician told her, “We don’t give out opioids to people who seek them. Let’s just see what Tylenol does.”

Whitney said her pain continued unabated for eight hours.

“I think the fact I was a woman of 84, alone, was important,” she told me. “When older people come in like that, they don’t get the same level of commitment to do something to rectify the situation. It’s like ‘Oh, here’s an old person with pain. Well, that happens a lot to older people.’”

Whitney’s experiences speak to ageism in health care settings, a long-standing problem that’s getting new attention during the COVID pandemic, which has killed more than half a million Americans, age 65 and older.

Ageism occurs when people face stereotypes, prejudice or discrimination because of their age. The assumption that all older people are frail and helpless is a common, incorrect stereotype. Prejudice can consist of feelings such as “older people are unpleasant and difficult to deal with.” Discrimination is evident when older adults’ needs aren’t recognized and respected or when they’re treated less favorably than younger people.

Almost 20 percent of Americans who are 50 or older say they have experienced discrimination in health care.

In health care settings, ageism can be explicit. An example: plans for rationing medical care (“crisis standards of care”) that specify treating younger adults before older adults. Embedded in these standards, now being implemented by hospitals in Idaho and parts of Alaska and Montana, is a value judgment: young peoples’ lives are worth more because they presumably have more years left to live.

Justice in Aging, a legal advocacy group, filed a civil rights complaint with the US Department of Health and Human Services in September, charging that Idaho’s crisis standards of care are ageist and asking for an investigation.

In other instances, ageism is implicit. Julie Silverstein, MD, president of the Atlantic division of Oak Street Health, gives an example of that: doctors assuming older patients who talk slowly are cognitively compromised and unable to relate their medical concerns. If that happens, a physician may fail to involve a patient in medical decision-making, potentially compromising care, Silverstein said. Oak Street Health operates more than 100 primary care centers for low-income seniors in 18 states.

Emogene Stamper, 91, of the Bronx in New York City, was sent to an under-resourced nursing home after becoming ill with COVID in March. “It was like a dungeon,” she remembered, “and they didn’t lift a finger to do a thing for me.” The assumption that older people aren’t resilient and can’t recover from illness is implicitly ageist.

Stamper’s son fought to have his mother admitted to an inpatient rehabilitation hospital where she could receive intensive therapy. “When I got there, the doctor said to my son, ‘Oh, your mother is 90,’ like he was kind of surprised, and my son said, ‘You don’t know my mother. You don’t know this 90-year-old,’” Stamper told me. “That lets you know how disposable they feel you are once you become a certain age.”

At the end of the summer, when Stamper was hospitalized for an abdominal problem, a nurse and nursing assistant came to her room with papers for her to sign. “Oh, you can write!” Stamper said the nurse exclaimed loudly when she penned her signature. “They were so shocked that I was alert, it was insulting. They don’t respect you.”

Nearly 20 percent of Americans age 50 and older say they have experienced discrimination in health care settings, which can result in inappropriate or inadequate care, according to a 2015 report. One study estimates that the annual health cost of ageism in America, including over- and undertreatment of common medical conditions, totals $63 billion.

One nursing home resident in every five has persistent pain, and a significant number don’t get adequate treatment.

Nubia Escobar, 75, who emigrated from Colombia nearly 50 years ago, wishes doctors would spend more time listening to older patients’ concerns. This became an urgent issue two years ago when her longtime cardiologist in New York City retired to Florida and a new physician had trouble controlling her hypertension.

Alarmed that she might faint or fall because her blood pressure was so low, Escobar sought a second opinion. That cardiologist “rushed me—he didn’t ask many questions and he didn’t listen. He was sitting there talking to and looking at my daughter,” she said.

It was Veronica Escobar, an elder law attorney, who accompanied her mother to that appointment. She remembers the doctor being abrupt and constantly interrupting her mother. “I didn’t like how he treated her, and I could see the anger on my mother’s face,” she told me. Nubia Escobar has since seen a geriatrician, who concluded she was overmedicated.

The geriatrician “was patient,” Nubia Escobar told me. “How can I put it? She gave me the feeling she was thinking all the time what could be better for me.”

Pat Bailey, 63, gets little of that kind of consideration in the Los Angeles County, CA, nursing home where she’s lived for five years since having a massive stroke and several subsequent heart attacks. “When I ask questions, they treat me like I’m old and stupid and they don’t answer,” she told me in a telephone conversation.

One nursing home resident in every five has persistent pain, studies have found, and a significant number don’t get adequate treatment. Bailey, whose left side is paralyzed, said she’s among them. “When I tell them what hurts, they just ignore it or tell me it’s not time for a pain pill,” she complained.

Most of the time, Bailey feels like “I’m invisible” and like she’s seen as “a slug in a bed, not a real person.” Only one nurse regularly talks to her and makes her feel she cares about Bailey’s well-being.

“Just because I’m not walking and doing anything for myself doesn’t mean I’m not alive. I’m dying inside, but I’m still alive,” she told me.

They wanted a doctor who would help them live, not figure out how they’re going to die.

—Shelli Bischoff 

Ed Palent, 88, and his wife, Sandy, 89, of Denver, similarly felt discouraged when they saw a new doctor after their long-standing physician retired. “They went for an annual checkup and all this doctor wanted them to do was ask about how they wanted to die and get them to sign all kinds of forms,” said their daughter Shelli Bischoff, who discussed her parents’ experiences with their permission.

“They were very upset and told him, ‘We don’t want to talk about this,’ but he wouldn’t let up. They wanted a doctor who would help them live, not figure out how they’re going to die.”

The Palents didn’t return and instead joined another medical practice, where a young doctor barely looked at them after conducting cursory examinations, they said. That physician failed to identify a dangerous staphylococcus bacterial infection on Ed’s arm, which was later diagnosed by a dermatologist. Again, the couple felt overlooked, and they left.

Now they’re with a concierge physician’s practice that has made a sustained effort to get to know them. “It’s the opposite of ageism: it’s ‘We care about you and our job is to help you be as healthy as possible for as long as possible,’” Bischoff said. “It’s a shame this is so hard to find.”

Never Too Old for Fun and Games

Play can improve the health and enrich the lives of older adults 

When Kathy Thomas’ “big Catholic family” gathers for the holidays, everybody plays bingo. Her 90-year-old mother, Rosemary Doyle (“RoRo” to the grandkids), calls the game, and the winners get fun prizes, like gift cards for Starbucks or Whataburger. 

“When we start the bingo, the kids look up from their phones and play; they even post the game on their Instagrams, and their friends all want to join,” said Thomas. “It’s something we can all do together.”

Playing together is a way that Thomas’ family stays connected. When the pandemic hit, the family kept up the tradition via Zoom. It’s just one example of how play can enrich the lives of older adults. 

“You’re never too young or too old to play,” said Anna Yudina, marketing director for the Toy Association. “Research links play with a number of wellness benefits in adults, such as reducing stress, boosting life satisfaction and empowering people to be creative, flexible thinkers.”

Play spans a wide gamut, from organized sports and serious hobbies to video games (about 15 percent of gamers in the United States are 55 or older). But all types of play seem to have positive benefits for older adults. Even spontaneous play with grandkids offers benefits—adults who play with children burn 20 percent more calories per week, experience fewer falls, become less reliant on walking aids and are less likely to develop Alzheimer’s in their 70s, according to the Genius of Play initiative, which promotes the value of play for children and adults. 

What Is Play? It’s Personal

Stuart Brown, MD, is the founder of the National Institute of Play, a nonprofit that studies the value of play. He resists offering an absolute definition of play because it’s so personal. One person might find hang gliding to be a joyful form of play; another might view it as sheer terror. But Brown does identify the properties of play: it’s done for its own sake; it’s voluntary and fun; it makes us lose track of time and feel less self-conscious. Play also offers opportunities for improvisation and leaves us wanting more.

“Play energizes us,” wrote Brown, author of Play: How It Shapes the Brain and Opens the Imagination and Invigorates the Soul (2009). “The ability to play is critical not only to being happy but also to sustaining social relationships and being a creative, innovative person.”

Brown identifies seven categories of play: body play/movement; object; social; imaginative; storytelling; transformative and creative; and attunement (such as the babbling and eye contact shared between mother and baby). 

Body and object primarily involve physical movement, helping to maintain muscle tone and coordination. Social play alleviates isolation and loneliness. The remaining categories engage the brain, helping to preserve cognitive function. 

But those distinctions aren’t hard and fast—depending on the specific play, there can be a great deal of overlap between body and mind. Group games can engage the mind while lessening loneliness. Crafts or music (examples of transformative play) involve both mind and body. And all forms of play promote relaxation and reduce stress, especially when laughter and humor are involved.

A Changed Life

Jeannette Jancetich says her favorite form of play—ballroom dancing—changed her life. She choked up a little when recalling the first time she walked into the Fred Astaire Dance Studio in Phoenix, AZ, two years ago.

“Today, I’m in better health, I have better posture, I feel great, I’ve lost weight and I’ve made friends who feel like family,” she said. 

A retired banking software executive, Jancetich, 72, said that, due to constant travel, she never had time for dance when she was working. Now, she takes lessons three times a week and competes often. She loves it all: the rehearsals, the costumes and makeup, and the choreographing of dance numbers to fit each competition event’s theme. 

Jancetich’s instructor, Sarah Petrov, estimates about 30 percent of her students are older adults. Teaching them reminds her of a job she had in college, working with older adults in a neuropsychology clinic to help improve their brain health.  

“Dancers must use both their cognitive and motor skills to follow complicated choreography,” she said. “That’s much like the exercises we used to improve brain health in the clinic.”  

Connecting through Play

Play connects people, often in ways that span generations, according to Mary “Molly” Camp, MD, an assistant professor of psychiatry at UT Southwestern Medical Center in Dallas, who specializes in geriatric mental health. She remembers bringing her young son, then 18 months old, to a nursing home to sing and visit with residents. He playfully tossed a ball to an elderly woman in a wheelchair who was nonverbal, due to dementia. Her face lit up and she threw the ball back to the boy.

“They had this immediate connection,” she said. “That tells me that play is hardwired and innate.” 

Similarly, Tomislav “Tom” Perić connected with younger people when he rediscovered his favorite form of play—jiujitsu—at age 62. Most of the people he trains with are young enough to be his child or grandchild.  

“They consider me the village elder,” he said. “It’s rewarding when younger people at least seem to listen when one offers advice or suggestions.”  

Now, at 70, he’s ranked 10th worldwide in his age and skill level categories. 

“There’s nothing that I’ve done in the past decade that has been as rewarding, physically and psychically, as martial arts,” he said. “It’s the only activity that makes me feel like I’m 35 again.”

At the end of each class, Perić said, “all cylinders are firing. I feel satisfied that I have learned something new. Physically, I feel more limber. I feel a sense of camaraderie with my teammates. And for a moment, I feel like anything is possible.”

Mastering skills like ballroom dance or martial arts involves practice and repetitive drills that require concentration and persistence. Do these pursuits still qualify as play? 

Yes, according to Camp.  

“People can approach play with a very serious mindset,” she said. “That sense of being fully immersed in the activity and ‘in the moment’ is what adds to their enjoyment.” 

Less serious, lighthearted play—card and board games, crafts, singalongs, puzzles and more—is also beneficial. Activities directors in senior living communities constantly try to devise new ways to get residents to play, to help them stay active and engaged and to meet other people. Play can serve as a distraction that helps ward off bouts of agitation and depression, common issues for those with Alzheimer’s or dementia. And while games like balloon badminton may seem simplistic, they lure residents to common areas for laughter and team play, which helps people feel like contributing members of their community.

Play can even heal relationships. Camp has heard from older adult patients who reported that some forms of play—like golfing or playing cards—helped mend or maintain longtime friendships that fractured in recent years over bitter political differences. Play provided a shared interest, Camp said, “that allowed them to keep connecting with each other without stepping on those land mines.” 

A Childlike Spirit 

As the creator of popular board games like Taboo, Outburst, Super Scattergories and Boom Again, Brian Hersch has carefully analyzed what makes an activity fun. 

At its best, he said, play reconnects us with childhood memories as well as with a childlike spirit. 

“Play allows us to disengage from the obligatory and takes us back to our childhoods,” he said. “It reminds us of those innocent times of just having fun, before life became crowded with obligations.” 

Hersch has two rules of thumb for every game he’s created: it must generate laughter and “head slaps.” When people laugh, they’ll play the game again and tell their friends about it. And head slaps happen when players truly connect to the game. 

“If it’s a trivia game, for example, and the questions lead players to say, ‘Oh, no one knows that,’ then it’s no longer fun,” he said. “But if they slap their heads and say, ‘Of course!’ when they hear an answer, then you know it’s working. Even if they couldn’t come up with the answers, they were connected to the game.” 

All Work, No Play

Many researchers believe American adults of all ages don’t spend enough time playing. Some may feel compelled to fill each day with productive activity; others may assume play is too silly for grownups. One study found that 84 percent of adult respondents said that taking time to play helps them be more productive at work. 

“Play is just as important for our overall health and wellness as sleep, nutrition and exercise,” said Tom Norquist, past president of the International Play Equipment Manufacturers Association. “It keeps us feeling young and energetic.” 

Norquist says that his career taught him to maintain a playful attitude in life. “I take pride in enjoying all those little moments—swinging on a tire swing with my granddaughters, hiking with my wife, doing cannonballs into our pool every summer—because I don’t take life too seriously. Play is a way of life.”  

Intimidated by Smartphones or Tablets? Help Is Available

New resources spring up to meet seniors’ needs in the pandemic 

Though the internet has come to the rescue for many older adults isolated by the pandemic, others own digital devices but don’t fully understand how to use them—or have no idea. Journalist Judith Graham, a columnist for Kaiser Health News (KHN), reports on the many ways elders can learn more about computers, smartphones and tablets. Her story was posted on the KHN website on June 24, 2021. 

Six months ago, Cindy Sanders, 68, bought a computer so she could learn how to email and have Zoom chats with her great-grandchildren.

It’s still sitting in a box, unopened.

“I didn’t know how to set it up or how to get help,” said Sanders, who lives in Philadelphia and has been extremely careful during the coronavirus pandemic.

Like Sanders, millions of older adults are newly motivated to get online and participate in digital offerings after being shut inside, hoping to avoid the virus, for more than a year. But many need assistance and aren’t sure where to get it.

A recent survey from AARP, conducted in September and October, highlights the quandary. It found that older adults boosted technology purchases during the pandemic, but more than half (54 percent) said they needed a better grasp of the devices they’d acquired. Nearly four in 10 people (37 percent) admitted they weren’t confident about using these technologies.

Sanders, a retired, hospital operating room attendant, is among them. “Computers put the fear in me,” she told me, “but this pandemic, it’s made me realize I have to make a change and get over that.”

With a daughter’s help, Sanders plans to turn on her new computer and figure out how to use it by consulting materials from Generations on Line. Founded in 1999, the Philadelphia organization specializes in teaching older adults about digital devices and navigating the internet. Sanders recently discovered it through a local publication for seniors.

Before the pandemic, Generations on Line provided free, in-person training sessions at senior centers, public housing complexes, libraries and retirement centers. When those programs shut down, it created an online curriculum for smartphones and tablets, and new tutorials on Zoom and telehealth, as well as a family coaching kit, to help older adults with technology. All are free and available to people across the country.

Demand for Generations on Line’s services rose tenfold during the pandemic as many older adults became dangerously isolated and cut off from needed services.

Those who had digital devices and knew how to use them could do all kinds of activities online: connect with family and friends, shop for groceries, order prescriptions, take classes, participate in telehealth sessions and make appointments to get COVID vaccines. Those without were often at a loss—with potentially serious consequences.

There’s a national hotline for those who need technical support. 

“I have never described my work as a matter of life or death before,” said Angela Siefer, executive director of the National Digital Inclusion Alliance, an advocacy group for expanding broadband access. “But that’s what happened during the pandemic, especially when it came to vaccines.”

Other organizations specializing in digital literacy for older adults are similarly seeing a surge of interest. Cyber-Seniors, which pairs older adults with high school or college students who serve as technology mentors, has trained more than 10,000 seniors since April 2020—three times the average of the past several years. (Services are free and grants and partnerships with government agencies and nonprofit organizations supply funding, as is true for several of the organizations discussed here.)

Older adults using digital devices for the first time can call 1-844-217-3057 and be coached over the phone until they’re comfortable pursuing online training. “A lot of organizations are giving out tablets to seniors, which is fantastic, but they don’t even know the basics, and that’s where we come in,” said Brenda Rusnak, Cyber-Seniors’ managing director. One-on-one coaching is also available.

Lyla Panichas, 78, who lives in Pawtucket, RI, got an iPad three months ago from Rhode Island’s digiAGE program, one of many local technology programs for older adults that started during the pandemic. She is getting help from the University of Rhode Island’s Cyber-Seniors program, which plans to offer digital training to 200 digiAGE participants in communities hardest hit by COVID-19 by the end of this year.

“The first time my tutor called me, I mean, the kids rattle things off so fast. I said, ‘Wait a minute. You have a little old lady here. Let me keep up with you,’” Panichas said. “I couldn’t keep up and I ended up crying.”

Panichas persisted, however, and when her tutor called again the next week she began “being able to grasp things.” Now, she plays games online, streams movies and has Zoom get-togethers with her son in Arizona and her sister in Virginia. “It’s kind of lifted my fears of being isolated,” she told me.

OATS (Older Adults Technology Services) is set to expand the reach of its digital literacy programs significantly after a recent affiliation with AARP. It runs a national hotline for people seeking technical support, 1-920-666-1959, and operates Senior Planet technology training centers in six cities (New York; Denver; Rockville, MD; Plattsburgh, NY; San Antonio, TX; and Palo Alto, CA). All in-person classes converted to digital programming once the pandemic closed down much of the country.

Germaine St. John, 86, a former mayor of Laramie, WY, found an online community of seniors and made dear friends after signing up with Senior Planet Colorado during the pandemic. “I have a great support system here in Laramie, but I was very cautious about going out because I was in the over-80 group,” she told me. “I don’t know what I would have done without these activities.”

Older adults anywhere in the country can take Senior Planet virtual classes for free. (A weekly schedule is available.) Through its AARP partnership, OATS is offering another set of popular classes at AARP’s Virtual Community Center. Tens of thousands of older adults now participate.

For those with low incomes, a federal program is temporarily offering discounts on devices and internet service. 

Aging Connected, another new OATS initiative, is focusing on bringing one million older adults online by the end of 2022.

An immediate priority is to educate older adults about the government’s new $3.2 billion Emergency Broadband Benefit for low-income individuals, which was funded by a coronavirus relief package and became available last month. That short-term program provides $50 monthly discounts on high-speed internet services and a one-time discount of up to $100 for the purchase of a computer or tablet. But the benefit isn’t automatic. People must apply to get funding.

“We are calling on anybody over the age of 50 to try the internet and learn what the value can be,” said Thomas Kamber, OATS’ executive director. Nearly twenty-two million seniors don’t have access to high-speed internet services, largely because these services are unaffordable or unavailable, according to a January report cosponsored by OATS and the Humana Foundation, its Aging Connected partner.

Other new ventures are also helping older adults with technology. Candoo Tech, which launched in February 2019, works with seniors directly in 32 states as well as organizations such as libraries, senior centers and retirement centers.

For various fees, Candoo Tech provides technology training by phone or virtually, as-needed support from “tech concierges,” advice about what technology to buy, and help preparing devices for out-of-the-box use.

“You can give an older adult a device, access to the internet and amazing content, but if they don’t have someone showing them what to do, it’s going to sit there unused,” said Liz Hamburg, Candoo’s president and chief executive.

GetSetUp’s model relies on older adults to teach skills to their peers in small, interactive classes. It started in February 2020 with a focus on tech training, realizing that “fear of technology” was preventing older adults from exploring “a whole world of experiences online,” said Neil Dsouza, founder and chief executive.

For older adults who’ve never used digital devices, retired teachers serve as tech counselors over the phone. “Someone can call in [1-888-559-1614] and we’ll walk them through the whole process of downloading an app, usually Zoom, and taking our classes,” Dsouza said. GetSetUp is offering about 80 hours of virtual technology instruction each week.

For more information about tech training for older adults in your area, contact your local library, senior center, department on aging or Area Agency on Aging. Also, each state has a National Assistive Technology Act training center for older adults and people with disabilities. These centers let people borrow devices and offer advice about financial assistance. Some started collecting and distributing used smartphones, tablets and computers during the pandemic.

For information about a program in your area, go to https://www.at3center.net/

What’s So Funny about Aging?

Humor Helps Older Adults Cope

When the COVID-19 pandemic struck in March 2020, Carmen Emery, 75, began emailing uplifting spiritual meditations to about 300 friends from church. She quickly realized the daily emails needed something more, so she added three or four funny memes at the end of each meditation, with one-liners like “My housekeeping style can best be described as ‘There appears to have been a struggle’” and “Don’t blame others for the road you’re on. That’s your own asphalt.”   

Emery’s friends appreciated the meditations, but they really loved the goofy memes. Messages of gratitude poured in.

“I get lots of people quoting their favorites,” she said. 

Buoyed by the response, Emery kept up with the messages, sending emails for more than 500 consecutive days, including two weeks in December when she battled COVID-19.  

“Looking for memes each day has been a blast,” she said. “And sharing humor lifted my spirits and gave me a way to spread joy with others.”

Health Benefits

Humor helps people weather difficult times, and a growing body of research suggests it goes even further. Humor is a tool that can help older adults stay healthier, happier and more able to cope with the challenges of aging. 

“Every single body system that is negatively affected by stress can be positively affected by humor,” said Karyn Buxman, a registered nurse and professional speaker, who calls herself a “neurohumorist.”

Laughter increases adrenaline and oxygen flow and releases endorphins. Laughing and enjoying humor help lower cortisol. (High levels of cortisol are linked to cancer, heart disease and diabetes.) Studies suggest that humor can help people solve problems and make better decisions. Humor can decrease loneliness, depression and anger.

Laughter, along with an active sense of humor, may help protect against a heart attack. Cardiologists at the University of Maryland Medical Center found that people with heart disease were less likely to laugh, in a variety of situations, compared to those without heart disease.

“The old saying that ‘laughter is the best medicine’ definitely appears to be true when it comes to protecting your heart,” said Michael Miller, MD, director of the Center for Preventive Cardiology at the University of Maryland. 

A small study at the University of Texas, Austin, asked healthy adults to watch a humorous, 30-minute video or a documentary. Researchers then measured artery function and flexibility. Both measures improved immediately in the volunteers who watched a comedy and stayed that way for almost 24 hours. Artery function decreased slightly among those who watched a documentary.

Laughing, Not Crying

Research points to humor as a powerful coping tool for helping older adults deal with the negative aspects of aging. As a caregiving expert who works with older adults, Pamela Wilson sees that often—like the time when she had to assist an older woman with Alzheimer’s in using the toilet. Humor lightened the mood. 

“Whoever thought I would need this kind of help at this age?” the woman joked. 

“Making a joke helped her to not be so embarrassed,” said Wilson. “Because we were laughing together, she didn’t feel as badly about the situation.” Wilson added that older adults who are able to adapt often seem to be the ones who are more able to laugh at themselves. 

“Especially as we age, life either gets funnier or more sobering,” said Dena Kouremetis, 70, who writes a column, (R)aging with Grace, for Psychology Today. “That adage about laughing instead of crying begins to make real sense.” 

If you’re feeling lonely or isolated, sharing laughter can help.

Humor is also a source of social connection that brings friends, families and couples together. Kouremetis says shared jokes and laughs keep her relationship with her husband humming along.  

“Humor gets you through the losses that come with aging,” she said. “If you don’t have a shared sense of humor, you’re not going to get through it.”

Humor also tends to be contagious and best enjoyed with others.  

“Sharing laughter—watching a favorite sitcom with a spouse or reminiscing about funny memories with friends—reduces isolation and loneliness, which contributes to good physical, psychological and cognitive health,” said Jennifer FitzPatrick, a social worker and author of Cruising through Caregiving: Reducing the Stress of Caring for Your Loved One (2016). 

Laughing With or Laughing At?

Humor about the process of aging is important and helpful as people age. Humor is very personal, and there is a line between what’s funny and what’s offensive, but the ups and downs of aging do offer a rich mine of humorous situations. Several aging and caregiving experts interviewed for this article praised The Kominsky Method, a Netflix dramedy series that tackles topics like erectile dysfunction, health problems and end-of-life with humor and empathy.  

“You have two characters [played by Alan Arkin and Michael Douglas] who are very good friends, talking about this stuff that happens every day when you’re older,” said Wilson. “They’re not afraid to talk about it. They’re laughing about it.”      

Aging provides plenty of what comedians might call “material.” Older adults are more likely to face chronic health issues, with the daily challenges that come with them: medications, doctor visits and more. Even active, healthy older adults sooner or later face the realities of aging—the need for reading glasses, occasional forgetfulness, diminished physical strength, minor aches and pains. Having the ability to laugh at the absurdities of life becomes an effective coping strategy. 

Humor is closely intertwined with positivity or being “in good humor”—maintaining a cheerful attitude and having a willingness to be playful and creative, according to Kathy Laurenhue, CEO of Wiser Now, Inc., a publishing company focused on well-being in aging. Positive, optimistic people often see the humor in a situation. They tend to be more resilient, have better coping and problem-solving skills, seek social support more often and live longer and healthier lives than those who are generally negative. 

Humor vs Laughter 

Laughter and humor aren’t quite the same thing, cautions Chandramallika Basak, associate professor at the Center for Vital Longevity at the University of Texas at Dallas.       

“Laughter is more expressive, but humor is more cerebral,” Basak said. This is reflected in research that suggests that aging-related cognitive decline can reduce an older person’s ability to comprehend humor. In one study, older adults were less likely to choose the correct punch line for a joke in a multiple-choice test. On the other hand, older subjects were more likely to show appreciation and enjoyment of humor.

“That’s not surprising to me as a cognitive scientist,” said Basak. “Short-term, working memory plays a big role in humor. That’s a function of the frontal lobe, one of the first areas of the brain to decline with age. But the amygdala, the part of the brain that responds to fear and laughter, doesn’t decline as rapidly.”  

As we age, our taste in humor may change too. Researchers have divided humor into three categories: affiliative humor, which promotes social bonding through self-deprecatory, ‘I can relate to that’ humor; aggressive humor, which mocks or ridicules others; and self-enhancing humor, which highlights the positive aspect of a situation. Older adults tend to enjoy affiliative humor and are more likely to object to aggressive humor. 

Coping with Fear

As a “physician-comedienne,” Cynthia Shelby-Lane, MD, takes humor very seriously. She completed training at the Second City Training Center in Chicago and performs standup in comedy clubs in her spare time. 

She’s convinced humor keeps her vital; she’s still practicing emergency medicine at 70. Humor also helps her connect with patients and brings relief in agonizing moments, such as the time in the emergency room when she handed a baby aspirin to a 350-pound, 6-foot-3 man who had just had a heart attack. 

“A baby aspirin?!” he said. “Are you kidding? Doc, have you seen my size?” The two shared a good laugh. The patient was moved to the ICU and died later that evening.

“I’m glad we could laugh together before he died,” she said. “He was so scared, but that moment eased his fear.” 

Humor’s ability to disarm fear also makes it a good teaching tool. Gail Rubin, a death educator, uses humor to nudge older adults to have conversations they’d rather not have about death and end-of-life planning. When she speaks to audiences, she tosses off one-liners like “Let’s get death out of the closet” and “Talking about sex won’t make you pregnant; talking about funerals won’t make you dead.” 

It’s an effective icebreaker. “When people laugh, they relax and they learn,” Rubin said. “Laughter opens people up to what they need to know.” 

Humor Interventions

If laughter is truly the best medicine, can humor be used as an intervention to promote health? Can people bring humor into their lives intentionally?

An older adult needn’t be good at telling jokes or being funny to enjoy the benefits of humor. But humor isn’t a one-size-fits-all prescription. 

“One person might really enjoy potty humor, another slapstick, and another satire,” said Marie Gress, a licensed social worker in Michigan. 

But anyone can intentionally add humor to the daily routine by nurturing friendships with people who make them laugh or by bookmarking funny videos on their computers. Buxman keeps a file of “moments of mirth”—funny experiences she can revisit, mentally, down the road, recreating the burst of good feeling. She even enlists strangers for hits of humor: “If I’m in an Uber, I’ll ask the driver, ‘Tell me about the craziest person you’ve ever driven.’” 

“It’s about mindset,” Buxman said. “Funny things are always happening. You can learn to start seeing and experiencing the humor that was always there.”  

Older Adults Are Becoming Nomads

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

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

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

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

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

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

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

Nomadland

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Growing Population

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

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

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

Job opportunities for nomads seem to be increasing too. 

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

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

Nudged by COVID

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

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

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

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

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

Flexibility Required

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

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

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

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

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

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

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

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

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

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

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

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

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

Carol Marak: Adviser and Advocate for Solo Agers

She helps people prepare to live on their own in their later years

This article is the next in our series on the future of aging: interviews with people who are experts in their fields and are also visionaries. We’re asking them to talk about what they believe will happen in the years ahead to change the experience of aging.

Carol Marak is a solo-aging advisor and advocate. Since 2016, she’s been educating people about how to age confidently without a spouse or adult children to rely on. 

On a warm, sunny day in May 2007, Carol Marak was hiking on a trail in Texas, missing her parents—when she stopped in her tracks, her future flashing before her eyes.

“What am I going to do?” she thought.

She’d just come from her father’s funeral. He had Alzheimer’s. Her mother, who had multiple chronic illnesses, had died four years earlier. Marak and her two sisters had been family caregivers for eight years. 

Marak, who was 56 and single with no children, had worked full time throughout in technology sales and blogged about caregiving on the side. By this time, she and her siblings were exhausted.

But if things were that hard with a whole family helping out, what would happen as Marak got older with no family nearby? “I thought, ‘Holy crap!’” she recalls. “‘What am I gonna do? I have no one.’”

“That was my huge, wake-up call. I knew immediately, I have got to prepare for this.”

Within a couple of years, Marak had decided not just to prepare herself but to help other solo agers. She started a Facebook group on the topic. And things snowballed.

The Challenges of Aging Solo

Almost three in 10 people 65 and older live alone today. That’s up 50 percent since 1960. They often describe themselves as “aging alone,” “solo agers” or “elder orphans”—typically meaning they have no kids or siblings, or at least none nearby. 

This poses special challenges. With no family members to look out for them, what happens if their cognition starts to decline? Who will take care of finances or help them find care? Similar questions must be asked regarding mobility and other health problems. If they break a hip, for example, instead of having an adult child become a caregiver, they’ll have to hire help. 

Solo agers may have to pay alone for housing—and pay for transportation if they can’t drive. They may have no one to check on them during hot summers and cold winters, and they face the prospect of loneliness, especially if they become homebound.

Marak’s Facebook group, which she started in 2016, is called Elder Orphans. It now has more than 9,000 members. Her hiking revelation has led to a career as a solo-aging advisor and advocate, helping people prepare for aging alone. She gives speeches, does webinars and offers group coaching. And she has a book coming out in 2022, Solo and Smart.

Marak advises potential solo agers to start preparing as early as age 45. She was 56 when she started and wishes she’d been younger. “You don’t have to come up with a plan at 45,” she says. “I’m just saying, start thinking ahead.” 

Here are the preparation steps she recommends:

  1. Assess your current, long-term needs (finances, housing, location, transportation, support team, social connections, health, fitness).
  2. Build support, connection and community. 
  3. Find purpose and live accordingly.
  4. Write out your plan and follow through.
  5. Be flexible and open as your life evolves.

We spoke with Marak about her tips for aging alone and what she believes the future holds for the expanding population of solo agers.

SCF: You talk about growing older confidently when solo aging. Is that possible? It seems like there are so many things to consider. Can people prepare for them all? 

CM: I think it’s possible. I’ll turn 70 this year, so this has been on my mind for 15 years, and I’m so much more confident now than when I was 55. The key ingredient is self-reliance.

SCF: Single people probably naturally lean toward being self-reliant, right?

CM: You would think so. But I still see people in my Facebook group that don’t feel confident about their capability to take good care of themselves. They still eat junk food; they still go to McDonald’s. They don’t exercise. They sit and watch TV. It’s like, are you kidding me? Well, no wonder you’re worried! No, you’re not going to be confident that way! [Laughs]

Five Questions to Ask about Home

When looking for a home for the older years—or evaluating a current home—Marak recommends asking the following questions:

  1. Does it make me feel content and satisfied? Or is it a burden on my peace of mind? 
  2. Can I afford it? Can I maintain it? Is it age-friendly?
  3. Does the location make me car-dependent? For example, in the suburbs and rural areas, shops and clinics aren’t usually within walking distance. What if you can’t drive? What are the transportation options?
  4. Can my family or friends reach my home quickly, any time of day or night, if there’s an urgent need?
  5. Does the home and location put me in a position where I’m alone most of the time? Would I be more content with an area that allows easy access to companions and social activities? If moving isn’t an option, how will I stay socially connected to friends and companions?


SCF: What’s the first thing people preparing to be solo agers should focus on?

CM: Well, that’s really up to the person. However, for me it was health. And my health was pretty good. My money was horrible. You would think I’d focus on my money first. But for me, because of my mom’s chronic illnesses and my dad’s Alzheimer’s, I wanted to focus on health because if I didn’t have that, it didn’t matter how much money I had, in my own assessment. 

This is all very personal. And that’s something that I teach: nobody can tell you where to start. Only you can.

SCF: When you say it like that, it’s kind of empowering.

CM: And that’s the key. We want to feel empowered, right? Do you know [senior- living innovator and entrepreneur] Dr. Bill Thomas? He once said to me, “Carol, you don’t ever want strangers taking care of you.” And that stuck with me. I don’t want strangers making decisions for me when I get older. Doesn’t that sound horrible? I’d much rather have a good friend—or a good neighbor, or someone that I’ve built a relationship with, or a sibling—to make those decisions. And that’s why it’s important to maintain that kind of relationship.

SCF: Step three of your “ways to age alone” plan is, “Find purpose and live accordingly.” This is something many people aspire to. Why is it important for solo agers in particular? 

CM: It gives them a sense of community. It gives them a feeling that “I’m connected to something,” because if you’re alone and you have no purpose—something to get you out of bed each morning, besides watching TV or eating something [that’s not good]. It keeps you connected.

And people misinterpret purpose. They think, “Oh, I don’t want a purpose. That’s too much trouble.” They think you’re out there to change the world. And that’s not what purpose is. It’s very personal, and it’s inside your heart.

SCF: Can you give an example?

CM: I can give you an example of a teacher I know. She’s 73 now. She’s been retired for about 10 years. She was a fabulous English teacher. She now donates her time at the local library—just a small, rural library. She connects so well with the students. You ought to see some of the projects they work on. It’s just incredible. These kids get so inspired, and they love her. 

SCF: That is changing the world in some ways.

CM: Yeah, but it doesn’t have to be big, and you don’t have to make a lot of money at it; it doesn’t have to cost you anything.

SCF: Are there some lesser-known, negative aspects to solo aging?

CM: The negatives to solo aging are the same negatives any senior faces. We all face financial difficulty or questions like, “Will [our] money outlive us?” Hopefully, it will outlive us! That’s a huge concern. “Will our health keep us strong and safe and independent in our home—wherever we live—so we aren’t dependent on the government to take care of us, or a stranger to take care of us, or have to hire a guardian to take care of us?” Oh, those are some horror stories there, you know? 

And that’s why it’s so important to start thinking ahead—thinking, what happens if you become cognitively impaired in some way? Who will step up for you and manage your finances? 

But we all face it. If you have a spouse, yeah, sure, it makes you feel more comfortable knowing someone’s there, but there’s no guarantee that he or she will be there—or that your kids will step up.

SCF: You mentioned cognitive impairment. Do you advise talking to a friend or loved one in advance about managing your finances, just in case? 

CM: Oh, absolutely, yes. And that’s one of the first steps, I think, in starting to make a plan: Get all of your paperwork—legal, finances—organized. And make a budget. Get organized there first, even before you start looking at affordable housing or making social connections, because if you don’t, you’re just going to be worried about all these things that need to be taken care of first. 

And your health is very important, depending on how healthy or unhealthy you are.

SCF: Do you have specific advice about saving money or planning financially?

CM: Money is a significant factor when growing older. How comfortable are you with your money, savings and investments? When considering, does it make you nervous, or does the thought of your retirement savings make you calm?

Here are the things I did to set my finances on the right track: hired a financial advisor that I trust. I created better spending habits; before spending, I researched for the lowest prices and avoided spending triggers like going to the grocery market when hungry or buying into the idea that I need this right away—impulse buying. There’s no reason you can’t sleep on it for a few days and find the least costly product or service.  

Live on a budget. Yes, you can. I did and still do. If I can do without something for a week, I probably don’t need it. Actively practice gratitude. Find an accountability partner who holds you to your commitment. Don’t shop while you wait.  

Think about your earliest money-related memories and experiences. Was money a frequent source of arguments or an avoided topic? What are your current “money scripts” or financial belief patterns? “Money is the root of all evil.” “Money is not that important.” “Money is there to spend.” “The rich get richer and the poor get poorer.” “I’m just not good with money.” “My family has never been rich.” “Money is a limited resource.” Change your thoughts and scripts about money. 

SCF: In general, when aging solo, is there anything that people tend to forget to plan for or that creeps up on them?

CM: The one thing that will creep up on you faster than I can say, “Boo!” is health issues. Don’t ignore your health. Eat nutritious foods, sleep well, stay fit and active, be around loving people who care about you, and love yourself more than you love anything else in the world.

SCF: How do you address people’s fears about aging solo? 

CM: If fear is overwhelming, talk with your doctor or a counselor and get help to deal with the fear. I spent seven years in therapy and am glad for it. Otherwise, if fear is ignored, a person will likely stagnate and not move forward. 

What helped me address my fears [were] therapy and talking with a trained counselor, then journaling. It helps to put negative thoughts on paper. Spend at least 30 minutes a day, every day, writing out your feelings. It doesn’t matter if the content makes sense or not. What matters is, you write your feelings down as a way of getting them out. 

Keep a gratitude list. Pray or meditate. As you put into practice all of these, I promise, the fear begins to dissipate or ease a bit. But you must be consistent. And you must put a plan in place. Learn what’s needed to make your life better. Research and take action steps and look for solutions. Hope is not a strategy. 

SCF: You yourself are a solo ager. How’s it going? Have you changed your thinking on any of this as you’ve gone along?

CM: If anything’s changed, I’m probably stronger and more clear and know myself well. I live in a [multigenerational] high-rise so that I’m surrounded by a lot of people that can watch out for me—and me watch out for them. I have made some really good, single friends here, as well as married friends. So it’s nice to be in that kind of environment.

SCF: What are some innovations your parents didn’t have access to that are improving boomers’ experience of solo aging?

CM: There is so much information online! And we have quite a few creative thought leaders in housing, applying different ways that we can age—like cohousing, for example, and creating little support systems where we live, like what they call pocket neighborhoods—and tiny houses. 

We have Uber and Lyft. My parents didn’t have access to that. Mother relied on us, the kids, to take her to the doctor. 

I also have an app on my phone called Snug Safety, a check-in service. I would have worried a lot less if Mom and Dad had stuff like this. Solo agers can create our own support team with technology and check in on each other.

SCF: Is society headed toward a bright or dim future for solo agers? 

CM: I definitely think we’re going in a better direction, only because we’re not hidden anymore. People—senior service providers, the aging sector—are starting to acknowledge us. And the one good thing about COVID-19: it really shed a light on isolation and loneliness. So I think we’re in a good place. 

SCF: Is there anything that needs to change to make it even better?

CM: Solo agers really need affordable housing. And it doesn’t have to be an affordable house. It could be an affordable [room rental], but just some ways to create community, so we can take care of each other and be friends with each other as a support team. We need senior housing developers thinking in those lines. Like, married couples—they’ll rent an assisted living or independent living apartment. Why can’t we have a Jack and Jill plan, where you have two separate bedrooms with your own bathrooms? Two solo agers could rent that. 

SCF: So far, we’ve talked a lot about challenges. What are the positive aspects of solo aging?

CM: Well, what I love about my life is, I’m alone. I don’t have anyone pulling on me, asking me to give up my privacy, asking me to do something for them, asking me to pay for something for them—like kids will do—and wanting me to put them first. I don’t think there’s anything wrong with us putting ourselves first and taking the best care of ourselves that we can. 

So I love my privacy, my alone time. I love me! That might sound weird, but it’s taken a long time to really accept me where I am.

To learn more about Marak and solo aging, visit her website, www.carolmarak.com.

This interview has been edited for length and clarity.

What Happens When a Geriatrician Becomes a Caregiver?

She learns a great deal—and not just about how difficult caregiving is

Journalist Judith Graham tells the extraordinary story of a geriatrician who had to become a caregiver twice over—for her husband and then her mother—in the midst of the pandemic. Graham is a contributing columnist for Kaiser Health News (KHN), and her article was posted on the KHN website on May 18, 2021. It also ran on the Washington Post.  

The loss of a husband. The death of a sister. Taking in an elderly mother with dementia.

This has been a year like none other for Rebecca Elon, MD, who has dedicated her professional life to helping older adults.

It’s taught her what families go through when caring for someone with serious illness as nothing has before. “Reading about caregiving of this kind was one thing. Experiencing it was entirely different,” she told me.

Were it not for the challenges she’s faced during the coronavirus pandemic, Elon might not have learned firsthand how exhausting end-of-life care can be, physically and emotionally—something she understood only abstractly previously as a geriatrician.

And she might not have been struck by what she called the deepest lesson of this pandemic: that caregiving is a manifestation of love and that love means being present with someone even when suffering seems overwhelming.

All these experiences have been “a gift, in a way: they’ve truly changed me,” said Elon, 66, a part-time associate professor at Johns Hopkins University School of Medicine and an adjunct associate professor at the University of Maryland School of Medicine.

Elon’s uniquely rich perspective on the pandemic is informed by her multiple roles: family caregiver, geriatrician and policy expert specializing in long term care. “I don’t think we, as a nation, are going to make needed improvements [in long term care] until we take responsibility for our aging mothers and fathers—and do so with love and respect,” she told me.

[Elon is] an extraordinary advocate for elders and families.

—Kris Kuhn, MD 

Elon has been acutely aware of prejudice against older adults—and determined to overcome it—since she first expressed interest in geriatrics in the late 1970s. “Why in the world would you want to do that?” she recalled being asked by a department chair at Baylor College of Medicine, where she was a medical student. “What can you possibly do for those [old] people?”

Elon ignored the scorn and became the first geriatrics fellow at Baylor, in Houston, in 1984. She cherished the elderly aunts and uncles she had visited every year during her childhood and was eager to focus on this new specialty, which was just being established in the United States. “She’s an extraordinary advocate for elders and families,” said Kris Kuhn, MD, a retired geriatrician and longtime friend.

In 2007, Elon was named geriatrician of the year by the American Geriatrics Society.

Her life took an unexpected turn in 2013 when she started noticing personality changes and judgment lapses in her husband, William Henry Adler III, MD, former chief of clinical immunology research at the National Institute on Aging, part of the federal National Institutes of Health. Proud and stubborn, he refused to seek medical attention for several years.

Eventually, however, Adler’s decline accelerated, and in 2017 a neurologist diagnosed frontotemporal dementia with motor neuron disease, an immobilizing condition. Two years later, Adler could barely swallow or speak and had lost the ability to climb down the stairs in their Severna Park, MD, house. “He became a prisoner in our upstairs bedroom,” Elon said.

By then, Elon had cut back on work significantly and hired a home health aide to come in several days a week.

In January 2020, Elon enrolled Adler in hospice and began arranging to move him to a nearby assisted living center. Then, the pandemic hit. Hospice staffers stopped coming. The home health aide quit. The assisted living center went on lockdown. Not visiting Adler wasn’t imaginable, so Elon kept him at home, remaining responsible for his care.

It was time to leave the East Coast behind and be closer to family.

“I lost 20 pounds in four months,” she told me. “It was incredibly demanding work, caring for him.”

Meanwhile, another crisis was brewing. In Kankakee, IL, Elon’s sister, Melissa Davis, was dying of esophageal cancer and no longer able to care for their mother, Betty Davis, 96. The two had lived together for more than a decade, and Davis, who has dementia, required significant assistance.

Elon sprang into action. She and two other sisters moved their mother to an assisted living facility in Kankakee while Elon decided to relocate a few hours away, at a continuing care retirement community in Milwaukee, where she’d spent her childhood. “It was time to leave the East Coast behind and be closer to family,” she said.

By the end of May, Elon and her husband were settled in a two-bedroom apartment in Milwaukee with a balcony looking out over Lake Michigan. The facility has a restaurant downstairs that delivered meals, a concierge service, a helpful hospice agency in the area and other amenities that relieved Elon’s isolation.

“I finally had help,” she told me. “It was like night and day.”

Previously bedbound, Adler would transfer to a chair with the help of a lift (one couldn’t be installed in their Maryland home) and look contentedly out the window at paragliders and boats sailing by.

“In medicine, we often look at people who are profoundly impaired and ask, ‘What kind of quality of life is that?’” Elon said. “But even though Bill was so profoundly impaired, he still had a strong will to live and retained the capacity for joy and interaction.” If she hadn’t been by his side day and night, Elon said, she might not have appreciated this.

Meanwhile, her mother moved to an assisted living center outside Milwaukee to be nearer to Elon and other family members. But things didn’t go well. The facility was on lockdown most of the time and staff members weren’t especially attentive. Concerned about her mother’s well-being, Elon took her out of the facility and brought her to her apartment in late December.

I thought, ‘Oh, my God, is this what we ask families to deal with?’

–Rebecca Elon, MD

For two months, she tended to her husband’s and mother’s needs. In mid-February, Adler, then 81, took a sharp turn for the worse. Unable to speak, his face set in a grimace, he pounded the bed with his hands, breathing heavily. With hospice workers’ help, Elon began administering morphine to ease his pain and agitation.

“I thought, ‘Oh, my God, is this what we ask families to deal with?’” she said. Though she had been a hospice medical director, “that didn’t prepare me for the emotional exhaustion and the ambivalence of giving morphine to my husband.”

Elon’s mother was distraught when Adler died 10 days later, asking repeatedly what had happened to him and weeping when she was told. At some point, Elon realized her mother was also grieving all the losses she had endured over the past year: the loss of her home and friends in Kankakee; the loss of Melissa, who’d died in May; and the loss of her independence.

That, too, was a revelation made possible by being with her every day. “The dogma with people with dementia is you just stop talking about death because they can’t process it,” Elon said. “But I think that if you repeat what’s happened over and over and you put it in context and you give them time, they can grieve and start to recover.”

“Mom is doing so much better with Rebecca,” said Deborah Bliss, 69, Elon’s older sister, who lives in Plano, TX, and who believes there are benefits for her sister as well. “I think having [Mom] there after Bill died, having someone else to care for, has been a good distraction.”

And so, for Elon, as for so many families across the country, a new chapter has begun, born out of harsh necessities. The days pass relatively calmly as Elon works, and she and her mother spend time together.

“Mom will look out at the lake and say, ‘Oh, my goodness, these colors are so beautiful,’” Elon said. “When I cook, she’ll tell me, ‘It’s so nice to have a meal with you.’ When she goes to bed at night, she’ll say, ‘Oh, this bed feels so wonderful.’ She’s happy on a moment-to-moment basis. And I’m very thankful she’s with me.”

Losing Sight

The epidemic of eye diseases nobody is preparing for

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

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

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

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

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

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

What Can Be Done?

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

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

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

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

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

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

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

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

Catch It Early 

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

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

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

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

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

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

Problems beyond Lost Vision

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

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

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

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

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

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

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

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

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

Help from Tech and Training

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

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

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

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

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

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

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

Making Adjustments

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

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

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

Telemedicine Is a Useful New Tool—with Limitations

Studies suggest there are problems it’s likely to miss

Elisabeth Rosenthal, editor-in-chief of Kaiser Health News (KHN) looks at what happens when patients consult their doctor virtually rather than in a face-to-face office visit. She sums up the evidence from studies and weighs the pros and cons in this article, written for KHN, which also ran on the New York Times. Her story was posted on the KHN website on May 6, 2021.   

Earlier in the pandemic, it was vital to see doctors over platforms like Zoom or FaceTime when in-person appointments posed risks of coronavirus exposure. Insurers were forced—often for the first time—to reimburse for all sorts of virtual medical visits and generally at the same price as in-person consultations.

By April 2020, one national study found, telemedicine visits already accounted for 13 percent of all medical claims, compared with 0.15 percent a year earlier. And COVID hadn’t seriously hit much of the country yet. By May, Johns Hopkins’ neurology department was conducting 95 percent of patient visits virtually, compared with just 10 such visits weekly the year before, for example.

COVID-19 let virtual medicine out of the bottle. Now it’s time to tame it. If we don’t, there is a danger that it will stealthily become a mainstay of our medical care. Deploying it too widely or too quickly risks poorer care, inequities and even more outrageous charges in a system already infamous for big bills.

The pandemic has demonstrated that virtual medicine is great for many simple visits. But many of the new types of telemedicine being promoted by start-ups more clearly benefit providers’ and investors’ pockets, rather than yielding more convenient, high-quality and cost-effective medicine for patients.

“Right now, there’s a lot of focus on shiny objects—ideas that sound cool—rather than solving problems,” said Peter Pronovost, MD, a national expert in medical innovation at University Hospitals Cleveland Medical Center, who has written about finding the value of virtual medicine.  “We know preciously little about its impact on quality.”

Even so, the financial world is abuzz with investment opportunities. In the first six months of 2020, telehealth companies raised record amounts of funding, with five start-ups each raising more than $100 million.

Virtual visits can save time for everybody, but they may also raise costs for patients.

There are now telehealth apps that target niche markets like the mental health of pregnant women. Others provide medicines, like HIV prevention pills, after a virtual consultation with their doctors. You can even do a digital eye appointment, meet with your dentist virtually to monitor your oral health and orthodontic progress, and send a dermatologist a photo of a suspicious mole.

With telemedicine generously reimbursed, many practices are offering—even encouraging—patients to visit virtually. But, intentionally or not, that choice becomes a revenue multiplier, adding to patient expense.

When he noticed a curious rash, a relative was first directed to a practice’s telemedicine portal and billed $235 for a five-minute video appointment. Since rashes are often hard to evaluate in two dimensions, he was told he needed to see a doctor in person for the diagnosis and then was charged $460 more for that visit. I worry that pandemic-era reimbursement practices have taken traditionally free screening calls and rebranded them as billed visits, with no value added.

Going forward, some types of virtual visits will deserve insurance coverage. Think of follow-up appointments to check blood pressure or an arrhythmia, in which measurements can now be collected at a pharmacy or at home and transmitted to the physician digitally.

For most patients, in-person visits were required in large part because it was the only way a doctor could bill. But they are colossal time sucks, and for people with disabilities, they created hardship. After a head injury last April—when I couldn’t yet drive—I was grateful for some insurance-reimbursed virtual visits with doctors and physical therapists.

But there are things that virtual medicine can miss, studies suggest.

One study showed that commercial telemedicine services were much more likely to prescribe antibiotics for children’s respiratory infections than a primary care doctor would be at an in-person visit. That’s in part because, if you can’t see into the ear to observe a bulging drum, for example, the safer course is to overtreat—even though that’s contrary to prescribing guidelines intended to prevent antibiotic resistance.

There is still real value in being in the same room, in touch, in the laying on of hands.

—Peter Pronovost, MD

An internist depresses the tongue and looks for pus on the tonsils to detect possible strep throat. A surgeon suspects appendicitis by pushing on the belly to see if there’s pain with rapid release.

Can psychiatrists develop a therapeutic relationship with a new patient equally well over Zoom? In some cases, sure. But better diagnosing of my own post-injury gait problems required office visits with hands-on maneuvers, like checking my reflexes and feeling my joints move.

“There is still real value in being in the same room, in touch, in the laying on of hands,” Pronovost said. Studies show that such interactions build trust, increasing the likelihood that patients will comply with treatment.

Telemedicine also raises new questions of equity. Even though it promises improved access for people in rural and underserved areas, video visits require high-speed internet, which is less common among the same groups. Alternatively, will the poor get mostly telemedicine clinics (cheaper, since no front-desk staff is needed), while those with good insurance have easy access to doctors’ offices?

Insurers are already rolling back their willingness from earlier in the pandemic to pay for telehealth visits. And providers and insurers are battling over reimbursement levels. Is a video call worth the same as an in-person doctor’s visit? If a commercial telemedicine-only doctor determines a patient requires an in-person assessment, is the fee discounted or waived? And how is a smart referral done if that telemedicine provider is thousands of miles away?

There is much to be resolved and fast, with scientific evidence and doctors, hopefully, driving the decisions. If we allow the market to make the choice, we risk preserving those telemedicine services that make money for business and providers—or save it for insurers—and lose those that most benefit patients.

 

Crafting: A Way to Cope during the Pandemic

It can ease isolation and even provide a sense of purpose

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

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

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

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

Finding Joy in Creativity

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

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

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

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

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

—Kris Stevenson 

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

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

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

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

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

Connection during Isolation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Collaboration and Community

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

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

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

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

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

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

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

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

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

Why Technology Matters So Much for Older People during a Pandemic

While technology ‘haves’ cope online, vulnerable ‘have-nots’ struggle

Access to technology can make a huge difference to vulnerable elders isolated by COVID-19. Many don’t have access. Judith Graham explains why and explores creative solutions in this article written for Kaiser Health News (KHN). Graham’s piece was posted on the KHN website on July 24, 2020, and also ran on CNN. 

Family gatherings on Zoom and FaceTime. Online orders from grocery stores and pharmacies. Telehealth appointments with physicians.

These have been lifesavers for many older adults staying at home during the coronavirus pandemic. But an unprecedented shift to virtual interactions has a downside: large numbers of seniors are unable to participate.

Among them are older adults with dementia (14 percent of those 71 and older), hearing loss (nearly two-thirds of those 70 and older) and impaired vision (13.5 percent of those 65 and older), who can have a hard time using digital devices and programs designed without their needs in mind. (Think small icons, difficult-to-read typefaces, inadequate captioning, among the hurdles.)

Many older adults with limited financial resources also may not be able to afford devices or the associated internet service fees. (Half of seniors living alone and 23 percent of those in two-person households are unable to afford basic necessities.) Others are not adept at using technology and lack the assistance to learn.

During the pandemic, which has hit older adults especially hard, this divide between technology “haves” and “have-nots” has serious consequences.

Older adults in the “haves” group have more access to virtual social interactions and telehealth services, and more opportunities to secure essential supplies online. Meanwhile, the “have-nots” are at greater risk of social isolation, forgoing medical care and being without food or other necessary items.

A Medicare Advantage plan found that about a third of its most vulnerable members couldn’t manage a telehealth appointment because they didn’t have the technology.

Dr. Charlotte Yeh, chief medical officer for AARP Services, observed difficulties associated with technology this year when trying to remotely teach her 92-year-old father how to use an iPhone. She lives in Boston; her father lives in Pittsburgh.

Yeh’s mother had always handled communication for the couple, but she was in a nursing home after being hospitalized for pneumonia. Because of the pandemic, the home had closed to visitors. To talk to her and other family members, Yeh’s father had to resort to technology.

But various impairments got in the way: Yeh’s father is blind in one eye, with severe hearing loss and a cochlear implant, and he had trouble hearing conversations over the iPhone. And it was more difficult than Yeh expected to find an easy-to-use iPhone app that accurately translates speech into captions.

Often, family members would try to arrange Zoom meetings. For these, Yeh’s father used a computer but still had problems because he could not read the very small captions on Zoom. A tech-savvy granddaughter solved that problem by connecting a tablet with a separate transcription program.

When Yeh’s mother, who was 90, came home in early April, physicians treating her for metastatic lung cancer wanted to arrange telehealth visits. But this could not occur via cell phone (the screen was too small) or her computer (too hard to move it around). Physicians could examine lesions around the older woman’s mouth only when a tablet was held at just the right angle, with a phone’s flashlight aimed at it for extra light.

“It was like a three-ring circus,” Yeh said. Her family had the resources needed to solve these problems; many do not, she noted. Yeh’s mother passed away in July; her father is now living alone, making him more dependent on technology than ever.

When SCAN Health Plan, a Medicare Advantage plan with 215,000 members in California, surveyed its most vulnerable members after the pandemic hit, it discovered that about one-third did not have access to the technology needed for a telehealth appointment. The Centers for Medicare & Medicaid Services had expanded the use of telehealth in March.

Other barriers also stood in the way of serving SCAN’s members remotely. Many people needed translation services, which are difficult to arrange for telehealth visits. “We realized language barriers are a big thing,” said Eve Gelb, SCAN’s senior vice president of health care services.

One alternative is a tablet already loaded with apps designed for adults 75 and older.

Nearly 40 percent of the plan’s members have vision issues that interfere with their ability to use digital devices; 28 percent have a clinically significant hearing impairment.

“We need to target interventions to help these people,” Gelb said. SCAN is considering sending community health workers into the homes of vulnerable members to help them conduct telehealth visits. Also, it may give members easy-to-use devices, with essential functions already set up, to keep at home, Gelb said.

Landmark Health serves a highly vulnerable group of 42,000 people in 14 states, bringing services into patients’ homes. Its average patient is nearly 80 years old, with eight medical conditions. After the first few weeks of the pandemic, Landmark halted in-person visits to homes because personal protective equipment, or PPE, was in short supply.

Instead, Landmark tried to deliver care remotely. It soon discovered that fewer than 25 percent of patients had appropriate technology and knew how to use it, according to Nick Loporcaro, the chief executive officer. “Telehealth is not the panacea, especially for this population,” he said.

Landmark plans to experiment with what he calls “facilitated telehealth”: nonmedical staff members bringing devices to patients’ homes and managing telehealth visits. (It now has enough PPE to make this possible.) And it too is looking at technology that it can give to members.

One alternative gaining attention is GrandPad, a tablet loaded with senior-friendly apps designed for adults 75 and older. In July, the National PACE Association, whose members run programs providing comprehensive services to frail seniors who live at home, announced a partnership with GrandPad to encourage adoption of this technology.

“Everyone is scrambling to move to this new remote-care model and looking for options,” said Scott Lien, the company’s co-founder and chief executive officer.

Nursing homes, assisted living centers and senior communities need to install communitywide Wi-Fi services.

PACE Southeast Michigan purchased 125 GrandPads for highly vulnerable members after closing five centers in March where seniors receive services. The devices have been “remarkably successful” in facilitating video-streamed social and telehealth interactions and allowing nurses and social workers to address emerging needs, said Roger Anderson, senior director of operational support and innovation.

Another alternative is technology from iN2L (an acronym for It’s Never Too Late), a company that specializes in serving people with dementia. In Florida, under a new program sponsored by the state’s Department of Elder Affairs, iN2L tablets loaded with dementia-specific content have been distributed to 300 nursing homes and assisted living centers.

The goal is to help seniors with cognitive impairment connect virtually with friends and family and engage in online activities that ease social isolation, said Sam Fazio, senior director of quality care and psychosocial research at the Alzheimer’s Association, a partner in the effort. But because of budget constraints, only two tablets are being sent to each long term care community.

Families report it can be difficult to schedule adequate time with loved ones when only a few devices are available. This happened to Maitely Weismann’s 77-year-old mother after she moved into a short-staffed, Los Angeles, memory-care facility in March. After seeing how hard it was to connect, Weismann, who lives in Los Angeles, gave her mother an iPad and hired an aide to ensure that mother and daughter were able to talk each night.

Without the aide’s assistance, Weismann’s mother would end up accidentally pausing the video or turning off the device. “She probably wanted to reach out and touch me, and when she touched the screen it would go blank and she’d panic,” Weismann said.

What’s needed going forward? Laurie Orlov, founder of the blog Aging in Place Technology Watch, said nursing homes, assisted living centers and senior communities need to install communitywide Wi-Fi services—something that many lack.

“We need to enable Zoom get-togethers. We need the ability to put voice technology in individual rooms, so people can access Amazon Alexa or Google products,” she said. “We need more group activities that enable multiple residents to communicate with each other virtually. And we need vendors to bundle connectivity, devices, training and service in packages designed for older adults.”

 

Row, Row, Row Your Boat

Growing interest in rowing lures older adults to the water

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

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

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

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

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

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

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

Vigorous but Safe

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

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

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

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

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

— Charles Gilbert

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

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

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

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

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

Competition as Motivation

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

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

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

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

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

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

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

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

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

‘Built-in Sisterhood’

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

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

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

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

Time in Nature

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

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

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

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

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

His Medical Crisis Took Us by Surprise

Suddenly my father-in-law was hospitalized, and we had put off planning

Journalist Judith Graham reveals what happens when problems that have always been hypothetical suddenly become real and need immediate solutions. Graham writes the Navigating Aging column for Kaiser Health News (KHN). Her article was posted on the KHN website on August 20, 2020, and also ran on CNN. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues.

Earlier this month, my husband picked up the phone and learned his 92-year-old father had been taken to the hospital that morning, feeling sick and short of breath.

We were nearly 2,000 miles away, on a vacation in the mountains of southern Colorado.

No, it wasn’t COVID-19. My father-in-law, Mel, who has diabetes, high blood pressure and kidney disease, was suffering from fluid buildup in his legs and around his lungs, and excruciating knee pain. Intravenous medications and steroid injections were administered, and he responded well.

Doctors monitored Mel carefully, adjusted his medications and recommended a few weeks of home health care after eight days in the hospital.

In other words, this was not a life-threatening emergency. Yet we realized how poorly prepared we were for a real crisis, should one arise. We needed a plan.

Why didn’t we have one already? The usual reasons: denial, avoidance and wishful thinking. It was easier to imagine that Mel would be all right until it became clear that we couldn’t take that for granted.

Although I routinely advise readers about preparing for changes in their health, I didn’t want to be a know-it-all with my husband’s family. Their assumption seemed to be, “We’ll deal with whatever comes up when that happens.”

Now, eyes wide open, we got organized.

Some background: Mel lives in a well-run continuing care retirement community in upstate New York, in the independent living section. His three sons all live at a distance: one out West, one overseas and one a few hours away.

Hiring a care manager. Last year, as Mel’s kidney function declined, I suggested we hire a geriatric care manager who could look in on him regularly. After a few visits, Mel let her go. Her services were too expensive, he complained. In truth, we understood, he didn’t want someone interfering in his affairs.

My husband respects his father’s autonomy and didn’t press the point.

So when Mel went to the hospital a few weeks ago, he was alone, with no one to turn to for assistance.

This was especially problematic because Mel has hearing loss, and it is almost impossible to talk with him by phone. “How are you, Dad?” my husband yelled on twice-a-day calls to check on his father in the hospital. “What?” Mel replied querulously. This was repeated a few times, with mounting frustration and no useful information exchanged.

Now a care manager who could serve as our eyes and ears on the ground was necessary, not optional, and we hired back the professional we’d already found.

Finding companion care. What kind of assistance was Mel going to need when he left the hospital, deconditioned and weaker than when he went in?

When we spoke with the physician overseeing Mel’s care in the hospital, he suggested that “companion care” for at least a few weeks would be a good idea. Mel needed someone to help him up out of the chair, stay at his side while he walked to the bathroom and bring him a glass of water, among other tasks. (Also, we realized, we needed to arrange for meals to be delivered to Mel and for someone from his senior community to buy groceries for him—a service they’d started during the pandemic.)

An excellent organization that works with older adults in Mel’s area supplied me with a list of 21 agencies that provide these kinds of services—a dizzying array of choices.

Fortunately, the senior community where Mel lives recommended an agency that often works with its residents. We hired 24/7 care for several days after Mel left the hospital with the understanding that we’d continue services if necessary. Now, this agency is on our list of essential resources.

Understanding the options. Mel’s senior community incorporates assisted living and a nursing home for residents who need short-term rehabilitation services or longer-term, round-the-clock care.

But it was clear Mel wanted to go home after being in the hospital instead of going to that rehab. Medicare would pay for a few weeks of visits from nurses and physical and occupational therapists. Would that be enough to set him on the road to recovery? We had no idea.

If Mel couldn’t return to his previous level of functioning after returning home, he might need to transition to assisted living, where he could receive more medical oversight and assistance. How would this work? We didn’t know and asked the geriatric care manager to find out.

Getting paperwork in order. Years ago, Mel assigned power of attorney for his health care decisions and financial and legal affairs to my husband. So long as Mel can manage on his own, he makes his own decisions: The legal papers were a backup arrangement.

But Mel hadn’t prepared a document naming all three sons as his personal representatives under the Health Insurance Portability and Accountability Act of 1996. This waives privacy concerns and gives them access to his medical information. It went on our to-do list.

The brothers also didn’t have a complete list of Mel’s doctors, the medications he was on and why he was taking them. Another item for our list, especially important since Mel left the hospital with prescriptions for 14 medications, several of them new. While he’d always managed on his own before, in his post-hospital fog it was clear he was nervous about managing this complicated regimen.

Understanding the prognosis. Before Mel’s hospitalization, we knew his kidney function was worsening. But what lay ahead? Was dialysis even an option for a 92-year-old in this time of COVID-19?

Who was best prepared to help us understand Mel’s prognosis and the big picture?

I’ve written for years about geriatricians’ comprehensive approach to the health of older adults. It turns out there’s a top-notch group of geriatricians affiliated with the hospital where Mel was being treated.

After several calls, I reached one who agreed to see Mel after he was released from the hospital. Now, we have another new team member who can help us understand Mel’s health trajectory and issues that might arise going forward.

Having the conversation. What has yet to happen is the conversation that my husband hasn’t wanted to have. “Dad, if your health takes a turn for the worse again, what do you want? What’s most important to you? What does quality of life mean to you? And what can we do to help?”

With Mel’s hearing problems, doing this over the phone won’t do.

My husband would have to fly cross-country and, ideally, meet his New York brother at Mel’s place for a conversation of this kind. Before that happens, the brothers should talk among themselves. What’s their understanding of what Mel wants? Are they on the same page?

Also, no one has discussed financial arrangements.

Each time we explain to Mel one of the new services we’ve arranged, his first question is “What’s the cost?” His impulse is to guard his cherished savings and not to spend. My husband tells him he shouldn’t worry, but this too is a conversation that has to happen.

Being prepared. Professionally, I know a lot about the kinds of problems families encounter when an older relative becomes ill. Personally, I’ve learned that families don’t really understand what’s involved until they go through it on their own.

Now, Mel has a new set of supports in place that should help him weather the period ahead. And my husband is keenly aware that planning doesn’t stop here. He’ll be attending to his father far more carefully going forward.

 

Kaiser Health News: The Story Behind the Grant

KHN doubles its output during the Covid pandemic—with some help from Silver Century

The year was 2016. By most accounts, print journalism was dying.

The rise of free digital content, the decline of trust in journalism and a drop in advertising revenue had led to what the Atlantic called a “print apocalypse.” Layoffs began; more layoffs were promised. Per the New York Times, “you would be hard-pressed to find a newsroom devoid of uncertainty anywhere in the country.” 

In the meantime, though, many online outlets were going strong. Silver Century Foundation, for one, had been publishing online articles about aging for more than half a decade. And through its growing, grantmaking efforts—now focused on directing media attention to aging-related topics—its influence was rising. 

As experienced journalists found themselves without employment, Kay Klotzburger, Silver Century’s founder and president, thought that now might be the perfect time to hire some of them to freelance. But she wasn’t alone. Another online outlet, Kaiser Health News, was also in the market for such writers. And Kaiser, backed in part by the formidable Kaiser Family Foundation, had readers in the millions—with a budget to match. 

As Klotzburger researched, she found that many seasoned journalists were, in fact, gravitating to Kaiser Health News. Instead of being daunted, she saw opportunity. 

Silver Century was publishing great content but was struggling to draw in a large readership. Since Klotzburger’s main goal was to get content both written and read, why not partner with an organization that already had a massive audience—plus a bigger staff?

Silver Century had already found success with a similar arrangement. In 2014, it became an ongoing funder for the Gerontological Society of America’s Journalists in Aging Fellowship Program, which was prompting exponentially more articles to be published about aging. But when it came to the Kaiser idea, there was a hitch. As Klotzburger put it, “Kaiser is a billion-dollar organization, and I’m a little minnow.” 

Step one: Get a foot in the door.

Kaiser Meets Silver Century 

Klotzburger asked her strategic planning consultant, Lois Favier, of New Experience NonProfit Services, to look into the possibility of working with Kaiser Health News.

“First, I did a little research,” Favier recalls. She found no clear way to contact Kaiser about grants. There was no donate button on the website, no call for funds. 

So she looked into which organizations were doing the funding, besides the Kaiser Family Foundation. “I discovered that these were highly well-known and wealthy foundations,” she says—organizations with hundreds of millions of dollars or more in their coffers. 

Given all this, did Kaiser Health News even need more funding? And without inside connections, could Silver Century find that out? Favier’s initial phone calls to the news outlet went unreturned. So Klotzburger tried to make contact herself. No luck.

It was an unusual situation—a foundation wanting to give away money but unable to get in touch with the entity it wanted to fund. Yet Klotzburger wasn’t about to give up. Around 2017, she enlisted David Goldsmith, a consultant to both nonprofits and foundations, to dive in further. 

The strategy was to identify ways in which KHN’s needs and mission aligned with Silver Century’s

Goldsmith took a new tack. Instead of contacting Kaiser Health News, he reached out to its main funder and publisher, Kaiser Family Foundation. And he did so with a tried-and-true strategy: identifying the needs of both the nonprofit and the foundation. 

“I’ve come to realize, it’s not about one keeping the other one alive,” he says. “The foundation has needs. The foundation has a mission. And the nonprofit has needs and a mission as well. So it’s about looking for how you can connect the two through a relationship that helps to meet both those needs.”

Goldsmith’s strategy worked. He was ultimately able to meet with Kaiser Family Foundation’s executive director of media and technology, David Rousseau, who is Kaiser Health News’ publisher.

“When I had that initial conversation with him,” Goldsmith says, “he mentioned that they had a fair amount of funding for the writing of articles on the issue of aging in general, but they did not have much funding for issues around the aging of baby boomers. So that kind of opened the door.” 

Goldsmith knew that Klotzburger was interested in aging well, no matter the age, so the two organizations’ needs would mesh. He set up a meeting with Rousseau and Klotzburger, “and the relationship built from there.”

A Unique Arrangement

For Kaiser, the relationship turned out to be an unusual one. About 60 percent of the funding for Kaiser Health News comes from the Kaiser Family Foundation. For the rest, Kaiser works mostly with large foundations in long-term partnerships.

The idea of working with a smaller funder that had a specific topic of interest was new. So there was a lot of internal discussion to be had. 

“It was kind of like, ‘Oh, this is cool. Well, do we do this? Can we do this?’” recalls Elisabeth Rosenthal, editor-in-chief of Kaiser Health News. Because the outlet was relatively young—it launched in 2009—it was also relatively flexible, she says. “The wonderful thing about Kaiser Health News is that we can look at each other and say, ‘Why don’t we do this?’”

One benefit of working with larger funders, though, is sustainability, Rousseau notes. “When we think about setting up a new program or expanding into a new geography, we want to make sure we can stay there for the long term and not just have a one- or two-year commitment to that region or that topic.”

On the topic of aging, Kaiser already had sustainable funding. Thanks to the Hartford Foundation and the Gordon and Betty Moore Foundation, Kaiser had a large team reporting on issues that older Americans face when they access health care—topics such as what the end of life looks like and how age-friendly hospitals are created.

But Klotzburger proposed a different angle: longevity. Silver Century’s tagline was “preparing for a longer life.” People were living longer but weren’t necessarily grasping what that entailed—and how to plan for it. 

… fortunately, with Silver Century, we found out it was a good fit.”

— Elisabeth Rosenthal

“As a society, we needed to start a more viable, informed conversation about longer lives and older people,” she says.

And this “sounded exactly like something I knew our newsroom wanted to cover that we didn’t have enough resources to cover,” Rousseau says. 

That was essential because of Kaiser’s commitment to maintaining a wall between funders and reporters. When a foundation approaches Kaiser to fund reporting on a topic, “the first question is, ‘Is this something that we’d do anyway, if we had additional money to do it?’” Rousseau says. If the answer is yes, Kaiser can take the grant. If it’s no, they can’t. “It’s the difference, really, between journalism and sponsored content.”

For example, large health care foundations often want more coverage on a specific disease, Rosenthal explains. Kaiser won’t take that money. But Klotzburger understood the boundaries “right from the start,” Rosenthal says. “And aging and longevity concern everyone. So it wasn’t a real niche issue.”

Over the next few months, Kaiser and Silver Century negotiated an agreement. The grant would be for one year, to start—not the multiple years Kaiser was accustomed to. And it would cover freelancers, not journalism salaries—another departure from the norm. 

For her part, Rosenthal was all for an outside-the-box arrangement. Because of Kaiser’s flexibility, “we can try a partnership with a new grantmaker or with a new media partner—or try a new form of journalism. And if it doesn’t work, we gave it our best, and no bad feelings, hopefully—it wasn’t a good fit. But fortunately, with Silver Century, we found out it was a good fit.”

A Massive Reach

In the first year—September 2018 to September 2019—Silver Century’s grant supported 31 articles. In year two, Silver Century supported 21 articles. Klotzburger has committed to a third year (2020-2021), upping the grant award by 50 percent. 

As a nonprofit, Kaiser Health News allows other outlets to republish articles for free with attribution. Silver Century-supported stories have been republished by myriad organizations, including CNN, the New York Times, NPR, USA Today, Time, Yahoo and ABC News.

“These are stories we wouldn’t be able to produce if not for the support from the Silver Century Foundation,” Rousseau says. 

They’re also topics that are under-covered in general. “Most of the reporting about care for seniors is looking at what happens when they’re sick,” Rousseau says. “A lot of the reporting we’ve been able to do with the support of Silver Century is focused more on healthy aging.”

During the Covid pandemic, KHN doubled its output, thanks to grantmakers like Silver Century. 

“The grants go into our sense of mission and purpose, and how we choose to assign our reporters to stories,” Rosenthal says. “The grants align with what we would like to cover anyway, but often, we wouldn’t have the resources to cover that without the grants.”

For example, during the COVID pandemic—a disease that disproportionately affected older people—Kaiser Health News “doubled the output of our stories,” Rosenthal says, “and that’s because of our grantmakers, who’ve allowed us to expand our staff and our freelance assignments.”

As the nation ages, “there really is so much to think about—particularly in this area of longevity,” Rosenthal says. “We all should be invested in this because we’re all going to be there [older] someday.”

Klotzburger now has frequent conversations with Rousseau and Rosenthal, lending insights and information. “Silver Century has been a really model funder,” Rousseau says. “They’ve respected that editorially independent firewall, but they’ve also contributed lots of ideas that have made our coverage smarter and better.”

Supported Articles

Here are just some of the Kaiser Health News articles that the Silver Century Foundation’s grant supported in 2020:

Left Behind in the ‘Cruel’ Race for Vaccines

Many seniors are stymied by computer hassles and jammed phone lines 

Many Americans are competing for COVID shots right now, but older people with few computer skills are having a particularly difficult time. In this article, written for Kaiser Health News (KHN) and NPR, journalist Will Stone explores the problem and some attempts to solve it. Stone’s story was posted on the KHN website on Feb. 4, 2021, and also ran on NPR. It was produced as part of a partnership that includes NPR and KHN. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues.

With millions of older Americans eligible for COVID-19 vaccines and limited supplies, many continue to describe a frantic and frustrating search to secure a shot, beset by uncertainty and difficulty. 

The efforts to vaccinate people 65 and older have strained under the enormous demand that has overwhelmed cumbersome, inconsistent, scheduling systems.

The struggle represents a shift from the first wave of vaccinations—health care workers in health care settings—which went comparatively smoothly. Now, in most places, elderly people are pitted against one another, competing on an unstable technological playing field for limited shots.

“You can’t have the vaccine distribution be a race between elderly people typing and younger people typing,” said Jeremy Novich, a clinical psychologist in New York City, who has begun a group to help people navigate the technology to get appointments. “That’s not a race. That’s just cruel.”

While the demand is an encouraging sign of public trust in the vaccines, the challenges facing seniors also speak to the country’s fragmented approach, which has left many confused and enlisting family members to hunt down appointments. 

Some public health departments have been inundated and are trying to hire more staff. 

“It’s just maddening,” said Bill Walsh, with AARP. It should be a smooth pathway, from signing up to getting the vaccine, and that’s just not what we’re seeing so far.” 

Glitchy websites, jammed phone lines and long lines outside clinics have become commonplace as states expand who’s eligible—sometimes triggering a mad dash for shots that can sound more like trying to score a ticket for a music festival than obtaining a lifesaving vaccine. 

After being inundated, some public health departments are trying to hire more staff members to handle their vaccination hotlines and specifically target seniors who may not be able to navigate a complicated, online, sign-up process.  

“Just posting a website and urging people to go there is not a recipe for success,” said Walsh. 

‘Terribly Competitive’ 

Like many other seniors, Colleen Brooks, 85, had trouble sorting through the myriad online resources about how to find the vaccine where she lives, on Vashon Island in the Puget Sound near Seattle.

“It was an overwhelming amount of information,” she said. “I knew it was here someplace, but it wasn’t easy to find out how to get it.”

After making calls, Brooks eventually got a tip from a friend, who had spotted the vaccines being unloaded at their town pharmacy. When she dropped by her health clinic to inquire about how to sign up, it happened they were giving out shots that same day.  

That was totally serendipitous for me, but I actually personally know several seniors who just kind of gave up,” said Brooks. 

Finding out how to get a vaccine appointment was more straightforward for Gerald Kahn, 76, who lives in Madison, CT. 

Kahn got an email notice from the state’s vaccine registration system telling him to make an appointment, but he ran into problems at the very end of the sign-up process. 

“As much as I would pound my finger on the face of my iPad, it didn’t do me any good,” he said.

So Kahn did what many have and called a younger family member, who was able to help him finish signing up. 

“I think there are a lot of people my age, maybe the preponderance, who can only go so far into the internet, and then we’re not only stymied but also frustrated,” he said. 

Patients in this age group want to know that they’re at least being heard, or somebody is thinking about the challenges they have.

—Philip Bretsky, MD

When Helen Francke, 92, logged on for a vaccine at the designated time, she discovered the spots available in Washington, DC, filled up almost instantaneously. 

“It was evident that I was much too slow,” she said. “It’s terribly competitive and clearly favors those with advanced computer skills.” 

The next week, Francke tried calling and going online—this time with the help of her neighbors—without success.

“If I had had to depend on the DC vaccination website and telephone, I’d still be anxious and unsuccessful,” said Francke, who got a shot only after finding information on a neighborhood discussion group that directed her to a hospital. 

In Arizona, Karen Davis, 80, ended up on a roundabout quest through state and hospital websites with no clear sense of how to actually book an appointment. 

I kept trying to do it and kind of banged my head against the wall too many times,” she said. 

Davis, a retired nurse, called her doctor and the pharmacy and then eventually turned to a younger relative, who managed to book a 5 a.m. appointment at a mass vaccination site. 

“I’m sure they did not expect older people to be able to do this,” she said. 

Miguel Lerma, who lives in Phoenix, said his 69-year-old mother has been unsuccessful in finding a shot. 

“She’s not an English speaker and doesn’t know technology well, and that’s how everything is being done,” said Lerma, 31. 

Lerma said it’s especially painful to watch his mother struggle to get the vaccine—because he lost his father to Covid last year. 

“She’s mourning not only for my dad, but she’s also suffering as an adult now because she depended on him for certain tasks,” Lerma said. “He would’ve handled all this.” 

‘Desperate’ Seniors Look for Help  

Philip Bretsky, a primary care doctor in Southern California, said his older patients would typically call him or visit a pharmacy for vaccines like the annual flu shot, rather than rely on novel, online, scheduling systems. 

“That’s not how 85-year-olds have interacted with the health care system, so it’s a complete disconnect,” he said. “These folks are basically just investing a lot of time and not getting anything out of it.” 

California’s recent decision to change its vaccination plan and open it up to those over 65 only adds to the confusion. 

Bretsky said his patients are being told to call their doctor for information, but he isn’t even sure when his office, which is authorized to give the vaccines, will receive any. 

Patients in this age group want to know that they’re at least being heard or somebody is thinking about the challenges they have,” he said. 

People are really desperate.… It’s a big mess.

—Jeremy Novich

There are some local efforts to make that happen.  

In the village of Los Lunas, NM, public health workers held an in-person, sign-up event for seniors who needed assistance or simply a device connected to the internet. 

Florida senior center recently held a vaccination registration event and a clinic specifically for people over 80 who might not have a computer. 

Novich, the clinical psychologist in New York, teamed up with a few other people to create an informal help service for older adults. It began as a small endeavor, advertised through a few synagogues and his Facebook page. They’ve now helped more than 100 people get shots.  

“We have a huge number of requests that are just piling up,” said Novich. 

“People are really desperate, and they’re also confused because nobody has actually explained to them when they are expected to get vaccinated.… It’s a big mess.” 

The ongoing shortage of vaccines has led Novich to halt the service for now. 

 

In the Red

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Credit cards aren’t the only source of temptation. 

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

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

How Debt Accrues

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

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

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

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

Sometimes debt leads to deeper debt.

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

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

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

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

Who’s in Debt

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

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

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

Depression and Desperation

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

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

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

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

Tackling the Problem

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

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

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

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

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

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

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

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

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

Working Longer

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

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

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

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

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

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

 

Older COVID Patients Battle ‘Brain Fog’ 

For those who have been critically ill, a full recovery can take months

Most older people who develop COVID-19 survive it, but release from the hospital is often followed by a long and difficult recuperation. Journalist Judith Graham explains what that’s like and what needs to be done to help them. She wrote her article for Kaiser Health News, and it was posted on the KHN website on Oct. 20, 2020. It also ran on CNN

“Lord, give me back my memory.”

For months, as Marilyn Walters has struggled to recover from COVID-19, she has repeated this prayer day and night.

Like other older adults who’ve become critically ill from the coronavirus, Walters, 65, describes what she calls “brain fog”—difficulty putting thoughts together, problems with concentration, the inability to remember what happened a short time before.

This sudden, cognitive dysfunction is a common concern for seniors who’ve survived a serious bout of COVID-19.

“Many older patients are having trouble organizing themselves and planning what they need to do to get through the day,” said Zijian Chen, MD, medical director of the Center for Post-COVID Care at Mount Sinai Health System in New York City. “They’re reporting that they’ve become more and more forgetful.”

Other challenges abound: overcoming muscle and nerve damage, improving breathing, adapting to new impairments, regaining strength and stamina and coping with the emotional toll of unexpected illness.

Most seniors survive COVID-19 and will encounter these concerns to varying degrees. Even among the age group at greatet risk—people 85 and older—just 28 percent of those with confirmed cases end up dying, according to data from the Centers for Disease Control and Prevention. (Because of gaps in testing, the actual death rate may be lower.)

A year after being critically ill with COVID, at least half of older patients will not have fully recovered.

Walters, who lives in Indianapolis, IN, spent almost three weeks in March and April heavily sedated, on a ventilator, fighting for her life in intensive care. Today, she said, “I still get tired real easy and I can’t breathe sometimes. If I’m walking, sometimes my legs get wobbly and my arms get like jelly.”

“Emotionally, it’s been hard because I’ve always been able to do for myself, and I can’t do that as I like. I’ve been really nervous and jittery,” Walters said.

Younger adults who’ve survived a serious course of COVID-19 experience similar issues, but older adults tend to have “more severe symptoms, and more limitations in terms of what they can do,” Chen said.

“Recovery will be on the order of months and years, not days or weeks,” said E. Wesley Ely, MD, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University Medical Center. Most likely, he speculated, a year after fighting the disease at least half of the critically ill older patients will not have fully recovered.

The aftereffects of delirium—an acute, sudden change of consciousness and mental acuity—can complicate recovery from COVID-19. Seniors hospitalized for serious illness are susceptible to the often-unrecognized condition when they’re immobilized for a long time, isolated from family and friends and given sedatives to ease agitation or narcotics for pain, among other contributing factors.

In older adults, delirium is associated with a heightened risk of losing independence, developing dementia and dying. It can manifest as acute confusion and agitation or as uncharacteristic unresponsiveness and lethargy.

“What we’re seeing with COVID-19 and older adults are rates of delirium in the 70 percent to 80 percent range,” said Babar Khan, MD, associate director of Indiana University’s Center for Aging Research at the Regenstrief Institute, and one of Walters’ physicians.

Family members should insist on rehab therapy after a patient leaves the hospital and returns home. 

Gordon Quinn, 77, a Chicago documentary filmmaker, believes he contracted COVID-19 at a conference in Australia in early March. At Northwestern Memorial Hospital, he was put on a ventilator twice in the ICU, for a total of nearly two weeks, and remembers having “a lot of hallucinations”—a symptom of delirium.

“I remember vividly believing I was in purgatory. I was paralyzed—I couldn’t move. I could hear snatches of TV—reruns of Law & Order: Special Victims Unit—and I asked myself, ‘Is this my life for eternity?’” Quinn said.

Given the extent of delirium and mounting evidence of neurological damage from COVID-19, Khan said he expects to see “an increased prevalence of ICU-acquired, cognitive impairment in older COVID patients.”

Ely agrees. “These patients will urgently need to work on recovery,” he said. Family members should insist on securing rehabilitation services—physical therapy, occupational therapy, speech therapy, cognitive rehabilitation—after the patient leaves the hospital and returns home, he advised.

“Even at my age, people can get incredible benefit from rehab,” said Quinn, who spent nearly two weeks at Chicago’s Shirley Ryan AbilityLab, a rehabilitation hospital, before returning home and getting several weeks of home-based therapy. Today, he’s able to walk nearly 2 miles and has returned to work, feeling almost back to normal.

James Talaganis, 72, of Indian Head Park, IL, also benefited from rehab at Shirley Ryan AbilityLab after spending nearly four months in various hospitals beginning in early May.

Talaganis had a complicated case of COVID-19: his kidneys failed, and he was put on dialysis. He experienced cardiac arrest and was in a coma for almost 58 days while on a ventilator. He had intestinal bleeding, requiring multiple blood transfusions, and was found to have crystallization and fibrosis in his lungs.

When Talaganis began his rehab on Aug. 22, he said, “my whole body, my muscles were atrophied. I couldn’t get out of bed or go to the toilet. I was getting fed through a tube. I couldn’t eat solid foods.”

In early October, after getting hours of therapy each day, Talaganis was able to walk 660 feet in six minutes and eat whatever he wanted. “My recovery—it’s a miracle. Every day I feel better,” he said.

To recover from a critical illness, sometimes what patients need most is human connections. 

Unfortunately, rehabilitation needs for most older adults are often overlooked. Notably, a recent study found that one-third of critically ill older adults who survive a stay in the ICU did not receive rehab services at home after hospital discharge.

“Seniors who live in more rural areas or outside bigger cities where major hospital systems are providing cutting-edge services are at significant risk of losing out on this potentially restorative care,” said Sean Smith, MD, an associate professor of physical medicine and rehabilitation at the University of Michigan.

Sometimes what’s most needed for recovery from critical illness is human connection. That was true for Tom and Virginia Stevens of Nashville, TN, in their late 80s, who were both hospitalized with COVID-19 in early August.

Ely, one of their physicians, found them in separate hospital rooms, frightened and miserable. “I’m worried about my husband,” he said Virginia told him. “Where am I? What is happening? Where is my wife?” the doctor said Tom asked, before crying out, “I have to get out of here.”

Ely and another physician taking care of the couple agreed. Being isolated from each other was dangerous for this couple, married for 66 years. They needed to be put in a room together.

When the doctor walked into their new room the next day, he said, “it was a night-and-day difference.” The couple was sipping coffee, eating and laughing on beds that had been pushed together.

“They both got better from that point on. I know that was because of the loving touch, being together,” Ely said.

That doesn’t mean recovery has been easy. Virginia and Tom still struggle with confusion, fatigue, weakness and anxiety after their two-week stay in the hospital, followed by two weeks in inpatient rehabilitation. Now, they’re in a new assisted living residence, which is allowing outdoor visits with their family.

“Doctors have told us it will take a long time and they may never get back to where they were before COVID,” said their daughter, Karen Kreager, also of Nashville. “But that’s OK. I’m just so grateful that they came through this and we get to spend more time with them.”

 

Climate Change Endangers Many Older Adults

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

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

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

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

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

So why the disconnect? 

Climate Disasters and Later Life

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

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

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

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

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

Chronic Problems Made Worse

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

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

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

Attitudes toward Climate Change

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

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

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

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

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

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

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

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

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

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

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

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

Making the Message Stick

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

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

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

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

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

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

— Rick Lent 

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

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

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

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

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

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

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

Separating Science and Politics 

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

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

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

What Will Later Life Be Like Beyond COVID-19?

Older people anticipate changes and challenges ahead

At a time when the future seems unknowable—except that the “new normal” may not be much like the past—journalist Judith Graham talked to almost a dozen older people about their own hopes and fears. Her article was posted on the Kaiser Health News (KHN) website on July 7, 2020. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues.

Months into the coronavirus pandemic, older adults are having a hard time envisioning their “new normal.”

Many remain fearful of catching the virus and plan to follow strict precautions—social distancing, wearing masks and gloves, limiting excursions to public places—for the indefinite future.

Mortality is no longer an abstraction for those who have seen friends and relatives die of COVID-19. Death has an immediate presence as never before.

Many people are grieving the loss of their old lives and would love nothing better than to pick up where they left off. Others are convinced their lives will never be the same.

“We’re at the cusp of a new world,” said Harry Hutson, 72, an organizational consultant and executive coach who lives in Baltimore.

He’s among nearly a dozen older adults who discussed the “new normal” in lengthy conversations. All acknowledged their vulnerability as states across the country lifted stay-at-home orders. (Adults 65 and older are more likely to become critically ill if infected with the coronavirus.) Here’s some of what they said:

Willetha, 67, and Harold, 68, Barnette, of Durham, NC. The Barnettes are an unusual couple: they divorced in 1995 but began living together again in 2014 when both Willetha and her elderly mother became ill, and Harold returned to help.

For Willetha, who has Crohn’s disease and is immunocompromised, the “new normal” is characterized by vigilance—masks, gloves, disinfectants, social distancing, working remotely (she’s a development officer at a school).

“I’m not going to be comfortable freely moving around this world until they’re able to do reliable antibody testing and there is a vaccine,” she said. “Right now, I think we all have to learn to live smaller.”

I’m preparing myself for a different social order.

—Harold Barnette

Harold believes that self-reliance and local support networks are more important than ever. “To me, the pandemic reveals troubling things about the state of institutions in our society. The elder care system is rotten and the health care system full of neglect,” he said.

“I’m preparing myself for a different social order. I’m thinking that will be built on relationships with family and people near to us and we’ll all be helping each other out more.”

Patricia Griffin, 80, of Oxford, PA. Griffin is a retired microbiologist who lives alone in a continuing care community and loves to travel. In March, as the coronavirus pandemic gathered steam, she was due to take a trip to the Amazon, which was canceled.

I’m leaning toward being cautious but not being completely a prisoner.

—Patricia Griffin

“I envision conditions for seniors being restrictive until we have a vaccine,” Griffin said. “That makes me angry because I don’t have that many years left. And I would like to do the things I want to do. At the moment, I’m leaning toward being cautious but not being completely a prisoner.”

A big frustration for Griffin is the lack of clear guidance for healthy older adults like her who do not have underlying medical conditions. “All we see are statistics that lump all of us together, the healthy with those that have multiple issues,” she said. “I’m wondering what my odds of getting really sick from this virus are.”

Wilma Jenkins, 82, of South Fulton, GA. Jenkins, who has coped with depression most of her life and describes herself as an introvert, lives alone in a small house just outside Atlanta.

“I confess I’m going to be afraid for a while,” she said.

During the pandemic, her three adult children and grandchildren have created a new tradition: Zoom meetings every Sunday afternoon. Previously, the entire family got together once a year, at Thanksgiving. “It helps me a lot, and I think it will last because we have so much fun,” Jenkins said.

Before her life ground to a halt, Jenkins regularly gave presentations at senior centers across Atlanta on what it’s like to grow old. “My work is helping little old people like me,” she said, “and when I can get out again, I’ll be reminding them that we have reached a point when we can wear the crown of age and we should be doing that proudly.”

Marian and Ed Hollingsworth, 66 and 72, of La Mesa, CA. Ed has a rare gastrointestinal cancer and is enrolled in a clinical trial of a new drug.

“My vision of the future is somewhat limited, given my age and my prognosis,” he said. “There’s a constant fear and uncertainty. I don’t see that changing anytime soon. We’ll be in the house a lot, cooking a lot, watching a lot of Netflix.”

“I’m looking at least a year or two of taking strong precautions,” said Marian, a patient-safety advocate.

“I always was the person who was active and doing for others. Now I’m the one at home having to ask for help, and it feels so foreign,” she said. Her most immediate heartache: “We don’t know when we’ll see our [four] kids again.”

Richard Chady, 75, of Chapel Hill, NC. Chady, a former journalist and public relations professional, lives in a retirement community and participates in the North Carolina Coalition on Aging.

“This pandemic has given me a greater appreciation of how precious family and friends are,” he said. “I think it will cause older people to examine their lives and their purpose a little more carefully.”

Chady is optimistic about the future. “I’ve been involved in progressive causes for a long time, and I think we have a great opportunity now. With all that’s happened, there’s more acceptance of the idea that we need to do more to improve people’s lives.”

Edward Mosley, 62, of Atlanta. Mosley lives alone in Big Bethel Village, an affordable senior housing community. Disabled by serious heart disease, he relies on Supplemental Security Income and Medicaid. In the past year, he has had multiple hospitalizations.

“The pandemic, it affected me because they canceled my doctors’ appointments, and I was in a bad way,” said Mosley, who had a pacemaker implanted in his chest before COVID-19 emerged. “But I’m doing better now. I can walk with a cane, though not very far.”

The hardest thing for Mosley is not being able to mingle with other people “because you don’t know where they’ve been or who they’ve been with. You feel like you’re in solitary confinement.”

Vicki Ellner, 68, of Glenwood Landing, NY. Ellner ran [the] Senior Umbrella Network of Brooklyn for 20 years. Today she works as a consultant for an elder care attorney on Long Island.

Before the coronavirus upended life in and around New York City, Ellner and the attorney were planning to launch an initiative aimed at older women. Now, they’ve broadened it to include older men and address issues raised during the pandemic. The theme: “You’re not done yet.”

Ellner explains it this way: “Maybe you were on a path and had a vision of your life in mind. Then all of a sudden you have these challenges. Maybe you lost your job, or maybe things have happened in your family. What we want to help people understand is you’re not done yet. You still have the ability to redirect your life.”

In her personal life, Ellner, who lives with a “significant other,” is determined to keep fear at bay. “We tell ourselves we’re doing everything we can to stay vital and get through this. We try to turn that into a positive.”

Harry Hutson, 72, of Baltimore. Hutson, an organizational consultant and executive coach, is married and has five grown children. He believes “an enormous change in lifestyle” is occurring because of the pandemic.

“We’re all more careful, but we’re also more connected,” he said. “Older friends are coming out of the woodwork. Everyone is Zooming and making calls. People are more open and vulnerable and willing to share than before. We’re all trying to make meaning of this new world.”

“We’re all having a traumatic experience—an experience of collective trauma,” Hutson said. As the future unfolds, “the main thing is self-care and compassion. That’s the way forward for all of us.”

Annis Pratt, 83, of Birmingham, MI. A retired English professor, novelist and environmental activist, Pratt lives alone in a home in suburban Detroit.

“What I’m looking forward to is getting back to interacting with real people. Much of my human contact now is on Zoom, which I consider about 75% of a personal encounter,” she said. “But every day, I make myself go out and talk to someone—like taking a vitamin pill.”

Pratt now has a “do not put me on a ventilator” order in her front hallway, along with a “do not resuscitate” order. “I know it’s very likely that if I get to the point where I have to go to the hospital, I’ll probably die,” she said. “Of course, I’m going to die anyway: I’m 83. But somehow, this pandemic has brought it all home.”

Going forward, Pratt sees two possibilities. “Our moral imaginations will have grown because of what we’ve all gone through, and we will do better. Or nothing will have changed.”

Most of all, she said, “I would like to get my wonderful, wonderful life back.”

The Doctor Is In (Virtually)

Older adults are testing telemedicine’s advantages, drawbacks

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

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

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

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

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

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

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

Advantages of Virtual Visits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Technological Challenges

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

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

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

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

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

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

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

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

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

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

Permanent Change or Emergency Stopgap?

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

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

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

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

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

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

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

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

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

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

Helpful preparation may include:

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

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

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

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

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

Older People Are Having Second Thoughts about Where to Live

From aging in place to assisted living, housing choices look different since the pandemic

In this piece written for Kaiser Health News (KHN), journalist Judith Graham investigates the dilemma older people and their families face as the pandemic calls many housing solutions into question. KHN posted her story on Sept. 18, 2020, and it also ran on CNN. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues.

Where do we want to live in the years ahead?

Older adults are asking this question anew in light of the ongoing toll of the coronavirus pandemic—disrupted lives, social isolation, mounting deaths. Many are changing their minds.

Some people who planned to move to senior housing are now choosing to live independently rather than communally. Others wonder whether transferring to a setting where they can get more assistance might be the right call.

These decisions, hard enough during ordinary times, are now fraught with uncertainty as the economy falters and COVID-19 deaths climb, including tens of thousands in nursing homes and assisted living centers.

Teresa Ignacio Gonzalvo and her husband, Jaime, both 68, chose to build a house rather than move into a continuing care retirement community when they relocate from Virginia Beach, VA, to Indianapolis, IN, later this year to be closer to their daughters.

Having heard about lockdowns around the country because of the coronavirus, Gonzalvo said, “We’ve realized we’re not ready to lose our independence.”

Alissa Ballot, 64, is planning to leave her 750-square-foot apartment in downtown Chicago and put down roots in a multigenerational cohousing community where neighbors typically share dining and recreation areas and often help one another.

“What I’ve learned during this pandemic is that personal relationships matter most to me, not place,” she said.

Kim Beckman, 64, and her husband, Mike, were ready to give up being homeowners in Victoria, TX, and join a 55-plus community or rent in an independent living apartment building in northern Texas before COVID-19 hit.

Because of the many COVID-19 deaths in nursing homes and assisted living facilities, many elders are nervous about where to live.

Now, they’re considering buying an even bigger home because “if you’re going to be in the house all the time, you might as well be comfortable,” Beckman said.

“Everyone I know is talking about this,” said Wendl Kornfeld, 71, who lives on the Upper West Side of Manhattan. She has temporarily tabled the prospect of moving into a continuing care retirement community being built in the Bronx.

“My husband and I are going to play it by ear; we want to see how things play out” with the pandemic, she said.

In Kornfeld’s circles, people are more committed than ever to staying in their homes or apartments as long as possible—at least at the moment. Their fear: if they move to a senior living community, they might be more likely to encounter a COVID outbreak.

“All of us have heard about the huge number of deaths in senior facilities,” Kornfeld said. But people who stay in their own homes may have trouble finding affordable help there when needed, she acknowledged.

More than 70,000 residents and staff members in nursing homes and assisted living facilities had died of COVID-19 by mid-August, according to the latest count from KFF, (Kaiser Family Foundation). This is an undercount because less than half of states are reporting data for COVID-19 in assisted living. Nor is data reported for people living independently in senior housing. (KHN is an editorially independent program of KFF.)

Nervousness about senior living has spread as a result, and in July, the National Investment Center for Seniors Housing & Care [NIC] reported the lowest occupancy rates since the research organization started tracking data 14 years ago. Occupancy dropped more in assisted living (a 3.2 percent decline from April through June, compared with January through March) than in independent living (a 2.4 percent decline). The organization doesn’t compile data on nursing homes.

In a separate NIC survey of senior housing executives in August, 74 percent said families had voiced concerns about moving in as COVID cases spiked in many parts of the country.

Overcoming Possible Isolation

The potential for social isolation is especially worrisome, as facilities retain restrictions on family visits and on group dining and activities. (While states have started to allow visits outside at nursing homes and assisted living centers, most facilities don’t yet allow visits inside—a situation that will increase frustration when the weather turns cold.)

Beth Burnham Mace, NIC’s chief economist and director of outreach, emphasized that operators have responded aggressively by instituting new safety and sanitation protocols, moving programming online, helping residents procure groceries and other essential supplies and communicating regularly about COVID-19, both on-site and in the community at large, much more regularly.

Mary Kazlusky, 76, resides in independent living at Heron’s Key, a continuing care retirement community in Gig Harbor, Washington, which is doing all this and more with a sister facility, Emerald Heights in Redmond, WA. 

“We all feel safe here,” she said. “Even though we’re strongly advised not to go into each other’s apartments, at least we can see each other in the hall and down in the lobby and down on the decks outside. As far as isolation, you’re isolating here with over 200 people: there’s somebody always around.”

One staff member at Heron’s Key tested positive for COVID-19 in August but has recovered. Twenty residents and staff members tested positive at Emerald Heights. Two residents and one staff member died.

Some families find that, since the pandemic, older relatives have trouble managing on their own. 

Colin Milner, chief executive officer of the International Council on Active Aging, stresses that some communities are doing a better job than others. His organization recently published a report on the future of senior living in light of the pandemic.

It calls on operators to institute a host of changes, including establishing safe visiting areas for families both inside and outside; providing high-speed internet services throughout communities; and ensuring adequate supplies of masks and other forms of personal protective equipment for residents and staff, among other recommendations.

Some families now wish they’d arranged for older relatives to receive care in a more structured environment before the pandemic started. They’re finding that older relatives living independently, especially those who are frail or have mild cognitive impairments, are having difficulty managing on their own.

“I’m hearing from a lot of people—mostly older daughters—that we waited too long to move Mom or Dad, we had our head in the sand, can you help us find a place for them,” said Allie Mazza, who owns Brandywine Concierge Senior Services in Kennett Square, PA. 

While many operators instituted move-in moratoriums early in the pandemic, most now allow new residents as long as they test negative for COVID-19. Quarantines of up to two weeks are also required before people can circulate in the community.

Many older adults, however, simply don’t have the financial means to make a move. More than half of middle-income seniors—nearly 8 million older adults—can’t afford independent living or assisted living communities, according to a study published last year. And more than 7 million seniors are poor, according to the federal Supplemental Poverty Measure, which includes out-of-pocket medical expenses and other drains on cash reserves.

Questions to Ask

For those able to consider senior housing, experts suggest you ask several questions:

  • How is the facility communicating with residents and families? Has it had a COVID outbreak? Is it disclosing COVID cases and deaths? Is it sharing the latest guidance from federal, state and local public health authorities?
  • What protocols have been instituted to ensure safety? “I’d want to know: Do they have a plan in place for disasters—not just the pandemic but also floods, fires, hurricanes, blizzards?” Milner said. “And beyond a plan, do they have supplies in place?”
  • How does the community engage residents? Is online programming—exercise classes, lectures, interest group meetings—available? Are one-on-one interactions with staffers possible? Are staffers arranging online interactions via FaceTime or Zoom with family? Are family visits allowed? “Social engagement and stimulation are more important than ever,” said David Schless, president of the American Seniors Housing Association.
  • What’s the company’s financial status and occupancy rate? “Properties with occupancy rates of 90 percent or higher are going to be able to withstand the pressures of COVID-19 significantly more than properties with occupancy below 80 percent, in my opinion,” said Mace of the National Investment Center for Seniors Housing & Care. Higher occupancy means more revenues, which allows institutions to better afford extra expenses associated with the pandemic.

“Transparency is very important,” Schless said.

 

 

Bob Blancato: Fighting Elder Abuse through Politics

He worked to get the Elder Justice Act passed. Now, he says, it’s long past time to fund it.

This article is the next in our series on the future of aging: interviews with people who are experts in their fields and are also visionaries. We’re asking them to talk about what they believe will happen in the years ahead to change the experience of aging.

Bob Blancato has educated Congress about elder abuse since the problem came to national light about four decades ago. Ultimately, beginning in 2003, he led the seven-year fight to get the Elder Justice Act passed. Yet it remains unfunded. Blancato believes the act could help prevent the scams and neglect that cause pain for so many older adultsand he intends to see this fight through.

In 1981, a US Senate committee released the first congressional report on a problem that was gradually coming to light—one that was “shameful” and “alien to the American spirit.” It was being called elder abuse. 

The report estimated that 4 percent of older Americans were neglected or were abused physically, sexually, financially or psychologically. 

Today, experts believe the number is actually closer to 10 percent. That’s about five million people 65 and older. By 2060, as America’s population ages, it could be closer to ten million. 

Bob Blancato is working to prevent that.

His goal: getting the Elder Justice Act funded. It was passed in 2010 to pay for prevention, education and prosecution programs across the country, but it’s never been fully funded. 

Research suggests that older people who are abused are more likely to develop depression, to be admitted to a hospital and even to die. Financial abuse alone costs older people $3 billion to $37 billion a year, according to the National Council on Aging.

Blancato believes the act could prevent a lot of this pain, but getting it funded is going to take a lot of politicking.

Fortunately for his pursuit, he has a venerable career in advocating for older Americans—dating back to a part-time job in 1973.

“When I was a junior at Georgetown University,” he recalls, “I had a professor who said, ‘You can get three credits one of two ways. You can either come hear my boring lectures or get yourself a job on Capitol Hill.’” 

Blancato got himself that job. 

He became a legislative assistant to Rep. Mario Biaggi, who was from Blancato’s home state, New York. The following year, Biaggi joined the newly created House Select Committee on Aging. Blancato ended up becoming staff director of the subcommittee that released that first report in 1981.

“It was an assignment that became a commitment,” he says. “If my boss had been put on another committee, I would have been assigned to work on that.” 

The commitment became a passion, and today Blancato is still fighting to improve the lives of older people. 

Becoming an Advocate

A few years after Blancato joined Biaggi’s staff, Florida congressman Claude Pepper, then in his 70s, became the Committee on Aging’s chairman. 

“He trained a bunch of us, who were in our 20s at the time, to do advocacy,” Blancato says. “We used to call ourselves the greatest inside lobbying group that Congress ever had, because we were working as staffers, but we were doing, in effect, lobbying for improved legislation.”

In 1988, Blancato became the first vice president of the new National Committee for the Prevention of Elder Abuse. Seven years later, President Bill Clinton appointed him executive director of the 1995 White House Conference on Aging. 

Then, in 2003, Sen. John Breaux of Louisiana introduced the Elder Justice Act in the Senate. “Senator Breaux called me and said, ‘Now Bob, we’re serious about this bill, and we need a dedicated coalition that will commit itself to try to get this bill passed. Since we all know you, we want you to run it,’” Blancato recalls. The group was to be called the Elder Justice Coalition. 

In 2010, after seven years of coalition advocacy and congressional stalls, the Elder Justice Act passed as part of the Patient Protection and Affordable Care Act. It was a momentous win. But disappointment was in store.

So far, the Elder Justice Act has received just 8 percent of the funding Congress approved. 

The act authorized $777 million to be spent over four years on various state and local programs. It could be renewed every year thereafter, as long as Congress appropriated money to it. The catch was, funding wasn’t mandated, even for the first four years. 

To date, a total of $66 million has been appropriated to the Elder Justice Act—8 percent of what Congress approved. 

So Blancato’s fight continues—now focused on funding the act. He is still the national coordinator for the Elder Justice Coalition. “We had five founding members, and now we have well over 3,000 different people who are part of the coalition in one form or another,” he says.

He’s also national coordinator of the Defeat Malnutrition Today coalition, executive director of the National Association of Nutrition and Aging Services Programs and president of the strategic consultation firm Matz, Blancato and Associates. 

The Silver Century Foundation spoke with Blancato about his journey—and why the Elder Justice Act continues to be underfunded.

SCF: Looking back over your career, what are you proudest of?

BB: Seeing the passage of the Elder Justice Act in 2010. The process that led to that was amazing; was frustrating; was inspiring; was the good about politics, the bad about politics. 

It proved the adage that there is no good policy without politics. In the end, both what we did right and what we haven’t done enough of going forward is, you’ve got to make your issues political issues as much as policy issues. If you go back home and you’re a member of Congress or a senator, you want to hear about this issue from people there. When [members of Congress] come back, they say, “What are we doing about this?” One of the jobs that we’re working on doing is improving grassroots advocacy around elder abuse.

[Blancato’s phone rings.]

Now that’s the perfect example of what we try to fight against: robocalls. 

SCF: Are robocalls a major issue you’re working on?

BB: We work on that a lot. In fact, we’ve been working very closely with the Justice Department, with the Federal Communications Commission, with Congress, all about cracking down on these robocalls, particularly the ones that swindle older people out of resources. As you know, it’s a huge problem.

I give credit to this [Trump] administration—not all the time—but I do think that they have understood one dimension of elder abuse that is important, which is that it’s a crime. And that you need to put the resources of your federal agency to work when you’re running into these kind of problems. 

[In 2019], the Justice Department organized a sweep, and they picked up over 200 different swindlers and got them arrested and stopped. They had fleeced older people out of some tremendous amount of money.

SCF: Which brings us to this point: elder abuse is already illegal. Why do we need an act about it?

BB: The act is more about having the resources to help people who are on the front lines of preventing elder abuse to be able to do their job better. The key feature of the Elder Justice Act was to give Adult Protective Services a dedicated funding stream, which they currently don’t have.

They are funded through a Social Services Block Grant. Block grants really mean that the state can decide where they spend the money. Under the Social Services Block Grant, you can spend it on any number of things, including Child Protective Services, home delivered meals, Adult Protective Services. But in 12 states in this country, they don’t spend a nickel on Adult Protective Services. Yet elder abuse occurs in those states.

So the rationale behind this was, let them have their own funding stream, and let us develop a decent data collection system so that we can make the case more effectively. Because right now, and for the last few years in this environment, if you have good data, you have a chance of getting money. If you have no data, then you’re in trouble. 

SCF: Is there something you wish Americans understood about elder abuse that we don’t?

BB: There’s a certain degree of denial still that I run into sometimes. Like when my colleagues who work for the coalition go up to visit Capitol Hill and talk to staff people—many of them very young—they don’t grasp it; they don’t see it. But then you say, “What if it happened to your grandmother? Your parents?” And then all of a sudden, it’s a different conversation. 

So what we always do—advocacy 101, you always have leave-behinds for when you walk out of a congressional office. You bring, in your little packet, a summary of the Elder Justice Act, maybe a couple of fact sheets, and then you bring a news clip from the closest newspaper you can find to that congressional office. And then the headline speaks for itself: it talks about a ring of swindlers [or] the older veteran who got caught up in a sweetheart scam with some young woman moving in with him, and then next thing you know, the guy’s out of $50,000. 

Or the grandkids scandal. Statistically, the average victim of elder abuse is an older woman living alone between the age of 75 and 80. The Census Bureau says that about 47 percent of all women 75 and over in this country now live alone. So you can see where the potential is for problems, right?

This is how I introduce this topic when I go out on the road and I talk to people who may not be that familiar with it. I say, “OK, let’s pretend for a moment that you’re an older woman, and you’ve been home all day. No one’s talked to you, no contact of any kind. The phone rings at 4:00. And you pick it up. And it’s a human voice; it’s contact. But guess what else it is. It’s a scammer, who’s trying to take advantage of your situation of wanting to have contact with somebody.” 

The minute you establish trust with an older person and you violate that trust, that’s elder abuse. It can happen between family members, it can happen with outsiders, it can happen on the telephone, it can happen with somebody driving down the street and they come knock on your door and say, “Look, there’s a big tree limb hanging over the back of your roof, and I’m more than happy to get rid of that for you, if you’ll just give me a check for the parts and stuff. I’ll be back later.” And then they never come back.

But there’s this one in particular that—and even with all the years I’ve worked, I don’t understand how this works—but you’re at home. The phone rings. “Hi, it’s your grandson. I’ve been arrested in Canada. I need $3,000 in bail money right away. Here’s where you send it.” And they make the voice sound like it’s actually your grandchild. It’s amazing! That’s the one I really hope they can bust, because there’s obviously an organized ring that’s doing that.

But the point is, you have to humanize this issue in the best way you can, so that people understand that it does exist. And that’s been a struggle. 

The Child Abuse Prevention and Treatment Act was passed in 1974. It became law. And we’ve now spent $8 or $9 billion helping to combat child abuse, which we should do. We passed a law in 1992 called the Violence Against Women Act to cut down on domestic violence, which we should do. But it took us until 2010 to pass an elder abuse bill—the Elder Justice Act—and we’re still struggling to get the money!

SCF: Why do you think that is?

BB: I’ll give you two reasons. One is, as fate had it, the Elder Justice Act only became law because of a strange process. The Elder Justice Act passed a very key Senate committee on two or three different occasions, but they could never get it over the finish line and get it passed in the full Senate and the full House.

So a wonderful human being, a former senator from Utah named Orrin Hatch, who was one of the authors of the Elder Justice Act, said to me in 2009, “Bob, despite the merits of this bill and all the good things that this bill could do, it’s never going to pass by itself. So you need to figure out what’s a moving vehicle—a bigger bill that’s going to come out of this committee that we can attach the Elder Justice Act to.” And I said, “OK, that’s great advice; we’ll monitor that situation.”

Well that year, the only bill that came out of the finance committee was the Affordable Care Act. And when Obama got elected and the administration found reason to support the bill—as compared to the previous administration, which opposed it—we said, “Well, I guess if this is the only vehicle we have, then let’s do our best to get it included in the final bill.”

That’s where one of the problems was: that bill never got a single Republican vote. And if you weren’t mandatorily funded in that bill, you had to go out year after year to go and get funding from the Appropriations Committee. 

Its placement in that bill hung over us for a long time. But at the same time, we wouldn’t have had a law if there wasn’t a place to put it. 

SCF: And nothing’s changed, right? It’s still part of that bill and you’re still having trouble getting funding?

BB: In a technical sense, yeah. I mean, technically speaking, the Elder Justice Act was a four-year bill, and its authority expired a number of years ago. But as long as you get funded, even at a small level, you have the organic ability to continue. But we don’t want to be in this limbo status forever. That’s why we want to get a new version passed to provide the authority to continue the work of the Elder Justice Act that’s already been started.

Little by little, we are seeing more support come forward. But our strategy going forward will be much more focused on the money side this time. 

SCF: Are you saying that the focus is passing a new version of the bill that is fully funded?

BB: We’re going to be seeking to get the bill that was passed repassed with a couple of changes, and then be more aggressive in the year-to-year funding cycle to get increased appropriation.

SCF: Let’s say, poof! The bill is fully funded. What’s the most important thing you’d like to see done first? Or what’s the biggest thing we’re missing out on by not having it funded?

BB: Well, your cases of elder abuse would drop, for a starting point. 

If you had an adequately funded Adult Protective Services operation—which does a number of things: it initially does investigation when a report comes in about the potential of elder abuse. It will seek to get a remedy for that particular case, whether it’s a prosecution or something else. But it also engages in educational activity to help prevent elder abuse to begin with. 

And then with the ombudsmen: if you have access to the nursing home and you are handling complaints that come in and you’re reporting them, you’re helping to reduce the instance of abuse in nursing homes.

If you can fund what they call forensic centers, so that when an older person goes to an emergency room with a bruise, and they assume it was a fall but it could have been physical abuse, a forensic center will teach you as an emergency room person what the difference is and how to look for it.

And then there’s funding for adequate staffing in nursing homes that was included in the Elder Justice Act. Right now we definitely need to step that up a little bit.

But I’ll tell you, the one good thing that has occurred—that continues to occur and has been done by both the Obama and the Trump administrations—that came out of the Elder Justice Act was the creation of what they call the Elder Justice Coordinating Council.

This is 15 federal agencies—all of whom have some work going on in the space of elder abuse prevention—coordinating their activities so they get maximum value for the dollar. So the Postal Service Inspection System can sit down with the Department of Justice. The Department of Health and Human Services can sit down with the Social Security Administration. And they can all compare notes on what work they’re doing to help prevent elder abuse, but under some direct authority to coordinate that activity.

It’s been great to see. I testified before the first meeting that this group had, in 2012. The cochairs at the time were the secretary of [Health and Human Services] and the attorney general. So they were there briefly to do their thing. And then each other agency introduced themselves and talked a little bit about what they were doing in the space, right? And I’m watching these other agencies—they were writing these notes down like this was the first time they ever heard about this. And I’m like, this is why you exist. This is exactly why you exist. 

Once we can put it in one place, then we’re at least doing something with what we have, to make a difference, to make a dent. So that stays. That continues. It’s very important work. That’s probably one of the more important features of the Elder Justice Act.

SCF: Is there one form of elder abuse that’s most pressing to get a handle on or that bothers you the most?

BB: The thing that bothers me the most is the growing cases of self-neglect. Statistics say basically that it’s in the top three categories of the fastest growing forms of elder abuse. And what bothers me about that is it coincides with the increased focus on isolation and loneliness among older people. 

When you get to the status of being a victim of self-neglect, that means you’ve been abandoned. 

SCF: No one is making sure you’re taking care of yourself.

BB: And there are some victims of self-neglect who were victims of neglect prior to that, where somebody was “taking care of them” but really wasn’t, and then they walked away or whatever and left these people on their own. We really have got to improve our understanding of the issue and how to deal with it, because it’s the saddest of them all, frankly.

The one that’s probably the most prevalent is financial elder abuse. The data suggests that older people lose as much as $3 billion a year [as] victims of financial abuse. But there is activity going on, at the federal level and at the state level, to combat financial abuse and exploitation. It’s tangible. You can put out tips: don’t do this; look out for this; be aware of this. That one’s a little easier. None of them are easy, but this is a little easier than dealing with self-neglect.

SCF: If someone wants to support funding the Elder Justice Act, is there anything they can do?

BB: Write a letter to your senators and your congressperson and ask them what their position is on it. Wait to see what comes back, and then take your follow-up from there. 

The people who are really creative will do things like get letters to the editor published during the holidays, for example, which is a time when everybody starts thinking about elder abuse, because it happens a lot in the holidays.

And then the other thing you can tell them to do is to go to our [website], www.elderjusticecoalition.com, and join us.

This interview has been edited for length and clarity.

COVID-19 Is Damaging Bereaved Families

The trauma and the grief could last for years

Losing someone you love is hard enough, but losing them to COVID can compound your grief. Journalist Judith Graham describes what’s happening as the pandemic wears on and where help can be found. Kaiser Health News posted her article on August 12, 2020. The story also ran on CNN. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues.  

Every day, the nation is reminded of COVID-19’s ongoing impact as new death counts are published. What is not well documented is the toll on family members.

New research suggests the damage is enormous. For every person who dies of COVID-19, nine close family members are affected, researchers estimate, based on complex demographic calculations and data about the coronavirus.

Many survivors will be shaken by the circumstances under which loved ones pass away—rapid declines, sudden deaths and an inability to be there at the end—and worrisome ripple effects may linger for years, researchers warn.

If 190,000 Americans die from COVID complications, . . . some models suggest, 1.7 million Americans will be grieving close family members, according to the study. Most likely to perish are grandparents, followed by parents, siblings, spouses and children.

“There’s a narrative out there that COVID-19 affects mostly older adults,” said Ashton Verdery, a coauthor of the study and a professor of sociology and demography at Pennsylvania State University. “Our results highlight that these are not completely socially isolated people that no one cares about. They are integrally connected with their families, and their deaths will have a broad reach.”

Because of family structures, Black families will lose slightly more close family members than white families, aggravating the pandemic’s disproportionate impact on African American communities. (Verdery’s previous research modeled kinship structures for the US population, dating to 1880 and extending to 2060.)

The potential consequences of these losses are deeply concerning, with many families losing important sources of financial, social and caregiving support. “The vast scale of COVID-19 bereavement has the potential to lower educational achievement among youth, disrupt marriages, and lead to poorer physical and mental health across all age groups,” Verdery and his coauthors observe in their paper.

Not being there in your love one’s time of need, not being able to say goodbye, make prolonged grief and post-traumatic stress more likely. 

Holly Prigerson, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City, sounds a similar alarm, especially about the psychological impact of the pandemic, in a new paper on bereavement.

“Bereaved individuals have become the secondary victims of COVID-19, reporting severe symptoms of traumatic stress, including helplessness, horror, anxiety, sadness, anger, guilt, and regret, all of which magnify their grief,” she and coauthors from Memorial Sloan Kettering Cancer Center in New York noted.

In a phone conversation, Prigerson predicted that people experiencing bereavement will suffer worse outcomes because of lockdowns and social isolation during the pandemic. She warned that older adults are especially vulnerable.

“Not being there in a loved one’s time of need, not being able to communicate with family members in a natural way, not being able to say goodbye, not participating in normal rituals—all this makes bereavement more difficult and prolonged grief disorder and post-traumatic stress more likely,” she noted.

Organizations that offer bereavement care are seeing this unfold as they expand services to meet escalating needs.

Typically, 5 percent to 10 percent of bereaved family members have a “trauma response,” but that has “increased exponentially—approaching the 40 percent range—because we’re living in a crisis,” said Yelena Zatulovsky, vice president of patient experience at Seasons Hospice & Palliative Care, the nation’s fifth-largest hospice provider.

Since March, Seasons has doubled the number of grief support groups it offers to 29, hosted on virtual platforms, most of them weekly. All are free and open to community members, not just families whose loved ones received care from Seasons. (To find a virtual group in your time zone, call 1-855-812-1136, Season’s 24/7 call center.)

Besides losing family members and friends, people are losing jobs and any sense of normalcy and safety.

“We’re noticing that grief reactions are far more intense and challenging,” Zatulovsky said, noting that requests for individual and family counseling have also risen.

Medicare requires hospices to offer bereavement services to family members for up to 13 months after a client’s death. Many hospices expanded these services to community members before the pandemic, and Edo Banach, president and CEO of the National Hospice and Palliative Care Organization, hopes that trend continues.

“It’s not just the people who die on hospice and their families who need bereavement support at this time; it’s entire communities,” he said. “We have a responsibility to do even more than what we normally do.”

In New York City, the center of the pandemic in its early months, the Jewish Board is training school administrators, teachers, counselors and other clinicians to recognize signs of grief and bereavement and provide assistance. The health and human services organization serves New Yorkers regardless of religious affiliation.

“There is a collective grief experience that we are all experiencing, and we’re seeing the need go through the roof,” said Marilyn Jacob, a senior director who oversees the organization’s bereavement services, which now include two support groups for people who have lost someone to COVID-19.

“There’s so much loss now, on so many different levels, that even very seasoned therapists are saying, ‘I don’t really know how to do this,’” Jacob said. In addition to losing family members, people are losing jobs, friends, routines, social interactions and a sense of normalcy and safety.

For many people, these losses are sudden and unexpected, which can complicate grief, said Patti Anewalt, director of Pathways Center for Grief & Loss in Lancaster, PA, affiliated with the state’s largest not-for-profit hospice. The center recently created a four-week group on sudden loss to address its unique challenges.

Coping with grief, especially when it is complicated by social isolation and trauma, takes time. Support groups can help. 

The day before Julie Cheng’s 88-year-old mother was rushed to the hospital in early July, she had been singing songs with Cheng’s sister over the phone at her Irvine, CA, nursing home. The next morning, a nurse reported that the older woman had a fever and was wheezing badly. At the hospital, COVID-19 was diagnosed and convalescent plasma therapy tried. Within two weeks, after suffering a series of strokes, Cheng’s mother died.

Since then, Cheng has mentally replayed the family’s decision not to take her mother out of the nursing home and to refuse mechanical ventilation at the hospital—something she was sure her mother would not have wanted.

“There have been a lot of ‘what ifs?’ and some anger: someone or something needs to be blamed for what happened,” she said, describing mixed emotions that followed her mother’s death.

But acceptance has sprung from religious conviction. “Mostly, because of our faith in Jesus, we believe that God was ready to take her and she’s in a much better place now.”

Coping with grief, especially when it is complicated by social isolation and trauma, takes time. If you are looking for help, call a local hospice’s bereavement department and ask what kind of services it provides to people in the community. Funeral directors should also have a list of counselors and grief support programs. One option is GriefShare, offered by churches across the country.

Many experts believe the need for these kinds of services will expand exponentially as more family members emerge from pandemic-inspired shock and denial.

“I firmly believe we’re still at the tip of the iceberg, in terms of the help people need, and we won’t understand the full scope of that for another six to nine months,” said Diane Snyder-Cowan, leader of the bereavement professionals steering committee of the National Council of Hospice and Palliative Professionals.

Will Lifelong Learning Change the Way We Age?

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

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

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

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

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

Learning as Reinvention 

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

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

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

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

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

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

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

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

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

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

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

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

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

Learning for Employability 

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

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

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

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

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

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

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

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

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

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

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

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

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

Joys of Learning

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

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

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

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

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

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

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

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

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

Age Diversity on Campus

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

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

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

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

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

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

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

Should You Change Your Living Will Because of the Pandemic?

Some older people are doing that—and ruling out intubation

What kind of hospital care would you want if you had COVID-19 and were desperately ill? In this article, journalist Judith Graham pulls together the facts about treatments, especially with ventilators, along with expert advice on what to do and how to decide. Her article was posted on the KHN website on May 12, 2020, and also ran on the Washington Post.

DENVER ― Last month, Minna Buck revised a document specifying her wishes should she become critically ill.

“No intubation,” she wrote in large letters on the form, making sure to include the date and her initials.

Buck, 91, had been following the news about COVID-19. She knew her chances of surviving a serious bout of the illness were slim. And she wanted to make sure she wouldn’t be put on a ventilator under any circumstances.

“I don’t want to put everybody through the anguish,” said Buck, who lives in a continuing care retirement community in Denver.

For older adults contemplating what might happen to them during this pandemic, ventilators are a fraught symbol, representing a terrifying lack of personal control as well as the fearsome power of technology.

Used for people with respiratory failure, a signature consequence of severe COVID-19, these machines pump oxygen into a patient’s body while he or she lies in bed, typically sedated, with a breathing tube snaked down the windpipe (known as “intubation”).

For some seniors, this is their greatest fear: being hooked to a machine, helpless, with the end of life looming. For others, there is hope that the machine might pull them back from the brink, giving them another shot at life.

“I’m a very vital person: I’m very active and busy,” said Cecile Cohan, 85, who has no diagnosed medical conditions and lives independently in a house in Denver. If she became critically ill with COVID-19 but had the chance of recovering and being active again, she said, “yes, I would try a ventilator.”

Out of all those who become infected with COVID-19, frail older adults are the least likely to survive treatment with a ventilator.

What’s known about people’s chances?

Although several reports have come out of China, Italy and, most recently, the area around New York City, “the data is really scanty,” said Carolyn Calfee, a professor of anesthesia at the University of California-San Francisco [UCSF].

Initial reports suggested that the survival rate for patients on respirators ranged from 14 percent (Wuhan, China) to 34 percent (early data from the United Kingdom). A report from the New York City Area appeared more discouraging, with survival listed at only 11.9 percent.

But the New York data incorporated only patients who died or were discharged from hospitals—a minority of a larger sample. Most ventilator patients were still in the hospital, receiving treatment, making it impossible for researchers to draw reliable conclusions.

Calfee worries that data from these early studies may not apply to US patients treated in hospitals with considerable resources.

“The information we have is largely from settings with tremendous resource gaps and from hospitals that are overwhelmed, where patients may not be treated with optimal ventilator support,” she said. “I would be very worried if people used that data to make decisions about whether they wanted mechanical ventilation.”

Still, a sobering reality emerges from studies published to date: older adults, especially those with underlying medical conditions such as heart, kidney or lung disease, are least likely to survive critical illness caused by the coronavirus or treatment with a ventilator.

“Their prognosis is not great,” said Douglas White, MD, a professor of critical care medicine at the University of Pittsburgh. He cautioned, however, that frail older adults shouldn’t be lumped together with healthy, robust older adults, whose prospects may be somewhat better.

The choice isn’t as black-and-white as go on a ventilator or die.

Like other clinicians, White has observed that older COVID patients are spending considerably longer on ventilators—two weeks or more—than is the case with other critical illnesses. If they survive, they’re likely to be extremely weak, deconditioned, suffering from delirium and in need of months of ongoing care and physical rehabilitation.

“It’s a very long, uphill battle to recovery,” and many older patients may never regain full functioning, said Negin Hajizadeh, MD, an associate professor of critical care medicine at the School of Medicine at Hofstra/Northwell on New York’s Long Island. “My concern is, who’s going to take care of these patients after a prolonged ventilator course—and where?”

In St. Paul, MN, Joyce Edwards, 61, who is unmarried and lives on her own, has been wondering the same thing.

In late April, Edwards revised her advance directive to specify that “for COVID-19, I do not want to be placed on a ventilator.” Previously, she had indicated that she was willing to try a ventilator for a few days but wanted it withdrawn if the treatment was needed for a longer period.

“I have to think about what the quality of my life is going to be,” Edwards said. “Could I live independently and take care of myself—the things I value the most? There’s no spouse to take care of me or adult children. Who would step into the breach and look after me while I’m in recovery?”

People who’ve said “give a ventilator a try but discontinue it if improvement isn’t occurring” need to realize that they almost surely won’t have time to interact with loved ones if treatment is withdrawn, said Christopher Cox, MD, an associate professor of medicine at Duke University.

“You may not be able to live for more than a few minutes,” he noted.

But the choice isn’t as black-and-white as go on a ventilator or die.

“We can give you high-flow oxygen and antibiotics,” Cox said. “You can use BiPAP or CPAP machines [which also deliver oxygen] and see how those work. And if things go poorly, we’re excellent at keeping you comfortable and trying to make it possible for you to interact with family and friends instead of being knocked out in a coma.”

People are thinking about what could happen to them and they want to talk about it. It’s opened up a lot of conversations.
— Rebecca Sudore, MD

Heather McCrone of Bellevue, WA, realized she’d had an “all-or-nothing” view of ventilation when her 70-year-old husband developed sepsis—a systemic infection—last year after problems related to foot surgery.

Over nine hours, McCrone sat in the intensive care unit as her husband was stabilized on a ventilator by nurses and respiratory therapists. “They were absolutely fantastic,” McCrone said. After a four-day stay in the hospital, her husband returned home.

“Before that experience, my feeling about ventilators was, ‘You’re a goner and there’s no coming back,’” McCrone said. “Now, I know that’s not necessarily the case.”

She and her husband both have advance directives stating that they want “lifesaving measures taken unless we’re in a vegetative state with no possibility of recovery.” McCrone said they still need to discuss their wishes with their daughters, including their preference for getting treatment with a ventilator.

These discussions are more important than ever―and perhaps easier than in the past, experts said.

“People are thinking about what could happen to them and they want to talk about it,” said Rebecca Sudore, MD, a professor of medicine at the UCSF. “It’s opened up a lot of conversations.”

Rather than focusing on whether to be treated with a ventilator, she advises older adults to discuss what’s most important to them—independence? time with family? walking? living as long as possible?—and what they consider a good quality of life. This will provide essential context for decisions about ventilation.

“Some people may say, my life is always worth living no matter what type of serious illness or disability I have,” she said. “On the other end of the spectrum, some people may feel there are health situations or experiences that would be so hard that life would not be worth living.”

Sudore helped create Prepare for Your Care, a website and a set of tools to guide people through these kinds of conversations. Recently it was updated to include a section on COVID-19, as have sites sponsored by Compassion & Choices and The Conversation Project. And the Colorado Program for Patient Centered Decisions has published a decision aid for COVID patients considering life support, also available in Spanish.

Some older adults have another worry: What if there aren’t enough ventilators for all the COVID patients who need them?

In that situation, “I would like to say ‘no’ because other people need that intervention more than I do and would benefit, in all probability, more than I would,” said Larry Churchill, 74, an emeritus professor of medical ethics at Vanderbilt.

“In a non-scarcity situation, I’m not sure what I’d do. I’m in pretty good health, but people my age don’t survive as well from any major problem,” Churchill said. “Most of us don’t want a long, lingering death in a custodial facility where the chances of recovery are small and the quality of life may be one we’re not willing to tolerate.”

Why Black Aging Matters Too

COVID-19’s exceptional toll on older African Americans is largely unnoticed

In this important and moving article, Kaiser Health News journalist Judith Graham recounts the myriad reasons why older Blacks are especially vulnerable to the coronavirus and describes their situation. This story also ran on CNN. Posted on the KHN website on September 3, 2020.

Old. Chronically ill. Black.

People who fit this description are more likely to die from COVID-19 than any other group in the country.

They are perishing quietly, out of sight, in homes and apartment buildings, senior housing complexes, nursing homes and hospitals, disproportionately poor, frail and ill, after enduring a lifetime of racism and its attendant adverse health effects. 

Yet older Black Americans have received little attention as protesters proclaim that Black Lives Matter and experts churn out studies about the coronavirus.

“People are talking about the race disparity in COVID deaths, they’re talking about the age disparity, but they’re not talking about how race and age disparities interact: they’re not talking about older Black adults,” said Robert Joseph Taylor, director of the Program for Research on Black Americans at the University of Michigan’s Institute for Social Research.

A KHN analysis of data from the Centers for Disease Control and Prevention underscores the extent of their vulnerability. It found that African Americans ages 65 to 74 died of COVID-19 five times as often as whites. In the 75-to-84 group, the death rate for Blacks was three and a half times greater. Among those 85 and older, Blacks died twice as often. In all three age groups, death rates for Hispanics were higher than for whites but lower than for Blacks.

(The gap between Blacks and whites narrows over time because advanced age, itself, becomes an increasingly important, shared risk. Altogether, 80 percent of COVID-19 deaths are among people 65 and older.)

The data comes from the week that ended Feb. 1, through Aug. 8. Although breakdowns by race and age were not consistently reported, it is the best information available.

Mistrustful of Outsiders

Social and economic disadvantage, reinforced by racism, plays a significant part in unequal outcomes. Throughout their lives, Blacks have poorer access to health care and receive services of lower quality than does the general population. Starting in middle age, the toll becomes evident: more chronic medical conditions, which worsen over time, and earlier deaths.

Several conditions—diabetes, chronic kidney disease, obesity, heart failure and pulmonary hypertension, among others—put older Blacks at heightened risk of becoming seriously ill and dying from COVID-19.

Yet many vulnerable Black seniors are deeply distrustful of government and health care institutions, complicating efforts to mitigate the pandemic’s impact.

The infamous Tuskegee syphilis study—in which African American participants in Alabama were not treated for their disease—remains a shocking, indelible example of racist medical experimentation. Just as important, the lifelong experience of racism in health care settings—symptoms discounted, needed treatments not given—leaves psychic scars.

In Seattle, Catholic Community Services sponsors the African American Elders Program, which serves nearly 400 frail, homebound seniors each year.

“A lot of Black elders in this area migrated from the South a long time ago and were victims of a lot of racist practices growing up,” said Margaret Boddie, 77, who directs the program. “With the pandemic, they’re fearful of outsiders coming in and trying to tell them how to think and how to be. They think they’re being targeted. There’s a lot of paranoia.”

“They won’t open the door to people they don’t know, even to talk,” complicating efforts to send in social workers or nurses to provide assistance, Boddie said.

In Los Angeles, Karen Lincoln directs Advocates for African American Elders and is an associate professor of social work at the University of Southern California.

Older Blacks are keeping to themselves. They’re deeply distrustful of government and of health care providers. 

“Health literacy is a big issue in the older African American population because of how people were educated when they were young,” she said. “My maternal grandmother, she had a third-grade education. My grandfather, he made it to the fifth grade. For many people, understanding the information that’s put out, especially when it changes so often and people don’t really understand why, is a challenge.”

What this population needs, Lincoln suggested, is “help from people who they can relate to”—ideally, a cadre of African American community health workers.

With suspicion running high, older Blacks are keeping to themselves and avoiding health care providers.

“Testing? I know only of maybe two people who’ve been tested,” said Mardell Reed, 80, who lives in Pasadena, California, and volunteers with Lincoln’s program. “Taking a vaccine [for the coronavirus]? That is just not going to happen with most of the people I know. They don’t trust it and I don’t trust it.”

Reed has high blood pressure, anemia, arthritis and thyroid and kidney disease, all fairly well controlled. She rarely goes outside because of COVID-19. “I’m just afraid of being around people,” she admitted.

Other factors contribute to the heightened risk for older Blacks during the pandemic. They have fewer financial resources to draw upon and fewer community assets (such as grocery stores, pharmacies, transportation, community organizations that provide aging services) to rely on in times of adversity. And housing circumstances can contribute to the risk of infection.

In Chicago, Gilbert James, 78, lives in a 27-floor senior housing building, with 10 apartments on each floor. But only two of the building’s three elevators are operational at any time. Despite a “two-person-per-elevator policy,” people crowd onto the elevators, making it difficult to maintain social distance.

“The building doesn’t keep us updated on how they’re keeping things clean or whether people have gotten sick or died” of COVID-19, James said. Nationally, there are no efforts to track COVID-19 in low-income senior housing and little guidance about necessary infection control.

Large numbers of older Blacks also live in intergenerational households, where other adults, many of them essential workers, come and go for work, risking exposure to the coronavirus. As children return to school, they too are potential vectors of infection.

‘Striving Yet Never Arriving’

In recent years, the American Psychological Association has called attention to the impact of racism-related stress in older African Americans—yet another source of vulnerability.

This toxic stress, revived each time racism becomes manifest, has deleterious consequences to physical and mental health. Even racist acts committed against others can be a significant stressor.

“This older generation went through the civil rights movement. Desegregation. Their kids went through busing. They grew up with a knee on their neck, as it were,” said Keith Whitfield, provost at Wayne State University and an expert on aging in African Americans. “For them, it was an ongoing battle, striving yet never arriving. But there’s also a lot of resilience that we shouldn’t underestimate.”

This year, for some elders, violence against Blacks and COVID-19’s heavy toll on African American communities have been painful triggers. “The level of stress has definitely increased,” Lincoln said.

During ordinary times, families and churches are essential supports, providing practical assistance and emotional nurturing. But during the pandemic, many older Blacks have been isolated.

In her capacity as a volunteer, Reed has been phoning Los Angeles seniors. “For some of them, I’m the first person they’ve talked to in two to three days. They talk about how they don’t have anyone. I never knew there were so many African American elders who never married and don’t have children,” she said.

Meanwhile, social networks that keep elders feeling connected to other people are weakening.

“What is especially difficult for elders is the disruption of extended support networks, such as neighbors or the people they see at church,” said Taylor, of the University of Michigan. “Those are the ‘Hey, how are you doing? How are your kids? Anything you need?’ interactions. That type of caring is very comforting and it’s now missing.”

In Brooklyn, NY, Barbara Apparicio, 77, has been having Bible discussions with a group of church friends on the phone each weekend. Apparicio is a breast cancer survivor who had a stroke in 2012 and walks with a cane. Her son and his family live in an upstairs apartment, but she does not see him much.

“The hardest part for me [during this pandemic] has been not being able to go out to do the things I like to do and see people I normally see,” she said.

In Atlanta, Celestine Bray Bottoms, 83, who lives on her own in an affordable senior housing community, is relying on her faith to pull her through what has been a very difficult time. Bottoms was hospitalized with chest pains this month—a problem that persists. She receives dialysis three times a week and has survived leukemia.

“I don’t like the way the world is going. Right now, it’s awful,” she said. “But every morning when I wake up, the first thing I do is thank the Lord for another day. I have a strong faith and I feel blessed because I’m still alive. And I’m doing everything I can not to get this virus because I want to be here a while longer.”

KHN data editor Elizabeth Lucas contributed to this story.

 

COVID-19 Sets Off a Pandemic of Despair for Older People

The longer their isolation goes on, the harder it is for many

As communities cautiously open up after the lockdown, older adults are being urged to not leave home yet because they’re more vulnerable than those who are younger. Journalist Judith Graham explores some of the consequences in this article that was posted on the KHN website on May 28, 2020. Funding from the Silver Century Foundation helps KHN develop articles (like this one) on longevity and related health and social issues. Graham’s story also ran on CNN 

As states relax coronavirus restrictions, older adults are advised, in most cases, to keep sheltering in place. But for some, the burden of isolation and uncertainty is becoming hard to bear.

This “stay at home awhile longer” advice recognizes that older adults are more likely to become critically ill and die if infected with the virus. At highest risk are seniors with underlying medical conditions such as heart, lung or autoimmune diseases.

Yet after two months at home, many want to go out into the world again. It is discouraging for them to see people of other ages resume activities. They feel excluded. Still, they want to be safe.

“It’s been really lonely,” said Kathleen Koenen, 77, who moved to Atlanta in July after selling her house in South Carolina. She’s living in a 16th-floor apartment while waiting to move into a senior housing community, which has had cases of COVID-19.

“I had thought that would be a new community for me, but everyone there is isolated,” Koenen said. “Wherever we go, we’re isolated in this situation. And the longer it goes on, the harder it becomes.”

(Georgia residents age 65 and older [were] required to shelter in place through June 12, along with other vulnerable populations.)

Her daughter, Karestan Koenen, is a professor of psychiatric epidemiology at Harvard University’s T.H. Chan School of Public Health. During a Facebook Live event this month, she said her mother had felt in March and April that “everyone was in [this crisis] together.” But now, that sense of communality has disappeared.

Making it worse, some seniors fear that their lives may be seen as expendable in the rush to reopen the country.

“[Older adults] are wondering if their lives are going to end shortly for reasons out of their control,” said Linda Fried, MD, dean of the Mailman School of Public Health at Columbia University, in a university publication. “They’re wondering if they’ll be able to get the care they need. And most profoundly, they’re wondering if they are going to be cast out of society. If their lives have value.”

If anything, I’ve seen a very strong will to live and acceptance of whatever one’s fate might be.

— Marc Agronin, MD 

On the positive side, resilience is common in this age group. Virtually all older adults have known adversity and loss; many have a “this too shall pass” attitude. And research confirms that they tend to be adept at regulating their reactions to stressful life events—a useful skill in this pandemic.

“If anything, I’ve seen a very strong will to live and acceptance of whatever one’s fate might be,” said Marc Agronin, MD, a geriatric psychiatrist and vice president of behavioral health at Miami Jewish Health, a 20-acre campus with independent living, assisted living, nursing home care and other services.

Several times a week, psychologists, nurses and social workers are calling residents on the campus, doing brief, mental health checks and referring anyone who needs help for follow-up attention. There’s “a lot of loneliness,” Agronin said, but many seniors are “already habituated to being alone or are doing OK with contact [only] from staff.”

Still, “if this goes on much longer,” he said, “I think we’ll start to see less engagement, more withdrawal, more isolation—a greater toll of disconnection.”

Erin Cassidy-Eagle, PhD, a clinical associate professor of psychiatry at Stanford University, shares that concern.

From mid-March to mid-April, all her conversations with older patients revolved around several questions: “How do we keep from getting COVID-19? How am I going to get my needs met? What’s going to happen to me?”

But more recently, Cassidy-Eagle said, “older adults have realized the course of being isolated is going to be much longer for them than for everyone else. And sadness, loneliness and some hopelessness have set in.”

She tells of a woman in her 70s who moved into independent living in a continuing care community because she wanted to build a strong social network. Since March, activities and group dining have been canceled. The community’s director recently announced that restrictions would remain until 2021.

“This woman had a tendency to be depressed, but she was doing OK,” Cassidy-Eagle said. “Now she’s incredibly depressed and she feels trapped.”

A 93-year-old plunged into despair after her assisted living facility went on lockdown in mid-March. Medications have not helped.

Especially vulnerable during this pandemic are older adults who have suffered previous trauma. Gary Kennedy, MD, director of the division of geriatric psychiatry at Montefiore Medical Center in New York City, has seen this happen to several patients, including a Holocaust survivor in her 90s.

This woman lives with her son, who got COVID-19. Then she did as well. “It’s like going back to the terror of the [concentration] camp,” Kennedy said, “an agonizing emotional flashback.”

Jennifer Olszewski, EdD, an expert in gerontology at Drexel University, works in three nursing homes in the Philadelphia area. As is true across most of the country, no visitors are allowed, and residents are mostly confined to their rooms.

“I’m seeing a lot of patients with pronounced situational depression,” she said, “decreased appetite, decreased energy, a lack of motivation and overall feelings of sadness.”

“If this goes on for months longer, I think we’ll see more people with functional decline, mental health decline and failure to thrive,” Olszewski said.

Some are simply giving up. Anne Sansevero, a geriatric care manager in New York City, has a 93-year-old client who plunged into despair after her assisted living facility went on lockdown in mid-March. Antidepressant and anti-anxiety medications have not helped.

“She’s telling her family and her health aides ‘life’s not worth living. Please help me end it,’” Sansevero said. “And she’s stopped eating and getting out of bed.”

The woman’s attentive adult children are doing all they can to comfort their mother at a distance and are feeling acute anguish.

What can be done to ease this sort of psychic pain? Kennedy of Montefiore has several suggestions.

Older adults may not own up to feeling depressed, but some will describe physical symptoms, such as difficulty sleeping or concentrating.

“Don’t try to counter the person’s perception and offer false reassurance. Instead, say, yes, this is bad, no doubt about it. It’s understandable to be angry, to be sad. Then provide a sense of companionship. Tell the person, ‘I can’t change this situation but I can be with you. I’ll call tomorrow or in a few days and check in with you again.’”

“Try to explore what made life worth living before the person started feeling this way,” he said. “Remind them of ways they’ve coped with adversity in the past.”

If someone is religiously inclined, encourage them to reach out to a pastor or a rabbi. “Tell them, I’d like to pray together or read this Bible passage and discuss it,” Kennedy said. “Comforting person-to-person interaction is a very effective form of support.”

Do not count on older adults to own up to feeling depressed. “Some people will acknowledge that, yes, they’ve been feeling sad, but others may describe physical symptoms—fatigue, difficulty sleeping, difficulty concentrating,” said Julie Lutz, PhD, a postdoctoral fellow at the University of Rochester.

If someone has expressed frequent concerns about being a burden to other people or has become notably withdrawn, that’s a worrisome sign, Lutz said.

In nursing homes, ask for a referral to a psychologist or social worker, especially for a loved one who’s recovering from a COVID hospitalization.

“Almost everybody that I’m seeing has some kind of adjustment disorder because their whole worlds have been turned upside down,” said Eleanor Feldman Barbera, PhD, an elder care psychologist in New York City. “Talking to a psychologist when they first come in can help put people on a good trajectory.”

The National Alliance on Mental Illness has compiled a COVID-19 information and resource guide, available at https://www.nami.org/covid-19-guide. The American Psychological Association has created a webpage devoted to this topic and recently wrote about finding local mental health resources. The Substance Abuse and Mental Health Services Administration has a 24-hour hotline, 1-800-662-4357. And the national suicide prevention hotline for those in acute distress is 1-800-273-8255.

 

Why the New Public Charge Rule Could Hit Older Immigrants Hard

Critics worry about the Trump administration’s changes

Digging into the possibilities opened up by this controversial new federal regulation, journalist Jaya Padmanbhan explores what it will mean to some immigrants and their families. This article originally appeared on the PBS Next Avenue website on Feb. 24, 2020.  Silver Century posts it with the permission of Next Avenue and the author. 

Devyani Dave immigrated from India to California in 1995 in her early 60s to live near her son and his family. Her green card was sponsored by her son (who prefers not to reveal his name), a citizen who came to the United States in 1973. When Dave arrived to start her new life, she had no health insurance and relied on her son to support her. Now, sitting on a bench at Priya Living, a senior-community facility in Santa Clara, CA, Dave said she feels fortunate to be in close proximity to her only child, especially as she ages.

But some immigration experts say the Trump administration’s new public charge rule, [which was put] into effect by the US Citizenship and Immigration Services on February 24, 2020, nationwide, will no longer welcome people in similar circumstances [to] Dave’s. That’s because, the analysts say, it will deem them likely to become liabilities for America.

How the Public Charge Test Has Changed 

Since 1999, federal immigration law has had a public charge test in place to deny people admission to the United States if the government identifies them as ones who may be “primarily dependent” on the government for support, either through cash-assistance programs or long term institutional care.

But the Trump administration is altering the definition of “public charge.” Under the new rule, any person who uses designated benefits for 12 months in any 36-month period might be considered a public charge. And the list of benefits has expanded to include Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly known as Food Stamps) and Section 8 housing assistance.

It’s nearly impossible for older immigrants to pass the “totality of circumstances” test.

A public-charge determination will be made, at the time of applying for a green card or admission at the US border, by an immigration officer after considering a “totality of circumstances,” a discretionary weighting system [that looks] at factors including age, health, family status, assets, education and skills.

The totality of circumstances test will penalize people 62 years or older, said Natalie Kean, senior staff attorney at Justice in Aging, a nonpartisan legal advocacy group addressing senior poverty, making it “nearly impossible for older adults to pass the ‘public charge’ test under the new criteria.”

Who Is Likely to Be Most Affected?

Kean and other immigrant analysts say the revised public charge rule will tilt negatively for immigrants with chronic health conditions or disabilities; those who are not fluent in English; and those earning less than 125 percent of the federal poverty limit—that’s $21,138 for a two-person household.

With these stringent benchmarks, the new rule could have an outsize impact on low-income, older immigrants of color, preventing some from becoming legal permanent residents in the country they live in or aspire to live in.

This will have “a ripple effect on their families who are here in the United States, as well as our communities in general,” said Kean.

When the Supreme Court ruled on January 27, 2020, to give the Trump administration the go-ahead for its public charge rule, a statement from the White House press secretary called the decision “a massive win for American taxpayers, American workers and the American Constitution.”

In a fact sheet promoting the new public charge rule, the White House cited a 2017 poll from America First Policies (a pro-Trump organization), saying that 73 percent of Americans favor requiring immigrants coming to the country to be self-sufficient. 

Critics of the new public charge rule, however, say older, poorer immigrants will be harmed by it. In an amicus brief filed by Justice in Aging and others to contest the new rule, one of the arguments points to the situation of five million older immigrants who “are likely to have supported their families, have contributed to our nation’s economy by, for example, paying taxes and contributing to Social Security, and have been integrated into the fabric of our country. Yet, under the Final Rule, they will be viewed as having failed to contribute to society.”

How Immigrants Are Reacting

“That’s not fair!” exclaimed Losa Petela, a 60-year-old, legal immigrant from the South Pacific archipelago of Tonga, who lives in Fremont, CA, and has worked as a home caregiver in the Bay Area for nearly 10 years. Citing her own example, Petela said that immigrants who’ve served their US community well, even if they are older, should be allowed to get their green cards.

Praveen Thakur, 79, a US citizen who came here over 50 years ago from India and lives in Santa Clara, CA, takes a slightly different view. “If the children take full responsibility [for their parents], then older parents should be allowed to come and get a green card so that they can stay with their families,” he said.

Dave makes another distinction: “Those whose children are contributing to the [United States] for so many years and who don’t have anyone left in India should be allowed to join their families,” she said.

Fear and Confusion

Fears about the implications of the new public charge rule are spreading.

“We know that health care providers and social service agencies across the country are already starting to get calls from concerned individuals, asking whether or not it is safe to remain enrolled in health, housing and nutrition programs,” said Madison Allen, senior policy attorney from the Center for Law and Social Policy, a nonpartisan nonprofit working on policy solutions for low-income people.

This chilling effect, caused by confusion as to who or what will be subject to the public charge test, has resulted in some legal immigrants disenrolling from public programs even before the February 24, 2020, official start date.

The New York City Department of Social Services has said that in 2018, roughly 11 percent of the city’s noncitizen immigrants who are eligible for and lawfully receiving SNAP benefits have either left the SNAP caseload or have decided not to enroll, at a higher rate than US citizens in the program. The agency cited a correlation between this decline in enrollment and the public charge proposals, due to a “fear of potential immigration consequences.”

Opposition to the Rule Change

Congresswoman Judy Chu, a Democrat representing communities near Los Angeles, said at a Jan. 31, 2020, press briefing, “By keeping families apart, Trump is making it harder on immigrants to succeed.” Last year, Chu introduced the No Public Funds for Public Charge Act, which would prevent federal funds from being used to implement the new public charge rule. The bill has 118 Democrat cosponsors from 34 states and no Republicans.

“We are in a wait-and-see period right now,” said Denny Chan, a senior staff attorney at Justice in Aging. Arguing that the new public charge rule unlawfully targets older immigrants and their families, five briefs have been filed in circuit courts by organizations advocating for the elderly.

“It’s going to be a lengthy process,” Chan said….

Older immigrants who are worried about the public charge rule, Chan said, should “speak to an immigration attorney to get individualized legal assistance before they make any decision to access, or apply for, benefits.”

Silver Century Foundation: The change in the public charge rule went into effect in late February, 2020, just as the coronavirus epidemic was exploding across the country. Since then, the US Citizenship and Immigration Services has agreed not to use the new rule to deny visas or green cards to immigrants who are tested or treated for COVID-19.  Advocacy groups say, however, that immigrants are still avoiding medical care because of fear and confusion.

 

Older and Wiser—but Dizzier

At some point, most people over 65 experience dizziness

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

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

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

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

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

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

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

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

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

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

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

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

What Causes Dizziness?

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

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

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

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

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

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

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

A thorough medication review is absolutely important.

Anupama Gangavati, MD

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

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

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

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

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

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

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

Trial and Error

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

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

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

That’s not uncommon, Stross said. 

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

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

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

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

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

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

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

Chronic Dizziness

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

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

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

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

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

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

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

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

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