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

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

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

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

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

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

How the Cycle Begins

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

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

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

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

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

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

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

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

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

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

Food Insecurity Plays a Role

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

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

Food insecurity especially affects people of color. 

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

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

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

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

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

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

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

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

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

Assessment and Diagnosis

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

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

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

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

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

Improving Nutrition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 Quarterbacking Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Managing Multiple Meds

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

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

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

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

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

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

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

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

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

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

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

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

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

Enlisting Care Partners

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

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

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

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

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

Becoming Age-Friendly 

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

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

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

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

 

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

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

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

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

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

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

Why Geriatricians Matter

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Managing Multiple Conditions

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

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

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

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

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

Lester adds that geriatricians are much better at prognostication.

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

Why the Shortage

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

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

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

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

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

Facing the Future 

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

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

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

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

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

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

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

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

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

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

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

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

Aging in Place

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An Iterative Process

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

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

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

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

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

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

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

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

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

Sooner, Rather than Later

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

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

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

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

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

When the Older Adult Resists

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

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

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

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

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

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

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

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

Family Conflict

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

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

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

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

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

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

A Good Decision

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Addiction Can Be Easily Missed

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

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

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

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

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

That scenario is not uncommon, Santiago added.

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

Confronting Trauma 

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

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

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

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

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

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

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

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

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

Getting Treatment

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

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

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

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

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

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

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

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

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

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

Finding Sobriety

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

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

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

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

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

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

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

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

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

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

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

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

Divide and Conquer 

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

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

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

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

Other questions to ask might include:  

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

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

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

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

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

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

Explore Resources 

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

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

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

Enlist Technology

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

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

Make the Most of Visits 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Distance can make problems seem worse than they actually are. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Strained Relationships 

Family dynamics often complicate the long-distance caregiving situation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Searching for Solutions

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

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

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

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

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

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

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

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

When Bob Evans lost his job in 2009, he began to consider what was next. He’d spent more than 30 years in the horticulture industry, mostly in sales and customer service positions in landscaping and lawn care. 

His wife reminded him that, in his 20s, Evans had wanted to become a nurse but set the dream aside to support the family. 

“It’s too late now,” he replied.

“I don’t think so,” she said. 

So Evans went back to school—in his mid-50s, the oldest person in his class. He earned a nursing degree and got a job as a registered nurse in a hospital. Just as he’d imagined in his 20s, he loved the work. 

People can expect later-in-life pivots, like Evans’ new career, to become more and more common as we live longer, according to the Stanford Center on Longevity. Human life expectancies doubled between 1900 and 2000. Living to age 100 will become commonplace by the middle of the 21st century. 

As more people live to 100, they may alternate time spent on work and career with periods devoted to family or caregiving.

“The 100-year life is here,” according to the Center’s report, The New Map of Life. “We’re not ready.”

Most people still expect life and career to follow the timeline shaped by a 60- or 70-year lifespan, according to the report, viewing the “extra” 20 or 30 years afforded by increased longevity as an extension of retirement and older age. In this model, college and graduate school, childrearing and prime earning years are crammed into the 20s, 30s and 40s. 

That needs to change, according to the report. This unparalleled demographic shift “calls for equally momentous and creative changes in the ways we lead these longer lives.” 

As more people live to 100, the report predicts, life trajectories will become more fluid and more flexible, and multiple transitions over the course of life will be viewed as “a feature, not a bug.” People will shift gears routinely, to new phases of work and career, possibly alternating with periods devoted to lifelong learning or family and caregiving responsibilities. 

Adapting to Change

“As people live longer, they’re realizing that retirement is not a destination, it’s a transition and a time of new beginnings,” said Dorian Mintzer, a retirement coach and coauthor of The Couple’s Retirement Puzzle: 10 Must-Have Conversations for Creating an Amazing New Life Together (2014). “It can be a time to rewire, rejuvenate and revolutionize.” 

Longer lives may lead more people to follow unconventional paths, like that of Jim and Lynda McDevitt of Plano, TX. Now in their early 70s, they’ve pivoted twice in the last two decades. After retiring in the early 2000s from long careers with the Internal Revenue Service, the couple opened a neighborhood wine shop called Corner Wines—and loved it. 

“We liked to say, ‘We’re like Cheers,’ because the shop was a place where everybody knew your name,” Lynda McDevitt said. “Most of the friends we have now, we made at our store.” 

Eventually, the shop’s six-days-a-week schedule began to take a physical toll, and the couple wanted to spend more time with their granddaughter. They sold Corner Wines in 2020. Now they call themselves “officially retired” but continue to stay engaged, providing occasional consulting services and leading “wine-themed” group tours to places like Tuscany and Napa Valley. 

Self-confidence is the key to success when you start a new career or any other new endeavor.

“We had such a passion for wine, we couldn’t let it go,” Lynda McDevitt said. 

Several factors made the McDevitts’ later-in-life transition possible. Both enjoy good health. Pensions from their IRS careers provided a financial base. Wine was their passion, but they’d honed practical skills while at the IRS: the basics of accounting, managing and marketing a business. Both had work experiences that gave them the confidence to start something new: Jim had presented proposals to top officials at the IRS; Lynda had fielded media interviews as an IRS spokesperson. 

That type of confidence is key in embarking on any new career or endeavor, Evans said. Even though he had worked in a very different field before he became a nurse, basic skills—like computer proficiency—buoyed his confidence to tackle the next phase. 

“Computer literacy was a big part of being able to jump back into college in my late 50s, to be able to function and graduate,” he said. “You can’t really stay in the game if you can’t work at a computer at least at a minimum level.” Former co-workers in his previous career who didn’t embrace the computer and internet have had more difficulty adapting, he added.

Along with confidence, a new start takes humility. 

“Assuming the role of novice required … swallowing my pride,” Evans said. That was humbling but necessary to learn the skills to serve patients.

Finding Purpose

In filming her 2022 documentary Lives Well Lived: Celebrating the Secrets, Wit & Wisdom of Age, which aired on PBS, filmmaker Sky Bergman chose interviewees, ages 75 and up, who were resilient, active and engaged—and discovered that all shared a common trait. 

“Everyone had a sense of purpose,” said Bergman, who is professor emeritus of photography and video at Cal Poly State University in San Luis Obispo, CA. “That purpose could change over time, and often did change over time, but that was the common thread.”

A health scare in 2003 helped Mellanie True Hills, 71, of Greenwood, TX, identify her next purpose. She developed a heart blockage, followed by atrial fibrillation (“afib”), which caused her heart to race. Surgery corrected the problem, but at the time, patients had little access to reliable information about afib. After Hills retired from her corporate job, she created a website, StopAfib.org, and began organizing annual patient conferences featuring experts. 

Skills developed over her long career in IT, web development and accounting all came to her aid. But Hills also credits her thirst for knowledge and her lifelong learning habit. 

When you start something new, don’t be afraid to change or to take a risk.

“When I was young, I had a boss who said, ‘Mellanie finds a vacuum and fills it,’” she said. “That is the mindset you need to have to start something new. You see a need and you fill it. It’s also a matter of not being afraid to change. That is hard for some older adults. Not being afraid to take a risk. Risk is the price you pay for opportunity.” 

Jan Gero pushes himself to keep taking risks artistically at the age of 90. After five previous careers—architect, modern dancer, fashion designer, documentary filmmaker and artist—he has reinvented himself as a monologist. Recently, he performed a one-man show, Naked at 90: An Evening with Jan Gero. 

His daily life is solitary, which he prefers, but he shares a video journal online and hosts The Compulsive New Yorker, a public access cable show from his apartment in New York. 

“I’m basically just saying what’s on my mind,” he said. “A lot of what I’m doing is trying to come to terms with death, because it’s a finality, a biological reality. Every day, I’m kind of asking myself the question, ‘Am I on the path to going down with a smile, rather than a sneer?’” 

Envisioning the Extra Years

Jerry Cahn, an executive coach in New York, recently launched a workshop titled, “Age Brilliantly: Maximize Your Ability to Lead a Fulfilling 100+ Year Life.” It’s not just for executives approaching retirement, however. 

The 30 “extra” years that many will enjoy shouldn’t be viewed as tacked on at the end of life, he said. Those years might be devoted to sabbaticals at any age, to provide breathing space for creative growth. Cahn cited a young professional who left one high-pressure job but postponed the start of his next job to devote four months to travel, including visits to Mount Everest, Nepal and the Camino de Santiago in Spain. 

Cahn added that many executives meticulously plan their finances for retirement and later life but head into their post-career years with vague plans, such as, “I’d like to travel.” 

“That might mean traveling six or seven weeks out of the year,” he said. “But what about the other 45 weeks? They don’t tend to think about that.” 

Mary “Molly” Camp, MD, assistant professor in the department of psychiatry at UT Southwestern Medical Center in Dallas, said more and more of her patients want to talk about how they’ll handle retirement and the second half of life. 

Young people might seek help for transitions—a guidance counselor when choosing a college or a therapist for premarital counseling. But there’s little to guide middle-aged or older people to prepare for the later transitions in life. Camp hopes that’s beginning to change.

“We’re evolving in our knowledge of human development, where we don’t think of adulthood as something you reach and then it plateaus and stays the same,” she said. “Instead, we’re understanding that life changes through lots of different phases, lots of different transitions, including career changes and retirement. It’s not that we turn 55 and everything becomes static.” 

Yet Another Chapter 

The COVID-19 pandemic forced Bob Evans to pivot again in 2020. His age and health issues made it too risky for him to work around COVID patients. He left nursing with plans to eventually return—then discovered that he enjoyed retirement. His wife, an IT recruiter, still works from their home in the Cleveland area, so Evans, 68, handles the household duties, including maintaining their large, landscaped yard, and volunteers with the Cleveland Hiking Club, helping to build a new pavilion at a local park. He looks in often on his father, who’s 93 and lives nearby. He’s developed an interest in family history. 

Just in case, he also keeps his nursing license up-to-date. 

“I’m not sure what the next chapter is going to be,” he said, “But that’s the fun part.” 

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. 

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.”  

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.”  

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.” 

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.” 

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.” 

 

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

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

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

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

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

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

— Elisabeth Rosenthal, MD

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

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

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

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

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

How We Got Here

How do medical providers get away with this? 

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

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

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

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

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

— Elisabeth Rosenthal, MD

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

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

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

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

What’s the Solution?

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

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

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

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

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

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

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

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

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

How to Price-Shop 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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