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Getting Older, Sleeping Less?

Older adults are more prone to sleep issues—but there’s hope
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Until age 45, Mary Jo Anderson says, she was a “champion sleeper.” 

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

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

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

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

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

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

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

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

The Roots of Sleeplessness

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

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

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

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

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

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

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

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

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

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

Resetting Sleep Rhythms

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

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

In addition, these steps may help:

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

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

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

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

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

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

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

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

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

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

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

Don’t Lose Sleep Over a Little Lost Sleep

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

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

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

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

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

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

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

When to See a Doctor

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

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

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

Don’t Get Discouraged

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

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

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

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

Are Pets Really Good for Older People?

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

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

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

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

Do the benefits of pet ownership really outweigh the risks?

Weighing Benefits with Costs

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

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

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

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

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

—James Moebius, veterinarian

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

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

Then there’s the trauma of losing a pet. 

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

Making It Work

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

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

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

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

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

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

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

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

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

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

Finding Solutions

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

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

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

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

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

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

Making Arrangements for Future Care  

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

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

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

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

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

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

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

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

Breaking the Age Barrier

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

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

Unfortunately, Russell’s social circle is unusual.

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

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

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

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

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

Friendship Transcends Age

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

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

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

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

— Art Russell, age 60

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

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

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

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

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

Friends Gone Viral

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

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

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

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

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

Intergenerational Collaboration

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New Challenges for Grandparents

Often idealized, grandparenting is more complicated than ever before
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As a divorced, single mom, Karen Spencer thought she was done raising children when her son and two daughters grew up and left home. It didn’t work out that way.

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

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

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

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

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

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

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

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

Blended Families

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

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

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

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

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

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

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

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

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

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

Close to Home

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

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

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

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

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

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

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

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

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

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

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

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

Walking the Line

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

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

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

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

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

Financial Challenges

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

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

Great-Grandparent Boom

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

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

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

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

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

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

Reaping the Rewards

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

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

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

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

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

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

 

Spiritual Support at the End of Life

Medical and hospice professionals are learning to meet patients’ spiritual needs
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This is part 2 in our series on spirituality and aging. Read part 1 here.

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

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

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

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

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

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

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

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

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

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

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

Spiritual Distress

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

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

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

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

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

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

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

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

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

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

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

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

Spiritual Turmoil

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

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

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

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

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

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

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

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

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

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

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

Spiritual Assessments

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

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

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

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

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

Spiritual Sensitivity

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

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

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

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

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

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

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

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

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

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

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

What Spirituality Means to Older People

It can provide a sense of purpose and connection—and a great deal more
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This is part 1 in our series on spirituality and aging. Read part 2 here.

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

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

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

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

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

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

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

Spiritual but Not Religious

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

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

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

‘Spirituality’ means different things to different people.

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

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

Life Changes Spur Shifts

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

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

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

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

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

Foundation for Living Longer and Healthier

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

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

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

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

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

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

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

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

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

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

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

“I think genuine happiness can come from having a spiritual practice,” he said. “As mind and body connect, that helps some people to end an addiction or to eat more healthfully. Also, there is something happening in the brain as people do spiritual practices. Spiritual practices direct more blood toward the temporal lobe, and that is good for de-stressing.”

Art as Spiritual Practice

Spiritual expression can range from communal activities like worship, scripture study or prayer, to personal practices such as journaling, meditating or spending time in nature.  

For Donna Bearden, 71, her spiritual practice centers on art and learning. She’s married to a retired United Methodist pastor but describes herself as spiritual but not religious.

“My spirituality could not develop within the church,” she said. “I believe a spiritual journey has to involve doubt, searching, asking hard questions. I couldn’t ask those questions without raising eyebrows.”

Bearden expresses her spirituality through art, writing and photography. She starts each morning writing in a journal and often heads outside with camera in hand. She’s fascinated by mandalas—a circular symbol in Hinduism and Buddhism that represents the universe—and creates them with the photos she’s taken.

“There is a zone artists and poets and other creatives talk about, the idea that words or an artist’s creation comes not from them but through them,” she said. “I have felt that zone, that connection to something greater than I.”

A Sense of Purpose

If there’s a link between spirituality and longevity, it might be ikigai (“what makes one’s life meaningful”), a Japanese term that Buettner cites in his work. Many faiths teach concepts of intrinsic human purpose that don’t require a youthful body or a sharp intellect: tikkun olam, the Jewish calling to repair the world; the Christian teaching of serving others; or the Buddhist idea of the bodhisattva, a person who chooses to strive for Buddhahood for the benefit of all sentient beings. Spiritual practices, such as meditation, can help people clarify and focus on their sense of higher calling.

Spirituality can also help older people turn outward when loss or physical limitations could easily spur them to turn inward, according to Missy Buchanan, author of Living with Purpose in a Worn-Out Body: Spiritual Encouragement for Older Adults (2008).  

“It’s the belief that ‘I’m here for a reason,’” Buchanan said. “Maybe I hurt today, but I can still do something good for somebody.”

For Cook, her work as a spiritual group leader provides a new sense of purpose and direction. In earlier years, she focused on career, raising kids, status and money—her family once lived in an 8,400 square foot home (“Isn’t that ridiculous?” she said). Those things don’t define her anymore.

“Now it’s about living a life in accord with who I was created to be,” she said. “The work I’m doing in spirituality is life-giving.”

Older Artists Keep Creating and Growing

But ageism raises obstacles for many
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Opera star Plácido Domingo made his name as a tenor. Indeed, many know him as one of the “Three Tenors,” performing with José Carreras and Luciano Pavarotti in the late 1990s. But now, at age 77, Domingo is a baritone.

That’s a concession to his aging voice, according to Colleen Mallette, a member of the voice faculty at Texas Christian University in Fort Worth. But it hasn’t diminished his star power.

“His voice has changed, but it’s even richer and better,” Mallette said. “He’s still such a bravura singer that no one feels slighted in the least.”

Like Domingo, performing artists—as well as fine artists—find they must adjust to physical limitations or decreased stamina as they age. For those who aren’t world-renowned, the opportunities to perform, to win roles and grants or to exhibit their work may dwindle as they get older.

At the same time, many artists say they find that maturity brings depth and authenticity to their work that they didn’t have in their youth. And with their habits of creativity, determination and adaptability, honed over time, many artists remain resilient and active well into older age.

Dwindling Roles

Ageism in art, though, is a barrier some artists must hurdle to keep creating. For screen performers, Hollywood can be particularly difficult. At the 2014 Golden Globes, Tina Fey famously praised Meryl Streep’s turn in the film August Osage County for “proving that there are still great parts in Hollywood for Meryl Streeps over 60.”

Streep, of course, is the exception. Many actors, especially women, find opportunities for work drying up past a certain age.

“I’ve had many, many studio heads and casting people and network heads look me in the eye and just go, ‘Yeah, this has been such a great reading, I wish they’d go with you, but they’re going to go younger,’” said actress Kathy Griffin, 57, speaking at a 2016 panel discussion on ageism in Hollywood.

Ageism is so problematic that in 2017 the California state legislature passed a law allowing actors to request the removal of their date of birth from industry databases, like IMDB.com. Actors’ unions argued that the law was necessary to protect actors from age discrimination. (In February 2018, US District Judge Vince Chhabria declared the law unconstitutional.)

On Broadway, many directors have begun experimenting with “color-blind” and “gender-blind” casting—choosing actors without regard to race or gender, according to Mark Lowry, editor and theater critic for TheaterJones.com, a regional arts website. But “age-blind” casting hasn’t caught on in the same way.

“Age is a little more complicated,” Lowry said. “Playwrights generally specify an age, and directors try to honor playwrights’ intentions.”

However, there are a few directors trying “age-blind” casting. A 2017 West End (London) revival of the comedy Daisy Pulls It Off featured actresses in a wide range of ages, all playing teen schoolgirls. And in his 2015 production of Romeo and Juliet, Kenneth Branagh cast Derek Jacobi, then 76, as Mercutio, a move the Guardian said “boldly challenges our prejudices about age on stage.”

Directors may be more willing now to be more realistic in casting and to choose older actors to play mature characters.

At the regional level, Carolyn Wickwire, 81, a professional actress in Albuquerque, NM, says she’s been surprised by how many roles she has been able to play. She has no experience to compare from her youth—Wickwire didn’t start acting professionally until age 51, after retiring from an administrator job. But she’s been so busy with roles in local theater productions, as well as gigs in TV series shot in Albuquerque (Better Call Saul, Longmire and Manhattan), that she’s had to pass up some tempting auditions. She has played characters ranging from age 65 to 91.

“They’re not always the biggest roles, but sometimes they are leads [or] strong supporting roles,” Wickwire said. She believes directors are moving toward “more realistic casting” and are more willing to include older characters and more apt to choose older actors for mature roles.

Some directors consciously tweak the ages of cast members to create a fresh dynamic. The revival of My Fair Lady on Broadway, which opened April 20, 2018, paired Lauren Ambrose, 40, as Eliza, with a slightly younger British actor, Harry Hadden-Paton, 37, as Professor Higgins. That’s a big departure from the original, in which 20-year-old Julie Andrews played opposite Rex Harrison, who was almost 50. The new version was soon sold out.

Not all performing arts prize youth as stubbornly as the stage and screen. It’s not uncommon in opera, for example, for older women to be cast as characters who are younger. Lowry notes that in the Richard Strauss opera Romeo and Juliet, Juliet is a girl of 14, but the role was written for a woman with a more mature voice, usually someone in her late 20s or early 30s.

Even in ballet, where few survive professionally past age 40, more dramatic roles often go to more experienced dancers.

“Certain roles require youth and energy, but the older ballerina … brings maturity and experience that a younger person might not have,” said Michelle Gifford, a former dancer with New York City Ballet and Texas Ballet Theater.

Ageism in Fine Arts

Even visual artists—working in arenas where unwrinkled faces or agile young bodies aren’t required—can encounter ageism, according to Joan Jeffri, director and founder of the Research Center for Arts and Culture in New York City.

The organization’s recent study, “Above Ground: Information on Artists III: Special Focus New York City Aging Artists,” found that 43 percent experienced discrimination because of age. In focus groups, artists reported that if a grant application asked their age, they felt certain “the application went right into the garbage,” Jeffri said.

Some galleries are trying to rectify that. The Carter Burden Gallery in New York’s Chelsea neighborhood shows only the work of artists 60 and older. The Museum of Modern Art in New York is currently running a yearlong installation, The Long Run, of works created by artists after age 45, including a piece created in 1977 by Georgia O’Keeffe at age 90.

Older artists have become “the rage” lately, Jeffri said, but even that poses a dilemma because the trend positions older artists as a “peculiarity, when they should be the norm. Age shouldn’t matter.”

Adjusting for Age

The physical and cognitive changes that accompany aging often affect artists’ ability to create or perform. Recent advances in medicine, nutrition and physical therapy have delayed that somewhat: orthopedic surgery might give a ballet dancer another year or two on an injured knee; a good fitness trainer and a skilled dermatologist might enable an actress to pass as an ingenue into her early 40s. But most older artists eventually must make some adjustments for aging.

For vocalists, for example, aging reduces the flexibility of cartilage around the vocal cords, limiting older singers’ ability to hit certain notes. And hormonal changes may lower a voice.

“Singing is being an athlete, pure and simple,” said Mallette of Texas Christian University. Like athletes, vocalists can use exercises and preventive measures to maintain their voices. Many older vocalists adjust the way they sing certain songs. She noted that Willie Nelson, 85, uses the twang in his singing style as a technique to avoid straining his vocal cords.

A study found that most artists have no plans to retire because they find their work meaningful and absorbing.

Similarly, the Art Cart program at the Research Center for Art and Culture helped visual artists with occupational therapy, such as fitting a painter with a special built-up paintbrush that helped her keep her hands steady. (The Art Cart program is now the Performing Arts Legacy Project for performers age 62 and up and is housed at The Actors Fund.)

And artists’ creative instincts help them adapt. One older artist had spent years creating sculptures out of safety pins; after developing arthritis, she worked in watercolor instead.

“She didn’t for a minute think she’d stop doing art,” Jeffri said. “She just found a new way to do it.”

That productive sense of joy can keep older artists engaged in their work well into their later years—and ultimately allow them to age more successfully, Jeffri said. The Above Ground study found that most artists had no plans to retire; most reported high levels of life satisfaction because their work was meaningful and absorbing.

“We found they are often more resilient than the general population,” Jeffri said. “Many older artists continue to go to the studio every day or every week, even if it takes an hour and a half to walk two blocks to get there.”

Out of the Game

In some cases, getting older eventually necessitates leaving an artistic profession. With its joint-punishing leaps and turns, plus the difficulties of pointe work for female dancers, ballet is a young person’s pursuit. Professional dancers know from the start that they’ll likely retire by age 40.

“At some point you start asking yourself, ‘What else is there in life besides the stage life?’” said Gifford, the former dancer.

Spurred by a painful ankle injury as well as a desire to do something new, she retired at age 47. Now she’s teaching and working as a répétiteur with the George Balanchine Trust. (Répétiteurs are hand-picked dancers with intimate knowledge of particular ballets, authorized to teach the steps and choreography to performing companies.)

Gifford knows former dancers who made more drastic career changes, morphing into lawyers, professors, doctors, full-time parents. “It’s a really great opportunity to recreate yourself; it’s pretty amazing if you take advantage of the life in front of you.”

Depth with Maturity

For those who do continue to perform or create, maturity brings depth and self-assurance.

“The main thing I see in older age is confidence,” said Linnea Glatt, 68, an artist in Dallas, TX, who works in mixed media. “When I was younger, I worried that people didn’t ‘get’ what I was doing. Now I don’t worry about that so much.”

Illness or disability can force fallow periods that ultimately prove creatively nurturing. Glatt saw that when she took a year off in 2001 for breast cancer treatment.

“It was the most productive time in my career, even though I did no work at all,” she said. “I looked through my old sketchbooks, something I never had time for, and began to really realize what I was after. I could see the beginning of the thread, the trajectory of my work.”

Even in acting, where youth seems so important, Albuquerque actress Wickwire sees benefits in getting older.

“For actors, in terms of life experience and understanding, being older is an advantage,” she said. “We bring a lot to the table.”

Love to Travel? Don’t Let Aging or a Disability Stop You

How to travel happily and safely at almost any age
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As a cultural attaché for the US Department of State, Teresa Wilkin lived abroad and traveled the world, and she kept traveling, extensively, after retiring in 2004.

But it wasn’t until last year that Wilkin, 69, had what she wryly calls her “first geriatric health challenge” on the road—a bout with deep vein thrombosis (DVT), a potentially life-threatening blood clot. She had traveled without incident on a long, multicountry tour with stops in Portugal, Rome and Crete, but the last leg, a four-hour flight from Chicago to Seattle, sent her to the emergency room.

“I was in a middle seat and didn’t want to get up or bother anybody, so I slept the entire flight,” she said. “I knew something was wrong the moment I got off the plane.”

Wilkin is now in good health and still traveling—she just got back from a trip to Martinique for Carnival. But as she’s learned, travel becomes more problematic as we age. Even the most seasoned traveler must adjust for health issues, limited mobility or stamina, and take steps to avoid ailments like jet lag, motion sickness and DVT.

For older adults who want to travel, or for younger adults who wish to travel with them, the key is thorough, needs-specific research and planning. How much walking or stair climbing is on the itinerary? Can wheelchairs be used? Does the hotel have an elevator? Will there be time to rest or nonstop activities? Will restaurants be able to meet dietary restrictions? Are trustworthy medical services available?

Even a seemingly unremarkable situation can make a trip difficult and less enjoyable, said Michael Zimring, MD, director of the Center for Wilderness and Travel Medicine at Mercy Medical Center in Baltimore. On a recent trip to San Miguel de Allende in Mexico,
Zimring saw how cobblestones and narrow sidewalks turned a simple walking tour into a hair-raising ride for an older man in a wheelchair who was in his tour group.

“Older travelers really need to prepare,” he said. “The last thing you need is to be stuck in an airport because you didn’t bring the right documents for your medical syringe, or stranded in a foreign country without an adequate supply of an essential medication.”

Traveling in the Face of Ableism

Older travelers must also confront ableism—the tendency of airlines, hotels or other providers to overlook the needs of individuals with disabilities. Large hotel chains in the United States comply with the Americans with Disabilities Act (ADA); smaller hotels, both at home and in other countries, often are not held to similar standards. In some cities overseas, taxis that can accommodate wheelchairs are virtually nonexistent.

Often, ableism shows up as overlooked obstacles that are unintentional or careless, according to Debra Kerper, owner of Easy Access Travel, a Dallas-based agency that caters to older travelers and people with disabilities. She recommends using Google—her favorite travel tool—to find a travel agent or tour operator experienced in serving people with physical limitations.

“A tour guide without that specialized experience is not going to look for curb cuts or notice seemingly small obstacles that are almost impossible to navigate on a scooter,” she said.

If you’re going overseas, find out what immunizations you’ll need and have those shots at least six weeks before you set out.

Kerper prechecks each itinerary herself or contracts with local guides who’ve already led disabled travelers on the route. An inexperienced guide might assume that a restaurant with a wheelchair ramp and wide aisles is accessible, not noticing that the only bathroom requires descending a flight of stairs. A cruise ship might be designed for accessibility, but if the ship anchors and passengers are tendered (transferred from ship to shore via a smaller boat), travelers with limited mobility might be unable to join the excursion.

Kerper, 68, knows what she’s talking about, firsthand. She is a double amputee with a variety of medical conditions, including lupus; she travels along on all of the trips she organizes. Some of her clients have severe disabilities, but she says travel can be almost as challenging for people with “hidden disabilities,” such as a person with diabetes who must stop often to check blood-sugar levels or a person with a bad back who can’t sit still for long periods. Preparation is the best medicine.

Preparing for Medical Situations

One of the most important considerations is the availability of trustworthy medical care. An emergency easily handled at home could turn into a costly nightmare in an unfamiliar city, Zimring said. A hospital outside the United States may refuse to provide service unless the patient pays up front, in cash. And remote areas might not have good medical facilities. Travelers should find out in advance what health care options will be at their destination.

Zimring’s advice for healthy travel, especially overseas: consult a physician who specializes in travel medicine at least six weeks before your trip.

“If you wait until the last minute to think about immunizations, it may be too late,” he said. A vaccination for Hepatitis B, for example, is normally given as a series over a period of six months, although it can be accelerated to a six-week period.

All adult travelers should be up-to-date on routine vaccinations: seasonal flu, measles/mumps/rubella (MMR) and tetanus/diphtheria/pertussis (Tdap). Additionally, the Centers for Disease Control (CDC) recommends the shingles vaccine for those 50 and older, and pneumococcal vaccines for those over 65.

Bring copies of your prescriptions. And before you leave home, make sure your meds are legal in the countries you’ll be visiting.

Some destinations may require additional vaccines, such as polio or yellow fever; the CDC website maintains a list by destination. These vaccines may pose risks for older people, and some travelers with health conditions, like diabetes, may require additional immunizations. To navigate these complexities, Zimring recommends consulting in advance with a physician certified by the International Society of Travel Medicine; travelers can visit ISTM.org to find a practitioner in their area.

It’s also crucial to make sure all prescriptions are filled. You may need an override from an insurance carrier to make sure you have enough medication for the entire trip, plus a few extra days’ worth in case of a delay. Bring copies of your prescriptions when you travel, and make sure your medications are legal in the countries you’re visiting. (Even a legally prescribed medication can lead to disastrous consequences—a UK citizen was sentenced to three years in prison in Egypt for bringing in Tramadol, an opioid painkiller, for her husband’s back pain.) Check with the embassy of the country you’re visiting if you’re unsure. If a traveler requires oxygen, be sure to check airline policies well in advance.

If you’re traveling abroad, understand what your medical insurance will, or won’t, cover and obtain supplemental insurance as needed. (Generally, Medicare does not cover overseas care.) Read the fine print. Some policies may exclude injuries related to specific, risky activities, like riding a motorbike in Southeast Asia. Be sure to pack information on how to use your policy if needed.

If you have specific medical concerns, such as heart disease, Zimring advises doing some advance research to find out if good quality, specialized care is available, even for domestic travel. Reputable tour operators are prepared to triage emergencies—getting injured or ill travelers to a hospital, for example—but beyond that, you’ll need guidance to find good specialists. Most carriers who offer medical insurance for travelers have networks of clinicians and hospitals overseas and can assist if needed. Some credit card concierge services may also be able to assist.

Think about What You Might Not Know Before You Go

Before traveling, Wilkin always signs up online for the US State Department’s Smart Traveler Enrollment Program (STEP) for every country she’s visiting overseas. This allows her to receive safety and security advisories via email (including health-related alerts, such as Zika virus updates) and enables the US embassy to contact her should an emergency arise, whether natural disaster, civil unrest or family emergency.

Make sure you have relevant contact information (both in your phone and written down on paper) and know how to call foreign numbers if you plan to use your cellphone; check with your carrier about international limitations on your service plan. Consider downloading an app like TravelSmart from Allianz Global Assistance, which uses geolocation to find nearby hospitals, doctor’s offices and embassies, with recommendations for hospitals vetted by Allianz. (The app is free and available to all travelers but there are extra features for Allianz Travel Insurance policyholders, like claim filing.)

If one or more people on your trip has mobility issues, plan early. Accessible rooms on cruise ships fill up months in advance. Kerper is leading a cruise from Dublin to Amsterdam in 2019, and in early 2018 it was almost booked.

Visualize how you’ll navigate every step. Don’t just make reservations for a flight and a hotel; consider how you’ll move from the airplane to the curb and then to the hotel and to your room. Will you be able to easily find a taxi that can accommodate a wheelchair or should you arrange that in advance? Will you encounter cobblestones, narrow sidewalks or many stairs at the hotel? Ask your tour guide or travel agent, call the hotel or destination or go online for answers.

If you haven’t much stamina, think about renting a wheelchair or scooter at your destination. You can have it delivered to your hotel.

For group programs, read tour and excursion descriptions carefully. Many tour companies rate the accessibility and difficulty of their programs. Road Scholar, for example, has a seven-level rating system for its programs catering to older travelers, ranging from “easy going” (typically bus trips with minimal walking or stairs) to “outdoor: challenging” (vigorous exertion in rugged and steep terrain).

Kerper encourages older travelers with joint problems or limited stamina to consider renting a scooter or wheelchair even if they don’t normally need one at home. Both can be reserved in advance for delivery at a hotel or other destination. Kerper uses a rental agency like Special Needs at Sea, which serves cruise lines and hotels in all port cities. (Elsewhere, she turns to Google for local agencies; in that case, it’s a good idea to check reviews first.)

Find out about options for travelers with limited mobility. The regular tour of the famous opera house in Sydney, Australia, for example, involves a climb of more than 200 steps. But there’s also another tour for those with limited mobility, available with advance reservations.

During plane travel, Zimring said, you can help prevent DVT by choosing an aisle seat, wearing loose clothing and drinking plenty of water. Walk before and during the flight as much as possible and do leg stretches (foot flexes, ankle rotations) when seated. To minimize jet lag, Zimring advises starting to adjust your sleep schedule gradually about seven days before departure.

On the trip, avoid heavy meals, alcohol and caffeine before bedtime. Melatonin supplements may help; ask your doctor first for advice on the best time to take them.

Connecting Generations through Travel

Valerie Grubb never expected she’d become traveling companions with her mother, let alone that the two of them would cover some 400,000 miles together over 20 years, visiting destinations like Italy, Australia, China, Thailand and Cambodia.

“Travel has brought my mother and me together in a way that no number of phone calls could,” said Grubb, who has put her lessons learned and tips into a book, Planes, Canes, and Automobiles: Connecting with Your Aging Parents Through Travel (2015).

Intergenerational travel offers a way to carve out time together, reconnect in a meaningful way and have fun. Even when plans go awry, Grubb said, “It makes for a great story when we’re back home.”

If you’re planning an intergenerational trip, make sure to include activities for every member of the group to enjoy. A cruise may offer a range of options from active to sedentary; one family member can relax on the boat while another opts for an active excursion on shore. Road Scholar offers a wide array of educational, group programs designed for grandparents and their grandchildren, such as the “Exploring the Northwoods with Your Grandchild” hiking trip or “Surf and Sea San Diego,” an active outdoor adventure. Kids spend time with their grandparents but also have time to make friends with other youngsters in the group.

As the younger traveler in her duo, Grubb said it’s important for her to know her mother’s current physical condition when planning a trip. This can change significantly in a year or two. She suggests visiting the older person in advance of a major overseas vacation, to get a good sense of his or her abilities. Then, be flexible and adjust travel plans if needed.

“When Mom and I first started traveling, we’d pack lots of sights in one day,” Grubb said. “Those days are gone.”

Gradually, their travel itineraries became simpler and less demanding. In the last year or so, they’ve had to limit their travels to car trips, due to new medical problems that preclude air travel. Grubb has also noticed that her mother, now 88, has become less tolerant of cultural differences and less adaptable to change as she’s aged, and this has altered their choice of destinations.

Expect the Unexpected

Even the most thoroughly researched and mapped trips can be thrown off kilter. Chances are, there will be glitches: delayed flights, missed connections, reservations that don’t show up in the system, unanticipated health issues, weather emergencies and plain old human error.

“Glitch-free trips are the odd ones these days,” Grubb said. “Something is going to go wrong. Set your mind up for it. Expect it.”

Kerper’s advice: try to roll with unexpected snafus and see them as part of the adventure. Recently, on a Caribbean cruise, as she was leading a group of travelers who used wheelchairs, they came to a shop on Bonaire that wasn’t accessible.

“We told the shop owner that we were looking to spend our money in his shop and asked if he could put out a ramp for us,” Kerper said. The shop didn’t have a ramp, so the employees brought trays of merchandise outside and mingled with the group as they made their selections. A routine shopping stop turned into a fun cultural encounter.

Kerper added that when she makes requests for accommodations, proprietors often say they will make the changes needed so that their establishments will be accessible in the future.

And that’s one of the most rewarding parts of the job, Kerper said: she’s not just helping clients have fun, she’s building awareness. “Just because you have limitations doesn’t mean you have to stay at home,” she said.

Looking for Work after 50? Are You Also Out of Luck?

The problem is serious, but there are new, hopeful signs
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At one point in her career, Amy Anderson supervised more than 50 people and managed a multimillion dollar budget for a Fortune 500 company. But after losing what she calls her “last good job” in 2013, she had no luck finding a position with anywhere near the same pay or status she once enjoyed.

Now, at age 57, she’s a cashier at a convenience store in the greater Cincinnati area, earning minimum wage with no benefits.

Anderson’s experience is not unique. Job opportunities are limited for older people seeking employment. According to a study by the Center for Retirement Research at Boston College, job changers over age 50 often end up shunted into what economist Matthew S. Rutledge calls “old-person” jobs: low-status, low-paying positions such as school crossing guards, nurses’ aides, security guards, delivery drivers and retail clerks. Occupations that require extensive training, computer use, numerical aptitude and union membership are significantly less open to older job seekers.

“We definitely believe that age discrimination and stereotyping is a big part of it,” Rutledge says. “In some cases it’s voluntary; older people may choose jobs that are less stressful or less physically demanding. But often it’s not.”

Older workers are often the first to be let go and have the hardest time finding another job.

Among jobs that are physically demanding, like farmer, electrician or repair person, only about a quarter of new hires are over 50. And in fields where jobs are scarce, older workers have an extremely difficult time finding work. In manufacturing—long a declining industry in the United States—men and women 55 to 64 were 25 percent less likely to be hired as machine operators and 58 percent less likely to land metal-worker jobs, compared to their younger peers.

Rutledge does caution that the Boston College study is skewed, in that it looks only at those who found jobs (the “winners” in the job market). In many cases, older workers don’t find work at all. Job seekers 55 and older are more likely to join the ranks of the long-term unemployed—those who’ve been looking for work for 27 weeks or more. In October 2017, 34.7 percent of job seekers 55 and older were long-term unemployed, compared with 23.7 percent of job seekers 16 to 54.

And many older job seekers who do find work are underemployed, ending up with jobs that offer lower pay, fewer hours and limited benefits, according to a 2015 AARP report, “The Long Road Back: Struggling to Find Work after Unemployment.”

Many older workers face a triple whammy: they’re often the first to go when companies make cutbacks, because seniority means their salaries are higher than those of their younger counterparts. Then they have the hardest time finding new jobs, at a time in life when they can often least afford it, when they’re also paying kids’ college tuition, or for care for aging parents. Mortgages aren’t yet paid up and retirement looms just a few years away.

Perception Problem

Why? Older workers face a perception problem, according to Beverley Riddick, executive director of the Ready To Work Business Collaborative, a nonprofit based in New York that encourages employers to hire talent they may have overlooked in traditional recruitment, including older workers.

Hiring managers may assume that an older job seeker is stuck in old habits or “won’t play well” with a supervisor who is the same age as his or her children. Riddick recalls the experience of a 60-something job candidate who felt he’d nailed a job interview—until the considerably younger hiring manager walked him out. Looking around at the office’s open layout, the hiring manager turned to the candidate and asked, “Do you think you’d fit in here?”

“At that moment, the candidate knew then that he wasn’t going to get the job, and he never heard back,” Riddick says.

The New Start Career Network, which serves long-term unemployed job seekers 45 and up in New Jersey, identified a list of stereotypes that contribute to the problem: the beliefs that older workers are not interested in acquiring new skills; that they lack ambition and energy and have cognitive or physical health challenges; that they are inflexible and less tech savvy; and that they will cost more in wages and health insurance.

There are times when being better educated limits an older person’s job prospects.

Even the hiring process itself puts older adults at a disadvantage, according to Claire Turner, director of the senior employment program at the Senior Source in Dallas. Many companies now use impersonal digital tools, like keyword searches, to screen resumes. Job seekers who don’t know how to work the system, or whose qualifications don’t fit preset, and sometimes arbitrary, requirements, end up eliminated before a human being even sees their resumes. For example, when an employer posts a job opening for candidates with three to five years of experience, the computer-based screening process may automatically filter out qualified people who happen to have more years of experience.

Older job hunters who do get past the computer screening process often don’t get past the first interview. Employers usually won’t say why they didn’t hire someone, and they’re particularly careful not to mention age. But older job candidates often sense a hiring manager’s dismay when they meet.

“The person turns up for the interview, and the hiring manager—someone in his 30s—will say something like, ‘Are you going to be able to get up these stairs in the lobby?’” Turner says.

Education Helps—Maybe

Older workers with the least education face the narrowest set of opportunities, according to the Boston College study. Anderson believes that was part of her problem: she lacks a college degree. She was able to prove herself in the workplace, but in the job market, that missing degree automatically disqualifies her for many jobs.

Paradoxically, however, education can also limit an older job seeker. After George Delianides, 60, of Saugus, MA, lost his position at age 58 at a marketing research firm, he decided to take his master’s degree off his resume.

“My thinking was, that omission might help get my foot in the door for at least an interview,” he said. “Otherwise the employer could assume that, with my age, experience and formal education, I was way out of their salary range.”

Riddick says that’s a common drawback for many older workers.

“Employers tend to back away from people who’ve earned higher salaries in the past,” she said. “They’ll say, ‘I’m not going to interview someone who made $125,000, because I’m only paying $75,000,’ even though that older job seeker might happily take that lower salary because of financial responsibilities.”

It’s Not Just about the Paycheck

When older workers are unemployed or underemployed, it’s not just their personal finances that suffer. Employment means more than a paycheck. Work offers routine, purpose and a social environment, all linked to better physical and emotional health.

“I’ve met some accomplished, wonderful people who feel unemployable for the first time in their lives,” Turner says. “It can be very discouraging.”

Anderson notes that, when her four children were young, her prospects for promotion were sometimes limited because she was unable to travel extensively.

“Now, I’m an empty nester, and I can put in those extra hours, but I can’t find a good job,” she said.

The good news: some major companies now offer internships or training programs meant for older people.

She adds that, if she were fully employed, she’d continue paying the maximum amount into social security until age 65 or later. Now, she’s draining her retirement savings to make ends meet and will likely need to start collecting benefits at the earliest possible date.

Most older Americans are already behind on saving for retirement; if they lose several prime earning years, they’ll fall even farther behind. That has negative implications for society as a whole.

“When older people start to deplete their own resources near retirement age, it makes them even more reliant on whatever federal or state backdrops are available,” says Greg McBride, Bankrate.com’s chief financial analyst.

Reasons for Hope

Not every company is unwilling to hire older workers. Some are actually taking strides to embrace their job experience and finding creative new ways to bring them back into the workforce.

Some major companies are offering internship or training programs specifically geared toward older employees. Many focus on professionals who’ve taken career breaks, such as parents who left to raise children. Goldman Sachs, for example, hosts a “returnship,” a highly selective, 10-week program that pays competitive salaries to qualified candidates, most of them 40 or older, who had achieved an executive-level status in their earlier career and who had been out of work at least two years.

“Internships help remove some of perceived risk that hiring managers may associate with hiring from this pool, and they give the participants a gradual and structured ramping-up platform,” writes Carol Fishman Cohen, CEO of iRelaunch, a company that works with professionals seeking to return to work, as well as with employers recruiting from this demographic group.

Some career experts advise proceeding with caution, however: not all internships pay, and they don’t always lead to permanent jobs.

The Senior Source’s Turner thinks she’s beginning to see an attitude change, especially among employers in smaller and medium-sized companies.

“They appreciate older workers’ work ethic and their reliability,” she says. “Employers are clamoring for people who are good with customers, and many people over 50 have those interpersonal skills.”

Focusing on those strengths, Delianides believes, is what helped him land another good job despite his age. His new position in marketing at a retail firm is roughly equivalent to his previous job in terms of responsibility. His pay is lower, but he didn’t expect to match his previous salary, given that he doesn’t have 18 years of seniority with the new employer.

“I played to my strengths,” he says. “I know the business. I’ve been in stressful situations before. I can be counted on.”

But for others like Anderson—who recently learned that the convenience store where she works will close soon—the inability to find a good job weighs heavily as they look to the future.

She’s taking it day by day, which keeps her focused, she says, adding, “Thinking ten years out overwhelms me.”

How to Save Yourself and Those You Love During a Disaster

Hurricanes, floods, active shooters: you’re safer if you know what to do
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When Hurricane Harvey struck his neighborhood on August 28, 2017, the Rev. John Stephens of Chapelwood United Methodist Church in Houston helped launch a “boat ministry.” He and several men in the church navigated privately owned boats into the rising flood waters to rescue neighbors stranded in their homes.

Stephens quickly noticed something victims had in common: most were older people.

“Maybe they were thinking, ‘I’ve seen Hurricane Allison, I’ve seen Rita, I’ve seen Ike,’ and thought they could weather the storm in their homes,” he said.

Maybe. But what Stephens discovered is something emergency-management experts already know—and struggle with: when disaster strikes, older adults are particularly vulnerable.

Almost three-quarters of the 739 people who died in Chicago’s deadly heat wave of 1995 were 65 or older, according to Eric Klinenberg, author of Heat Wave: A Social Autopsy of Disaster in Chicago (2002). Similarly, when Hurricane Katrina struck New Orleans in 2005, three-quarters of those who died were over 60, according to a Knight Ridder analysis, and among those, about half were over 75.

“The victims of Katrina were not disproportionately poor; they were disproportionately old,” wrote Amanda Ripley, author of The Unthinkable: Who Survives When Disaster Strikes—and Why (2008).

The key to surviving a disaster is clear thinking, ahead of time when possible, and during the event itself—making a plan will greatly improve your chance of survival. It’s also important to understand why older adults are more vulnerable, so family, neighbors and communities can help reduce complications and casualties as much as possible.

Planning to Survive

Not all disasters are predictable; forecasters can predict a hurricane, communities can know they are in tornado alleys, yet many emergencies are sudden—earthquakes, transportation accidents, an active shooter. Many people watch these events unfold elsewhere on the news and feel helpless, thinking that there’s no way to prepare. However, surprisingly simple measures—in advance, during and after the emergency—can mean the difference between life and death in an emergency, especially for older adults.

“Even a minor amount of preparation can pay major dividends,” wrote Russel L. Honoré in Survival: How Being Prepared Can Keep You and Your Family Safe (2010). Honoré, a retired US Army lieutenant general, led planning and response operations following several hurricanes, including Katrina.

The American Red Cross’s publication, Disaster Preparedness for Seniors by Seniors, offers three steps for preparedness: get a kit; make a plan; be informed.

Assemble a disaster kit for sheltering at home. The kit should contain enough food, water, medication and medical supplies (hearing aids, glasses, etc.) to last at least three days. Plan on at least one gallon of water per person per day. Include food items that are nonperishable and that don’t require cooking, such as peanut butter, granola bars and canned tuna, meats or beans. (Be sure to store a can opener in your kit, and replenish food periodically to ensure your supply is fresh.)

A flashlight and weather radio are also recommended. Stock extra batteries or buy hand-cranked models. Store vital records and documents (including passports, driver’s licenses, birth and marriage certificates and social security cards) in a fireproof, waterproof container, and make sure it is accessible to grab in an immediate evacuation.

Know how to turn off gas and electric utilities in your home. Keep your car’s gas tank at least half full at all times.

Discuss an emergency plan with family members, or with friends, neighbors, church acquaintances—people who will know to check on you as soon as possible. Decide where you’ll shelter in your home in severe weather, and where you might go if evacuated for an anticipated disaster such as a hurricane. Make a plan for how you’ll stay in touch with family members if you’re separated. Know how to turn off utilities (gas, electricity) in your home. Review your plan every six months and update as needed. Be sure to include out-of-town relatives in your planning and discuss how you’ll let them know your whereabouts should you evacuate.

Power outages after a disaster may drag on for days, even weeks, making it difficult to replenish basic supplies such as gasoline or medication. Keep your gas tank at least half full at all times. If possible, work with your pharmacist and insurance company to obtain a seven-day, emergency supply of all medications. Store them in a waterproof container and rotate them through your medication schedule to keep them fresh. Keep a supply of cash on hand too—ATMs and credit card machines often don’t work if the power is out.

Be prepared to communicate. During Hurricane Harvey, many people called for help with their cell phones, via 911 or social media. Keep your cell phone charged and protected from the elements. Consider investing in a protective case (like an OtterBox) and extra batteries, or a hand-cranked or solar charger. Write down important phone numbers because when your cell battery dies, you won’t be able to access your contacts. Learn steps to minimize power consumption on your cell phone—such as dimming the background light or selecting low-power mode—to extend battery life.

After an emergency, cell service is often overloaded but texting may still work when the network is busy. Don’t forget to try your landline, if you have one, as it may work when cell service is out or slow. Discuss your plans for communication with out-of-town relatives as well as immediate family members.

Finally, stay informed through reliable media sources and community notifications.

Pets and Valuables

If you have a pet, the family disaster kit should include enough food, medicine and water for each animal for at least three days. Prepare to evacuate your animals too.

“If it’s not safe for you to stay behind, then it’s not safe to leave pets behind either,” according to the Red Cross’ online pet-preparation guide. Ready leash or carrier, copies of medical records and any special, care instructions (in a waterproof container or bag), as well as current photos of your pets if you have them, in case an animal gets lost. Ensure that your pet’s vaccinations are up to date. Consider having it microchipped by your veterinarian, which may help you find it should you become separated.

Most American Red Cross shelters do not accept pets, although they do accept service animals. You’ll need to make alternate arrangements to shelter your pet. Find out which hotels along your evacuation route will accept animals. Some will waive no-pet policies in an emergency but call first to confirm. Make a list, with phone numbers, of friends, relatives, boarding facilities, animal shelters or veterinarians that might care for your animals in an emergency.

The ASPCA recommends placing a rescue alert sticker near the front door of your home to notify emergency personnel of animals in the house. Some fire departments provide these. If you do leave with your pets, write “evacuated” on the sticker, so responders don’t waste time looking for them.

In an emergency, your first priority is to keep family members safe. But if time permits, consider moving valuables to safer locations. If you’re anticipating flooding, for example, family photos might be stored upstairs or on a high shelf in a sealed, plastic, storage container. High-value items like jewelry may be moved to a safe or other secure storage.

But Why Are Older People So at Risk?

If you’re concerned about helping an older adult, it helps to understand why they are so vulnerable in disasters.

If an older person has problems with mobility, can’t drive, has no access to transportation or becomes easily confused, evacuation can be difficult. Social isolation contributes too, because they might feel as if they have nowhere to go or no one to ask for help.

In Hurricane Katrina, many low-income older adults were hampered by an unlucky quirk of timing, noted Honoré. The hurricane made landfall in southeastern Louisiana on August 29, 2005—a few days before Social Security or disability checks arrived. For some, that meant there was no money to buy a tank of gas, a bus ticket or an extra bag of groceries.

“When a hurricane hits at the end of the month, the poor, elderly and disabled people who rely on government checks will not have the money to evacuate,” Honoré wrote.

Along with the heroes come the exploiters. When older people go into crisis mode, they’re more vulnerable, scared and not quite as wary.

–Liz Loewy

Older adults are not just physically more vulnerable; they’re also more likely to suffer financially in a disaster’s aftermath. An older adult’s home may have been paid off long ago and thus may not be adequately insured. Applying for disaster aid is a complex and often confusing process that may require multiple visits to an agency office. And then there are the fraudsters—bogus repair services, fake charities and identity thieves—who show up in the wake of every disaster, targeting older adults.

“Along with the heroes come the exploiters,” said Liz Loewy, co-founder of EverSafe, an identity protection service, and former chief of the Elder Abuse Unit in the Manhattan district attorney’s office. “Anyone can fall for a scam, but when older people go into crisis mode, they’re more vulnerable, scared and not quite as wary and able to recognize a scam.”

Loewy adds that even those outside of the disaster area may be vulnerable, as fake charities crop up, purporting to help victims, but actually pocketing donations instead.

Preparing for the Unexpected

Sudden disasters can take many forms and occur in many places: an active shooter, a sinking cruise ship, a car accident, a hostage situation, a terrorist attack.

While it’s not possible to anticipate every emergency, some basic habits can help. Being aware of your surroundings will boost your chances of survival in almost any situation. For example, if you enter a public space like a movie theater, make a note of the location of the exits. If you’re on a cruise, attend the safety demonstration, pay attention and take notes if you think you might forget details.

You can’t guarantee your safety, but you can improve your odds. Many assume plane crashes are generally unsurvivable, but among all passengers involved in serious accidents between 1983 and 2000, more than half survived. (Serious accidents are defined by the National Transportation Safety Board as those involving fire, serious injury or substantial aircraft damage.) Survival often depended on simple steps: paying attention to the flight attendants’ safety briefing, noting the location of exits or evacuating the plane quickly, without pausing to grab luggage.

Preparing as a Nation

About 70 people died in Hurricane Harvey; still too many, but far fewer than the more than 1,800 deaths in Hurricane Katrina. The two disasters were different—for one thing, the water rose much faster in Katrina—but the contrast points to some progress in national preparedness to help keep seniors safe.

“We learned a lot of lessons during Katrina,” said Carrie Reyes, director of emergency
management for Plano, TX. “The best way we can help seniors to be more prepared is through education. We need to demystify disaster and make them aware of the tools to help them prepare.”

She notes that emergency managers at local levels have become much more proactive in establishing connections with older adults in their communities. Reyes, for example, frequently visits older-adult living communities and meets with groups to provide education and to involve them in community disaster planning.

After the events of Hurricanes Katrina and Rita, special needs issues—such as limited mobility, medical conditions or cognitive issues, all of which affect many older adults—were fully integrated into all phases of emergency management. (This was part of an amendment to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, which established laws guiding federal natural-disaster assistance for state and local governments.)

“Emergency managers are now tasked by federal legislation to engage our entire community,” Reyes said. “That includes the very young, the very old and those who may have access or functional needs.”

Some communities have developed systems to better track older adults and those with special needs; several counties in Florida, for example, offer vulnerable-population registries. Residents register their name, location and any special needs in the system. In the event of disaster, the registry may be used to help locate registrants during search and rescue operations.

The neighbor, whom they’d never met, said, “My house is dry and I have a second floor. We’d like you to stay until the water recedes.”

— Carrie Reyes

Reyes, who was deployed after Hurricane Harvey to Port Aransas, TX, to assist local emergency managers in rescue and recovery, also thinks that there’s more awareness of older adults’ needs in disasters.

“There was a lot of spontaneous sheltering and neighbors checking on neighbors with Harvey,” she said. Someone with a key to a local school, for example, might open it as a makeshift shelter if the school was located on higher ground.

Reyes’ great uncle and aunt, both in their 80s, live in Houston; when their house began taking on water, a neighbor knocked on their door. “The neighbor, whom they’d never met, said, ‘My house is dry and I have a second floor. We’d like you to stay until the water recedes.’”

Family members and neighbors can help older adults prepare. If you live close by, include them in family or neighborhood disaster planning. Offer to assemble a disaster kit or to purchase supplies for one.

Reach out to older adults in your community who may not have family nearby or other sources of social support. Provide your contact information and check in on them before a known emergency and after an event occurs.

Simply staying in touch with an older-adult neighbor or family member can be crucial. Author Klinenberg believes isolation contributed to the high death rate among seniors in the Chicago heat wave.

“Decades of migration out of Chicago, where the total population decreased by more than a million between 1950 and 1990, and several neighborhoods lost more than half their residents, increased the likelihood that the city’s seniors would be isolated and alone,” he wrote. By contrast, in neighborhoods like Little Village, where social ties were strong and residents enjoyed congregating in public spaces, older adults fared better during the heat wave.

Even after Preparing, Leaving Might Be Best

Sometimes, older adults may resist evacuation, simply because they’ve lived long enough to survive disasters before. Many who died in Hurricane Katrina, for example, were middle aged when Hurricane Camille struck in 1969; having survived, they felt they could manage.

“I think Camille killed more people during Hurricane Katrina than it did in 1969,” said Max Mayfield, former director of the National Hurricane Center. “Experience is not always a good teacher.”

When an older adult doesn’t want to evacuate, Reyes recommends a realistic but respectful conversation.

“Say, ‘Hey, Mom, Dad, if you stay here, it might get bad and I might not be able to come get you for a couple of days; is that what you want?’” she said. “Respect their wishes but make sure both of you understand the outcome of those decisions.”

Bill and Paulette Rogers of Port Aransas, TX, both in their 60s, learned just how bad it can get during Harvey. They decided to ride out the storm at home, even though their grown children begged them to evacuate. When the storm struck, a tree tore through their upstairs bedroom and water began to surge into the house. The couple ended up spending the night in their pick-up truck, with water up to their shoulders, expecting to die.

Thankfully, they survived.

“This is the dumbest thing I’ve ever done,” Bill Rogers later told a reporter.

Playbook for Later Life

Want to stay active and engaged in your later years? Start while you’re young
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In July, 2017, Baltimore Ravens offensive lineman John Urschel rocked the sports world with a stunning announcement: he was retiring from pro football, at the top of his game, at age 26.

Urschel, once dubbed “the NFL’s smartest man,” will work full time on his doctorate in mathematics at MIT. His announcement came just two days after a report revealed that chronic traumatic encephalopathy (CTE) had been found in 110 of the 111 brains of former NFL players studied.

While he didn’t publicly detail his reasons, it’s clear that Urschel’s choice to sacrifice one love—football—was made in the interest of his long-term well-being.

What if all young adults had solid, relevant information to help them make choices that could boost their chances for health and well-being in their 50s, 60s, 70s and beyond? What if there was a playbook for later life?

Here are some key plays to help young people score points in favor of a healthier, happier older adulthood.

Play #1: Toss Your Chair

The average American sits 13 hours per day, and it’s killing us.

Sedentary lifestyles have long been blamed for obesity, heart disease and other problems, but a mounting body of evidence now suggests that sitting eight hours a day —at a desk or in front of a computer or television—may create more health havoc than regular trips to the gym can possibly counteract.

“For every hour we sit, two hours of our lives walk away,” writes James A. Levine, MD, author of Get Up! Why Your Chair is Killing You and What You Can Do About It (2014). “The list of health consequences is an alphabet soup of life’s torments: A is for arthritis, B is for blood pressure, C is for cancer, D is for diabetes … and so it goes.”

What to do: People in their 20s can take advantage of this recent research to tweak their environments to reduce their chair time. Find ways to stand more, move more and sit as little as possible. If you work at a desk, consider a standing or a treadmill model. Or try sitting on an exercise ball or a backless stool, to force your core muscles to work harder. Use a tracking device, like a Fitbit, to remind you to get up and move every 30 minutes or so. Make a few of these changes in your 20s, and you’ll save yourself thousands of hours of life-sapping sitting.

Play #2: Don’t Go to Extremes

More and more adults, young and old, are testing themselves in Ironman triathlons and ultramarathons or with extreme sports like surfing, mountain biking or skateboarding. But while these sports get people moving, they may come at a price.

The thrill of extreme sports goes with a higher risk for severe neck and head injuries. According to a study presented at the 2014 annual meeting of the American Academy of Orthopaedic Surgeons, of the 4 million injuries reported from 2001 to 2011 among extreme-sports participants, 11.3 percent were head and neck injuries. Teens and young adults accounted for the highest percentage. Injuries were mostly likely to occur, in order, in skateboarding, snowboarding, skiing and motocross.

Similarly, endurance athletes may ultimately put too much unhealthy stress on their hearts. (Endurance athletes are those who train at an intensive level six to 10 hours per week, or more, and participate in at least two or three marathons or similar events per year.) Two recent studies showed a surprisingly high incidence of plaque in their hearts, a possible hallmark of cardiovascular disease. Another, earlier study found that long-time, elite, male endurance athletes had a higher incidence of scarring within their heart muscles.

What’s not clear is whether these higher incidences of plaque or scarring actually threaten heart health or increase mortality risk.

“In fact, the overwhelming amount of evidence is that endurance athletes … have youthful cardiovascular systems and they live longer,” said Benjamin Levine, MD, a professor of cardiology at the University of Texas Southwestern Medical Center and director of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian in Dallas.

Levine says the takeaway is this: if you’re sedentary, adopting a regular schedule of two to three hours of exercise per week will greatly reduce your risk of cardiovascular disease. But doing more won’t further reduce your risk of heart attack.

What to do: Exercising is far better than being inactive—just don’t overdo it and stick to safer sports. The American Heart Association recommends a minimum of 150 minutes of moderate physical exercise a week. For joggers, a Danish study recommended a leisurely jog a few times a week (about one to two-and-half hours total) at a moderate pace.

Play #3: Start the Simple 7

The American Heart Association’s “Simple 7” is a list of key behaviors that can help ensure heart health: maintaining a healthy weight and normal blood pressure; controlling cholesterol; reducing blood sugar; being active; eating better; and stopping smoking. People who follow these guidelines in their 20s have a lower risk of heart disease in middle age, according to a Northwestern University study.

A bonus: mounting evidence suggests that what’s good for your heart is also good for your brain. While keeping your heart healthy will keep you physically vital longer, maintaining cognitive function will enable you to stay engaged in your longevity. According to a study published in 2017 by the American Academy of Neurology, “people who took care of their heart health in young adulthood may have larger brains in middle age, compared to people who did not take care of their heart health.”

What to do: Make “the Simple 7” part of your lifestyle in your 20s. And strive to form one or two good, new habits. Learning to cook, for example, will help you avoid unhealthy fats, sugars and salt found in prepared convenience foods and fast foods. Ditto for practicing portion control, eating more veggies or eating one or two meatless meals each week.

Play #4: Drink and Be Merry—in Moderation

“Moderation is best in all things,” according to the Greek poet Hesiod. For living a longer, healthier life, that’s your best approach when it comes to alcohol.

Excessive intake of alcohol, of course, will put you on a path to poor health and an early death. New research suggests that those who are alcohol-dependent, particularly women, may shorten their lives even more than smokers. Alcoholism leads to lower bone mass, even among younger men, putting them at greater risk of fractures and poor healing, according to a study at the Medical University at Innsbruck, Austria.

However, doctors aren’t advocating abstaining entirely, and a few diets, such as the Mediterranean diet, include a glass of red wine with the evening meal. In a study of the British National Health Service’s patient records, published in 2017 in the BMJ, researchers found that drinking no alcohol was associated with an increased risk of heart disease compared with moderate drinking. Like many studies, however, this one points to links between drinking and cardiovascular health but doesn’t prove a cause-and-effect relationship. Most physicians aren’t ready to encourage nondrinkers to take up tippling.

“We don’t understand the physiology of how moderate amounts of alcohol might benefit your heart,” said Abraham Jacob, MD, a cardiologist and founder of Heart & Vitality in Plano, TX. “But we do know that there’s a flavonoid in the skin of the grapes used to make wine, which may explain why it helps us when we’re talking about drinking a glass of red wine.”

What to do: If you enjoy drinking alcohol, keep your intake moderate. In the British study, moderation was defined as the equivalent of six pints of beer or 10 small glasses of wine per week, preferably spread out over at least three days. If you’re drinking stronger stuff, dial down accordingly.

Play #5: Find Work That Matters

You’ve heard the old chestnut, “Nobody on their deathbed has ever said, ‘I wish I had spent more time at the office.’” But Maria Carney, MD, chief of geriatric and palliative medicine at Northwell Health in New Hyde Park, NY, believes that keeping busy is important to health and vitality later in life. She’s observed that many of her most vital older patients are still engaged in work they enjoy. And those who are not fulfilled by their work or activities seem less happy.

“Many people tell me, ‘I never should’ve retired,’” she said. “Whether it’s paid work, volunteer work or even working on a hobby—work seems to keep people engaged, connected to others and vital.”

Young adults make crucial job and career choices that have enormous implications for well-being later in life. One Ohio State University study found that work life in your 20s may affect your mental health in midlife. People who were generally unhappy with their jobs in their 20s and 30s were more likely to experience some health backlash by the time they reached their 40s.

“If I can give just one piece of health advice for 20 year olds, I would suggest finding a job they feel passionate about,” Hui Zheng, associate sociology professor at Ohio State University, told the New York Times in an October 17, 2016 article. “That will, in turn, make them more engaged in life and healthier behaviors.”

But don’t spend your 20s sitting on the sidelines waiting until the “perfect” career path reveals itself, counters Meg Jay, author of The Defining Decade: Why Your Twenties Matter—And How to Make the Most of Them Now (2012). “Research shows that getting going in the work world is the beginning of feeling happier, more confident, competent and emotionally stable in adulthood,” she writes. Jay encourages young adults to build “identity capital”—skills, accomplishments and experiences that earn them a place in the adult marketplace and move them closer, bit by bit, to meaningful work they enjoy.

What to do: Choose a job that yields higher satisfaction, even if it means slightly less pay. If your first job is less than ideal, focus on building that identity capital so you’ll be better prepared when a better opportunity arises.

Play #6: Give Kids a Strong Start

Family relationships and the home environment in childhood have long-term implications for health and well-being. Begun in 1938 and still ongoing, the Harvard Study of Adult Development found that a warm and intimate childhood was one of the key predictors of successful aging.

Childhood behaviors and habits also affect our later years. One University of Aberdeen, Scotland, study has linked early misbehavior—stealing, bullying, disobedience, irritability—to chronic pain in middle age. And a longitudinal study by the University of Wisconsin-Madison found that the higher the study participant’s rank in high school, the lower the probability of worsening health many years later as participants neared retirement age.

A Lancet Commissions study, Dementia prevention, intervention and care, identified higher educational achievement in childhood as one of several factors that might have the potential to delay or prevent dementia.

“Stimulating your mind, or learning another language, may help build brain reserve early in life,” said Laura Gitlin, one of the study’s coauthors and director of the Center for Innovative Care in Aging at Johns Hopkins University. “The basic conclusion is that we should be investing in the best education possible for all children.”

What to do: If you’re raising children, if you’re grandparents or if you’re a teacher, be aware that the experiences of the youngsters in your care will affect their health and well-being later in life. Do what you can to give them the strongest start possible.

Save on Health Care at the Playground

Designers are creating playgrounds just for older people
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When Ronni Bennett discovered elder playgrounds online a few years ago, she immediately fell in love with the concept. She began researching how the outdoor parks, designed specifically for the social and fitness needs of older adults, have become popular in Asia and Europe. She interviewed designers and looked into the special equipment involved.

Bennett, 75, a retired web producer who writes an influential blog about “what it’s really like to get old,” began lobbying her city council to build an elder playground in Lake Oswego, OR, the town where she lives. She was successful: her community now has a fitness park with 10 pieces of equipment designed specifically for older adults, including three that are wheelchair-friendly.

But, claiming it would be impossible to enforce an “elders only” policy, Lake Oswego officials named the park “FIT Spot.”

Bennett blames ageism. “I am so sorry the word ‘elder’ is not in the name,” she said. “But that is how things go in a culture as terrified of aging as ours is. Nobody wants to say there are old people here.”

Bennett’s experience may help explain why elder playgrounds are taking off much more slowly in the United States than in other parts of the world. While interest is growing, only a handful of dedicated “elder playgrounds” have been installed in the United States. Convincing communities to give money and space to parks that are for elders only is proving to be a hard sell.

Roots in China

Elder playgrounds have been around for about 20 years in other countries. In 1995, with the adoption of the “Physical Health Law of the People’s Republic of China” along with an “Outline of Nationwide Physical Fitness Program,” China began building outdoor fitness centers geared to all ages. In 2003, the University of Lapland in Finland, partnering with manufacturer Lappset, designed and built a playground for elders for research. Around the same time, Japan began repurposing children’s playgrounds as “Nursing Home Prevention Parks,” with specialized workout stations and classes, in response to the nation’s aging demographics. The concept quickly spread to Germany, England, Spain and Canada.

Elder playgrounds typically feature low-impact exercise equipment designed for the specific fitness priorities of older adults, such as building balance, coordination and flexibility. Equipment is lower to the ground and equipped with seats or grips geared to people who might have limited mobility or strength.

Regular use of an elder playground can boost older adults’ physical fitness and help prevent illness. One study found improvements in balance, coordination and speed after just three months.

Some elder playgrounds have been built in the United States, and there are hopeful signs that more are on the way. Colin Milner, founder and CEO of the International Council on Active Aging (ICAA), notes that many manufacturers of outdoor playground and fitness equipment have added or expanded lines of equipment specifically for older adults in recent years.

“These companies don’t jump on board unless they feel there is a significant opportunity,” Milner said.

While ICAA hasn’t tracked elder playgrounds specifically, its 2015 survey of health clubs, senior centers, retirement communities and continuing care retirement communities (CCRCs) found that 21 percent planned to purchase outdoor exercise equipment by 2017. At the time of the survey, some 41 percent planned to add game courts by 2017, 38 percent intended to create outdoor fitness or exercise trails and 57 percent aimed to install walking trails or paths.

From Kids to Elders

Michael Cohen, a veteran designer of children’s playgrounds, first became intrigued with spaces devoted exclusively to older adults when he saw a Good Morning America report on a “pensioners’ playground” in Manchester, England. That led him to found Must Have Play, an Ithaca, NY-based design group exclusively focused on innovative playgrounds for older adults. He has designed several elder playgrounds for parks in US cities, but so far none have actually been built.

Cohen envisions elder playgrounds as places that offer more than a good workout. He’d like to see elder playgrounds promote play in forms suited for older adults’ abilities, with courts or equipment for sports like pickleball, paddle ball, bankshot basketball or bocce ball, and loaded with features like water elements, walking paths and game tables.

“Ideally, an elder playground is not just a place to exercise,” Cohen said. “It’s an inviting space where you’d want to spend time.”

In the United States, playgrounds that cater to multiple generations are catching on more quickly than those designed exclusively for older adults.

That’s what happened at Carbide Park, in Galveston County, TX, which added an elder playground in 2014. The park has become a favorite destination for field trips from three local senior centers. On days when the weather is not too hot, busloads of older adults arrive to enjoy the park, according to Julie Diaz, director of parks and cultural services for Galveston County.

“If they want to go outside, they know they can come here to exercise, to swing or just to sit and talk with other seniors,” Diaz said. “The elder playground provides the type of exercise they need, and it’s very specific to them.”

Some elder playgrounds have arisen as outdoor extensions of local senior centers, such as the fitness park at the Rockville (MD) Senior Center. Cohen says that’s a big plus—proximity to a senior center or a senior residence gives visitors access to clean bathrooms and a place to go for help in the event of emergency.

The Rockville park features equipment developed especially for the needs of older adults, according to Chris Klopfer, the center’s senior sports and fitness supervisor.

“The playground encourages functional training, which incorporates more than one muscle group at a time, and that helps them with their day-to-day function, so that they can stay healthy and strong and age in place,” Klopfer said. “In today’s society we rely on medication for different ailments. I think we need to continue to push in the direction of physical exercise.”

The Rockville playground’s equipment has hand grips on everything, so that older exercisers can stabilize themselves. If they do fall, a non-slip surface made from rubberized tires makes injuries less likely.

One local trainer regularly brings older adult clients to the park for workouts when the weather is good. One of the trainer’s clients, Ellie Rouff, 72, adjusted her workout schedule to allow for more sessions at the park.

“I’m still working in an office and sit at a desk five days a week, so if I can be outside, I love it,” Rouff said. She likes the fact that the equipment has usage instructions and allows her to do exercises she couldn’t otherwise. She can no longer do push-ups on the floor but can perform them on one of the machines.

Boosting Fitness

Research suggests that regular use of an elder playground can boost older adults’ physical fitness and help prevent illness. The University of Lapland studied one group of 40 people, ages 65 to 81, and found significant improvements in balance, speed and coordination after just three months of guided exercise (90 minute, once-a-week sessions) on an elder playground.

Increased fitness not only improves quality of life, it can also help keep the cost of health care down, ICAA’s Milner notes, citing a study that found that adults who do 90 minutes of cardio exercise a week can save $2,500 annually on health care.

“By age 80, 46 percent of Americans can’t lift 10 pounds,” Milner said. “If you can’t lift 10 pounds, that’s a precursor to moving into a nursing home. Just simply getting people outdoors five to 10 minutes can make a huge difference in their mental health, attitude, overall health and well-being.”

Elder playgrounds also promote social engagement, an important factor given that many older adults become isolated and lose social ties. Numerous studies have linked isolation with poorer health among older adults.

Cohen designs elder playgrounds with conversational seating, to make them inviting even to people who may not wish to exercise. The exposure to sunlight helps reduce vitamin D deficiency and may help older adults sleep better at night.

The Multigenerational Option

In the United States, playgrounds that cater to multiple generations, instead of being designed exclusively for older adults, are catching on more quickly than elder playgrounds. These multigenerational playgrounds offer features and equipment appropriate for children as well as older adults. To motivate more adults to take their kids to play more often, the nonprofit KaBOOM! has built more than 50 multigenerational playgrounds in the United States since 2012 through a partnership with Humana and the Humana Foundation. (To build the playgrounds, local communities apply for KaBOOM! grants, enlist funding partners and recruit volunteers.)

But while multigenerational spaces offer great benefits, they’re not designed exclusively with seniors’ needs in mind, Cohen said.

“In reality, many multigenerational designs tend to pay short shrift to the needs of older adults,” he said. Many are essentially children’s playgrounds with a walking path added nearby or a few exercise machines located in adjacent space.

Milner agrees. “Multigenerational can be a little bit intimidating to older adults,” he said. “The noise might be overbearing.” Children who play raucously can be overwhelming to those living with dementia and possibly a safety issue if the children are underfoot among adults with mobility issues.

A study at Germany’s Wiesbaden Polytechnic indicated that many older adults found it embarrassing to exercise in the presence of younger people and were more inclined to use more private playground settings visited mostly by generational peers.

Another factor: some older people simply don’t feel comfortable around children. As a single, older man, Cohen says he’d personally feel uncomfortable on a playground and thinks some parents might feel that way too.

“I want a place where I can maybe meet a friend for a game of bocce, or where I can read,” he said. “I don’t necessarily want a lot of kids around.”

The Lake Oswego FIT Spot has naturally attracted some multigenerational use—it’s located near a children’s playground, so some grandparents and parents use the equipment while keeping an eye out as kids play nearby. But Ronni Bennett thinks it’s important to have dedicated spaces where elders, especially those who can’t afford a health-club membership, know they can meet peers and exercise comfortably and safely.

“With so much concern over health care costs, to me, elder playgrounds are a money-saving no brainer,” she said. “The point is to keep moving and to have fun at it. When people don’t exercise, they die younger than they should.”

Medical Tourism: Are Local Doctors Always the Best Choice?

Why people leave home for health care in other states or overseas
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Patients travel from around the United States and the world to see Richard Guyer, MD, an orthopedic spine surgeon at the Texas Back Institute in Plano, TX, because he is a recognized, widely published expert in disc-replacement surgery.

But when Guyer, 66, recently needed surgery himself—a complex procedure to remove a benign tumor—he flew to Florida. Good care was available in his own hospital, but he chose a surgery center where surgeons perform the procedure, on average, 50 times a week, using advanced techniques.

Guyer’s experience—both as sought-after surgeon and as traveling patient—is becoming more common. Proximity no longer determines health care. A growing number of Americans are willing to travel to other states or overseas as part of a trend called “medical tourism.”

Medical tourists travel to save money, to get cutting-edge or high quality care or for procedures not available locally.

Medical tourists leave home to access the best available care or to save money or, in some cases, both. Patients Beyond Borders, an information service for consumers, estimates that 1.7 million Americans will go overseas for elective medical care in 2017. The global medical tourism market is estimated to be $45 to $72 billion annually, with approximately 14 million patients crossing borders worldwide, including those who travel to the United States for medical care.

Data on domestic medical tourism—traveling within the United States to another state for health services—is scarce and largely anecdotal. But, noting a growing willingness to travel for care, physicians and medical centers are adjusting their practices to attract patients, particularly for out-of-pocket elective procedures.

What Sends Patients Packing

Within the United States, medical travel typically takes patients to centers of excellence for highly complex procedures, such as the Cleveland Clinic for heart surgery, or to research hospitals offering the latest and best care, such as Memorial Sloan Kettering Cancer Center.

Older Americans are driving the trend. Josef Woodman, CEO of Patients Beyond Borders, estimates that about 85 percent of overseas medical travelers fall within the ages of 45 to 65—too young to qualify for Medicare but at an age more likely to develop complex medical conditions.

Other drivers include the relatively inexpensive cost of travel and wide disparities in care and treatment pricing at home and abroad. Also, the Internet makes it easier for patients to research options and for providers at different locations to share medical records.

Gaps in health care insurance are also a factor, especially as a growing number of patients rely on health plans with high deductibles.

“As health plans continue to become more expensive and less cost-efficient for the patient, the ‘underinsured’ patient can often realize cost savings on more expensive surgeries over and above their plan reimbursement,” Woodman wrote in an email interview.

A 2012 study by Woodman, published in AARP International’s Journal, identifies three categories of medical tourists:

  • Value patients, usually those 50 and older, who are uninsured or underinsured or who seek procedures that insurance doesn’t cover
  • Access patients, who live in areas where available health care lacks quality or where specific procedures may not be available
  • Quality patients, who are willing to travel for exceptional specialty care, including cutting-edge surgeries or new therapies

Bill Ruth falls into the quality category. When the 64-year-old retired teacher and coach learned that he needed heart surgery, he called on a few physician friends for advice. They steered Ruth to the Cleveland Clinic or Baylor University Medical Center in Dallas, even though Ruth lives in Estes Park, CO. After researching his options and interviewing physicians, Ruth chose Baylor. He traveled to Dallas, where the procedure was successfully performed. Within a few days, Ruth was up and walking five miles at a time. And within a few weeks, he went to the high school in Pennsylvania, where he once taught, for his induction into the school’s athlete hall of fame.

Ruth’s insurance plan, through the teachers’ union, covered all of his medical costs; he picked up the cost of travel for himself and for his wife.

As a triathlete who organizes health and fitness programs in his community, Ruth said he would never consider just going to the nearest provider without doing his research.

Treatment abroad can be 20 to 80 percent less expensive, depending on the country and the procedure, and including the cost of travel.

“You want the best care possible,” he said. “Why shouldn’t people travel to get the best medical care?

“Some people put more research into buying a car (than medical care). But when you really care about your health and your activity level, you do what it takes to find the best care.”

Typically, for necessary procedures like Ruth’s, insurance will cover the treatment at most US locations, although often at out-of-network rates. (Be sure to confirm coverage with the insurance provider before any procedure.) Patients almost always pay the cost of travel.

But in some cases, medical travel is paid for by an employer. Home-improvement retailer Lowe’s sends employees in need of complex, non-emergency heart surgery to the Cleveland Clinic. Lowe’s, which self-insures its employees, struck deals for bundled prices with the Cleveland Clinic, allowing Lowe’s to save money even after paying all medical and travel costs. By going to a center of excellence for heart surgery, patients enjoy better outcomes and fewer readmissions, which in turn helps employees return to work healthier.

Lowe’s typically picks up the cost of the trip for a caregiver too and sometimes pays the deductible as an added incentive. (Employees who don’t wish to travel may choose a local provider and receive normal coverage.) Other large, self-funding companies, including Walmart, Boeing and PepsiCo, have similar approaches.

Heading Overseas

Patients are traveling to Thailand for plastic surgery, Germany for cancer treatments, Costa Rica and Mexico for dental care, Turkey for eye specialists, Israel for fertility treatments, Poland for dental implants, the United Arab Emirates for bariatric surgery, to list a few.

About 70 percent of Americans who go overseas for medical care do so for elective treatments that insurance typically doesn’t cover, such as dental work, cosmetic surgery, bariatrics or fertility treatments, Woodman said.

Opting for treatment abroad can be 20 to 80 percent less expensive, depending on the country and the procedure, even after the cost of travel. What’s problematic, however, is judging quality of care.
Leigh Turner, PhD, associate professor at the Center for Bioethics, University of Minnesota, cautions that much of the information available online is created by providers, who have a financial stake in painting a positive picture.

When you travel for care, coordinating long-term follow-up and managing postsurgical complications can be problematic.

“It’s not so easy to spot the bad actors,” Turner said. Overseas providers are “businesses that are trying to attract patients, and they are quite savvy in painting a positive picture. While the Internet gives patients more access to information, it’s also creating more misinformation.”

It’s extremely important for medical tourists to do their homework. Patients must have a good understanding of the desired procedure and make careful assessments of the quality of the provider. Patients Beyond Borders advises contacting physicians in advance for references and to check accreditations.

“If the doctor is evasive, hurried, or frequently interrupted, or if you cannot understand his or her language, then either dig deeper or move on,” Woodman writes in his book, Patients Beyond Borders: Everybody’s Guide to Getting Affordable, World-Class Healthcare (2015).

Medical-tourism concierge services can help you locate clinics and arrange travel, but they are not regulated and do not provide medical advice. Some may steer patients toward clinics that pay commissions. You should get recommendations from former customers, ask how the agency is compensated and use a US-based agency if possible.

Those who use overseas hospitals have little recourse in the event of poor outcomes. Regulation and oversight can vary widely, although that may be changing. The Joint Commission International (an independent, not-for-profit accrediting organization for US hospitals and medical providers) now accredits more than 400 hospitals worldwide, giving patients some reassurance as to quality.

Costs of Medical Tourism

Medical travel remains an option largely for those who can afford it. With very few exceptions, you must cover your own travel costs, as well as those of any accompanying caregiver.

Medicare patients may seek care at any US provider that accepts their plan, but aside from a very few rare circumstances, Medicare doesn’t pay for overseas procedures or travel costs, foreign or domestic. (Some Medicare Advantage plans might cover the cost of the trip for those who must go to a distant US facility for transplant surgery.)

Patients must also consider nondollar costs. There will be additional time spent traveling to the location and recovering there. You may need to avoid air travel, especially very long flights, for a period of time after surgery. When you are overseas, language and cultural differences can create additional stress. “Receiving care at a facility where you do not speak the language fluently might increase the chance that misunderstandings will arise about your care,” warns the Centers for Disease Control and Prevention’s website.

Some overseas hospitals offer hotels or resorts where patients may stay for recovery and post-op care before returning home. However, coordinating long-term follow-up and managing postsurgical complications can be problematic. Studies suggest that when patients are admitted for complications at a different hospital than where the original surgery took place, mortality rates are higher.
Guyer, the Texas surgeon, sees that as a key difference between domestic medical travel and overseas travel.

“If a patient comes here from Montana for surgery and later has problems, they can send pictures, we can consult over the phone, and they can fly back if need be,” he said. “If somebody goes abroad for surgery and then has a problem, we don’t like to take care of it here, because we weren’t there for the surgery.”

Effects of Medical Travel

Many hope that the trend toward medical tourism could drive improvements in quality and help keep costs down in the United States.

“Theoretically, it makes sense—as you expand patients’ options, there’s increased competition in terms of quality and price,” said Steve Wojcik, vice president of public policy for the National Business Group on Health. “That benefits everybody.”

When employers like Lowe’s send patients to the Cleveland Clinic, for example, that takes patients away from local providers.

“In those cases, a local provider might approach a big employer and say, ‘We know you’re sending people out of town; here’s our data, and here’s what we can offer you,’” Wojcik said.

But while increased competition should reduce prices and improve quality in theory, price transparency in the United States is still spotty, especially for nonelective procedures, and price disparity is wide. A 2013 Journal of the American Medical Association study of domestic providers found a wide range in pricing for hip replacement surgery: as low as $11,000 or as high as $125,000. Also, when researchers posed as patients prepared to pay cash, more than half of the hospitals queried would not provide prices upon request.

Some US medical centers offer a concierge service to assist with trip arrangements.

“There’s no correlation between cost and quality,” said Jesse Gomez, executive vice president of sales and marketing for BridgeHealth, a Denver health consulting firm that negotiates bundled rates for self-insured employers for procedures at centers of excellence. “But fortunately for consumers, objective provider data is becoming increasingly more accessible.”

Gomez notes that patients can now find average prices for common procedures from the Health Care Cost Institute by way of its consumer website and hospital quality ratings by way of websites like www.carechex.com.

But some foreign providers make it even easier. Bumrungrad International Hospital in Bangkok, a top destination for global medical tourism, publishes costs online for some 30 procedures and offers package pricing in many specialty areas.

“We can only hope for this kind of transparency to visit us sooner than later here in the US,” said Woodman of Patients Beyond Borders.

The desire to attract patients is clearly changing the way some medical providers do business. The Cleveland Clinic’s website offers extensive information for foreign and domestic travelers, plus a concierge service to assist with trip arrangements. Other centers of excellence that attract domestic medical travelers are improving the ways they integrate post-treatment and follow-up care with local providers.

Some of those providers are becoming more transparent and consumer-friendly on pricing, especially those that cater to cash patients. For example, Guyer’s clinic negotiated with the Texas Health Center for Diagnostics & Surgery to offer a package price, which allows out-of-pocket patients to pay up front and avoid unexpected charges.

The option of medical tourism is also encouraging people to become more educated and more proactive in their own medical care.

“The patients who travel to see me have done their homework,” Guyer said. “They know all about the procedure and they know what questions to ask.”

How to Deal with Your Digital Afterlife

A guide to handling problems nobody even imagined until recently
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Sara Ivey, 63, calls it one of the few gifts of cancer: time to plan.

When her husband, Jerald Sluder, was diagnosed with advanced melanoma, the Dallas couple had time to organize his affairs before his death in December 2016 at age 64. In addition to drawing up a will and advanced health care directives, they assembled a list of login information for his email and social media accounts as well as his banking and investment accounts.

Had her husband died suddenly, Ivey said, managing his online estate “would have been a nightmare upon a nightmare upon a nightmare.”

The digital revolution has created an increasingly thorny end-of-life issue: when we die, what happens to our online accounts and our Facebook pages, or to all the photos, genealogy records, recipes and other content we’ve saved in the cloud?

To deal with these complications, attorneys and other end-of-life experts now encourage clients to create a digital estate plan—a document listing all digital activities and assets, as well as login information and instructions for how to handle each account after death. That includes email, cloud storage, social media profiles, money management, health and medical portals, frequent flyer and travel memberships, web hosting or blogging information, and entertainment and shopping website accounts.

“People can’t inherit what you designate in your will unless you tell them how to get at it,” said Judith Kolberg, author of Creating Your Digital Estate Plan (2015).

Will your autopayments go on without you? Will your heirs know how to find your online accounts?

A digital estate plan doesn’t take the place of a will; rather, it should be prepared in tandem with a will and other end-of-life documents. Experts advise against including passwords or other login information in a will, as it would be inconvenient and expensive to update every time a password changes. Also, wills become public record after a person dies, so it’s possible someone could use the information to fraudulently access accounts. The digital plan serves as an easily updated addendum to help execute the deceased person’s wishes as stated in the will.

Taking this step can reduce hassle for heirs or executors, as well as prevent fraud, Kolberg said. The digital estate plan should be stored in a password-protected spreadsheet, as well as on a paper copy kept in a safe deposit box or other safe place. She also advises making appointments with yourself to update the plan regularly.

“Tie updating your digital estate plan to another activity that you do on a regular basis, such as your changing your automobile oil or paying your quarterly taxes,” Kolberg said.

Why Worry about It

“You can’t take it with you” applies to online assets just as it does to family heirlooms. Photographs, recipes, genealogy records and writings stored online over the course of a lifetime must be dealt with when someone dies: deleted, transferred to physical storage (such as a thumb drive) or maintained by someone who can continue to pay the annual or monthly storage fees.

All those pages of “Terms and Conditions” that users typically flip past when creating online accounts contain the specifics for what happens after death at websites such as Facebook, Twitter and Instagram, or to email. Heirs typically don’t have claim to that material.

“Those are usually restrictive about post-death access,” said Carl Levy, a trusts and estates attorney at Chiesa Shahinian & Giantomasi in New Jersey.

For example, Facebook owns all the content, including photos, that people upload to the site. While Facebook hasn’t generally deleted the pages of deceased users, there’s no guarantee that the social media network will preserve them in perpetuity. Facebook users who want their material to “live on” should download photos or other content onto a hard drive or find other ways to preserve it. A Facebook user may also name a legacy contact, a person who can either delete the deceased’s page or maintain a memorial page.

Accounts that store content—such as movies, music or TV shows on iTunes or eBooks on Kindle—usually “die” with the account holder. Heirs can’t continue to use the content. That’s because the user didn’t purchase the material itself, just a license to use it, which typically expires upon death. However, to date, these sites haven’t shut down accounts of people who die, nor taken steps to prevent family members with login information from continuing to access the content.

For cloud-based content created or owned by individuals—such as photos, recipes or genealogy records—the biggest concern becomes ensuring that the material is stored or maintained after death, if desired. If payments lapse for the host account, legally the website can delete material.

Money Matters

With the advent of online banking and investing, it’s conceivable that someone could die leaving almost no paperwork behind. Many people manage investment accounts on a paperless basis. Updates on accounts and bills may come exclusively through email. When a paperless person dies without leaving specific information on his or her online accounts, that leaves a major headache and investigative chore for heirs.

Reconstructing a dead person’s accounts “is a hassle, but it’s getting easier,” Kolberg said. Many banking and investing websites now offer options, usually under “settings,” where family members can find instructions for what to do if the owner dies.

To locate banking and investment accounts, heirs can start with the deceased’s federal income tax return. Except for newly acquired accounts, investments should be listed in Schedule B, Schedule D and/or 1099 forms. Heirs can contact the investment institutions, and after they provide a death certificate and the deceased’s social security number, the institution will generally transfer assets into an estate account. That’s a new account opened after someone has passed away, into which the executor deposits the deceased person’s money. This allows for bill and debt paying and, ultimately, distribution of funds to beneficiaries.

Once an estate has been settled, the executor should make sure that online accounts are closed.

“Anything kept up is susceptible to phishing and hacking,” Kolberg said.

Naming a Digital Executor

Some experts recommend designating a “digital executor” who can navigate and implement the digital estate plan—someone trustworthy who also knows how to handle online accounts, especially if the principal estate executor isn’t tech savvy. However, others advise against this approach.

“Having one person that handles solely the digital aspect and another handling the rest could be cumbersome,” said elder law attorney and financial advisor Patrick Simasko of Simasko Law in Michigan. “Most of the time, you would want only one executor.”

Some states don’t legally recognize digital executors; some have not yet enacted any legislation relating to digital assets. Individuals should seek an attorney’s advice on adding a digital executor.

Those sorting out a deceased person’s digital property should proceed with caution.

“While having a list of accounts, websites and login information is certainly helpful, care must be taken in accessing the account or website,” Levy said. “States are beginning to adopt statutes which govern who is allowed to access online information and under what circumstances.” (In general, an estate’s executor can access the deceased person’s online accounts, but terms and conditions vary.)

Further complicating the issue are federal statutes that protect privacy and impose penalties upon those who access online information without following proper procedures. But unless fraud or theft occurs, those statutes are rarely enforced, according to Julie C. McKain, an estate planning and probate attorney in Rockport, TX.

“… The problem is, the technology is evolving faster than the law’s ability to keep up.

–Julie C. McKain

She advises clients to tread lightly—wait until the executor is named, which typically takes 30 days after the person passes away, before accessing the deceased’s online accounts. However, if an online account must be accessed to prevent a loss to the estate, she does tell clients to take steps such as halting auto-payments.

This is one of those areas where the law and a website’s terms and conditions don’t really impact what the average American does after a loved one dies,” McKain said. “The problem is, the technology is evolving faster than the law’s ability to keep up.”

If in doubt, heirs should consult an attorney before accessing any online accounts. In addition, if an estate is involved in ongoing or threatened litigation, executors must be careful not to destroy anything that might be evidence—including digital assets.

Some online investment and banking accounts can be handled after death without logging on. Instead, a family member or executor may notify the provider about the death (with appropriate documentation), and the provider will close the account.

To navigate all of this, a growing number of services are emerging to help individuals think ahead about what they’d like to see happen in the event of their deaths and to assemble and update all relevant information into one place. Websites such as Assets in Order, Estate Map, PasswordBox’s Legacy Locker, and SecureSafe allow users to input online accounts and encrypted data and to name trusted family members or friends who may access the data. Other sites, like FinalRoadmap.com and Everplans.com, guide users in assembling login information as well as creating an online repository of health care directives, funeral wishes, plans for pets, family photos, even favorite family recipes. FinalRoadmap also allows users to craft messages that will be automatically sent to loved ones after death.

But user beware: dozens of businesses have sprouted up in the area and a shakeout is likely; some have already shut down or been absorbed by other companies. Before choosing an online repository, you should check to see what guarantees are in place should the company merge or go out of business.

Keeping Social Media Alive

Should you maintain a social media life after death? Heirs may wrestle with that question if the deceased had been an active presence on Facebook or other social media. They usually have three options for each account: delete it, leave it as is or have it turned into a memorial account.

Accounts that no longer serve a purpose, like LinkedIn and dating sites, should be deleted. Same for selling or shopping accounts such as eBay or PayPal.

Other decisions are less cut and dried. Some families opt to leave social media accounts “as is” but that option can have unforeseen consequences. Active Facebook accounts, for example, may generate unsettling alerts and notifications—such as a friend recommendation for someone who has passed away.

Also, a dead person’s online presence can create opportunities for phishing, hacking or scamming. One scenario, Kolberg said, is that a scammer might see the deceased’s alma mater on Facebook, then contact the family posing as a college representative and proposing a donation to a bogus memorial scholarship fund in the person’s name.

On the other hand, setting up a memorial social media page can serve as a way for friends and family to process grief and remember someone who has died.

Nowadays, we live on online, even after we pass away.

 –Sara Ivey

“Facebook creates this visual, multimedia ecosystem,” said Molly Kalan, a Boston-based marketing executive who wrote her master’s thesis on how people grieve on social media. “It’s a dynamic archive of stories, and people can keep adding to those stories. The page can commemorate a birthday or anniversary. You can reflect on that as you go through different waves of grief. I think it’s a positive.”

More than six months after her husband’s death, Ivey continues to monitor his email account. From time to time, she receives emails with key information, such as a notice of an old 401(k) account that her husband had apparently forgotten about and that she didn’t know existed.

While she expects to shut down his email soon, Sara Ivey plans to keep her husband’s Facebook page up indefinitely.

“That’s important to me, to keep his memory alive,” she said. “It has become a forum to stay connected with family and mutual friends.”

Having gone through the process, Ivey has designated her older son as the person who will manage her online presence should something happen to her.

“Nowadays, we live on online, even after we pass away,” she said.

Grandpa Gets Around…Using Uber

How older adults benefit from the sharing economy
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When Kerri Couillard founded Babierge, she expected the business would mostly attract young families who were traveling. The Albuquerque-based fledgling company connects people who need baby gear for a few days with those who have equipment to rent.

Couillard was surprised when, instead, many of her customers were people like Yvonne Mull: a 78-year-old Santa Fe grandmother who rents baby gear for just a few days here and there when her grandson comes to visit. 

“I don’t want to buy it and I don’t want to store it,” Mull said. “This works perfectly for me.”

Older customers are surprising many companies that, like Babierge, are part of the sharing economy, in which people rent out rooms, cars, boats and other assets, or buy and sell services directly from each other, all connected by way of the Internet. Also known as the gig economy or the on-demand economy, it includes businesses like the home-sharing enterprise Airbnb and the ride-hailing service Uber.

While many of these companies assumed that their customer base would be dominated by millennials, “It turns out that the baby boomer generation is a big user of the on-demand economy,” said Rowan Benecke, global technology practice chair for public relations firm Burson-Marsteller.

25 percent of Americans who are 55 or older say they’re providing services in the sharing economy.

In conjunction with the Aspen Institute and Time magazine, Burson-Marsteller developed a survey in late 2015 that revealed that 29 percent of people over age 60 have used sharing-economy services, just slightly more than the 28 percent noted in the 50-59 age group.

The fact that older adults are getting involved is good news, because the sharing economy now occupies a significant and growing position in the United States.  PricewaterhouseCoopers (PwC) estimates that the sharing economy totaled $15 billion in 2014—and will grow to $335 billion by 2025.

“Companies are realizing that there’s still an untapped market among older adults, and that paying attention to this market segment is a good idea,” Benecke said. “Older adults do have a lot of purchasing power.”

Many people, like Linda and Richard Barnhart, ages 69 and 71, of Scroggins, TX, find that the sharing economy offers benefits like convenience and good prices. The Barnharts learned about Airbnb from their daughter and used the service to rent privately owned homes in San Diego and near Yosemite for recent trips with friends.

“You get much better accommodations for a lesser price,” Linda Barnhart said. “In each instance, we were able to rent an entire house, rather than just a couple of hotel rooms. It worked out great.”

More than Bargains

Some observers believe the sharing economy offers even more than bargains and convenience; they believe that services provided on demand could create a new, cost-effective avenue for older adults to stay independent longer.

“Use TaskRabbit to get help around the house, use Instacart to deliver your groceries, use Uber to drive you to your medical appointments; the list goes on,” says Glenn Carter, a blogger at the Casual Capitalist.

Having convenient access to these services, at a reasonable price, could be a game changer, allowing older adults to avoid or postpone moving into assisted living.

“When you compare the cost of a mortgage with the cost of assisted living facilities, in some cases it can make more financial sense to use those services and age in place, rather than move to a facility, depending on the level of care required, of course,” said Nela Richardson, PhD, chief economist for national real estate brokerage Redfin.

And Dr. Joseph Coughlin, director of the Massachusetts Institute of Technology AgeLab, thinks ride-sharing services could help solve the critical problem of transportation that plagues many older adults.

“Uber improves on cabs in a few critical ways—loved ones can track Uber cars’ progress, for instance—and other, smaller services go even further,” he writes in a blog post. He points to SilverRide and Lift Hero, which match older passengers with drivers who are willing and trained to provide extra service, such as assisting customers to and from their doors, or accompanying them on doctors’ visits.

Participating in the sharing economy gives older people with a way to earn extra cash—and, just as important, to stay active and engaged.

However, not everyone sees the sharing economy as a panacea.

“Seniors 75 and up are less likely to use a smartphone, and most of these services depend on that,” said Laurie Orlov, blogger for the Aging in Place Technology Watch. A 2015 Pew study found that, while nearly two-thirds of all Americans have a smartphone, only about a quarter of adults 65 and older own one. (Some 78 percent of older adults do own cell phones, but they tend to be more basic devices, the study noted.)

Already, though, some companies are finding ways to get around the smartphone gap.

GreatCall, which markets Jitterbug cell phones and medical alert products to older people, recently announced GreatCall Rides, a pilot program in five markets (California, Florida, Arizona, Dallas/Fort Worth, TX, and Chicago) with significant populations of older adults. GreatCall customers simply press 0 to call an operator on their Jitterbug phone and order a Lyft ride; GreatCall adds the cost of the ride (plus a nominal fee) to the customer’s monthly bill. No cash is involved.

“Even among those older adults who do use a smartphone, the comfort level with the technology may still be a barrier,” said Gyre Renwick, head of healthcare enterprise partnerships at Lyft. “They may not be comfortable downloading and using an app, for example. By offering another option, we took away that barrier.”

For those who do own smartphones but lack confidence using apps, Lyft has an ambassador program. Jeff Roberts, a Lyft driver in Fort Worth, TX, visits independent living communities to get the word out and to provide “tech support.” He hosts learning sessions to give hands-on guidance and pamphlets with step-by-step instructions for using the app.

Roberts saw the opportunity for serving an older customer base after watching his grandmother discover Lyft. “She no longer drives but with Lyft can get her hair done each week and run errands,” he said.

Getting in on the Game

Some companies see an even bigger business opportunity in wooing older adults to provide services as “offerors” in the sharing economy.

Uber estimates that one in four of its drivers is 50 and older. A study by Airbnb showed that hosts 60 and older represent its fastest-growing age demographic; women 60 and up earn a higher percentage of five-star reviews (top reviews) than any other age and gender combination. And DogVacay, which pairs pet sitters with pet owners, estimates that 25 percent of its sitters are 50 and older.

Many older Americans have acquired assets—such as rooms in a large home or an extra car—that end up unused after the kids have moved out or they’ve stopped commuting to work. Companies like Airbnb and RelayRides (a car-sharing service) “let seniors monetize assets that would otherwise be gathering dust,” said Coughlin of AgeLab.

Participating as offerors also provides a way to earn extra cash—and, just as important, to stay active and engaged. Research suggests that people who become isolated in their later years don’t live as long or fare as well, health-wise, as those with strong social networks.

The sharing economy has opened new connections, both human and canine, for retired handyman Jon Palmer, 60, of Plano, TX. Palmer was devastated when his own dog, a black lab named Gracie, passed away two years ago. Later, when a lost black lab wandered onto his front porch, he took it as a sign.

“I had the best time caring for my new friend while waiting for her family to pick her up,” Palmer said. “I knew then where my next path would take me.”

Sharing-economy companies, created by young visionaries, could ultimately change the lives of older adults profoundly.

Now he offers dog boarding and day care out of his home by way of DogVacay.com. His wife works during the day, so this gives him canine companionship as well as a way to bring home some cash.

In meeting new clients, “I feel as if I make new friends every week doing this,” he said. “And I’m not the type to sit and watch TV all day.” Another bonus: while sitting jobs keep him busy, they don’t require Palmer to climb on ladders or to work outdoors in hot weather, as his previous job often did.

Palmer is part of a growing trend. An April 2015 report from PwC estimated that, while 7 percent of all Americans consider themselves providers in the sharing economy, of those ages 55 and up, 25 percent do.

However, Palmer doesn’t face one of the biggest downsides of the gig economy, given that his wife still works full time. For most, the work doesn’t provide the safety net that full-time employment does. Income often fluctuates, and the work doesn’t come with health insurance or other benefits.

While it’s clear that older adults are taking on gig-economy jobs, “what’s not clear is whether they’re doing this because they’re semiretired and value freedom and flexibility, or because they’ve been downsized out of a full-time, full-benefit job and have to settle for contract work,” says Bloomberg View blogger Justin Fox.

For those who do have a safety net—Social Security for income and Medicare for health insurance—doing jobs “on demand” offers a way to stay active, earn some extra cash and keep a flexible schedule. Or put another way, adults who remain able and willing to work may be the best positioned segment to work in the on-demand economy.

Room for Growth

While many older adults do use the sharing economy, experts agree there are still untapped avenues for increased usage among older adults. The Burson-Marsteller survey revealed two factors that may keep seniors out of the sharing economy: awareness and trust.

“Only 20 percent of the people surveyed, ages 60 and up, were familiar with the term ‘sharing economy,’” Benecke said. “There’s an opportunity for these companies to raise the awareness and to educate older potential customers about the services they are providing.”

Perception is also an issue, said Michelle Barnhart, associate professor of marketing at Oregon State University, who has studied consumers age 80 and up. “There’s a perceived difference between the shared economy versus the more heavily regulated, commercialized economy that we’ve all become accustomed [to]. We tend to feel like a company that watches its employees and is bonded and licensed and insured is a safer option than a peer-to-peer exchange.”

Still, Barnhart turned her parents, Linda and Richard, on to Airbnb, and she suspects that’s how many older adults initially connect to the sharing economy—through word-of-mouth by way of children or other trusted friends and relatives.

For the older Barnharts, the smartphone piece wasn’t an issue because they both retired recently from jobs that required them to use technology. However, that could be a barrier for her peers, Linda Barnhart believes. 

If businesses can help overcome these barriers to connect with older adults, they stand to profit. While sharing-economy companies were created by a younger generation of tech visionaries—with young, urban consumers in mind—they could ultimately change the lives of older adults most profoundly.

Says blogger Glenn Carter, “Where the sharing economy really stands out is its ability to keep [older adults] social and to help them live more independently.

Ellen Goodman: It’s Time to Talk about Death

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

Ellen Goodman, a Pulitzer Prize winning columnist, has been examining social change for most of her career. As a writer and speaker, Goodman has given a voice to progressive ideas and to women’s issues in particular. Now she is steering how we think about death and dying with her nonprofit organization, the Conversation Project, which calls itself a public health campaign and a movement, working to change the way people talk about, and prepare for, their end-of-life care.

The first glimmer of Ellen Goodman’s vision for the Conversation Project started with a suitcase.

When she was 25, Goodman went home to visit her family. Her father had been diagnosed with terminal cancer and would pass away three months later. Her mother had just given him a gift: a brand new suitcase.

Goodman jokes that the suitcase may qualify her family for the “Denial Hall of Fame” but adds she has carried the baggage of that image ever since. Because no one in her family was willing to talk about her father’s impending death, she says, there was no chance to say goodbye.

“I still wonder if my father was lonely in the silence that surrounded our inability to talk about what we all knew,” she says.

Ninety percent say talking with loved ones about end-of-life care is important; only 27 percent have actually done so.

Even though the Goodmans talked about just about everything else, the topic of death was taboo. Now, Ellen Goodman has cofounded a project to break the silence, to get people to start talking about their wishes for the end of life. 

“We hope that these conversations will begin at the kitchen table with the people you love,” she says.

Fostering Discussion

Decades after her father’s death, when her mother developed dementia and reached the end of life, Goodman found herself making difficult decisions about her care, with no sense of what her mother’s wishes might have been.  

“I had to say no to one procedure and yes to another, no to the bone marrow test, yes and yes again to antibiotics,” she says. “How often I wished I could hear her voice telling me what she wanted. And what she didn’t want.” 

Goodman’s family was not alone. According to a Conversation Project survey, even though 90 percent of people say that talking with their loved ones about end-of-life care is important, only 27 percent have actually done so.

To help bridge that gap, in 2010 Goodman cofounded the Conversation Project, a nonprofit that aims to get people talking with their families and medical providers about how they’d like to be cared for, well in advance of when a health crisis occurs. The project has created a Conversation Starter Kit, a discussion guide about what’s most important in the last phase of life. To date, more than 300,000 people have downloaded the free starter kit from www.theconversationproject.org. The project is also working to spread the word through worship groups, at local health centers and in the medical community.

Comforting Survivors

While the Conversation Project will help those at the end of life, it’s just as important for survivors. When someone passes away, studies show that depression rates plummet six months after a death if the family has had “the conversation.”

Atul Gawande, author of Being Mortal (2014) and an advisor to the Conversation Project, says that when families face difficult end-of-life decisions with no sense of their loved one’s wishes, “it’s incredibly traumatic for the family and the doctor involved.”

Death is no longer what we used to think of as natural. It comes as a cascading number of decisions.

Stories of individual families’ experiences with end-of-life questions are featured on the Conversation Project website. There’s Hong Yee, an Asian man who feels guilt about his grandmother’s not-so-good death.

“In retrospect, perhaps, we could have asked her if she wanted a feeding tube…we could have asked what she wanted and respected those wishes,” he mused.

In contrast, there’s the story of Jane, whose mother shared her wishes (“no heroics”) and her desire to be buried in the town where she lived, rather than in a family plot in another state. After her mother passed away, Jane said, knowing her wishes were honored was a source of extreme comfort.

Then there’s Linda, whose mother, Helen, did have the conversation, dealing with her impending death “honestly, openly and with great humor.” Helen signed forms for her cremation while she was still alert mentally and immediately enrolled in hospice, ensuring access to good care and pain medication when it was needed. 

“Hospice answered many requests: a massage therapist for comfort, a harpist who played by her bed; we had help with bathing, and a nurse was available day and night,” said Linda. She urged others, “Please, create the ending you want. Have the conversation too. For whatever comes next.” 

Says Goodman: “This is the gift, maybe the last gift, we can give one another.” 

We talked with Goodman about her vision for a time when people can talk openly about their wishes for the end of life—and have a better chance of dying in the way that honors those wishes.

SCF: As a society, we haven’t always needed to talk about death in the ways we do now. One might say we’re learning new skills that our parents or grandparents didn’t need as often.

EG: Medical technology has advanced so much. People are living 30 years longer than they did a century ago. That’s the good news. The harder news is that death is no longer what we used to think of as natural. It comes as a cascading number of decisions. We are faced with these decisions, which our grandparents were, by and large, not faced with. It’s a huge difference.

SCF: Another difference is, death used to be part of life. Most people died at home, so people were more familiar with death and dying—and perhaps more comfortable talking about it?

EG: Let’s not look at the past in rose-colored glasses. People died of infections and whooping cough, suddenly and tragically of diseases we can now cure. But it is true—that people saw death and they knew it up close.

SCF: Today, because of their age and numbers, boomers in particular are kind of in charge of moving the culture forward—to a better way of dealing with dying in these modern times.

EG: This is the generation of people who are now turning 65 at the rate of 10,000 a day. This generation has been [a] social-change agent of our culture all the way through their lives and they’ve also been outspoken, Lord knows. So it seems likely that, starting with [baby boomers] and going on down, we will be much more comfortable talking about these things.

SCF: How do you think your goals and your project might alter the future of how we live with death? How are your efforts going to have an effect on society?  

EG: We are a people-centered project, not a patient-centered project, and our goal is that how you live at the end of your life will be thought about and structured by your own desires. Obviously, that’s not always going to happen—there are car accidents and tragedies—but there would be a much greater number of people who would die in something we might call a “good death.”

SCF: You’ve written that everyone seems to have “a piercing memory of a good death or a hard death.” How do you define a good death? 

EG: I think the closest we’ve come is that it’s a death in which people’s wishes were respected, whatever those wishes were.

It’s not for me to say what somebody else’s experience should be. It is a death in which the people that you love know what you want and are able to help that happen.

SCF: You mentioned that the Conversation Project is people-centered, not patient-centered. In your view, is the end-of-life process too medically driven, instead of personally directed? If so, what might a more person-centered approach look like?

EG: I always think about how we transformed birth in this country a generation ago. It was because women and families said to the medical establishment that birth was not just a medical experience, it was a human experience. And now we are saying that dying is not just a medical experience, it’s a human experience and we need to keep people at the center. 

SCF: Is death a subject that’s avoided in other cultures the way many Americans avoid it?

EG: People often say, “Well, in my family/tribe/ethnic group/religion, [talking about death] is really taboo. I think we are talking about it more openly than we did, though. I’ve seen a change in the years since we’ve been in operation. We’ve had, for example, our “Death over Dinner” events, which sounds far from casual, but people have come and told stories.

As a journalist myself, one of the astounding things to me is, I’ve never been involved in anything where everybody has a story. I mean everybody has a story. I tell people I’m involved in a project to encourage conversations about end-of-life wishes. There’s kind of like half a beat, and then out pours a story. It’s just amazing.

[Editor’s note: For three years, the Conversation Project has partnered with the Death Over Dinner organization to encourage people during a designated week to host dinner parties to talk about their end-of-life wishes.]

SCF: Then again, when you’re talking to loved ones, they may be resistant, even hostile, when you try to bring up the topic of end of life. Any suggestions for broaching the subject in ways that might be less threatening or upsetting?

EG: There are lots of things that we have on the website about ways to approach it: telling someone your own story; showing them a letter; showing them this column that you’re writing; telling a story themselves; asking for a story.

One thing that works really well for adult children when talking with their parents is asking for help: “Hey Mom, hey Dad, when the times comes, I may have to make decisions for you and I really need your help in figuring out what I should do.” That’s useful because parents like to be in a position to help their children.

SCF: What are a few specific end-of-life issues—medical, financial, emotional—addressed in the starter kit?

EG: The starter kit is a non-scary, non-medical conversation starter, literally. It asks you questions like what matters to you, where do you want to spend your last days, are you a person who wants all the information or would you rather doctors and families make decisions. Of course, it also asks whether you want every imaginable treatment no matter your condition, or whether there will come a time when you want comfort care only.

SCF: Could you talk a little about multicultural aspects? For example, in Being Mortal, Atul Gawande talks about how some African Americans worry more about receiving too little treatment rather than too much, which is the opposite of what many Caucasians fear. 

EG: That’s true, and understandable for historical reasons.

We are doing several multi-ethnic projects. One is the Conversation Sabbath, where we’re trying to get the word out through faith communities [to] virtually every religion you can think of. We’re also doing a project with community health centers that is looking at the differences between different ethnic groups. It’s like a pilot project. How does it work at a largely Asian community health center, an African-American community health center, a Hispanic community health center?

SCF: Have you heard yet from any participants who used the Conversation Starter Kit, and then put the information they’d gleaned to use? I’d love to have an example of how it worked in real life.  

EG: A lot of people have told me, “I thought this would be so hard. I never thought my father would talk to me about this. But when we actually sat down, it wasn’t painful. It was one of the most intimate conversations we’ve ever had.” I’ve heard that repeatedly.

SCF: Having this conversation can bring up some complicated issues. Boiled down, what do you think it’s really about?

EG: I actually think the end-of-life conversation is about life, how you want to live at the end, what matters to you, and sharing those intimate feelings and information with the people you love.