At an assisted living facility in New York State, a small crowd had gathered at the dining room entrance at lunchtime, waiting for the doors to open. As a researcher observed, one woman, growing tired and frustrated, asked the man in front of her to move; he didn’t appear to hear.“Come on, let’s get going!” she shouted — and pushed her walker into him.In Salisbury, Md., a woman awoke in the darkness to find another resident in her bedroom in an assisted living complex. Her daughter, Rebecca Addy-Twaits, suspected that her 87-year-old mother, who had dementia and could become confused, was hallucinating about the encounter.But the man, who lived down the hall, returned half a dozen times, sometimes during Ms. Addy-Twaits’s visits. He never menaced or harmed her mother, but “she’s entitled to her privacy,” Ms. Addy-Twaits said. She reported the incidents to administrators.In long-term care facilities, residents sometimes yell at or threaten one other, lob insults, invade fellow residents’ personal or living space, rummage through others’ possessions and take them. They can swat or kick or push.Or worse. Eilon Caspi, a gerontologist at the University of Connecticut, has searched news coverage and coroners’ reports and identified 105 resident deaths in long-term care facilities over 30 years that resulted from incidents involving other residents.The actual number is higher, he said, because such deaths don’t always receive news media attention or are not reported in detail to the authorities.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Medicare Advantage plans say it reduces waste and inappropriate care. Critics say it often restricts coverage unnecessarily.Slowly but steadily, Marlene Nathanson was recovering. She had suffered a stroke in November 2022 at her home in Minneapolis and spent a week in a hospital; afterward, when she arrived at Episcopal Homes in St. Paul for rehabilitation, she couldn’t walk. Weakness in her right arm and hand left her unable to feed herself, and her speech remained somewhat garbled.But over three weeks of physical, occupational and speech therapy, “she was making good progress,” her husband, Iric Nathanson, said. “Her therapists were very encouraging.” Ms. Nathanson, then 85, had begun to get around using a walker. Her arm was growing stronger and her speech had nearly returned to normal.Then, on a Wednesday afternoon, one of her therapists told the Nathansons that their Medicare Advantage plan had refused a request to cover further treatment. “She has to leave our facility by Friday,” the therapist said, apologetically.Mr. Nathanson, then 82, felt anxious and angry. He didn’t see how he could arrange for home care aides and equipment in 48 hours. Besides, he said, “it didn’t seem right that the therapists and professionals couldn’t determine the course of her care” and had to yield to an insurance company’s dictates. “But apparently it happens a lot.”It does. Traditional Medicare rarely requires so-called prior authorization for services. But virtually all Medicare Advantage plans invoke it before agreeing to cover certain services, particularly those carrying high price tags, such as chemotherapy, hospital stays, nursing home care and home health.“Most people come across this at some point if they stay in a Medicare Advantage plan,” said Jeannie Fuglesten Biniek, associate director of the program on Medicare policy at KFF, the nonprofit health policy research organization. After years of steep growth, more than half of Medicare beneficiaries are now enrolled in Advantage plans, which are administered by private insurance companies.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Trained negotiators can help families struggling with vexing elder-care issues.The four adult children were in agreement.Their father, William Curry, a retired electrical engineer and business executive, was sinking deeper into dementia. They had found a memory care facility about a mile from their parents’ house in Chelmsford, Mass., where they thought Mr. Curry would do better.But their mother, Melissa, who was 83 when her family began urging her to make this change in 2016, remained determined to continue caring for her 81-year-old husband at home, despite the increasing toll on her own health. When her children raised the issue of a move, “she wouldn’t discuss it,” said her daughter, Shannon Curry, 56. “She’d clam up. Sometimes she’d cry.”Yet Melissa Curry’s memory was faltering, too. She would forget to give her husband his medications, or get the doses wrong. The family worried about falls and fires. Even after they persuaded her to accept a hired aide several days a week, the couple was still alone most of the day as well as overnight.As the weeks passed, “we were really at an impasse,” Ms. Curry said. “Do you override your mother?”Enter the mediator. Through a friend, Ms. Curry learned about Elder Decisions, a company offering “elder adult family mediation.” Her parents and siblings all agreed to give it a try. Crystal Thorpe, the company’s principal and founder, and a co-mediator, Rikk Larsen, interviewed family members by phone, then scheduled a session around the parents’ dining room table.Often associated with business disputes or divorce and custody cases, trained mediators can also help families struggling with an array of vexing elder-care issues: appropriate living arrangements, care responsibilities, communication and information sharing, and health and financial decisions.When families seek mediation, they “want to do what is best, but have different perspectives on what ‘best’ might mean,” Ms. Thorpe explained.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Homeownership is not the boon to older Americans that it once was.When it came to housing, Susan Apel and Keith Irwin thought they had planned adroitly for later life. They bought a four-bedroom house on two acres in Lebanon, N.H., 24 years ago, and “we made sure to pay off the mortgage before we retired,” said Ms. Apel, 71.That way, the home equity they had built up — they estimate their house is now worth about $700,000 — would allow them to sell and downsize into smaller, more manageable quarters when they needed them.That time has arrived. Ms. Apel, a retired law professor, is having trouble climbing stairs. Mr. Irwin, 71, previously an account manager for a local business, is wearying of yard work and snow shoveling, and finding workers to do those chores instead has become difficult.“We’re seeing the writing on the wall,” Ms. Apel said. They have started shopping for “a nice two-bedroom condo with a little den, all on one floor.”But they can’t find one. Local developers are putting up four-level townhouses with even more stairs. The few suitable one-floor homes available get instantly snapped up. City dwellers fleeing Covid helped pump up housing prices: One unit the couple saw recently cost $950,000 and needed work, Ms. Apel reported. Even “tiny shoeboxes” are selling for $600,000.“We were very grateful to live in this lovely place and to have paid off our house,” Ms. Apel said. “It never occurred to us that it didn’t give us the ability to move out of it.”We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

The pandemic played a role in increased consumption, but alcohol use among people 65 and older was climbing even before 2020.The phone awakened Doug Nordman at 3 a.m. A surgeon was calling from a hospital in Grand Junction, Colo., where Mr. Nordman’s father had arrived at the emergency room, incoherent and in pain, and then lost consciousness.At first, the staff had thought he was suffering a heart attack, but a CT scan found that part of his small intestine had been perforated. A surgical team repaired the hole, saving his life, but the surgeon had some questions.“Was your father an alcoholic?” he asked. The doctors had found Dean Nordman malnourished, his peritoneal cavity “awash with alcohol.”The younger Mr. Nordman, a military personal finance author living in Oahu, Hawaii, explained that his 77-year-old dad had long been a classic social drinker: a Scotch and water with his wife before dinner, which got topped off during dinner, then another after dinner, and perhaps a nightcap.Having three to four drinks daily exceeds current dietary guidelines, which define moderate consumption as two drinks a day for men and one for women, or less. But “that was the normal drinking culture of the time,” said Doug Nordman, now 63.At the time of his hospitalization, though, Dean Nordman, a retired electrical engineer, was widowed, living alone and developing symptoms of dementia. He got lost while driving, struggled with household chores and complained of a “slipping memory.”We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Federal law requires states to go after the assets, usually homes, of people who died after receiving benefits for long-term care.The letter came from the state department of human services in July 2021. It expressed condolences for the loss of the recipient’s mother, who had died a few weeks earlier at 88.Then it explained that the deceased had incurred a Medicaid debt of more than $77,000 and provided instructions on how to repay the money. “I was stunned,” said the woman’s 62-year-old daughter.At first, she thought the letter might be some sort of scam. It wasn’t.She asked not to be identified, because the case is unresolved and she doesn’t want to jeopardize her chances of getting the bill reduced. The New York Times has reviewed documentation substantiating her account.The daughter moved into the family’s Midwestern home years earlier, when her widowed mother, who had vascular dementia, began to need assistance.Her mother was well insured, with Medicare, a private supplemental “Medigap” policy and long-term care insurance. The only reason she enrolled in Medicaid was that she had signed up for a state program that allowed her daughter to receive modest payments for caregiving.But that triggered additional monthly charges through a Medicaid managed care organization, and now the state wants that money back.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

New criteria could lead to a dementia diagnosis on the basis of a simple blood test, even in the absence of obvious symptoms. Determining whether someone has Alzheimer’s disease usually requires an extended diagnostic process. A doctor takes a patient’s medical history, discusses symptoms, administers verbal and visual cognitive tests.The patient may undergo a PET scan, an M.R.I. or a spinal tap — tests that detect the presence of two proteins in the brain, amyloid plaques and tau tangles, both associated with Alzheimer’s.All of that could change dramatically if new criteria proposed by an Alzheimer’s Association working group are widely adopted.Its final recommendations, expected later this year, will accelerate a shift that is already underway: from defining the disease by symptoms and behavior to defining it purely biologically — with biomarkers, substances in the body that indicate disease.The draft guidelines, Revised Criteria for Diagnosis and Staging of Alzheimer’s Disease, call for a simpler approach. That could mean a blood test to indicate the presence of amyloid. Such tests are already available in some clinics and doctors’ offices.“Someone who has biomarker evidence of amyloid in the brain has the disease, whether they’re symptomatic or not,” said Dr. Clifford R. Jack Jr., the chair of the working group and an Alzheimer’s researcher at the Mayo Clinic.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

A society in which members of different generations do not interact “is a dangerous experiment,” said one researcher.On Fridays at 10 a.m., Richard Bement and Zach Ahmed sign on to their weekly video chat. The program that brought them together provides online discussion prompts and suggests arts-related activities, but the two largely ignore all that.“We just started talking about things that were important to us,” said Mr. Ahmed, 19, a pre-med student at Miami University in Oxford, Ohio.Since the pair met more than a year ago, conversation topics have included: Pink Floyd, in a long exploration led by Mr. Bement, 76, a retired sales manager in Milford Township, Ohio; their religious faiths (the senior conversation partner is Episcopalian; the younger is Muslim); their families; changing gender norms; and poetry, including Mr. Ahmed’s own efforts.“There’s this fallacy that these two generations can’t communicate,” said Mr. Bement. “I don’t find that to be true.”“Zach tells me about his organic chemistry class, about being a student in 2024. I afford Zach an opportunity to share with me what it’s like to be him, and vice versa.”Miami University began Opening Minds Through Art, a program designed to foster intergenerational understanding, in 2007 and introduced an online version in 2022. This semester, about 70 pairs have enrolled in the video program. Another 73 students engage in O.M.A.-sponsored arts activities with people who have dementia at a nursing home, a senior center and an adult day program.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

The move to a long-term care facility is often difficult but necessary for frail patients. For their partners, it can mean a new set of challenges.Even as the signals of approaching dementia became impossible to ignore, Joseph Drolet dreaded the prospect of moving his partner into a long-term care facility.Mr. Drolet, 79, and his beloved Rebecca, 71, both retired lawyers and prosecutors in Atlanta, had been a couple for 33 years, though they retained separate homes. In 2019, she began getting lost while driving, mishandling her finances and struggling with the television remote. The diagnosis — Alzheimer’s disease — came in 2021.Over time, Mr. Drolet moved Rebecca (whose surname he asked to withhold to protect her privacy) into his home. But serving as her round-the-clock caregiver, as she needed help with every daily task, became exhausting and untenable. Rebecca began wandering their neighborhood and “getting dressed in the middle of the night, preparing for trips that weren’t happening,” Mr. Drolet recalled.Last year, when he determined that Rebecca no longer really knew where she was, he felt it was time to move her to a nearby memory-care residence.Putting a spouse or partner in a nursing home, for any reason, represents a fraught transition for any couple, one that can mean release from the sometimes crushing burden of caregiving, but can also be accompanied by lingering depression, anxiety and guilt, studies have shown.“That everything was on my shoulders for the care of a very vulnerable person — that stress left,” Mr. Drolet said. After Rebecca left, “the 24-hour duties could be taken by somebody else.” His constant fear of what would happen to Rebecca if he died or became disabled also abated.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Last Thanksgiving, Cynthia Mosson had been on her feet all day in her kitchen in Frankfort, Ind., preparing dinner for nine. She was nearly finished — the ham in the oven, the dressing made — when she suddenly felt the need to sit down.“I started hurting in my left shoulder,” said Ms. Mosson, 61. “It got really intense, and it started to go down my left arm.” She grew sweaty and pale and told her family, “I think I’m having a heart attack.”An ambulance sped her to a hospital where doctors confirmed that she had suffered a mild heart attack. They said testing revealed serious blockages in all her coronary arteries and told her, “You’re going to need open-heart surgery,” Ms. Mosson recalled.When such patients head into an operating room, what happens next has a lot to do with their sex, a recent study in JAMA Surgery reported. The study reinforced years of research showing that male and female patients can have very different outcomes following an operation called coronary artery bypass grafting.C.A.B.G. (pronounced like the vegetable) restores blood flow by taking arteries from patients’ arms or chests, and veins from their legs, and using them to bypass the blocked blood vessels.“It’s the most common cardiac operation in the United States,” taking place 200,000 to 300,000 times a year, said Dr. Mario Gaudino, a cardiothoracic surgeon at Weill Cornell Medicine and lead author of the study.Twenty-five to 30 percent of C.A.B.G. patients are women. How do they fare? The mortality rate for C.A.B.G., though low, is much higher for women (2.8 percent) than men (1.7 percent), Dr. Gaudino and his colleagues found.Analyzing results from about 1.3 million patients (average age: 66) from 2011 to 2020, the researchers also determined that after C.A.B.G., about 20 percent of men had complications that included strokes, kidney failure, repeat surgeries, infections of the sternum and prolonged respirator use and hospital stays. Among women, more than 28 percent did.Cardiac and pulmonary rehabilitation respiratory therapist Abbey Smit, right, took Ms. Mosson’s blood pressure at a rehabilitation appointment at IU Health Frankfort Hospital.Kaiti Sullivan for The New York TimesOf those complications, “many are relatively minor and self-resolving,” Dr. Gaudino said. But recovering from sternal wound infections can take months, he noted, and “if you have a stroke, that can affect you for a long time.” Though outcomes improved for both sexes over the decade, the gender gap remained.The study “should be regarded as an exploding flare in the sky for all clinicians who care for women,” an accompanying editorial said. Yet to cardiac researchers, the results sounded familiar.“This has been something we’ve known since the 1980s,” said Dr. C. Noel Bairey Merz, a cardiologist and researcher at Cedars-Sinai Medical Center. Heart disease, she pointed out, remains the leading cause of death for American women.With C.A.B.G., “the general assumption was that it was getting better because the technology, the knowledge, the skills and training were all improving,” she said. To see the gender disparity persist “is very disappointing.”Several factors help explain those differences. Women are three to five years older than men when they undergo bypass surgery, in part because “we recognize coronary artery disease more easily and earlier in men,” Dr. Gaudino said. “Men have the classic presentation we study in medical school. Women have different symptoms.” These may include fatigue, shortness of breath and pain in the back or stomach.Fewer than 20 percent of patients enrolled in clinical trials have been female, so “what we’ve been taught is essentially based on research in men,” he added.Partly because they’re older — about 40 percent are over 70 — women are more apt than men to have developed health problems like diabetes, high blood pressure and vascular conditions, “all factors that increase risk in cardiac surgery,” Dr. Gaudino said. They also have smaller, more fragile blood vessels, which can make surgery more complex.The disparities affect other forms of cardiac treatment and surgery, too. Women have worse outcomes than men five years after receiving a stent, a 2020 review of randomized trials reported.Ms. Mosson’s daily medications.Kaiti Sullivan for The New York TimesThey’re “less likely to be prescribed and to take statins, and particularly less likely to take the high-intensity statins, which are the most lifesaving,” Dr. Bairey Merz said. “The list goes on and on.”When C.A.B.G. works well, the results can feel miraculous. Rhonda Skaggs, 68, had a quadruple bypass in July 2022 and spent 12 days in intensive care before going home to Brooksville, Fla. Six months passed before she returned to work at a Home Shopping Network outlet store.“Now, you’d never know I had open-heart surgery,” she said. “I walk 10,000 steps a day. I teach line dance classes twice a week. I have my life back.”But Susan Leary, 71, a retired New York City teacher now living in Fuquay-Varina, N.C., is facing a second procedure after bypass surgery at Duke University last month.“Women are less likely to get all the vessels that need to be bypassed bypassed,” said her cardiothoracic surgeon, Dr. Brittany Zwischenberger, co-author of the call-to-arms editorial in JAMA Surgery.A few years before, Ms. Leary had sought a procedure to shrink away the “ugly-looking” varicose veins in her legs; now, she lacked viable blood vessels for grafting. “How did I know I was going to need some of those veins for my heart?” she said.She had a double bypass, instead of the triple bypass she needed, which represents “incomplete revascularization.”“It can contribute to worse outcomes and future interventions,” Dr. Zwischenberger said. “Fortunately, she’s a candidate for a stent” for the third blocked artery, which involves inserting a mesh tube into the vessel to widen it. The procedure is scheduled for next month.Advocates of improved care for women argue that their surgical risks can be reduced.Dr. Lamia Harik, a cardiothoracic surgery researcher at Weill Cornell Medicine, and her colleagues have found that nearly 40 percent of women’s mortality during C.A.B.G. stems from interoperative anemia. (Their study is in press.)On the treadmill during her rehabilitation appointment. Ms. Mosson has begun a three-times-weekly cardiac rehab program, recommended for patients who’ve undergone bypass surgery. She finds that her stamina is improving.Kaiti Sullivan for The New York TimesThat occurs when operating teams administer fluids to dilute patients’ blood during the procedure, allowing them to use the large cardiopulmonary bypass machine (“the pump”) that keeps blood oxygenated and flowing while surgeons do the grafting.“This is something modifiable,” Dr. Harik said. For women, surgeons might use smaller pumps or reduce the volume of added fluid, or both.To learn more, Dr. Gaudino and other researchers have begun enrolling women, and only women, in two new clinical trials. The international ROMA study, the first all-female surgical trial, will investigate two C.A.B.G. techniques to see which produces better outcomes; the federally funded Recharge trial will compare stenting with C.A.B.G.“In the past, a lot of surgeons thought this was inevitable,” Dr. Gaudino said of the differences between the sexes. “Maybe they will not disappear, but they can be minimized.”Ms. Mosson said her surgeons were pleased with the results of her quadruple bypass, though she was readmitted to the hospital briefly for fluid in her lungs. She has begun a three-times-weekly cardiac rehab program, recommended for patients who’ve undergone bypass surgery, and finds that her stamina is improving.She still contends with the psychological aftermath of her heart attack and surgery, as Ms. Skaggs did and Ms. Leary still does. They describe shock — none had a history of heart disease — depression and anxiety. “I’m still struggling with the fear it will happen again,” Ms. Mosson said.One antidote, for Ms. Leary, was being recruited for ROMA; Duke is among the clinical trial sites. She jumped at the chance to enroll.“Let me be a part of it,” she said. “Maybe my daughter will need this information someday.”