Mentoring programs bring together those just starting to care for family members with dementia and those who have been coping for some time.On Thursday mornings, Julia Sadtler and Debora Dunbar log onto Zoom to talk about caring for their husbands with Alzheimer’s disease, in hourlong conversations that are usually informative, sometimes emotional and always supportive.Both men are patients at Penn Memory Center in Philadelphia, which began this mentorship program for caregivers in September. By design, the two women are at different stages.Dr. Dunbar, a nurse-practitioner who lives in Wallingford, Pa., is younger, at 61, but has coped with caregiving for far longer: Her husband, Jeffrey Draine, 60, was diagnosed with early-onset Alzheimer’s in 2017. “It’s something I’ve developed expertise in,” she said.Philip Sadtler, 80, received his diagnosis just two years ago, so his wife has long lists of questions about what lies ahead. How will she know when Philip should stop driving? How can she handle the guilt of leaving him at home sometimes while she volunteers or sees friends? How long can the couple, who live in Berwyn, Pa., continue traveling to California to visit their daughter and her family?“The sense of being overwhelmed can be crushing,” said Ms. Sadtler, 81, a retired school admissions director. She also participates in a Penn Memory caregiver support group, but felt drawn to the mentorship’s one-on-one nature. “I knew that someone who’s been down this road would be a great help,” she said.“Caregiving in general is hard, but caregiving for a person with dementia is harder,” said Felicia Greenfield, Penn Memory’s executive director. “Caregivers report high rates of anxiety and depression. They have a harder time attending to their own health. Things change socially; their friends don’t understand or come around anymore.”It’s also, she added, a financially draining and physically demanding role, often lasting for years, continuing even if a family member moves into assisted living or a nursing home. The center’s Caring Collective mentorship matches newcomers to the challenge with those who have walked the walk.A new study documents the extent of that burden. Using data from the longitudinal federal Health and Retirement Study, a University of Michigan team compared about 2,400 older adults (average age: 75) who developed dementia during a two-year follow-up with 2,400 others who did not. The researchers matched the groups for health and disability, demographic characteristics, economic status and health care use.“They were very similar people at baseline, so we could demonstrate the impact of dementia,” said HwaJung Choi, a health economist and the lead author. “We were surprised at the huge change over two years.”Debora Dunbar with her husband, Jeffrey Draine, at home in Wallingford, Pa., in 2018. Mr. Draine, 60, was diagnosed with early-onset Alzheimer’s in 2017. “It’s something I’ve developed expertise in,” Ms. Dunbar said.Mark Makela for The New York TimesAt the start, people in both groups received about 12 hours of unpaid care a month from family and friends. After two years, the control group showed little change, but in the group with dementia, “the care hours for family members increased dramatically,” to 45 hours a month, Dr. Choi said.That figure refers only to hands-on help with so-called activities of daily living — bathing, dressing, using the toilet. Taking into account tasks such as shopping, meal preparation and handling finances, unpaid caregivers spent 27 hours assisting the control group each month, compared with 76 hours for the group with dementia.Only about 3 percent of either group used a nursing facility, including rehab stays, at the start; over two years, more than one in five of those with dementia had used or moved into a nursing facility. About 47 percent of the people with dementia had at least one hospital stay, versus 35 percent of those without dementia.Moreover, largely because of the expense of long-term care, those who had developed dementia lost more than 60 percent of their median wealth over a longer eight-year follow-up. “It’s a devastating problem for individuals and families, and also for society in general,” Dr. Choi said.None of that will come as a surprise to families caring for people with dementia.“I remembered how absolutely terrified I was at the beginning,” said Susan Jewett, 76, who first proposed the mentoring idea to Penn Memory after her husband’s death in 2020.Her pitch: “Maybe I could be useful to someone who is earlier in the process.”Mentoring can benefit both parties, said Justin McBride, a senior administrator at Duet: Partners in Health and Aging, which began a similar program in Phoenix in 2016. “We hear all the time that supporting another person in need gives mentors a sense of purpose,” he said. “It helps them make sense of their own journey.”The relatively low cost of such volunteer programs could make them replicable in many locations. They operate on a small scale, however. Duet’s program, which like Penn’s involves screening and training mentors, has about 20 pairs enrolled.It requires a six-month commitment, but most mentoring relationships last a year or two. Penn’s newer Caring Collective, requiring a three-month commitment, has enrolled 20 mentors and 40 mentees.Larger organizations like the Alzheimer’s Association also work to support dementia patients and caregivers. Its free 24/7 helpline responded to 215,000 contacts in the 2023 fiscal year, and its online community called ALZConnected has about 10,000 active members. It conducts more than 27,000 caregiver support groups nationally.Still, support programs aim to keep family caregivers on the job — a job that may simply grow too demanding, especially since many (spouses, in particular) are themselves quite old, with their own health problems and limited ability to afford paid help.“People in government need to hear about what’s going on,” Ms. Greenfield said.A new federal initiative is on the horizon. Medicare plans to fund an eight-year model program called GUIDE, to provide care coordination, education and support; it will include payment for respite services, allowing caregivers a break from their responsibilities.Workplaces can also play a role, especially for adult children who are working while also caring for aging parents. While employers estimate that 35 percent of their workforces are caregivers, the actual proportion is 56 percent, according to a recent Bank of America report.Those workers need policies like leaves of absence, flexible scheduling and counseling. Yet a 2021 report for the Rosalynn Carter Institute for Caregivers found that most employers didn’t offer them.Mentoring provides a different kind of support, but one that early participants say has proved uniquely valuable. Mary Perkins, 76, who cares for her husband at their home in Lewes, Del., has been talking regularly with Susan Jewett.Her husband, Wes Perkins, 82, has vascular dementia and Alzheimer’s; at one point, when he required institutionalization for dementia psychosis, his care became particularly difficult. “I was a mess,” Ms. Perkins said. “I needed to talk with someone who understood.”Even more than advice on specific programs and strategies, Ms. Perkins said, she benefited from hearing Ms. Jewett’s own story. “I looked at her face on FaceTime, and I saw hope,” Ms. Perkins said. “I knew she’d gone through hell and she was surviving, even thriving. If she could live through it, I could, too.”Mr. Perkins is back at home now, taking medication to control his symptoms and enrolled in a local PACE program, a comprehensive state and federal effort that provides some paid home care. The couple can take walks together, go out for breakfast, drive to the beach. “We still have good times,” Ms. Perkins said. “It’s better than I ever thought it could be.”At some later date, she plans to become a mentor herself.

Over-the-counter devices have been available for a year now. New research suggests they may have unexpected benefits.A year ago, the Food and Drug Administration announced new regulations allowing the sale of over-the-counter hearing aids and setting standards for their safety and effectiveness.That step — which was supposed to take three years but required five — portended cheaper, high-quality hearing aids that people with mild to moderate hearing loss could buy online or at local pharmacies and big stores.So how’s it going? It’s a mixed picture.Manufacturers and retailers have become serious about making hearing aids more accessible and affordable. Yet the O.T.C. market remains confusing, if not downright chaotic, for the mostly older consumers the new regulations were intended to help.The past year also brought renewed focus on the importance of treating hearing loss, which affects two-thirds of people over age 70. Researchers at Johns Hopkins University published the first randomized clinical trial showing that hearing aids could help reduce the pace of cognitive decline.Some background: In 2020, the influential Lancet Commission on Dementia Prevention, Intervention and Care identified hearing loss as the greatest potentially modifiable risk factor for dementia.Previous studies had demonstrated a link between hearing loss and cognitive decline, said Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins and lead author of the new research.“What remained unanswered was, If we treat hearing loss, does it actually reduce cognitive loss?” he said. The ACHIEVE study (for Aging and Cognitive Health Evaluation in Elders) showed that, at least for a particular group of older adults, it could.Of nearly 1,000 people ages 70 to 84 with untreated mild to moderate hearing loss, half received hearing assessments from audiologists, were fitted with midpriced hearing aids and were counseled on how to use them for several months. The control group participated in a health education program.Over three years, the study found that hearing-aid use had scant effect on healthy volunteers at low risk of cognitive loss. But among participants who were older and less affluent, hearing aids reduced the rate of cognitive decline by 48 percent, compared with the control group, a difference the researchers deemed “clinically meaningful.”This subset of participants had lower income and “were older, less educated, with higher rates of diabetes and hypertension,” Dr. Lin said. Because such factors are also associated with dementia, “the people at higher risk really stand to benefit the most,” he said.In trying to slow cognitive decline, “with a lot of other therapies and treatments, we learn that they can be too little, too late,” he added. ACHIEVE indicates that “they can still see the benefits later in life.” Another three years of follow-up should reveal any further effects of hearing-aid use on both groups.The researchers also plan to publish findings on how hearing-aid use affects brain atrophy, social isolation, depression and quality of life.Some experts object to emphasizing a connection between dementia and hearing loss, “as though it plants a dementia seed and the hearing aid keeps it from germinating,” said Dr. Jan Blustein, a medical researcher at the N.Y.U. Grossman School of Medicine.Because of the stigma of dementia, “people who would potentially get treatment for hearing loss may be less likely to,” Dr. Blustein said.She added that enabling greater social interaction, with its known beneficial effects on cognition and mental health, is reason enough to promote hearing-aid use. Researchers at the University of Colorado also recently reported that consistent hearing-aid use by older adults was associated with a lower risk of falls.But acquiring quality hearing aids over the counter, as opposed to more expensive prescription devices through an audiology practice, can still feel challenging.The F.D.A. reviews “self-fitting” hearing aids, the kind users can customize with a smartphone app; it has found eight brands in compliance with regulations since 2022. A small study recently published in JAMA Otolaryngology found that patients who were given a commercially available, self-fitting hearing aid in a clinical trial could, after six weeks, hear as well as patients fitted with the same device by audiologists.But not everyone with hearing loss feels comfortable with online sales and do-it-yourself adjustments via apps. And devices that aren’t self-fitting, and instead use preset controls, don’t undergo F.D.A. review at all.“It’s still Day 1 of the market’s opening,” said Barbara Kelley, executive director of the Hearing Loss Association of America, an advocacy and support group. “The price points are all over. There’s still confusion among consumers.”Adding to that uncertainty, some marketers have resorted to misleading advertising — some claim that their devices restore natural hearing, for instance. No hearing aid can do that.“There are bad actors,” said Kate Carr, president of the Hearing Industries Association, which represents major manufacturers. “One company was advertising ‘C.I.A. technology.’” In response, the F.D.A. published a guide for consumers this year.Still, progress. Self-fitting O.T.C. aids that perform well are now widely available for about $1,000 a pair; prescription hearing aids purchased through audiologists cost several times more.Perhaps because older Americans don’t know about or mistrust the new over-the-counter devices, or because they still find the price a barrier, initial sales appear modest. (Traditional Medicare doesn’t cover hearing aids; Medicare Advantage plans offering hearing benefits still leave patients paying most of the costs.)Lexie Hearing, a major manufacturer, sells self-fitting O.T.C. devices for $799 to $999 a pair online and in 14,000 stores nationwide. According to Seline van der Wat, the chief operating officer, the company is on track to sell 90,000 pairs this year. But Lexie, whose hearing aids are designed and engineered by Bose, is encouraged by its findings that 94 percent of those buyers are first-time purchasers.“We’re finally able to access a part of the market that was previously unpenetrated because of the costs,” she said. The company projects sales of 260,000 pairs next year and a million per year in 2027.Other device makers and distributors are ramping up, too. Best Buy announced that 200 more of its stores began carrying O.T.C. hearing aids this summer, and that number will reach 600 this fall. The global vision company EssilorLuxottica plans to introduce hearing aids embedded in eyeglass earpieces late next year.Several traditional manufacturers have also begun selling over-the-counter devices, sometimes teaming up with better-known consumer companies to promote brand recognition: WS Audiology with Sony, Sonova with Sennheiser. Some experts expect Apple, Sanyo or other consumer-electronics giants to enter the field.To help guide buyers, HearAdvisor — a company founded by two audiologists and a hearing scientist — has built an independent acoustic lab in Rockford, Ill., to evaluate and rank both prescription and O.T.C. hearing aids for those with mild to moderate loss.“We’re trying to be the Good Housekeeping seal of approval for hearing aids,” Andy Sabin, a co-founder, said.After testing about 50 devices to date, HearAdvisor gave its “Expert Choice” award to 13. In general, O.T.C. devices that cost $1,000 or more perform well, Dr. Sabin said, while those sold online today for under $500 “are most often junk.” A few may actually reduce intelligibility.Wirecutter, a division of The New York Times, has also evaluated hearing aids, and the Hearing Loss Association has planned a series of webinars called OTC 101. The first, on Nov. 1, will feature F.D.A. regulators.The United States is the first country to develop a regulated O.T.C. hearing aid market, and “the tech companies and the retailers are still experimenting,” Dr. Lin pointed out. He predicts increased innovation and lower prices ahead.At the moment, though, he said, “it’s still very much a work in progress.”

Benefits extended earlier in the coronavirus pandemic have been rolled back. But many older Americans are not taking advantage of the aid still available.It has never been easy for Mary Cole to support herself and the 19-year-old grandson who lives with her in Bristol, Va., on her monthly $914 Supplemental Security Income check.But it’s getting harder. “I’ve been struggling a lot,” Ms. Cole said.Because benefits counselors at her local agency on aging have helped her apply for several kinds of public assistance, she pays only $158 in rent for her apartment in a subsidized Section 8 building.A federal program helps Ms. Cole, 69, with heating costs. The state underwrites her Medicare premiums, and a Medicare savings program allows her to fill prescriptions for heart disease, hypertension, pulmonary disease and diabetes.But benefits that increased in the early years of the coronavirus pandemic have been rolled back since the federal government ended the public health emergency this year. Ms. Cole’s heating assistance dropped from $900 in 2021 to $600 last year.Her benefits through SNAP — the Supplemental Nutrition Assistance Program, or food stamps — had risen to $351 a month; they have since dropped to $140 a month. “That’s not going to feed us both,” she said. She has long since spent the federal stimulus checks mailed out in 2020 and 2021.By the last week of the month, she often runs out of money and considers visiting a nearby food pantry. “I don’t like to do that,” Ms. Cole said. “I figure I’m taking something away from other people.”Poverty among older Americans jumped sharply in 2022, the Census Bureau recently announced. Using the supplemental poverty measure, which economists have found is a more accurate reflection of income and spending than the official poverty rate, the proportion of people over age 65 living in poverty climbed from a modern low of 9.5 percent in 2020 to 10.7 percent in 2021.Last year, the figure reached 14.1 percent, representing more than eight million older Americans.“It’s quite alarming,” said Ramsey Alwin, president and chief executive of the National Council on Aging. “It’s really unacceptable.” Poverty among children also rose steeply, and median household income declined.In southwestern Virginia, where the District Three Governmental Cooperative provides senior services and has helped more than 3,000 low-income residents like Ms. Cole apply for benefits this fiscal year, 20 percent of older residents live in poverty.“We see it going up,” said Debbie Spencer, director of aging and disability services at the cooperative. She described clients “trying to decide if they’re going to eat or buy fuel or buy their medicines.”How poor is poor? The supplemental measure defined poverty last year as an annual income below $15,998 for single adult renters ($22,624 for a two-adult household), with regional variations; the threshold was somewhat lower for homeowners, regardless of whether they had mortgages.Black, Hispanic and Indigenous older Americans have higher poverty rates; so do women and those who aren’t married.The Elder Index, devised by gerontologists at the University of Massachusetts Boston, also calculates how much money older adults need to meet their basic needs. In metropolitan Chicago, for example, a single renter over age 65 in good health required $2,481 per month last year for housing, health care, food, transportation and other expenses, according to the calculator.The same renter in Bristol, Va. — Ms. Cole’s hometown — needed $1,794. Nationally, the average Social Security retirement benefit last year came to $1,792 monthly.“Poverty rates fell in the early years of the pandemic because of the stimulus payments many older adults received,” along with raises in other benefits, said Richard Johnson, an economist at the Urban Institute.As those payments and benefit increases ended, inflation took off, eroding buying power before it began declining.“Social Security has cost-of-living increases, but they come with a lag,” Dr. Johnson said. Monthly inflation peaked in June 2022, but the cost-of-living adjustment for Social Security benefits, a hefty 8.7 percent increase, didn’t factor into beneficiaries’ checks until January.“A lot of seniors live close to the line, so it doesn’t take much to tip them over” into poverty, said Teresa Ghilarducci, an economist at the New School for Social Research. Her studies also show the pandemic’s effect on older workers’ employment; so many retired early or were pushed out that about a million fewer older adults are now in the work force.Even if senior poverty rates were to stabilize or decline next year, eased by the higher benefits some states provide, the figures generally remain stubbornly high compared to those in other industrialized nations with stronger public safety nets.The proportion of older Americans living below the official poverty level fell drastically through the 1960s and 1970s, largely because of expansions and increases in Social Security. But there has since been a plateau.“It’s not fully appreciated how persistent senior poverty has been,” Dr. Johnson said. “The decline really slowed in the 1990s and hasn’t improved significantly since.”Economists and advocates have suggested solutions: raising the minimum Social Security benefit; increasing Social Security payments after people reach age 85, when health care costs typically increase; and improving S.S.I. benefits for older adults and people with disabilities who lack the work history to qualify for Social Security. Those steps would require congressional action.For now, though, enrolling more older people in existing programs could have real impact. Federal benefits go a long way toward reducing poverty. Social Security alone lifted 20 million people over age 65 above the poverty level last year, according to census data. SNAP, housing subsidies and S.S.I. prevented another 1.6 million seniors from sinking into poverty.But only about half of the older people eligible for food stamps have enrolled, meaning five million are missing out, Ms. Alwin said. Considering all public programs, “about $30 billion is left on the table every year that could help with food and medicine and other basic needs,” she said. “It’s eye-popping.”Though most older people recognize that they qualify for Social Security, they’re often less aware of energy and housing assistance, Medicaid and Medicare programs for low-income beneficiaries, state property tax rebates or food stamps. “They may think they’re not for them but for someone else who’s more in need,” Ms. Alwin said.Moreover, applying for these programs can be complicated and time-consuming; some require digital access and skills. Some applicants just give up.“We err on the side of making sure that not one person gets benefits they’re not entitled to, and we sacrifice a lot of people who are eligible,” Dr. Ghilarducci said.The National Council on Aging’s online Benefits Checkup tool shows which public and private programs seniors qualify for; the council also operates a toll-free help line (1-800-794-6559) staffed by benefits experts. With federal and foundation funding, it supports 84 benefit enrollment centers through local aging and family service agencies, senior centers and United Way programs.Though such benefits counselors helped Ms. Cole receive assistance with housing, heating and food, she still doesn’t feel secure, and she relies on another source of support.“God will take care of me,” she said. “I have faith that he will take care of my needs.”

If the state were to change its course, aid in dying would become more accessible to millions of Americans.Judy Govatos has heard that magical phrase “you’re in remission” twice, in 2015 and again in 2019. She had beaten back Stage 4 lymphoma with such aggressive chemotherapy and other treatments that at one point she grew too weak to stand, and relied on a wheelchair. She endured several hospitalizations, suffered infections and lost nearly 20 pounds. But she prevailed.Ms. Govatos, 79, a retired executive at nonprofit organizations who lives in Wilmington, Del., has been grateful for the extra years. “I feel incredibly fortunate,” she said. She has been able to take and teach lifelong learning courses, to work in her garden, to visit London and Cape Cod with friends. She spends time with her two grandchildren, “an elixir.”But she knows that the cancer may well return, and she doesn’t want to endure the pain and disability of further attempts to vanquish it.“I’m not looking to be treated to death. I want quality of life,” she told her oncologist. “If that means less time alive, that’s OK.” When her months dwindle, she wants medical aid in dying. After a series of requests and consultations, a doctor would prescribe a lethal dose of a medication that she would take on her own.Aid in dying remains illegal in Delaware, despite repeated legislative attempts to pass a bill permitting it. Since 2019, however, it has been legal in neighboring New Jersey, a half-hour drive from Ms. Govatos’s home.But New Jersey restricts aid in dying to terminally ill residents of its own state. Ms. Govatos was more than willing, therefore, to become one of four plaintiffs — two patients, two doctors — taking New Jersey officials to federal court.The lawsuit, filed last month, argues that New Jersey’s residency requirement violates the Constitution’s privileges and immunities clause and its equal protection clause.“The statute prohibits New Jersey physicians from providing equal care to their non-New Jersey resident patients,” said David Bassett, a lawyer with the New York firm Wilmer Cutler Pickering Hale and Dorr, which brought the suit with the advocacy group Compassion & Choices.“There’s no justification that anyone has articulated” for such discrimination, he added. The suit also contends that forbidding New Jersey doctors to offer aid-in-dying care to out-of-state patients restricts interstate commerce, the province of Congress.The New Jersey Attorney General’s office declined to comment.“I’d like not to die in horrible pain and horrible fear, and I’ve experienced both,” Ms. Govatos said. Even if she enrolls in hospice, many of the pain medications used cause her to pass out, hallucinate and vomit.To be able to legally end her life when she decides to “is a question of mercy and kindness,” she said.It’s the third time that Compassion & Choices has pursued this route in its efforts to broaden access to aid in dying. It filed similar suits in Oregon in 2021 and in Vermont last year. Both states agreed to settle, and their legislatures passed revised statutes repealing residency requirements, Oregon in July and Vermont in May.The plaintiffs hope New Jersey, another blue state, will follow suit. “We hope we never have to go before a judge. Our preference is to negotiate an equitable resolution,” Mr. Bassett said. “That’s what’s important for our patient plaintiffs. They don’t have time for full-fledged litigation.”“It’s not the traditional process of trying to convince a state legislature that this is a good idea,” said Thaddeus Pope, a law professor at Mitchell-Hamline School of Law in St. Paul, Minn., who tracks end-of-life laws and court cases.Dropping residency requirements in New Jersey could have a far greater impact than it will in Oregon or Vermont. The sheer population density along New Jersey’s borders — there are almost 20 million residents in the New York metropolitan area alone — means medical aid in dying would suddenly become available to vastly more people, and much more quickly than it would through legislation.With a major airport and direct flights, “it’s easier to get to Newark than Burlington, Vermont,” Mr. Pope pointed out.Many states where aid in dying is legal have relaxed their statutes because of findings like those in a 2017 study, in which about a third of California patients who asked a doctor about aid in dying either died before they could complete the process or became too ill to continue it.But New Jersey still uses the stricter series of steps that Oregon first codified in 1994. That means two verbal requests to a doctor at least 15 days apart, a written request with two witnesses, and a consultation with a second physician; both must confirm that the patient is eligible. There’s a 48-hour wait after the written request before a prescription can be written.Even without having to establish residency, “it won’t be a walk in the park,” Mr. Pope said. “You can’t just pop over to New Jersey, pick up the drugs and go back.”Finding a doctor willing to prescribe can take time, as does using one of the state’s few compounding pharmacies, which combine the necessary drugs and fill the prescription.Although no official would check to see whether patients travel home with the medication, both Mr. Bassett and Mr. Pope advise that the lethal dose ought to be taken in New Jersey, to avoid the possibility of family members facing prosecution in their home states for assisting in a suicide.Still, preventing dying patients from having to sign leases and obtain government IDs in order to become residents will streamline the process. “Not everyone has the will, the financial means, the physical means” to establish residency, said Dr. Paul Bryman, one of the doctor plaintiffs and hospice medical director in southern New Jersey. “These are often very disabled people.”Bills recently introduced in Minnesota and New York don’t include residency requirements at all, Mr. Pope noted, since they seem likely to be challenged in court.“I think the writing’s on the wall,” he said. “I think all the residency requirements will go, in all the states” where aid in dying is legal. There are 10, plus the District of Columbia (though the legality in Montana depends on a court decision, not legislation).Despite the often heated wrangling over aid-in-dying laws, very few patients actually turn to lethal drugs in the end, state records show. Last year, Oregon reported that 431 people received prescriptions and 278 died by using them, just .6 percent of the state’s deaths in 2022.In New Jersey, only 91 patients used aid in dying last year. Roughly a third of those who receive prescriptions never use them, perhaps sufficiently reassured by the prospect of a swift exit.Fears of “death tourism,” with an onrush of out-of state patients, have not materialized, said John Burzichelli, a former state assemblyman who helped steer New Jersey’s statute through the legislature and now favors allowing eligible nonresidents to participate. “I don’t see lines of people at the tollbooths coming to take advantage of this law,” he said.If her cancer returns and New Jersey has balked at allowing out-of-staters to legally end their lives there, Ms. Govatos contemplates traveling to Vermont. She envisions a goodbye party for a few friends and family members, with poetry reading, music and “very good wine and lovely food.”But driving over the Delaware Memorial Bridge would be so much simpler. “It would be an incredible gift if I could go to New Jersey,” she said.

Las personas de más edad pueden confundir la covid persistente con otras afecciones de esta etapa de la vida. Una investigación identifica cuatro grupos concretos de síntomas relacionados con la condición.Pregúntale a Patricia Anderson cómo está, y quizá no obtendrás una respuesta rutinaria. “Hoy trabajo y estoy bien”, dijo un martes reciente. “El sábado y el domingo estuve postrada en cama. La covid prolongada es una montaña rusa”.Antes de la pandemia, Anderson practicaba artes marciales y no tenía auto, sino que caminaba y tomaba autobuses en la zona de Ann Arbor, Míchigan, donde trabaja como bibliotecaria médica. Justo antes de contraer COVID-19 en marzo de 2020, había acumulado —sí, lleva la cuenta— 11.409 pasos en un día.El virus le causó escalofríos extremos, dificultad para respirar, un trastorno del sistema nervioso y tal deterioro cognitivo que, durante meses, Anderson fue incapaz de leer un libro.“Estuve muy enferma durante mucho tiempo y nunca mejoré”, afirmó. Algunos días, el cansancio reducía su número de pasos a tres dígitos. Los intentos de rehabilitación trajeron avances, y luego recaídas.Las decenas de síntomas conocidos de manera colectiva como covid prolongada, o pos-covid, pueden dejar fuera de juego a cualquiera que haya sido infectado. Pero afectan sobre todo a algunos pacientes de edad avanzada, que pueden ser más propensos a ciertas formas de la enfermedad.Alrededor del 11 por ciento de los adultos estadounidenses ha desarrollado covid prolongada después de una infección, informaron los Centros para el Control y la Prevención de Enfermedades (CDC, por su sigla en inglés) el mes pasado, por debajo del casi 19 por ciento registrado entre junio de 2022 y junio de 2023. La cifra sugiere que algunos adultos dejan atrás el síndrome a medida que pasa el tiempo.Las personas mayores de 60 años en realidad tienen tasas más bajas de covid prolongada en general que aquellos de entre 30 y 59 años. Esto podría reflejar tasas de vacunación y refuerzo más elevadas entre los estadounidenses de más edad, o un comportamiento más precavido, como usar cubrebocas y evitar aglomeraciones.“También puede haber factores biológicos que aún no comprendemos”, aseguró Akiko Iwasaki, inmunóloga e investigadora de la Facultad de Medicina de Yale. Aunque el conocimiento que hay de la covid prolongada ha aumentado, añadió, aún queda mucho por saber sobre la enfermedad.Solo recientemente Anderson, de 66 años, ha recuperado la mayor parte de sus funciones cognitivas y algunas físicas; ahora puede dar entre 3000 y 4000 pasos diarios. Pero usa un cubrebocas N95 siempre que sale y un bastón con asiento plegable para sentarse, de modo que “si voy de compras y me quedo sin fuerzas a mitad del pasillo, puedo descansar”.Y se preocupa. Su jefe le ha permitido seguir trabajando a distancia, pero ¿y si la biblioteca empieza a exigirle más de su actual jornada semanal de manera presencial? “No puedo jubilarme”, señaló. “Me da mucho miedo”.Según los CDC, la covid prolongada comienza cuando los síntomas persisten un mes o más después de la infección. Pero la Organización Mundial de la Salud la define como “la continuación o el desarrollo de nuevos síntomas” tres meses después de la infección inicial, los cuales duran al menos dos meses sin ninguna otra explicación.La extensa lista de síntomas de la covid prolongada incluye dificultades respiratorias, enfermedades cardiovasculares y metabólicas, enfermedad renal, trastornos gastrointestinales, pérdida cognitiva, fatiga, dolor y debilidad muscular y problemas de salud mental.“Casi no hay sistema orgánico al que no afecte la covid prolongada”, explicó Ziyad Al-Aly, investigador clínico de salud pública de la Facultad de Medicina de la Universidad de Washington y autor principal de un estudio reciente que demuestra que estos síntomas pueden persistir durante dos años.“Puede afectar a casi todo el mundo, desde niños hasta adultos mayores, a lo largo de toda la vida”, afirmó.Aunque es más probable que la covid prolongada afecte a personas que enferman gravemente de covid y requieren hospitalización —y los síntomas de la covid prolongada duran más en esos pacientes—, también puede aparecer tras infecciones leves. Puede aparecer tras el primer brote de covid, o tras el segundo o el cuarto.Paxlovid reduce el riesgo de covid prolongada en aproximadamente un 20 por ciento entre las personas de 60 años y en aproximadamente un 34 por ciento entre las personas mayores de 70 años. Wolfgang Rattay/ReutersAunque, en general, las personas mayores no son más propensas a padecer covid prolongada, la investigación de Al-Aly, realizada a partir de grandes bases de datos del Departamento de Asuntos de los Veteranos, muestra que tienen más riesgo de padecer cuatro grupos concretos de síntomas:Trastornos metabólicos, como diabetes de nueva aparición y colesterol alto.Problemas cardiovasculares, como cardiopatías, infartos y arritmias como la fibrilación auricular.Problemas gastrointestinales, como diarrea y estreñimiento, pancreatitis y enfermedades hepáticas.Accidentes cerebrovasculares, deterioro cognitivo y otros síntomas neurológicos.Jane Wolgemuth contrajo COVID-19 en junio de 2022, junto con su marido. “Él lo superó en dos días”, recordó. “Yo estuve en cama una semana”.Ambos se sintieron mejor tras tomar el antiviral oral Paxlovid. Sin embargo, meses después, Wolgemuth, de 69 años, empleada jubilada de un banco de Monument, Colorado, empezó a notar problemas cognitivos, sobre todo al conducir.“No reaccionaba con la rapidez suficiente”, relató. “La niebla cerebral se estaba apoderando de mí”.Las personas mayores pueden confundir la covid prolongada con otras afecciones comunes a la edad avanzada. “Pueden pensar: ‘Tal vez solo estoy envejeciendo o necesito ajustar mi medicación para la presión arterial’”, dijo Mónica Verduzco-Gutiérrez, catedrática de medicina de rehabilitación en el Centro de Ciencias de la Salud de la Universidad de Texas en San Antonio. Es coautora de las directrices de la Academia Americana de Medicina Física y Rehabilitación para el tratamiento de la covid prolongada.La covid prolongada también puede agravar los problemas de salud que ya padecen muchas personas mayores. “Si tenían un deterioro cognitivo leve, ¿pasan a la demencia? Lo he visto”, aseguró Verduzco-Gutiérrez. Una afección cardiaca leve puede agravarse, reducir la movilidad de una persona mayor y aumentar el riesgo de caídas.“La mejor manera del mundo de prevenir la covid prolongada es prevenir la covid”, afirmó Al-Aly. A medida que aumentan las tasas de infección en todo el país, usar cubrebocas de nuevo en lugares cerrados y comer al aire libre en restaurantes puede ayudar a reducir el contagio.“Definitivamente, hay que vacunarse”, señaló. “La vacunación y los refuerzos reducen, pero no eliminan, el riesgo de covid prolongada”, entre un 15 y un 50 por ciento, según los estudios.“Hazte la prueba para asegurarte de que se trata de covid, luego llama a un proveedor lo antes posible y comprueba si eres apto para recibir Paxlovid”, dijo. El tratamiento antivírico también reduce el riesgo de contraer la covid prolongada en aproximadamente un 20 por ciento para las personas de 60 años, y en un 34 por ciento para las mayores de 70.Dado que aún no hay estudios longitudinales todavía, no está claro si las personas mayores se recuperan más lentamente de la covid prolongada. Pacientes como Anderson y Wolgemuth han probado toda una serie de tratamientos: suplementos, electrolitos, prendas de compresión y diversos regímenes de fisioterapia. “Pero no disponemos de un medicamento que haya demostrado revertirla”, concluyó Iwasaki.Ciertos enfoques de rehabilitación han demostrado ser efectivos, señaló Verduzco-Gutiérrez, pero no hay suficientes programas o clínicas con experiencia en covid prolongada. Algunos médicos descartan los síntomas prolongados, según informaron los pacientes.Eso los deja, en gran medida, buscando soluciones por su cuenta.“Se están organizando juntos para abogar por la investigación y encontrar tratamientos”, dijo Iwasaki, comparando a los pacientes con covid prolongada con los activistas contra el sida de la década de 1980. Codirige el estudio LISTEN de Yale, que trabaja con pacientes con covid prolongada para comprender mejor sus condiciones.El gobierno de Joe Biden anunció recientemente una nueva oficina federal para liderar investigaciones sobre la covid prolongada y están comenzando más ensayos clínicos. Sin embargo, por ahora, muchos pacientes dependen de grupos como Long Covid Support y Covid-19 Longhauler Advocacy Project, y participan en Patient-Led Research Collaborative.Sheila McGrath, de 71 años, que vive en Herndon, Virginia, se recuperó de su primera infección por covid en febrero de 2020, pero ha sufrido desde su segundo episodio cinco meses después. Aunque su salud ha mejorado, “no he vuelto a ser la misma de antes”, dijo.Ahora ella y Anderson son copresentadoras de un chat en línea de apoyo a covid prolongada. “A menudo alguien termina llorando”, dijo McGrath. “Están muy frustrados porque no los escuchan, no los validan, les dicen que es psicosomático y les niegan el tratamiento. Ninguno de nosotros quiere estar enfermo”.

Older people are less likely to be diagnosed but more likely to experience certain kinds of illnesses, research suggests.Ask Patricia Anderson how she is doing, and you probably will not get a routine answer. “Today, I’m working and I’m fine,” she said on a recent Tuesday. “Saturday and Sunday, I was bedridden. Long Covid is a roller coaster.”Before the pandemic, Ms. Anderson practiced martial arts and did without a car, instead walking and taking buses around Ann Arbor, Mich., where she is a medical librarian. Just before contracting Covid-19 in March 2020, she had racked up — oh, she keeps track — 11,409 steps in one day.The virus caused extreme chills, shortness of breath, a nervous system disorder and such cognitive decline that, for months, Ms. Anderson was unable to read a book.“I was very sick for a long time, and I never really got better,” she said. On some days, fatigue cut her step count to three digits. Rehabilitation attempts brought progress, then crashes.The dozens of symptoms collectively known as long Covid, or post-Covid, can sideline anyone who has been infected. But they take a particular toll on some older patients, who may be more prone to certain forms of the illness.About 11 percent of American adults have developed long Covid after an infection, the Centers for Disease Control and Prevention reported last month, down from the almost 19 percent recorded from June 2022 to June 2023. The figure suggests that some adults are pulling out of the syndrome as time passes.People over age 60 actually have lower rates of long Covid overall than those aged 30 to 59. That might reflect higher vaccination and booster rates among older Americans, or more protective behavior like masking and avoiding crowds.“There may also be biologic factors we don’t understand yet,” said Akiko Iwasaki, an immunologist and researcher at Yale School of Medicine. Though knowledge of long Covid has increased, she added, much remains unknown about the illness.Only recently has Ms. Anderson, 66, regained most cognitive and some physical function; she can manage 3,000 to 4,000 daily steps now. But she wears an N95 mask whenever she goes out and takes a sitting cane so “if I go shopping and run out of steam halfway down the aisle, I can rest.”And she worries. Her employer has allowed her to continue working remotely, but what if the library starts requiring more than her current one day a week on-site? “I can’t afford to retire,” she said. “It’s very scary.”The C.D.C. says long Covid begins when symptoms persist a month or more after infection. But the World Health Organization defines long Covid as “the continuation or development of new symptoms” three months after the initial infection, lasting at least two months with no other explanation.The extensive list of long Covid symptoms includes breathing difficulties, cardiovascular and metabolic diseases, kidney disease, gastrointestinal disorders, cognitive loss, fatigue, muscle pain and weakness and mental health problems.“There’s almost no organ system long Covid doesn’t touch,” said Dr. Ziyad Al-Aly, a clinical epidemiologist at Washington University School of Medicine and senior author of a recent study showing that these symptoms can persist for two years.“It can affect nearly everyone from children to older adults, across the life span,” he said.Though long Covid is more likely to afflict people who become severely ill with Covid and require hospitalization — and long Covid symptoms last longer in those patients — it can also follow mild infections. It can arise after the first bout of Covid, or the second or fourth.Paxlovid reduces the risk of long Covid by about 20 percent among those in their 60s and by about 34 percent among those over 70.Wolfgang Rattay/ReutersWhile older people are not more prone to long Covid overall, Dr. Al-Aly’s research using large Veterans Affairs databases shows that they are more at risk for four particular clusters of symptoms:Metabolic disorders, including new-onset diabetes and high cholesterol.Cardiovascular problems, including heart disease, heart attacks and arrhythmias like atrial fibrillation.Gastrointestinal problems like diarrhea and constipation, pancreatitis and liver disease.Strokes, cognitive decline and other neurological symptoms.Jane Wolgemuth caught Covid in June 2022, along with her husband. “He waltzed through it in two days,” she recalled. “I was in bed for a week.”They both felt better after taking the oral antiviral Paxlovid. Yet months later, Ms. Wolgemuth, 69, a retired bank employee in Monument, Colo., began noticing cognitive problems, particularly when driving.“I wasn’t reacting fast enough,” she said. “The brain fog was really taking over.”After an MRI and other tests came back normal, Ms. Wolgemuth was diagnosed with long Covid. She has been taking supplements and trying light therapy, and she has stretched her walking distance to four miles most days.She feels more herself, she said, but “it’s remarkable how destructive Covid was.”Seniors may mistake long Covid for other conditions common at older ages. “They may think, ‘Maybe I’m just aging or I need to adjust my blood pressure medication,’” said Dr. Monica Verduzco-Gutierrez, the chair of rehabilitation medicine at the University of Texas Health Science Center at San Antonio. She has co-authored American Academy of Physical Medicine and Rehabilitation guidance statements for treating long Covid.Long Covid can also exacerbate the health problems many seniors already contend with. “If they had mild cognitive impairment, do they move into dementia? I’ve seen that happen,” Dr. Verduzco-Gutierrez said. A mild heart condition can become more serious, reducing an older person’s mobility and increasing fall risks.“The best way in the world to prevent long Covid is to prevent Covid,” Dr. Al-Aly said. As infection rates tick up across the country, masking again in close quarters and eating outdoors at restaurants can help reduce infection.“Definitely get boosted,” he said. “Vaccination and boosters reduce but don’t eliminate the risk of long Covid” — by 15 percent to 50 percent, studies have found.“If you’re infected, get tested to be sure it’s Covid, then call a provider as soon as possible and see if you are eligible for Paxlovid,” he said. The antiviral treatment also reduces the risk of long Covid by about 20 percent for those in their 60s, and by about 34 percent for those over 70.Without longitudinal studies yet, it’s unclear if older people recover from long Covid more slowly. Patients like Ms. Anderson and Ms. Wolgemuth have tried an array of treatments — supplements, electrolytes, compression garments, various physical therapy regimens. “But we don’t have a medicine that has been shown to reverse it,” Dr. Iwasaki said.Certain rehabilitation approaches have proven to be effective, Dr. Verduzco-Gutierrez pointed out, but there are not enough programs or clinics experienced with long Covid. Some doctors dismiss long Covid symptoms, patients have reported.That leaves them searching for solutions largely on their own.“They are rising up together to advocate for research and find treatments,” Dr. Iwasaki said, comparing long Covid patients to the AIDS activists of the 1980s. She co-directs the Yale LISTEN study, which works with long Covid patients to better understand their conditions.The Biden administration recently announced a new federal office to lead long Covid research, and more clinical trials are beginning. For now, though, many patients rely on groups like Long Covid Support and the Covid-19 Longhauler Advocacy Project, and participate in the Patient-Led Research Collaborative.Sheila McGrath, 71, who lives in Herndon, Va., recovered from her first Covid infection in February 2020, but has suffered ever since her second bout five months later. Though her health has improved, “I haven’t gotten back to where I was,” she said.Now she and Ms. Anderson co-host an online chat for Long Covid Support. “Often someone winds up in tears,” Ms. McGrath said. “They’re so frustrated with not being listened to, not being validated, being told it’s psychosomatic, being refused treatment. None of us wants to be sick.”

A series of hurdles prevented the facilities from shielding older people, despite the best efforts of staff. Experts are calling for reforms before the next virus arrives.The first terrifying wave of Covid-19 caused 60,000 deaths among residents of nursing homes and other long-term care facilities within five months. As the pandemic wore on, medical guidelines called for promptly administering newly approved antiviral treatments to infected patients at high risk of severe illness, hospitalization or death.Why, then, did fewer than one in five nursing home residents with Covid receive antiviral treatment from May 2021 through December 2022?It’s hardly the only way that the nation’s nursing homes proved unable to keep patients safe. A series of studies assessing their attempts to protect vulnerable patients and workers from Covid, along with interviews with experts inside and outside the industry, presents a very mixed pandemic report card.Brian McGarry, a health economist at the University of Rochester, and David Grabowski, a health care policy researcher at Harvard Medical School, both gave the health care system a D grade overall for nursing homes’ pandemic performance.“I kept waiting for the cavalry to come, and it really hasn’t, even today,” Dr. Grabowski said. “At no time during the pandemic did we prioritize nursing homes.” More than 167,000 residents have died, Medicare reported this month, along with at least 3,100 staff members.It was Dr. McGarry, Dr. Grabowski and their co-authors who discovered the failure to deliver antiviral medications. Early on, antivirals meant monoclonal antibodies, a difficult treatment. The drugs were in short supply and administered intravenously; patients might need to leave the facility to receive them.But in December 2021, the Food and Drug Administration granted emergency authorization to Paxlovid, a pill taken for five days. It drastically improves the prognosis for eligible patients who are 65 and older, sick and frail.Virtually every nursing home resident meets that description. This is “the highest of the high-risk groups,” Dr. McGarry said. Age and chronic illnesses make the residents vulnerable, “and they’re living in an environment that’s perfect for spreading airborne viruses,” he added, with shared rooms, communal spaces and staff moving from one patient to the next.As the saying went, a nursing home was like a cruise ship that never docked.But research recently published in JAMA found that only a quarter of infected residents received antivirals, even during the last six weeks of the study — by which time Paxlovid was widely available and free.About 40 percent of the nation’s approximately 15,000 nursing homes reported no antiviral use at all.“They’re basically depriving people of treatment,” said Dr. Karl Steinberg, a medical director at three nursing homes in Southern California and former president of AMDA, the medical association representing providers in long-term care. “It’s surprising and disturbing.”Only a quarter of infected nursing home residents received antivirals, even when Paxlovid was widely available and free, according to a recent study.Pfizer, via ReutersOne bright spot, several industry leaders agreed, was the federally coordinated rollout of the Covid vaccine, which sent providers to facilities in late 2020 and early 2021 to vaccinate residents and staff.“A remarkable achievement, a collaboration between science and government,” said Dr. Noah Marco, chief medical director of Los Angeles Jewish Health, which cares for about 500 residents in three skilled nursing facilities.By early 2022, Medicare reported, 87 percent of residents and 83 percent of employees had been vaccinated, though it took a federal mandate to reach that staff rate. Studies have shown that high staff vaccination rates prevent infections and deaths.But “we totally dropped the ball on boosters,” Dr. McGarry said. “We just left it up to each nursing home.” Medicare reported this month that about 62 percent of residents per facility, and just 26 percent of staff, are up-to-date on Covid vaccinations, including recommended boosters.“It’s disappointing,” Dr. Steinberg said. But with workers less likely to perceive Covid as a deadly threat, even though hospitalization and death rates recently began climbing again, “people say no, and we cannot force them,” he said.Other grounds for poor grades: Early federal efforts prioritized hospitals, leaving nursing homes short of critical protective equipment. Even after the federal government began sending point-of-care testing kits to most nursing homes, so they wouldn’t have to send tests off to labs, getting results took too long.“If we can find and detect people carrying Covid, we’ll keep them out of the building and prevent transmission,” Dr. McGarry explained. That largely meant staff members, since Medicare-mandated lockdowns shut out visitors.A resident of a senior living center in Oregon after getting a booster shot. Medicare reported this month that about 62 percent of residents per facility, and just 26 percent of staff, are up-to-date on Covid shots.Alisha Jucevic for The New York TimesNursing homes apparently didn’t make much use of the testing kits. By fall 2020, fewer than a fifth had the recommended turnaround of less than 24 hours. “It negates the value of doing the test in the first place,” Dr. McGarry said.As for those lockdowns, which barred most family members until November 2021, the consensus is that however reasonable the policy initially seemed, it continued for far too long.“In retrospect, it caused a lot of harm,” Dr. Steinberg said. “We saw so much failure to thrive, people losing weight, delirium, rapid onset of dementia. And it was usually the staff who were bringing in Covid anyway. A big lesson is that family visitors are essential,” assuming those visitors are tested before they enter and that they use protective gear.Dr. David Gifford, a geriatrician and the chief medical officer of the American Health Care Association, which represents long-term care providers, pointed to a variety of frustrating problems that prevented nursing homes from doing a better job during the pandemic.Point-of-care kits that required 15 minutes to read each test and thus couldn’t screen workers arriving for a shift. Prescribing information emphasizing such a long list of possible drug interactions with Paxlovid that some doctors were afraid to use it. And the same suspicion and resistance toward boosters and antivirals that now affect the country as a whole.“Nursing homes did as much as they could with what they had,” he said. “The health care system as a whole sort of ignored them.”Staffing, already inadequate in many facilities before Covid, took a hit it has yet to recover from. “It’s our No. 1 issue,” Dr. Gifford said. His association has reported that nursing homes lost nearly 245,000 employees during the pandemic and have regained about 55,000.“The people working in nursing homes certainly get an A for effort” for persevering at their dangerous jobs, Dr. Steinberg said. But so many have left that nursing homes now often restrict new admissions.Some long-proposed changes could help protect residents and staff from future pandemics.Facilities could improve their ventilation systems. They could abandon “semiprivate” rooms for private ones. Dividing buildings into smaller units with consistently assigned staff — an approach pioneered by the Green House Project — would both bolster relationships and reduce residents’ exposure to infection from workers coming and going.All those changes would require more investment, however, principally from Medicaid, which underwrites most nursing home care. And with more money would come increased federal oversight, which the industry rarely welcomes.“Investment in our industry, in order for us to provide the highest-quality care, is absolutely necessary,” Dr. Marco said. “But where is the government and public will to do that? I personally don’t see a lot of encouragement right now.”

Life expectancy increasingly figures into calculations about whether screenings and treatments are appropriate. Here’s how to find out yours. At her annual visit, the patient’s doctor asks if she plans to continue having regular mammograms to screen for breast cancer, and then reminds her that it’s been almost 10 years since her last colonoscopy.She’s 76. Hmmm.The patient’s age alone may be an argument against further mammogram appointments. The independent and influential U.S. Preventive Services Task Force, in its latest draft guidelines, recommends screening mammograms for women 40 to 74, but says “the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women age 75 years or older.”Screening for colorectal cancer, with a colonoscopy or with a less invasive test, becomes similarly questionable at advanced ages. The task force gives it a C grade for those 76 to 85, meaning there’s “at least moderate certainty that the net benefit is small.” It should only be offered selectively, the guidelines say.But what else is true about this hypothetical woman? Is she playing tennis twice a week? Does she have heart disease? Did her parents live well into their 90s? Does she smoke?Any or all such factors affect her life expectancy, which in turn could make future cancer screenings either useful, pointless or actually harmful. The same considerations apply to an array of health decisions at older ages, including those involving drug regimens, surgeries, other treatments and screenings.“It doesn’t make sense to draw these lines by age,” said Dr. Steven Woloshin, an internist and director of the Center for Medicine and Media at the Dartmouth Institute. “It’s age plus other factors that limit your life.”Slowly, therefore, some medical associations and health advocacy groups have begun to shift their approaches, basing recommendations about tests and treatments on life expectancy rather than simply age.“Life expectancy gives us more information than age alone,” said Dr. Sei Lee, a geriatrician at the University of California, San Francisco. “It leads to better decision making more often.”Some recent task force recommendations already reflect this broader view. For older people undergoing lung cancer tests, for instance, the guidelines advise considering factors like smoking history and “a health problem that substantially limits life expectancy” in deciding when to discontinue screening.The task force’s colorectal screening guidelines call for considering an older patient’s “health status (e.g., life expectancy, co-morbid conditions), prior screening status and individual preferences.”The American College of Physicians similarly incorporates life expectancy into its prostate cancer screening guidelines; so does the American Cancer Society, in its guidelines for breast cancer screening for women over 55.But how does that 76-year-old woman know how long she will live? How does anybody know?A 75-year-old has an average life expectancy of 12 years. But when Dr. Eric Widera, a geriatrician at the University of California, San Francisco, analyzed census data from 2019, he found enormous variation.The data shows that the least healthy 75-year-olds, those in the lowest 10 percent, were likely to die in about three years. Those in the top 10 percent would probably live for another 20 or so.All these predictions are based on averages and can’t pinpoint life expectancy for individuals. But just as doctors constantly use risk calculators to decide, say, whether to prescribe drugs to prevent osteoporosis or heart disease, consumers can use online tools to get ballpark estimates.For instance, Dr. Woloshin and his late wife and research partner, Dr. Lisa Schwartz, helped the National Cancer Institute develop the Know Your Chances calculator, which went online in 2015. Initially, it used age, sex and race (but only two, Black or white, because of limited data) to predict the odds of dying from specific common diseases and the odds of mortality overall over a span of five to 20 years.The institute recently revised the calculator to add smoking status, a critical factor in life expectancy and one that, unlike the other criteria, users have some control over.“Personal choices are driven by priorities and fears, but objective information can help inform those decisions,” said Dr. Barnett Kramer, an oncologist who directed the institute’s Division of Cancer Prevention when it published the calculator.He called it “an antidote to some of the fear-mongering campaigns that patients see all the time on television,” courtesy of drug manufacturers, medical organizations, advocacy groups and alarmist media reports. “The more information they can glean from these tables, the more they can arm themselves against health care choices that don’t help them,” Dr. Kramer said. Unnecessary testing, he pointed out, can lead to overdiagnosis and overtreatment.A number of health institutions and groups provide disease-specific online calculators. The American College of Cardiology offers a “risk estimator” for cardiovascular disease. A National Cancer Institute calculator assesses breast cancer risk, and Memorial Sloan Kettering Cancer Center provides one for lung cancer.Calculators that look at single diseases, however, don’t usually compare the risks to those of mortality from other causes. “They don’t give you the context,” Dr. Woloshin said.Probably the broadest online tool for estimating life expectancy in older adults is ePrognosis, developed in 2011 by Dr. Widera, Dr. Lee and several other geriatricians and researchers. Intended for use by health care professionals but also available to consumers, it offers about two dozen validated geriatric scales that estimate mortality and disability.The calculators, some for patients living on their own and others for those in nursing homes or hospitals, incorporate considerable information about health history and current functional ability. Helpfully, there’s a “time to benefit” instrument that illustrates which screenings and interventions may remain useful at specific life expectancies.Consider our hypothetical 76-year-old. If sh e’s a healthy never-smoker who is experiencing no problems with daily activities and is able, among other things, to walk a quarter mile without difficulty, a mortality scale on ePrognosis shows that her extended life expectancy makes mammography a reasonable choice, regardless of what age guidelines say.“The risk of just using age as a cutoff means we’re sometimes undertreating” very healthy seniors, Dr. Widera said.If she’s a former smoker with lung disease, diabetes and limited mobility, on the other hand, the calculator indicates that while she probably should continue taking a statin, she can end breast cancer screening.“Competing mortality” — the chance that another illness will cause her death before the one being screened for — means that she will probably not live long enough to see a benefit.Of course, patients will continue to make decisions of their own. Life expectancy is a guide, not a limit on medical care. Some older people don’t ever want to stop screenings, even when the data shows they’re no longer helpful.And some have exactly zero interest in discussing their life expectancy; so do some of their doctors. Either party can over- or underestimate risks and benefits.“Patients simply will say, ‘I had a great-uncle who lived to 103,’” Dr. Kramer recalled. “Or if you tell someone, ‘Your chances of long-term survival are one in 1,000,’ a strong psychological mechanism leads people to say, ‘Oh thank God, I thought it was hopeless.’ I saw it all the time.”But for those seeking to make health decisions on evidence-based calculations, the online tools provide valuable context beyond age alone. Considering projected life expectancy, “You’ll know what to focus on, as opposed to being frightened by whatever’s in the news that day,” Dr. Woloshin said. “It anchors you.”The developers want patients to discuss these predictions with their medical providers, however, and caution against making decisions without their involvement.“This is meant to be a jumping-off point” for conversations, Dr. Woloshin said. “It’s possible to make much more informed decisions — but you need some help.”

Many aging baby boomers have long histories with drugs, cannabis and alcohol. “The field wasn’t ready for that,” said one expert.When Dr. Benjamin Han, a geriatrician and addiction medicine specialist, meets new patients at the School of Medicine at the University of California, San Diego, he talks with them about the usual health issues that older adults face: chronic conditions, functional ability, medications and how they’re working. He asks, too, about their use of tobacco, alcohol, cannabis and other nonprescription drugs. “Patients tend to not want to disclose this, but I put it in a health context,” Dr. Han said.He tells them, “As you get older, there are physiological changes and your brain becomes much more sensitive. Your tolerance goes down as your body changes. It can put you at risk.”That’s how he learns that someone complaining about insomnia might be using stimulants, possibly methamphetamines, to get going in the morning. Or that a patient who has long taken an opioid for chronic pain has run into trouble with an added prescription for, say, gabapentin.When one 90-year-old patient, a woman fit enough to take the subway to his previous hospital in New York City, began reporting dizziness and falls, it took Dr. Han a while to understand why: She washed down her prescribed pills, an increasing number as she aged, with a shot of brandy.He has had older patients whose heart problems, liver disease and cognitive impairment were most likely exacerbated by substance use. Some have overdosed. Despite his best efforts, some have died.Until a few years ago, even as the opioid epidemic raged, health providers and researchers paid limited attention to drug use by older adults; concerns focused on the younger, working-age victims who were hardest hit.But as baby boomers have turned 65, the age at which they typically qualify for Medicare, substance use disorders among the older population have climbed steeply. “Cohorts have habits around drug and alcohol use that they carry through life,” said Keith Humphreys, a psychologist and addiction researcher at the Stanford University School of Medicine.Aging boomers “still use drugs far more than their parents did, and the field wasn’t ready for that.”Evidence of a growing problem has been stacking up. A study of opioid use disorder in people over 65 enrolled in traditional Medicare, for instance, showed a threefold increase in just five years — to 15.7 cases per 1,000 in 2018 from 4.6 cases per 1,000 in 2013.Tse-Chuan Yang, a co-author of the study and a sociologist and demographer at the University at Albany, said the stigma of drug use may lead people to underreport it, so the true rate of the disorder may be higher still.Fatal overdoses have also soared among seniors. From 2002 to 2021, the rate of overdose deaths quadrupled to 12 from 3 per 100,000, Dr. Humphreys and Chelsea Shover, a co-author, reported in JAMA Psychiatry in March, using data from the Centers for Disease Control and Prevention. Those deaths were both intentional, like suicides, and accidental, reflecting drug interactions and errors.Most substance use disorders among older people involve prescribed medications, not illegal drugs. And since most Medicare beneficiaries take multiple drugs, “it’s easy to get confused,” Dr. Humphreys said. “The more complicated the regimen, the easier to make mistakes. And then you have an overdose.”The numbers so far remain comparatively low — 6,700 drug overdose deaths in 2021 among people 65 and older — but the rate of increase is alarming.“In 1998, that’s what people would have said about overdose deaths in general — the absolute number was small,” Dr. Humphreys said. “When you don’t respond, you end up in a sorrowful state.” More than 100,000 Americans died of drug overdoses last year.Alcohol also plays a major role. Last year, a study of substance use disorders, based on a federal survey, analyzed which drugs older Americans were using, looking at the differences between Medicare enrollees under 65 (who may qualify because of disabilities) and those 65 and older.Of the 2 percent of beneficiaries over 65 who reported a substance use disorder or dependence in the past year — which amounts to more than 900,000 seniors nationwide — more than 87 percent abused alcohol. (Alcohol accounted for 11,616 deaths among seniors in 2020, an 18 percent increase over the previous year.)In addition, about 8.6 percent of disorders involved opioids, mostly prescription pain relievers; 4.3 percent involved marijuana; and 2 percent involved non-opioid prescription drugs, including tranquilizers and anti-anxiety medications. The categories overlap, because “people often use multiple substances,” said William Parish, the lead author and a health economist at RTI International, a nonprofit research institute.Although most people with substance use problems don’t die from overdoses, the health consequences can be severe: injuries from falls and accidents, accelerated cognitive decline, cancers, heart and liver disease and kidney failure.“It’s particularly heartbreaking to compare rates of suicidal ideation,” Dr. Parish said. Older Medicare beneficiaries with substance use disorders were more than three times as likely to report “serious psychological distress” as those without such disorders — 14 percent versus 4 percent. About 7 percent had suicidal thoughts, compared with 2 percent who didn’t report substance disorders.Yet very few of these seniors underwent treatment in the past year — just 6 percent, compared with 17 percent of younger Medicare beneficiaries — or even made an effort to seek treatment.“With these addictions, it takes a lot to get somebody ready to get into treatment,” Dr. Parish said, noting that almost half of the respondents over 65 said they lacked the motivation to begin.But they also face more barriers than younger people. “We see higher rates of stigma concerns, things like worrying about what their neighbors would think,” Dr. Parish said. “We see more logistical barriers,” he said, such as finding transportation, not knowing where to go for help and being unable to afford care.It may be “harder for older adults to try to navigate the treatment system,” Dr. Parish said.Uneven Medicare coverage also presents obstacles. Federal parity legislation, mandating the same coverage for mental health (including addiction treatment) and physical health, guarantees equal benefits in private employer insurance, state health exchanges, Affordable Care Act marketplaces and most Medicaid plans.But it has never included Medicare, said Deborah Steinberg, senior health policy attorney at the Legal Action Center, a nonprofit working to expand equitable coverage.Advocates have made some inroads. Medicare covers substance use screening and, since 2020, opioid treatment programs like methadone clinics. In January, following congressional action, it will cover treatment by a broader range of health professionals and cover “intensive outpatient treatment,” which typically provides nine to 19 hours of weekly counseling and education. Expanded telehealth benefits, prompted by the pandemic, have also helped.But more intensive treatment can be hard to access, and residential treatment isn’t covered at all. Medicare Advantage plans, with their more limited provider networks and prior authorization requirements, are even more restrictive. “We see many more complaints from Medicare Advantage beneficiaries,” Ms. Steinberg said.“We’re actually making progress,” she added. “But people are overdosing and dying because of lack of access to treatment.” Their doctors, unaccustomed to diagnosing substance abuse in older people, may also overlook the risks.In an age cohort whose youthful drinking and drug use have sometimes provided amusing anecdotes (a common refrain: “If you can remember the ’60s, you weren’t there”), it can be difficult for people to recognize how vulnerable they have become.“That person may not be able to say, I’m addicted,” Dr. Humphreys said. “It’s a Rubicon people don’t want to cross.”A joke about dropping acid at Woodstock “makes me colorful,” he added. “Crushing OxyContin and snorting it is not colorful.”

Nearly three-quarters of hospice organizations are now for-profit. Complaints of fraud and profiteering are growing.In the nearly 20 years that Megan Stainer worked in nursing homes in and around Detroit, she could almost always tell which patients near death were receiving care from nonprofit hospice organizations and which from for-profit hospices.“There were really stark differences,” said Ms. Stainer, 45, a licensed practical nurse. Looking at their medical charts, “the nonprofit patients always had the most visits: nurses, chaplains, social workers.”The nonprofit hospices responded quickly when the nursing home staff requested supplies and equipment. By contrast, she said, “if you called and said, ‘I need a specialized bed,’ with for-profits it could take days — days when the patient is in a bed that’s uncomfortable.”Ms. Stainer, now a private duty nurse and certified death doula in Hamburg, Mich., also found nonprofits more willing to keep patients enrolled and for-profits more prone to “live discharge” — removing patients from hospice ostensibly because they no longer met the criteria for declining health, then re-enrolling them later.“It seemed like people were being discharged when they still needed their services,” Ms. Stainer said. “There never seemed to be a logical reason.” But long enrollments and live discharges can help hospices boost profits and avoid financial penalties, analysts have pointed out.Researchers have for years reported that there are, indeed, substantial differences overall between for-profit and nonprofit hospices; a new study based on family caregivers’ experiences provides additional evidence.Medicare began covering hospice care four decades ago, when most hospices were nonprofit community organizations relying heavily on volunteers. It has since become a growth industry dominated by for-profit businesses.In 2001, 1,185 nonprofit hospices and just 800 for-profits provided care for Americans with terminal illnesses who were expected to die within six months. Twenty years later, almost three-quarters of the nation’s 5,000-plus hospices were for-profits, many affiliated with regional or national chains.The shift was probably inevitable, said Ben Marcantonio, interim chief executive of the National Hospice and Palliative Care Organization, which represents both types along with some government hospices. Roughly half of Americans who die each year now turn to hospice. The number of Medicare beneficiaries enrolling in hospice rose to 1.7 million in 2020 from 580,000 in 2001.“The growth of for-profit providers is largely responding to growing need,” Mr. Marcantonio said. “It’s evolved within a health care system that not only accepts but encourages for-profit providers. To think hospice would be exempt from that forever probably wasn’t realistic.”Yet the proliferation of for-profit hospices has stoked fears that dying patients and their families are being shortchanged to improve companies’ bottom lines.The most recent report from MedPAC, the independent agency advising Congress on Medicare spending, found that in 2020, for-profits received 20.5 percent more from Medicare than they spent providing services. The margin for nonprofits, whose daily per-patient expenditures are higher, averaged 5.8 percent.“We’re not going to get profiteering out of the business until we make changes,” said Larry Atkins, chief policy officer of the National Partnership for Healthcare and Hospice Innovation, which represents about 100 nonprofit hospices.He acknowledged, only a bit grudgingly, that “there are a lot of sophisticated players on the for-profit side that do a decent job.”Barbara Reiss discovered that in 2017, when her 85-year-old mother was dying of cancer at her home in River Ridge, La. A for-profit hospice proved “very responsive to us,” she said, even when the family called for advice at 2 a.m. The hospice provided all the necessary supplies and drugs and sent nurses regularly.“When we were really having trouble, they came,” Ms. Reiss said. Her mother died peacefully, and the family turned to the same for-profit hospice three years later, when her father died in assisted living at 95.But numerous studies have documented that as a group, nonprofits provide better care. All hospices within a geographic area receive the same daily payment per Medicare beneficiary, but patients enrolled in nonprofits receive more visits from nurses, social workers and therapists, according to a 2019 study by the consulting firm Milliman.For-profits are more likely to discharge patients before they die, a particularly distressing experience for families. “It violates the implicit contract hospice makes, to care for patients through the end of life,” Dr. Atkins said.Dr. Joan Teno, a Brown University health policy researcher, and her team reported in 2015 on these “burdensome transitions,” in which patients were discharged, hospitalized and then readmitted to hospice.That happened to 12 percent of patients in for-profits affiliated with national chains, and to 18 percent of patients enrolled in for-profits that weren’t chain-affiliated — but to only 1.4 percent of patients in nonprofit hospices.Dr. Teno’s latest study, undertaken with RAND Corporation, analyzes the family caregiver surveys that Medicare introduced in 2016. Using data from 653,208 respondents from 2017 to 2019, the researchers ranked about 31 percent of for-profit hospices as “low performers,” scoring well below the national average, compared with 12.5 percent of nonprofits.More than a third of nonprofits, but only 22 percent of for-profits, were “high performers.” In 2019, the Department of Health and Human Services’ inspector general’s office also reported that most hospices it identified as low-performing were for-profits.Apart from such differences, the hospice industry has been plagued by fraud in several states. Investigations by The Los Angeles Times in 2020 and by the state auditor found that scores of new for-profit hospices were getting certified and billing Medicare in California.The number far outstripped need, and dozens of hospices shared common addresses, the auditor noted, concluding that “numerous indicators suggest large-scale hospice fraud and abuse” in Los Angeles County. Last year, the state imposed a moratorium on hospice licenses.In November, national hospice associations urged Medicare to take action in Nevada, Arizona and Texas, where similar patterns of growth and abuse have emerged.Researchers and critics have also raised alarms about private equity firms acquiring hospice organizations and, intending to resell them within a few years, reducing costs through measures like cutting staff. Most of those acquisitions were previously nonprofits.Advocates, researchers and industry leaders have long lists of reforms they think will fight fraud and improve services, from strengthening the way Medicare conducts quality surveys to shifting from a per-diem payment model to more individualized reimbursement.“It’s clear we need to strengthen oversight, but we must also modernize payment programs to meet the needs of patients and make it harder for people to game the system,” Representative Earl Blumenauer, an Oregon Democrat who has long been involved in end-of-life legislation, said in an email.Meanwhile, families seeking reliable, compassionate hospice care for loved ones need to undertake research, at a time when they shouldn’t have to, to select a provider. “It’s not as simple as avoiding all for-profits,” Dr. Teno said. “Because of the variations, you have to really look at the data.”The Medicare.gov website notes not only which hospices are nonprofit but also other quality measures. (The National Hospice Locator also provides such information, and the CaringInfo site from the National Hospice and Palliative Care Organization offers general guidance.)Dr. Teno advised caution if more than 40 percent of a hospice’s patients have dementia or are in assisted living facilities or nursing homes, both associated with higher profit margins.Quality hospices provide not only “routine home care,” the most common type of hospice service, but also higher levels of care when needed, including inpatient services. Look for a hospice with a four- or five-star rating, she added, although some geographic regions lack one.Most family caregivers still give hospice care high approval ratings, despite its changes and problems, but the need for improvement is clear.“It’s a small segment of the health care system, but it’s such an important one,” Dr. Teno said. “If you screw it up, people don’t forget.”