Despite solid financial track records, many older Americans have a hard time refinancing because of their mortality risks and lower retirement incomes.In late 2019, Molly Stuart’s contract ended at the community college where she worked. “Normally, I’d just get a new job, but then Covid happened,” she said. So she collected unemployment for awhile, then retired.In 2021, hoping to give herself some financial breathing room, she tried to refinance the three-bedroom ranch house she had bought 18 years earlier on an acre of land in Sacramento County, Calif.“I’m an extremely good risk,” said Ms. Stuart, 60, a lawyer. She had a 30-year work history and a credit rating above 800. Her remaining mortgage was $102,000, but she estimated that the house was worth about $500,000. She had already paid off the mortgage on another house in Sacramento, which she rented out.But her mortgage company denied her application. “I didn’t qualify for a refinance because I didn’t have enough income,” she said. “It was extremely frustrating.”But not uncommon. Older adults have higher credit ratings than any other age cohort, yet recent studies have shown that they’re substantially more likely to be rejected for most kinds of mortgages. That raises barriers for older Americans hoping to renovate or retrofit their homes, or to extract home equity as a buffer against medical expenses, widowhood or other crises.Much of older adults’ wealth is tied up in real estate. Among homeowners aged 65 to 74, home equity represented about 47 percent of their net worth in 2019, according to federal data; among those over 75, it was 55 percent. Among Black homeowners over 62, it accounted for almost three-quarters of their net worth.But a house is not a financial asset, noted Lori Trawinski, director of finance and employment at the AARP Public Policy Institute in Washington. “It only turns into a financial asset if you take out a loan or you sell it.”Getting that loan may be harder than owners expect.In February, Natee Amornsiripanitch, an economist at the Federal Reserve Bank of Philadelphia, published an analysis of more than 9 million mortgage applications collected through the Home Mortgage Disclosure Act from 2018 to 2020. He found that rejection rates rose steadily with age, particularly accelerating for applicants over 70.Focusing on refinancing applications, he reported a rejection rate of 17.5 percent for all ages. But for those in their 60s, it topped 19 percent, and among those 70 and older it was more than 20 percent — statistically significant differences.What’s more, older applicants paid slightly higher interest rates when they took out either refinances or new purchase mortgages.The study’s methodology controlled for credit scores and property types, as well as economic and demographic factors, said Alicia Munnell, director of the Center for Retirement Research at Boston College, which republished Dr. Amornsiripanitch’s work. “He’s looking at the well-heeled and the less well-heeled. Age is still a factor.”Although the federal Equal Credit Opportunity Act has long prohibited discrimination by age (as well as race, color, religion, national origin, sex and marital status), lenders are allowed to consider age if they deem it pertinent to creditworthiness.Dr. Amornsiripanitch determined, for example, that lenders attributed more than half of their rejections of older applicants to “insufficient collateral.” He speculated that lenders didn’t find those homes to be worth as much as applicants had thought, possibly because older owners occupy older homes, and might have deferred maintenance.Lenders also worry about older borrowers’ mortality risks. During the course of a 30-year loan, “someone dying is really inconvenient to a lender and can be costly,” Dr. Munnell explained. If the mortgage gets paid off early, a bank or mortgage company then re-lends the money, possibly at lower interest rates. If the property winds up in foreclosure after a death, the bank faces legal action.And, as in Ms. Stuart’s case, lenders care about reduced income after retirement. “People who are employed are lower risk than people who aren’t,” said Teresa Ghilarducci, a labor economist at The New School for Social Research in New York City. “It’s harder to get a mortgage after you retire.”That’s particularly true because today’s seniors are more apt to have debt, and more of it, than previous generations. That affects their debt-to-income (D.T.I.) ratios, a metric that lenders pay keen attention to.“High D.T.I. is a key denial reason,” said Linna Zhu, a research economist at the Urban Institute in Washington whose research has also documented higher rejection rates at older ages.A study she published in 2021 found mortgage denial rates of 18.7 percent for people over 75, 15.4 percent for those 65 to 74 and 12 percent for people under 65.Dr. Zhu and her colleagues reported, however, that the likelihood of denial depends on the type of loan. Home equity lines of credit, which don’t start charging interest or requiring repayment until the homeowner uses the credit, had similarly high rejection rates across all age groups.In contrast, cash-out refinances that provide a lump sum — a popular product during the recent period of rising home prices and super-low interest rates — were denied to more than 21 percent of applicants over 75 in 2020, compared with just 14.6 percent of would-be borrowers under 65.And for home equity conversion mortgages — a type of reverse mortgage secured by the Federal Housing Administration — younger borrowers actually had higher rejection rates.Extremely low interest rates in recent years have made borrowing easier for everyone, masking these age discrepancies, Dr. Zhu said. But as rates have climbed sharply, “it will be more challenging to tap your home equity,” she said.Policy changes could reduce these age-related barriers. Rather than lenders’ relying so heavily on income and debt to assess creditworthiness, “it’s important to look at alternate sources of wealth for a more comprehensive picture of someone’s financial background,” Dr. Zhu said.Changing these assessments would require “a collective effort,” Dr. Zhu said, involving commercial lenders, the federally sponsored Fannie Mae and Freddie Mac and federal agencies like the F.H.A. and the Department of Housing and Urban Development.That approach would have helped Ms. Stuart, who had substantial assets but modest income after retiring. After her mortgage company turned her down for refinancing, she used her savings to pay six months of her mortgage in advance — the maximum length of time her lender would allow. That lessened the pressure of monthly payments, and she may choose to do it again.But compared to refinancing, which would have lowered her monthly payments for the next 30 years without depleting her savings, it’s a temporary solution. “It’ll be fine,” she said of her experience. “But it was unreasonable.”

Following even basic screenings and operations, patients often must arrange for someone to deliver them home. For older people, it can be a tall order.Robert Lewinger is tired of being berated by his gastroenterologist because he’s overdue for a colonoscopy. He’s perfectly willing to have one. And he’s more than ready for cataract surgery on his second eye.The problem: Mr. Lewinger, 72, a retired lawyer who lives in Manhattan, can’t schedule either of these procedures, which involve anesthesia or sedation, unless he supplies the name and phone number of the person taking him home afterward. Otherwise, clinics and outpatient surgical centers refuse to make appointments.Mr. Lewinger is also willing to undergo Mohs surgery, as his dermatologist has recommended, for two small skin cancers on his face. But the surgeons associated with her practice also insist on medical escorts, even though most Mohs surgery is performed under local anesthesia and doesn’t require them.Transportation itself isn’t the difficulty; Mr. Lewinger could summon an Uber or a Lyft, call a car service or hail a cab. What he needs is “someone to escort me out of the building, take me back to my apartment and see me into it,” he explained. “It shouldn’t be so hard.”It is, though. Mr. Lewinger is divorced and lives alone, like a growing number of older Americans. His daughter lives in Boston; the cousin who brought him home after cataract surgery a few years ago has moved away. He doesn’t have friends to help. Phone calls to Aetna, his Medicare Advantage insurer, revealed that Medicare doesn’t cover a medical escort. He struck out with home-care agencies, too.He even offered maintenance workers in his apartment building $100 to pick him up after their shifts. “They lost interest when I couldn’t be specific about what time they’d have to be there,” Mr. Lewinger said.Older people across the country describe similarly maddening efforts to find “door-through-door” escorts for outpatient surgery and screenings that involve anesthesia — especially if facilities require those escorts to remain on the premises until the patient’s discharge.The problem is “rampant,” said Janet Seckel-Cerrotti, executive director of FriendshipWorks, a nonprofit whose trained volunteers serve as free medical escorts in and around Boston. “We see it every day. It’s hard on your dignity.”Doctors explain that door-through-door requirements are a safety measure. With a colonoscopy, for instance, patients often receive an anesthetic, like propofol, or a narcotic such as Demerol or fentanyl, combined with anti-anxiety medication like Versed or Valium.“They affect the brain, and they can stay in the system for four to six hours,” said Carol Burke, a gastroenterologist at the Cleveland Clinic and a past president of the American College of Gastroenterology. “You’re not in full control of your faculties.”On a bus or in an Uber, she said, “what if you fall asleep or you start to vomit or you don’t remember where you’re going?”Is such caution truly necessary? “A very hard question,” said Thomas Oetting, an ophthalmologist at the University of Iowa School of Medicine and a spokesman for the American Academy of Ophthalmology.Though liability fears clearly play a role, “how safe do we have to be?” he asked. He specializes in cataract surgery, which also often involves intravenous anesthesia. After the operation, “if there’s a one-in-a-million chance that someone falls and breaks a hip, should everybody have to have someone take them home?”For now, though, they usually do, forcing older patients without nearby family, or friends who still drive, to scramble.Some rely on religious congregations. In Boulder, Colo., Jan DeCourtney, 65, earned enough credits by volunteering through TimeBank Boulder to secure other volunteers to accompany her to and from cataract surgeries. In Beaverton, Ore., Gerry Lukos joined Viva Village, part of the Village Movement, which supports aging in place; she used volunteer drivers/escorts three times last year.Trying to solve the escort problem can require considerable research, involving providers, local nonprofits and home-care companies. Some possibilities:Talk to your medical provider. Policies vary. The surgeons to whom Mr. Lewinger was referred require escorts for Mohs procedures, but most don’t, said Terrence A. Cronin Jr., president of the American Academy of Dermatology. “The local anesthesia we use is usually lidocaine, which doesn’t disrupt the mental abilities of our patients, so they are able to drive themselves home,” he said in an email.For cataract surgery, you may be able to avoid intravenous anesthesia, which is less often used in other countries. Dr. Oetting also practices at V.A. Iowa City, where cataract surgery involves a shorter-acting oral sedative (typically Valium) and patients remain in the clinic for two or three hours afterward. “Then we feel more comfortable having them leave on a van,” he said.Colonoscopies can be done without sedation, too. Alternatively, the Cleveland Clinic and other providers sometimes allow patients with early morning appointments to remain for several additional hours after the procedure before going home on their own.You can also screen for colon cancer annually with an accurate at-home FIT (fecal immunochemical test) and skip the colonoscopy, though the 5 to 6 percent of people who get a positive result will need one as a follow-up anyway.Look for local nonprofit groups. The National Volunteer Caregiving Network connects about 700 community organizations nationwide, most of which provide door-through-door transportation without charge. “It’s neighbors helping neighbors,” Tammy Glenn, the executive director, said.Shepherd’s Centers of America, which provides support services for older adults, has 55 affiliates in 17 states; most offer escorts to and from medical appointments without charge.The roughly 250 local village organizations across the country often help with door-through-door, though there’s an annual fee — usually subsidized for lower-income seniors — to join the village.You can also consult your local Area Agency on Aging or use the Eldercare Locator to find public or nonprofit transportation services.Contact home-care companies. Medicare doesn’t cover medical escorts. “Nonemergency medical transportation,” including an attendant, is a covered Medicaid benefit, but state policies vary widely, Alice Burns of the Kaiser Family Foundation said.But if you can afford out-of-pocket costs, you may find help. In New York, Westchester County and Long Island, VNS Health (formerly the Visiting Nurse Service of New York) provided medical escorts almost 1,800 times last year. Patients can book a certified home health aide to accompany them at about $140 for a four-hour block.Many home-care companies, already scrambling to hire staff, won’t agree to such short one-time stints, which produce less income than continuing assignments for both the aides and the agency. But some companies will, sometimes charging slightly higher rates than for continuing care. Give plenty of notice before your appointment.Executives at nonprofits and home-care companies said they glimpsed signs of change, with insurers and hospitals beginning to cover escorts or supporting local nonprofits that provide them.It’s not happening fast enough for Mr. Lewinger, but he has decided on a plan.He asked his doctor to prescribe an at-home FIT for colon cancer, instead of a colonoscopy. For cataract surgery, he’ll make an appointment, then call VNS Health; he can afford the charges.To locate a surgical practice that doesn’t require an escort after Mohs procedures, he’ll have to start making calls.He wishes Medicare and medical practices would simplify this process. After all, the costs of treating cancer, or injuries when a person with poor eyesight falls, would far exceed the expenses for door-through-door transportation.He envisions “just a straightforward ‘Call this number and they’ll arrange it,’” he said. “It shouldn’t be up to the patient to figure it out.”

Most older cancer patients received invasive care in the last month of their lives, a new study finds. That may not be what they wanted.In July, Jennifer O’Brien got the phone call that adult children dread. Her 84-year-old father, who insisted on living alone in rural New Mexico, had broken his hip. The neighbor who found him on the floor after a fall had called an ambulance.Ms. O’Brien is a health care administrator and consultant in Little Rock, Ark., and the widow of a palliative care doctor; she knew more than family members typically do about what lay ahead.James O’Brien, a retired entrepreneur, was in poor health, with heart failure and advanced lung disease after decades of smoking. Because of a spinal injury, he needed a walker. He was so short of breath that, except for quick breaks during meals, he relied on a biPAP, a ventilator that required a tightfitting face mask.He had standing do-not-resuscitate and do-not-intubate orders, Ms. O’Brien said. They had discussed his strong belief that “if his heart stopped, he would take that to mean that it was his time.”Listening in on the phone while a hospital palliative care nurse-practitioner talked to her father about his options, Ms. O’Brien provided a blunt translation to an always blunt man: “Dad, your heart and lungs are done.”The next day, he declined surgery to repair his hip. A startled anesthesiologist and an orthopedist called his daughter, apparently expecting her to talk her father into agreeing to the operation. She didn’t try.“He was dying,” she said in an interview. “He’d either die comfortably or, with a big surgical incision, he’d die uncomfortably. Or die of something more complicated — potential infections, bowel obstructions, so many things that can happen.” Mortality rates after hip fractures, though improving, remain high.Her father, who wasn’t cognitively impaired, had decided that surgery was “silly” and unnecessary. She supported his decision and contacted a local hospice.Families often have to run interference in such scenarios, and a new study in JAMA Network Open helps explain why. The authors, most of them at Case Western Reserve University School of Medicine, analyzed five years of data from a cancer registry, nursing home assessments and Medicare claims to look at “aggressive end-of-life care” among 146,000 older patients with metastatic cancer.They compared nursing home residents’ care in the last 30 days of their lives with the care for non-institutionalized patients living in communities, the lead author, Siran Koroukian, a health services researcher at Case Western Reserve, said.The team looked for commonly used markers of aggressive care, including cancer treatment, repeated emergency room visits or hospitalizations, admission to an intensive care unit, lack of hospice enrollment until three days before death, and death in a hospital.“In all probability, hospice should have been considered” for these patients, said Sara Douglas, a co-author and oncology researcher at the Case Western Reserve University School of Nursing.Yet the majority of both groups — 58 percent of community dwellers and 64 percent of nursing home residents — received aggressive treatment in their final 30 days. A quarter underwent cancer treatment: surgery, radiation, chemotherapy.Although studies repeatedly show that most patients want to die at home, 25 percent of the community dwellers and almost 40 percent of the nursing home residents died in hospitals.Hospice leaders, palliative care specialists, health care reformers and advocacy groups have worked for years to try to lower such numbers. “Patients who received this type of aggressive care experience more pain, actually die sooner, have a much poorer quality of life at the end. And their families experience more doubt and trauma,” Dr. Douglas said.Because the researchers used large databases, the study can’t indicate whether some patients actually opted for continued treatment or hospitalization. Some treatments the authors deemed aggressive could instead have been palliative, intended to increase comfort, like radiation to shrink tumors that might impede breathing.Still, “these are really sobering statistics,” said Douglas White, director of the Center for Ethics and Decision Making in Critical Illness at the University of Pittsburgh School of Medicine.A lot of factors contribute to invasive actions in patients’ final days and weeks. Some originate within the health care system itself. Doctors may be reluctant to initiate difficult conversations about what dying patients want, or be poorly trained in conducting them.“The minute you have this conversation, people assume, ‘You’re giving up on me,’” Dr. Douglas said. Even having an advance directive and a Physician Order for Life-Sustaining Treatment, or P.O.L.S.T., doesn’t always ward off aggressive treatment.But studies also show that even when crucial discussions take place, patients and surrogate decision-makers frequently misinterpret them. “Families often leave these conversations with much more optimistic expectations than their doctors meant to convey,” Dr. White said.His research has documented the effects of optimism bias. Surrogates understand positive prognoses more accurately than negative ones. They may grasp that most people in this situation will die, but insist that their particular loved one is different, fiercer, stronger. Misplaced optimism then leads to more aggressive treatment.Sometimes, family demands prevail even over the patient’s own wishes. Jennifer Ballentine, chief executive of the Coalition for Compassionate Care of California, knew that one of her relatives didn’t want high-intensity care if he became terminally ill. But when he developed aggressive prostate cancer at 79, his wife insisted that he pursue treatment.“He refused. He kept saying he just wanted to be in hospice,” Ms. Ballentine recalled. “She kept saying, ‘Absolutely not.’ ” He capitulated until, after three exhausting months of chemotherapy with several hospital stays, he died in hospice care.The health care system could improve end-of-life care. When palliative care is introduced soon after a diagnosis, patients have a better quality of life and less depression, a study of people with metastatic lung cancer found. Though they were less likely to undergo aggressive treatment, they survived longer.Palliative care doctors, skilled in discussions of serious illness, are scarce in some parts of the country, however, and in outpatient practices.Adopting a so-called concurrent care approach to hospice might also ease these transitions. The Medicare hospice benefit requires patients to forgo treatment for their terminal illness; hospice through the Veterans Health Administration system, with more liberal criteria, allows patients to receive both treatment and hospice.A recent study of veterans with end-stage kidney disease, who were likely to die within days if forced to discontinue dialysis, shows the impact of concurrent care. Palliative dialysis — administered less often or for shorter periods than the standard regimen — can help control symptoms like shortness of breath.“Being required to stop a treatment that is helping your quality of life can mean that you won’t sign up for hospice,” said the lead author, Melissa Wachterman, a palliative care doctor at Harvard Medical School.In her study, veterans who discontinued dialysis when they enrolled in hospice received just four days of care before they died, so short a time that even expert hospices would struggle to provide full support. Those receiving concurrent dialysis as hospice patients, almost all through the V.A., averaged 43 days of hospice care.Medicare has authorized pilot studies of concurrent care, but for now, patients and families must often seize the reins to make their end-of-life wishes known and determine how best to fulfill them.Some patients want every possible action taken to extend their lives, even briefly. For those who feel otherwise (former President Jimmy Carter, for instance), asking about palliative care and hospice can open the door to straightforward discussions.James O’Brien was among the latter. His daughter drove 12 hours, from Little Rock to Santa Fe, to spend a quiet day with him. “We had some good time together,” she said. “We talked about what was going to happen.”She was there as the hospice team provided medication to keep him comfortable and withdrew the biPAP. “It was very peaceful,” she said. “I told him I loved him. I knew he could hear me. I stayed with him until he took his last breath.”

Anxiety disorders are common among seniors, but an influential panel seems likely to recommend against routine screening. Some experts disagree.Susan Tilton’s husband, Mike, was actually in good health. But after a friend’s husband developed terminal cancer, she began to worry that Mike would soon die, too.At night, “I’d lie down and start thinking about it,” recalled Ms. Tilton, 72, who lives in Clayton, Mo. “What would I do? What would I do?” The thought of life without her husband — they’d married at 17 and 18 — left her sleepless and dragging through the next day.“It was very hard to shut it off,” she said of her worrying. “How could I get along by myself? What would I do with the house?”Years earlier, Ms. Tilton had been seeing a therapist and taking medication for depression, but she ended therapy when her doctor retired. In late 2021, she consulted Dr. Eric Lenze, who heads the psychiatry department at the Washington University School of Medicine in St. Louis, for help with a different health problem, not fully recognizing that her anxiety was itself a diagnosable disorder.“I just thought it was the way things were — you worried,” she said. “I believe I’ve had it since I was a child. To me, it was my normal way of thinking.”A lot of older people can empathize. Anxiety is the most common mental health disorder; a 2017 study of older adults in six countries found that more than 17 percent had experienced an anxiety disorder within the past year.Generalized anxiety disorder, Ms. Tilton’s diagnosis, is the most common type among seniors. “The most prominent symptom is severe, difficult-to-control worry,” said Dr. Carmen Andreescu, a geriatric psychiatrist at the University of Pittsburgh School of Medicine and an author of a recent editorial on late-life anxiety in JAMA Psychiatry.“There’s this continuing fear that something bad is going to happen,” she added. “It can be all-consuming.”Other forms of anxiety include social anxiety disorder, phobias, panic disorder and post-traumatic stress disorder. Anxiety frequently occurs alongside depression, complicating diagnosis and treatment. The coronavirus pandemic, of course, led to rising anxiety and depression in all adult age groups.Recently, attention to anxiety has increased because of a draft recommendation from the United States Preventive Services Task Force, an independent expert panel that reviews research on preventive measures.The panel concluded that adults ages 18 to 64, including those who are pregnant and postpartum, should be screened for anxiety and gave that recommendation a “B” rating, meaning it had “moderate net benefit.” (Screening means testing patients who don’t exhibit symptoms or raise concerns about a particular health problem but may be experiencing it nonetheless.)For people 65 and older, though, the task force issued an “I” rating, meaning it found insufficient evidence of benefits and harms.“It’s a very scientifically rigorous process,” said Lori Pbert, a clinical psychologist and health behavior researcher at the University of Massachusetts Chan Medical School who served on the panel.When it came to older adults, “evidence was lacking on the accuracy of screening tools and the benefits and harms of screening,” she said. The team also wanted more evidence of treatment effectiveness.“It’s a strong call for the clinical research that’s needed,” Dr. Pbert said. The task force will publish its final recommendation later this year.Dr. Andreescu and the other authors of the editorial, including Dr. Lenze, politely but strongly disagree. An “I” rating “makes people not look for or treat something that’s already an undertreated condition,” Dr. Lenze said.“With a common disorder that causes a lot of impairment of quality of life and that has simple, inexpensive, straightforward kinds of treatment, I think screening is called for,” he added.Whatever the final task force recommendation, the discussion of anxiety in older people highlights a prevalent but often overlooked mental health concern. “A lot of these cases fly under the radar,” Dr. Andreescu said.That may reflect the way symptoms of anxiety can differ among older people, whose primary care doctors often lack the training to recognize mental health disorders. In addition to severe worry, seniors often experience insomnia or irritability; they may develop a fear of falling, engage in hoarding or complain of physical discomforts like muscle tension, a choking sensation, dizziness or shakiness.But underdiagnosis also stems from older patients’ reluctance to ascribe their problems to psychological issues. “Some resent a label of ‘anxious,’” Dr. Andreescu said. “They’d rather call it ‘high stress,’ something that doesn’t indicate psychological weakness.”And since aging involves genuine sources of fear and distress, from falls to bereavement, people may see anxiety as normal, as Ms. Tilton did.It has serious consequences, however. “It has an impact on the health of our brains and our bodies,” Dr. Andreescu said. Studies have demonstrated connections between anxiety and cardiovascular disease, with greatly increased risks of coronary heart disease, heart failure, stroke and death. Patients with higher anxiety levels are more likely to engage in substance abuse, too.Research also consistently shows that anxiety is linked to cognitive decline and dementia. Dr. Andreescu’s neuroimaging studies have found that “anxiety actually shrinks and ages the brain,” she said.And it degrades people’s everyday lives. Jim Wright, a Pittsburgh executive who has participated in Dr. Andreescu’s research, described having “a lot of sleepless nights.”“I’ll wake up at 2 a.m. and lie there worrying about every random thing you can think of,” said Mr. Wright, 60, who has also developed hypertension that has proved difficult to control.John Modell, 81, a retired history professor in Pittsburgh and another study participant, worries about memory loss and about getting lost on local walks or stranded by airlines on trips. “I’m aware of being anxious 20 or 50 times a day,” said Mr. Modell, whose father died of Alzheimer’s disease. His symptoms have led him to stop traveling and have curtailed his social life; he thinks they contributed to his divorce, too.Neither man has sought treatment for anxiety. “I’ve learned to live with it,” Mr. Wright said. Yet anxiety can be treated with antidepressants like Prozac, Lexapro and Zoloft, called selective serotonin reuptake inhibitors, combined with specialized forms of cognitive behavioral therapy.(Benzodiazepines and related drugs, which many seniors turn to for temporary relief from insomnia and anxiety, are not recommended for long-term use. “The risks of confusion and falls are well-known,” Dr. Lenze said. “And they’re habit-forming medications. They’re harder to stop.”)Because older people require higher doses of antidepressants and are already likely to be taking multiple medications, doctors proceed cautiously. “It’s a bigger challenge” to treat older anxious patients, Dr. Andreescu said. “It’s more complicated.”The drugs can take weeks longer to bring relief than in younger people, she said, which may lead patients to think they aren’t working and stop taking them. Older patients may also relapse and require a different regimen.With time, though, “we do get it under control,” Dr. Andreescu said. “People do respond to treatment.”Ms. Tilton, for instance, said she had regained her equilibrium. Dr. Lenze increased her dosage of duloxetine (sold under the brand name Cymbalta) and added mirtazapine (Remeron). “I’m feeling really good right now,” she said.A particular pleasure: improved sleep. “I can lie down on the bed and conk out in a second,” she said. “It’s a real treat.”

Seniors continue to bear the brunt of deaths and hospitalizations, even as most of the nation abandons precautions: “Americans do not agree about the duty to protect others.”In early December, Aldo Caretti developed a cough and, despite all his precautions, came up positive for Covid on a home test. It took his family a couple of days to persuade Mr. Caretti, never fond of doctors, to go to the emergency room. There, he was sent directly to the intensive care unit.Mr. Caretti and his wife, Consiglia, both 85, lived quietly in a condo in Plano, Texas. “He liked to read and learn, in English and Italian,” said his son Vic Caretti, 49. “He absolutely adored his three grandchildren.”Aldo Caretti had encountered some health setbacks last year, including a mild stroke and a serious bout of shingles, but “he recuperated from all that.”Covid was different. Even on a ventilator, Mr. Caretti struggled to breathe. After 10 days, “he wasn’t getting better,” said Vic Caretti, who flew in from Salt Lake City. “His organs were starting to break down. They said, ‘He’s not going to make it.’”At least, this late in the pandemic, families can be with their loved ones at the end of life. When the family agreed to remove Mr. Caretti from the ventilator and provide comfort care, “he was alert, very aware of what was happening,” his son said. “He was holding everyone’s hand.” He died a few hours later, on Dec. 14.For older Americans, the pandemic still poses significant dangers. About three-quarters of Covid deaths have occurred in people over 65, with the greatest losses concentrated among those over 75.In January, the number of Covid-related deaths fell after a holiday spike but nevertheless numbered about 2,100 among those ages 65 to 74, more than 3,500 among 75- to 84-year-olds and nearly 5,000 among those over 85. Those three groups accounted for about 90 percent of the nation’s Covid deaths last month.Hospital admissions, which have also been dropping, remain more than five times as high for people over 70 than for those in their 50s. Hospitals can endanger older patients even when the conditions that brought them in are successfully treated; the harmful effects of drugs, inactivity, sleep deprivation, delirium and other stresses can take months to recover from — or can land them back in the hospital.“There continue to be very high costs of Covid,” said Julia Raifman, a public health policy specialist at the Boston University School of Public Health and a co-author of a recent editorial in The New England Journal of Medicine.Ms. Bravo of New Mexico and her sister, Desi Bravo, at a family event several years ago. “Our world has gotten much smaller,” Ms. Bravo said.Adria Malcolm for The New York TimesThe demographic divide reflects a debate that continues as the pandemic wears on: What responsibility do those at lower risk from the virus have to those at higher risk — not only older people, but those who are immunosuppressed or who have chronic conditions?More on the Coronavirus PandemicCovid Vaccine Mandate: New York City will end its aggressive but contentious coronavirus vaccine mandate for municipal workers, Mayor Eric Adams announced, signaling a key moment in the city’s long battle against the pandemic.End of an Era: The Biden administration plans to let the coronavirus public health emergency expire in May, a sign that federal officials believe the pandemic has moved into a new, less dire phase.Canceled Doses: As global demand for Covid-19 vaccines dries up, the program responsible for vaccinating the world’s poor has been negotiating to try to get out of its deals with pharmaceutical companies for shots it no longer needs.Mask Rules: Many countries dropped pandemic mask requirements months ago. But in places like South Korea, which only recently got rid of its rule, masks remain common. This is why.Should individuals, institutions, businesses and governments maintain strategies, like masking, that help protect everyone but particularly benefit the more vulnerable?“Do we distribute them among the whole population?” Dr. Raifman asked of those measures. “Or do we forgo that, and let the chips fall where they may?”Nancy Berlinger, a bioethicist and research scholar at the Hastings Center, made a similar point: “The foundational questions about ethics are about what we owe others, not just ourselves, not just our circle of family and friends.”Three years in, the societal answer seems clear: With mask and vaccination mandates mostly ended, testing centers and vaccination clinics closed and the federal public health emergency scheduled to expire in May, older adults are on their own.“Americans do not agree about the duty to protect others, whether it’s from a virus or gun violence,” Dr. Berlinger said.Only 40.8 percent of seniors have received a bivalent booster. Some who have not believe they have strong protection against infection, a C.D.C. survey reported last month (though the data indicated otherwise).Others worry about side effects or feel unsure of the booster’s effectiveness. Seniors may also find it difficult to locate vaccination sites, make appointments (especially online) and travel to the sites.In nursing homes, where the early pandemic proved so devastating, only 52 percent of residents and 23 percent of staff members were up-to-date on vaccinations last month. Early on, a successful, federally funded campaign sent health care workers into nursing homes to administer the original vaccine doses. Medicare also mandated staff vaccinations.But for boosters, nursing homes were permitted to develop their own policies — or not.“It makes absolutely no sense,” said David Grabowski, a health policy professor at Harvard Medical School. “This is the group that should have the highest vaccination rate in the country. Everyone there is very susceptible.”The Covid costs for older people extend beyond the most extreme dangers and include limited activities, diminished lives and continuing isolation and its associated risks.In Hillsboro, Ore., Billie Erwin, 75, feels particularly vulnerable because she has Type 1 diabetes. She and her husband have foregone concerts and theater performances, indoor restaurant meals with friends, moviegoing and volunteering. Her book group fell apart.“We used to spend a lot of time on the Oregon coast,” Ms. Erwin said. But because the trip involves an overnight stay, they’ve gone just twice in three years; annual visits to the Oregon Shakespeare Festival ended for the same reason.The ongoing constraints have exacerbated the depression Ms. Erwin also contends with; some days, she doesn’t bother getting dressed.“I’m disappointed we don’t consider other people as much as we ought to,” she said. “I don’t know that most people even think about it.”Donna Bolls of Charlotte, N.C., though she and her husband got sick with Covid in May, has largely returned to her prepandemic routines. “I feel like I’m living life on my terms, doing the things I want to do,” she said.Travis Dove for The New York TimesEleanor Bravo, 73, who lives in Corrales, N.M., lost her sister to Covid early in the pandemic; two years passed before the family could gather for a memorial. “I had this inordinate fear that if I got Covid, I would die too,” Ms. Bravo said.She did develop Covid in July, and recovered. But she and her partner still avoid most cultural events, travel and restaurants. “Our world has gotten much smaller,” she said. An organizer with Marked by Covid, a national nonprofit organization, she is working to build a memorial to the 9,000 New Mexicans who have died of the virus.Of course, many older Americans, too, have resumed their prepandemic routines. In Charlotte, N.C., Donna and David Bolls, both 67, fell ill with Covid in May — “the sickest I’ve been that I can remember,” Ms. Bolls said.But afterward, they returned to restaurants, concerts, shopping, her part-time retail job and his church choir, without masks. “It’s a risk I’m willing to take,” she said. “I feel like I’m living life on my terms, doing the things I want to do.”Though the political viability of mandates for masks, vaccination or improved indoor air quality appears nil, policymakers and organizations could still take measures to protect older (and immunocompromised) people without forcing them to become hermits.Health care systems, pharmacies and government agencies could start renewed vaccination campaigns in communities and in nursing homes, including mobile clinics and home visits.Remember the “senior hours” some supermarkets instituted early in the pandemic, allowing older customers to shop with smaller crowds and less exposure? Now, “public spaces are not accessible to people concerned about infections,” Dr. Raifman said.They could be. Markets, libraries and museums could adopt some masks-required hours. Many Off Broadway theaters already designate two or three masked performances each week; others could follow suit. Steven Thrasher, author of “The Viral Underclass,” organized a masked book tour last fall with stops in 20 cities.“Between the extremes of closing everything to mitigate transmission and doing nothing, there’s a middle ground,” Dr. Raifman said. “We can mitigate transmissions in smart and inclusive ways.”Yet Vic Caretti, who has found a grief support group helpful, encounters comments from strangers in Salt Lake City because he wears a mask in public.“I don’t think people understand how Covid affects older Americans,” Mr. Caretti said with frustration. “In 2020, there was this all-in-this-together vibe, and it’s been annihilated. People just need to care about other people, man. That’s my soapbox.”

“Granny flats” are popping up in backyards across the country, affording Americans a new housing option. Some communities are not happy about it.Forty-five years ago, Betty Szudy and her wife, Maggie Roth, both 70, bought a Craftsman bungalow in Oakland, Calif. In 2017, at the same time their son and his wife were fruitlessly searching for an affordable apartment in the neighborhood, California was liberalizing its housing laws to encourage so-called accessory dwelling units, or A.D.U.s.So, the family looked into building one. The parents now live in the main house and the adult children in the A.D.U. — in this case, a once-decrepit garage transformed into a 400-square-foot studio with a kitchen and bath.The arrangement makes it simple to share meals, planned or spontaneous, and to pick up items for the other household at Trader Joe’s. “I love having them around,” Ms. Szudy said.“It made total sense,” she said. “The idea of having a family compound, being close but having separate spaces.”In Portland, Ore., on the other hand, it’s the younger family — Jules Radkin and Pia da Silva, their two children and a dog — who occupy the primary four-bedroom house. Ms. da Silva’s parents moved into the A.D.U., a 740-square-foot, two-bedroom structure also converted from a garage.Vona da Silva and her husband, Richard Silva, Ms. da Silva’s parents, had been planning to age in place in a downtown condo. But with their daughter’s expanding family outgrowing their small house, the older couple sold their condo. In 2014, they bought the property both families now share, designing and building their backyard A.D.U. with plenty of grab bars. Since Mr. Silva died last year at 83, Ms. da Silva, 80, has lived there alone.“It absolutely exceeded all our expectations,” she said of the arrangement. With the children so close, “if they need child care, I pitch in. If I need care in the future, they will pitch in. They are prepared to be caregivers.”The elder Ms. da Silva, right, with her grandson Henry and her daughter Pia.Tojo Andrianarivo for The New York TimesAccessory dwelling units — also known as in-law suites, granny flats, casitas or guest cottages — come in many forms. They can be free-standing or attached to the main house on the property they share; they can be apartments in basements or atop garages. An A.D.U., which is typically 600 to 1,000 square feet, has a bathroom, a kitchen or kitchenette, and, usually, a separate entrance.Its function can change over the decades. A rental that generates income for young homeowners might later become a refuge for returning young adults, then become a way for older homeowners to defray housing costs and remain in their neighborhoods.In an aging nation, an A.D.U. makes particular sense for people in their 60s and up who don’t want to move and will need nearby caregivers, either family members or hired aides. Mr. Silva died at home of pulmonary fibrosis, and in his final weeks and months, his daughter and son-in-law had to walk only a few yards to help care for him.“They came over and did whatever needed to be done,” Ms. da Silva said. With such proximity, “everybody has to be respectful,” she acknowledged. “But for us, it’s been wonderful.”As affordable housing grows increasingly scarce for both young and old, A.D.U.s provide several advantages. “They create housing that doesn’t alter the look or feel of a community,” said Zoe Baldwin, the New Jersey director of the Regional Plan Association, a nonprofit group in the Northeast.“It’s a way to add capacity within the existing footprint,” she said, a strategy planners sometimes call “gentle density.” A.D.U.s don’t require much government investment in infrastructure, and they reduce energy consumption and costs.Accordingly, they are growing more popular. Ten states and the District of Columbia, as well as many municipalities, have adopted or revised laws to encourage A.D.U. construction, reducing barriers like zoning, parking restrictions and onerous approval processes.In California, which has passed a series of laws enabling the use of A.D.U.s, permits rose to nearly 20,000 in 2021 from about 1,200 in 2016, the year before the first law took effect, the state has reported.AARP, which supports A.D.U.s, has helped 17 cities pass such legislation in the past two years, among them Pittsburgh; Denver; Louisville, Ky.; Raleigh, N.C.; and Kansas City, Mo. “It’s encouraging to see the numbers growing,” said Rodney Harrell, the organization’s housing expert.By analyzing real estate listings, Freddie Mac, the federally chartered housing finance company, estimated in 2020 that the United States had 1.4 million legal A.D.U.s, half of them in California, Florida, Texas and Georgia. Between 2009 and 2019, sales listings of houses with A.D.U.s rose an average 8.6 percent annually, the company found.Further growth is “just inevitable,” said Harold Simon, the retired editor of the community development magazine Shelterforce. “1.4 million units is not a fad.” He helped draft one of three accessory unit bills now working their way through the New Jersey Legislature.Ms. da Silva said that with her daughter’s family so close, “if they need child care, I pitch in. If I need care in the future, they will pitch in.”Tojo Andrianarivo for The New York TimesStill, accessory units face suspicion and opposition from some quarters. Single-family zoning, widely used since the 1950s to control development, but also to maintain racial and economic exclusion, is often “sacrosanct, the 11th commandment,” Mr. Simon said. About 80 percent of the nation’s neighborhoods permit only single-family homes, AARP has found.Besides, “towns don’t like being told what to do,” said Melissa Kaplan-Macey, director of the Regional Plan Association in Connecticut, which helped enact statewide A.D.U. legislation in 2021. To pass the bill, supporters included a provision allowing municipalities to opt out, and a number have. Some towns are adopting their own A.D.U. laws, and others are continuing to bar A.D.U.s altogether.In some locations, laws ostensibly enabling accessory units create so many restrictions — including parking and owner-occupancy requirements — that they actually discourage construction.“A.D.U.s should be treated similarly to other forms of housing, to the single-family house next door,” Dr. Harrell said.Creating these units can be dauntingly expensive. A Berkeley study in 2021 found that median construction costs in California were $150,000, and even higher in the Bay Area, for an average 615-square-foot unit.Ms. Szudy and Ms. Roth refinanced their primary house to spend between $150,000 and $200,000 building their backyard studio in Oakland.“The financing is the next big frontier,” Ms. Kaplan-Macey said. A.D.U. proponents will have to work with lenders, manufacturers and property tax authorities to make the option affordable for homeowners with more modest incomes.But the idea is clearly catching on. In Bend, Ore., Julie and Paul Anderson built a contemporary-style house four years ago and added an attached one-bedroom apartment. Her parents have spent four months there each summer, escaping the heat in Tucson, Ariz., where they live; a tenant rents it the rest of the year.Ms. Anderson and her husband have considered moving into the ground-floor A.D.U. when they retire and renting out the larger space upstairs to supplement their income. But the needs of their parents, all in their 70s and 80s, take precedence for now.“We have peace of mind,” Ms. Anderson said, “knowing that if an older family member needs care, we have this space.”

Reforms embedded in the Inflation Reduction Act will bring savings to seniors this year. Already some lawmakers are aiming to repeal the changes.Steve Lubin spent a lot last year on insulin to control his Type 2 diabetes.A retired nurse in Philadelphia, Mr. Lubin relies on Medicare for health coverage, including a Part D plan to cover drug expenses. Yet his out-of-pocket costs kept mounting, including a deductible of $480, monthly supplies of two forms of insulin, and higher prices once he entered the “coverage gap.” His total insulin tab in 2022: $1,582.So Mr. Lubin, 68, was cheering for the sprawling federal Inflation Reduction Act, which among other provisions called for capping insulin prices for Part D beneficiaries at $35 a month, with no deductible. He signed petitions circulated by the American Diabetes Association and the Pennsylvania Health Access Network asking Congress to vote yes.“My income is definitely down from when I was working, and the expenses go up,” he said. “It’s difficult.”But Mr. Lubin also supported the bill because, after working in an intensive care unit for years, he had seen patients suffer the serious consequences of diabetes when they could not afford their prescriptions.“You’d take their history and find out that they were rationing their insulin or couldn’t take it at all,” he recalled.In August, Congress passed the bill, and President Biden signed it. Mr. Lubin’s out-of-pocket insulin costs for 2023 will fall to $630. The legislation establishes other requirements to lower drug prices for Medicare beneficiaries, about three-quarters of whom have Part D plans.“It’s one of the biggest changes to the way Medicare deals with prescription drugs,” said David Lipschutz, associate director of the Center for Medicare Advocacy. “It signals lawmakers’ willingness to take on a very powerful lobby.”Some provisions took effect on Jan. 1; others will phase in over several years. “Collectively, these represent substantial out-of-pocket cost savings, especially for those who use expensive drugs,” said Juliette Cubanski, deputy director of the Kaiser Family Foundation’s Medicare policy program. They could also bolster Medicare by reducing its spending.Beneficiaries will see three significant changes in 2023.The first is the $35 monthly cap on insulin, which will affect more than a million insulin users who have Part D through Medicare Advantage plans or free-standing plans purchased along with traditional Medicare.From 2007 to 2020, beneficiaries’ aggregate out-of-pocket insulin costs quadrupled, even though the number of users only doubled. They spent an average $54 a month on insulin in 2020, according to a Kaiser Family Foundation analysis.The cap will save average users at least 35 percent and applies immediately, without requiring them to first pay the Part D deductible, which amounts to $505 in 2023. About 10 percent of Part D insulin users, like Mr. Lubin, paid more than $1,300 out of pocket in 2020 and will save much more.Although all Part D plans must cap the cost, they aren’t required to offer every form or brand of insulin.“People should make extra sure their plan isn’t dropping their insulin from the formulary,” Dr. Cubanski said.But Medicare’s open enrollment period ended on Dec. 7, and its online cost comparison tool doesn’t reflect changes mandated by the new law, which was passed after Part D plans had already set prices.“People might have made different choices if they’d had more information,” Dr. Cubanski said.So Medicare has begun a one-time special enrollment period through the end of 2023, allowing insulin users to drop, add or change Part D plans. Beneficiaries have to call the 1-800-MEDICARE number to make a switch. Counselors at State Health Insurance Assistance Programs can also help with the decision.In the second major change, adult vaccines covered by Part D, typically offered at pharmacies, are now free, without deductibles or co-pays, just as the flu and pneumonia vaccines (covered by Part B) have been.That will in particular improve access to the shingles vaccine, the most expensive adult vaccine. In 2018, the Kaiser Family Foundation reported, Part D enrollees paid $57 per dose out of pocket — and each recipient needs two doses.Although shingles risk rises with age, only 46 percent of adults over age 65 had been vaccinated by 2020, the Centers for Disease Control and Prevention reported. Rates were much lower among Black and Hispanic older adults.“It’s disappointing because this is a spectacularly effective vaccine,” said Dr. William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center. Shingrix, the current vaccine, is about 90 percent effective, and a new study has found that its protection persists a decade after vaccination.A serious disease in itself, shingles can also cause the lingering nerve pain called post-herpetic neuralgia. “It varies from being annoying to being absolutely life-changing,” Dr. Schaffner said.With Shingrix available at pharmacies without charge, “the receptivity to vaccination for older adults will increase substantially, especially among underserved populations,” he predicted.Also free: hepatitis A and hepatitis B vaccinations, and Tdap, which protects against tetanus, diphtheria and pertussis (whooping cough).The third major change: When prices for drugs covered under Part D, and some under Part B, increase faster than the inflation rate, the law now requires drug manufacturers to pay rebates or face stiff penalties.Although those rebates will go to Medicare, not to individuals, “if you’re responsible for a portion of a drug’s cost and there are limits on how much that can increase, in theory your costs should decrease,” Mr. Lipschutz said.It will take months for Medicare to determine which price increases will prompt rebates and how much the rebates will amount to. But the Congressional Budget Office has estimated that this provision will save Medicare more than $56 billion over 10 years.Medicaid has employed a similar strategy since 1990. “It definitely has an effect on keeping spending in check,” Dr. Cubanski said. “The hope is that it will have the same effect for Medicare.”The changes in subsequent years will be more dramatic.In 2025, Medicare will set a $2,000 annual limit on out-of-pocket spending for Part D beneficiaries. “Nowadays, a lot of drugs can cost $500 or $1,000 a month,” Dr. Cubanski said. “Or maybe you take 10 medications, and that adds up to high out-of-pocket costs.”A kind of cap will take effect even sooner, in 2024. That’s when Medicare will eliminate the 5 percent co-pay that beneficiaries are responsible for once they pass the catastrophic expenditure threshold, effectively limiting out-of-pocket costs to about $3,250. The $2,000 cap takes hold the following year. Access to low-income subsidies will broaden, as well.Probably the most significant policy change is that the new law requires Medicare to begin bargaining with drug manufacturers, “the first time the federal government is not just allowed but required to negotiate prices on behalf of Medicare beneficiaries,” Dr. Cubanski said.Starting in 2026, the prices of 10 brand-name drugs covered by Part D, selected from those with the highest Medicare spending, will reflect those negotiations. The drugs must have been on the market for several years with no generic or biosimilar competitors.Medicare will provide negotiated prices for 15 additional drugs the following year, another 15 in 2028 and 20 each year thereafter. Negotiated prices for selected Part B drugs will be available in 2028.Given the thousands of covered drugs, “it’s a pretty modest proposal when it comes to restraining the cost,” Mr. Lipschutz said. Nevertheless, he added, “the pharmaceutical industry is likely to try to undermine this law — it will be looking for loopholes and escape hatches.”Republicans in Congress, nearly all of whom voted against the Inflation Reduction Act, have already introduced legislation to repeal the measures intended to lower drug prices, and supporters are braced for court challenges, too.But for now, the law is in effect. “It can give people peace of mind,” Dr. Cubanski said. “They won’t go bankrupt or go into medical debt to afford the prescriptions they need.”

Hace más o menos una década, Andrea Clay se conectó a internet para leer sobre las nuevas directrices revisadas sobre el chequeo del cáncer de cuello uterino.Ninguno de sus proveedores de atención sanitaria le había mencionado que las mujeres mayores de 65 años con un riesgo promedio de cáncer de cuello uterino podían dejar de hacerse la prueba de papanicoláu si hasta entonces se habían realizado las pruebas pertinentes.Pero eso es lo que recomendaba el Grupo de Trabajo de Servicios Preventivos de Estados Unidos, según supo Clay, junto con el Colegio Estadounidense de Obstetras y Ginecólogos y la Sociedad Estadounidense del Cáncer.Enfermera y técnica de urgencias médicas en Edison, Washington, Clay se alegró en silencio. A lo largo de décadas de pruebas, nunca había tenido un resultado anormal en la prueba de papanicoláu y no pertenecía a ningún grupo de alto riesgo.“Ya no quería estar en esos estribos”, dijo. “No creo que sea necesario”. Imprimió las directrices, lista para pelearse si una enfermera o doctor le insistía en que siguiera haciéndose la prueba. Pero nadie lo hizo.Ahora, de 74 años, ya no se ha hecho exámenes para cáncer cervical en años. “Ya acabé con eso”, expresó.En cambio, JB Lockhart, de 70 años, una oficinista jubilada de Lake Oswego, Oregón, sigue programando un papanicoláu anual.El año pasado, cambió de ginecóloga-obstetra. “Me dijo que ya no tenía que hacerme la prueba”, recuerda Lockhart. “Pensé: hasta cierta edad todavía se puede contraer cáncer cervical”.Le dijo a la médica: “Prefiero estar tranquila y prevenir”.A Lockhart no la disuade el hecho de que el grupo de trabajo y los grupos médicos recomienden que se realice el cribado para el cáncer cervicouterino solo cada tres o cinco años (dependiendo de las pruebas a las que se sometan las pacientes) ni la recomendación de que las mujeres con un número determinado de resultados normales pueden dejar de hacerse la prueba a los 65 años.La calificación “D” del grupo de trabajo para el cribado del cáncer cervicouterino en mujeres mayores, la cual significa “certeza moderada o alta de que el servicio no tiene ningún beneficio neto o de que los daños superan los beneficios”, tampoco la ha hecho desistir.Muchas otras mujeres mayores siguen haciéndose pruebas de detección de este tipo de cáncer, según un estudio reciente publicado en JAMA Internal Medicine.Usando datos de Medicare para analizar a 15 millones de mujeres durante 20 años, los investigadores encontraron que la proporción que recibió al menos una prueba de papanicoláu o VPH (virus del papiloma humano) disminuyó de casi el 19 por ciento en 1999 al 8,5 por ciento en 2019, una victoria potencial para aquellos preocupados por las pruebas excesivas y el tratamiento excesivo en adultos mayores.“Esperábamos la tendencia”, dijo la autora principal del estudio, Jin Qin, investigadora de salud pública en la División de Prevención y Control del Cáncer de los Centros para el Control y la Prevención de Enfermedades. “Pero a esta escala, a este nivel, es un poco sorprendente”.Las directrices especifican que las mujeres con un riesgo promedio pueden dejar de someterse al chequeo de cáncer cervical después de los 65 años si, en los últimos 10 años, han tenido tres pruebas de papanicoláu consecutivas negativas o dos pruebas de VPH consecutivas negativas (que pueden hacerse al mismo tiempo que una papanicoláu). Las pruebas negativas más recientes deben haberse realizado en los últimos cinco años.Las mujeres que se hayan sometido a una histerectomía y no tengan lesiones precancerosas previas también pueden dejar de hacerse exámenes.Cuando se les dice que pueden dejar de hacerlo, “muchas de mis pacientes se alegran”, afirma Hunter Holt, médico de familia de la Universidad de Illinois, Chicago, y coautor del estudio. No muchas estaban deseosas de tener que desvestirse y que les introdujeran un espéculo para que un profesional de la salud raspara células del cuello uterino para analizarlas.Las mujeres con un riesgo medio de cáncer de cuello uterino pueden dejar de someterse a las pruebas de cribado a partir de los 65 años si no han dado positivo recientemente. Pero muchas mujeres se sienten incómodas al hacerlo.Tony Dejak/Associated PressAun así, más de 1,3 millones de mujeres mayores de 65 años siguieron recibiendo cribados y servicios relacionados en 2019; el 10 por ciento tenía más de 80 años, un grupo de riesgo especialmente bajo. “Con millones de pacientes, se convierte fácilmente en un costo para todos”, dijo Qin. El estudio calculó que Medicare gastó aproximadamente 83,5 millones de dólares en 2019.Entonces, ¿se está examinando de más a quienes siguen haciéndose estas pruebas? No necesariamente.“No todas las mujeres deben dejar de hacerse las pruebas a los 65 años”, señaló Sarah Feldman, ginecóloga oncóloga del Brigham and Women’s Hospital de Boston y coautora de un editorial que acompaña al estudio de Qin.Algunas mujeres se consideran de alto riesgo debido a antecedentes de cáncer cervicouterino o lesiones precancerosas o porque tienen un sistema inmunitario debilitado. Según Feldman, estas mujeres deben seguir sometiéndose a las pruebas, a veces hasta 25 años después de un resultado positivo. Las mujeres que estuvieron expuestas en el útero al fármaco dietilestilbestrol, o DES, también se consideran de alto riesgo.Otras mujeres deben seguir haciéndose pruebas de detección porque no se han sometido a suficientes pruebas previas o no están seguras de cuántas se han hecho y cuándo. Es posible que algunas no se hayan sometido a un control adecuado porque no contaban con seguro médico antes de tener derecho a Medicare y no podían pagar las pruebas.Dado que los registros de Medicare no incluían historiales médicos anteriores a los 65 años, los investigadores no pudieron determinar cuántas pruebas eran innecesarias. Pero varios estudios han revelado que muchas mujeres no se someten a las pruebas recomendadas antes de los 65 años y, por tanto, no deberían dejar de hacérselas después.Alrededor del 20 por ciento de los casos de cáncer del cuello de útero en Estados Unidos se dan en mujeres mayores de 65 años, señaló Feldman. “Es una enfermedad prevenible si se realiza un examen de diagnóstico a las personas adecuadas y se trata”, afirmó.Sin embargo, todo examen conlleva daños y beneficios. En el caso de las pruebas de detección de cáncer cervical, dijo Holt, las desventajas pueden incluir incomodidad, especialmente porque los tejidos vaginales se adelgazan con la edad y angustia emocional para las víctimas de abuso sexual.Además, “cuando vemos algo en la prueba, tenemos que responder”, dijo. “Cualquier prueba de detección que dé positivo puede provocar ansiedad, estrés y estigma”.Un resultado positivo también conlleva otros procedimientos, normalmente una biopsia en la que se utiliza un colposcopio, un instrumento de visión que amplía el cuello uterino. En ocasiones, las biopsias pueden provocar hemorragias e infecciones, y los resultados suelen mostrar que la paciente no tiene cáncer ni precáncer (aunque estos pueden desarrollarse en el futuro).También puede haber falsos positivos. Aunque los datos sobre los resultados del chequeo en mujeres mayores de 65 años son escasos, Holt y varios coautores publicaron en 2020 un estudio en el que se estimaban las tasas de falsos positivos en mujeres más jóvenes. Según su modelo, las mujeres que se someten a pruebas de detección durante 15 años a partir de los 30 años deberían hacerse una colposcopia, quizá dos, dependiendo de qué pruebas se realicen y con qué frecuencia.Entre el 60 por ciento y el 75 por ciento de esos procedimientos no encontrarían lesiones precancerosas ni cáncer, lo que indicaría que los resultados de las pruebas iniciales eran falsos positivos.Tiene sentido que las mujeres hablen con sus proveedores de atención médica sobre cuándo deben dejar de hacerse las pruebas. Las personas mayores constituyen una población diversa: las mujeres mayores de 65 años pueden tener múltiples parejas sexuales, lo que aumenta su riesgo de cáncer, por ejemplo, o quizá padezcan enfermedades graves que muy probablemente acabarían con sus vidas mucho antes de que lo hiciera el cáncer de cuello uterino.Los investigadores han observado que los adultos mayores a menudo son reacios a renunciar a las pruebas de detección del cáncer, independientemente de lo que digan las directrices.Mara Schonberg, internista del Beth Israel Deaconess Medical Center de Boston, lleva años trabajando para ayudar a las mujeres mayores a reducir las mamografías innecesarias, que el Grupo de Trabajo de Servicios Preventivos no recomienda a las mayores de 75 años, con el argumento de que no hay pruebas suficientes de su beneficio.Schonberg elaboró un folleto para explicar los pros y los contras. Reunió una muestra de 546 mujeres mayores de 75 años y descubrió que la mitad de las que recibieron el folleto estaban más informadas y eran más propensas a hablar de la mamografía con sus médicos. Además, más de la mitad de las que lo leyeron se hicieron una mamografía de todos modos. Una “ayuda para la toma de decisiones” similar no consiguió disuadir a las personas mayores de someterse a una prueba de cáncer de colon.La Sociedad de Medicina Interna General desaconseja las pruebas de detección del cáncer a los pacientes con una esperanza de vida inferior a 10 años. Pero la esperanza de vida puede ser un concepto difícil de discutir con los pacientes.Una encuesta realizada a proveedores de California que realizaban pruebas de detección del cáncer cervical en mujeres de bajo riesgo mayores de 65 años, a pesar de conocer las directrices en contra, evidenció qué es lo que dificulta que estas se pongan en práctica. El 56 por ciento de los profesionales de la salud creía que si dejaban de realizar la prueba no detectarían un caso de cáncer, pero casi el mismo número reconocía que se tardaba menos tiempo en realizar la prueba que en explicar a las pacientes por qué era innecesaria. Y el 46 por ciento señaló que las pacientes los “presionaban” para que siguieran haciéndoles la prueba.Lockhart programó una cita en febrero para su próxima prueba de papanicoláu. La persona encargada le explicó que no necesitaba otra prueba, pero Lockhart dijo que seguiría haciéndosela de todos modos.

About a decade ago, Andrea Clay went online to read about newly revised guidelines on cervical cancer screening.None of her health care providers had mentioned that women over age 65 who were at average risk for cervical cancer could stop getting Pap tests if they had been adequately screened until then.But that’s what the United States Preventive Services Task Force recommended, Ms. Clay learned, along with the American College of Obstetricians and Gynecologists and the American Cancer Society.A nurse and emergency medical technician in Edison, Wash., Ms. Clay quietly cheered. Over decades of screening, she’d never had an abnormal Pap result and wasn’t in any high-risk group.“I didn’t want to be in those stirrups anymore,” she said. “I didn’t see the need for it.” She printed out the guidelines, ready for battle if a nurse practitioner or doctor insisted she continue screening. But nobody did.Now 74, she hasn’t undergone tests for cervical cancer in years. “I’m done,” she said.However, JB Lockhart, 70, a retired office worker in Lake Oswego, Ore., still schedules an annual Pap.Last year, she switched to a new obstetrician-gynecologist. “She told me I didn’t need to get tested any more,” Ms. Lockhart recalled. “I thought, you can still get cervical cancer over a certain age.”She told the doctor, “I’d rather set my mind at ease and be preventive.”Ms. Lockhart isn’t dissuaded by the fact that the task force and medical groups recommend cervical cancer screening only every three to five years (depending on which tests patients undergo), or by the recommendation that women with a specified number of normal results can stop at 65.The task force’s “D” rating for cervical cancer screening in older women, meaning “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits,” hasn’t discouraged her, either.A lot of other older women continue cervical cancer screening, a recent study in JAMA Internal Medicine reported.Using Medicare data to look at 15 million women over 20 years, the researchers found that the proportion who received at least one Pap or HPV (human papillomavirus) test dropped from almost 19 percent in 1999 to 8.5 percent in 2019 — a potential victory for those concerned about over-testing and overtreatment in older adults.“We expected the trend,” said the study’s lead author, Jin Qin, an epidemiologist at the Centers for Disease Control and Prevention’s Division of Cancer Prevention and Control. “But at this magnitude, this level, it’s a little surprising.”The guidelines specify that women at average risk can stop cervical cancer screening after age 65 if, within the past 10 years, they have had three consecutive negative Pap tests or two consecutive negative HPV tests (which can be done at the same time as a Pap). The most recent negative tests must have been performed within five years.Women who’ve had hysterectomies and no previous precancerous lesions can also forgo screening.Told that they can stop, “a lot of my patients are overjoyed,” said Dr. Hunter Holt, a family medicine practitioner at the University of Illinois Chicago and a co-author of the study. Not many looked forward to undressing and having a speculum inserted so that a health care professional could scrape off cervical cells for testing.Women at average risk for cervical cancer can stop screenings after age 65 if they have not had recent positive tests. But many women are uncomfortable doing so. Tony Dejak/Associated PressYet more than 1.3 million women over age 65 still received screening and related services in 2019; 10 percent were over 80, an especially low-risk group. “With millions of patients, it adds up quickly to a cost for everyone,” Dr. Qin said. The study put the Medicare cost at $83.5 million in 2019.Are those who continue screening over-tested, then? Not necessarily.“Stopping at 65 is not OK for every woman,” said Sarah Feldman, a gynecologic oncologist at Brigham and Women’s Hospital in Boston and the co-author of an editorial accompanying Dr. Qin’s study.Some women are deemed high-risk because of a history of cervical cancer or precancerous lesions, or because of compromised immune systems. These women should continue screening, sometimes for as long as 25 years after a positive test result, Dr. Feldman said. Women who were exposed in utero to the drug diethylstilbestrol, or D.E.S., are also considered high risk.Other women should continue screening because they haven’t had enough previous tests or aren’t sure how many they’ve had and when. Some may have been inadequately screened because they were uninsured before becoming eligible for Medicare and couldn’t afford testing.Because the Medicare records didn’t include medical histories before age 65, the researchers couldn’t determine how many tests were unnecessary. But a number of studies have found that many women don’t receive the recommended screenings before age 65 and thus shouldn’t stop the tests after then.About 20 percent of cervical cancer in the United States occurs in women older than 65, Dr. Feldman pointed out. “It’s a preventable disease if you screen the right people and treat it,” she said.All screening involves harms as well as benefits, however. In the case of cervical cancer testing, Dr. Holt said, the downsides can include discomfort, especially since vaginal tissues thin with age, and emotional distress for victims of sexual abuse.Moreover, “when we see something in the test, we have to respond,” he said. “Any screening test that’s positive can lead to anxiety and stress and stigma.”A positive result also leads to further procedures, typically a biopsy involving a colposcope, a viewing instrument that magnifies the cervix. Biopsies can occasionally cause bleeding and infection, and the results often show that the patient has no cancer or precancer (though those may develop in the future).False positives may also occur. Though data on screening outcomes for women over 65 is scarce, Dr. Holt and several co-authors published a 2020 study estimating false positive rates for younger women. On average, according to their model, women screened for 15 years starting at age 30 would be expected to have one colposcopy, perhaps two, depending on which tests were done and how frequently.Sixty to 75 percent of those procedures would find no precancerous lesions or cancer, indicating that the initial test results were false positives.It makes sense for women to talk with their health care providers about when they should stop testing. Seniors are a diverse population: Women over 65 may have multiple sexual partners, increasing their cancer risk, for example, or they may have serious illnesses that could very likely end their lives well before cervical cancer could.Researchers have found that older adults can be reluctant to give up cancer screenings, whatever the guidelines say.Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston, has worked for years to help older women reduce unnecessary mammograms, which the Preventive Services Task Force doesn’t recommend for those over 75, citing insufficient evidence of benefit.Dr. Schonberg developed a brochure to explain the pros and cons. She assembled a sample of 546 women over 75 and found that the half who received the brochure were more knowledgeable and more likely to discuss mammography with their doctors. Then, more than half of those who read it had a mammogram anyway. A similar “decision aid” failed to deter seniors from colon cancer screening.The Society of General Internal Medicine recommends against cancer screenings for patients with life expectancies of less than 10 years. But life expectancy can be a tough concept to discuss with patients.A survey of California providers who performed cervical cancer screening in low-risk women over 65, despite knowing the guidelines to the contrary, showed what makes it difficult. Fifty-six percent of the providers believed they might miss a cancer diagnosis if they stopped testing, but about the same number also acknowledged that it took less time to do the test than to explain to patients why it was unnecessary. And 46 percent reported “pressure” from patients to continue.Ms. Lockhart has made a February appointment for her next Pap test. The office scheduler explained that she didn’t need another screening, but Ms. Lockhart said she would continue anyway.

Lynne Ingersoll and her cat, Jesse, spent a quiet Thanksgiving Day together in her small bungalow in Blue Island, Ill.A retired librarian, Ms. Ingersoll never married or had children. At 77, she has outlived her parents, three partners, her two closest friends, five dogs and eight cats.When her sister died three years ago, Ms. Ingersoll joined the ranks of older Americans considered “kinless”: without partners or spouses, children or siblings. Covid-19 has largely suspended her occasional get-togethers with friends, too. Now, she said, “my social life consists of doctors and store clerks — that’s a joke, but it’s pretty much true.”Like many older adults, Ms. Ingersoll copes with an array of health problems: kidney disease, asthma, heart disease requiring a pacemaker, arthritis that makes walking difficult even with a cane. She’s managing, but “I can see a time when that’s not going to be true,” she said. “I’m not sure what I’m going to do about it.”An estimated 6.6 percent of American adults aged 55 and older have no living spouse or biological children, according to a study published in 2017 in The Journals of Gerontology: Series B. (Researchers often use this definition of kinlessness because spouses and children are the relatives most apt to serve as family caregivers.)About 1 percent fit a narrower definition — lacking a spouse or partner, children and biological siblings. The figure rises to 3 percent among women over 75.Those aren’t high proportions, but they amount to a lot of kinless people: close to a million Americans without a spouse or partner, children or siblings in 2019, including about 370,000 women over 75.“We assume that everyone has at least some family, but that’s not the case anymore,” said Rachel Margolis, a sociologist at the University of Western Ontario and co-author of the study.Several demographic factors have fostered increased kinlessness. Baby boomers have lower marriage rates and higher divorce rates than their parents, and more have remained childless. The rise of so-called gray divorce, after age 50, also means fewer married seniors, and extended life spans can make for more years without surviving family.Books stacked in Ms. Ingersoll’s home. She has outlived her parents, three partners, her two closest friends, five dogs and eight cats. Jamie Kelter Davis for The New York Times“All the pathways to singlehood have grown,” said Dr. Deborah Carr, a sociologist and researcher at Boston University.Among older couples, cohabitation has increased as an alternative to marriage, but those seniors are less likely than married couples to receive care from their partners. Those in committed relationships who don’t live with their partners are less likely still.In addition, seniors who are Black, female and have lower levels of wealth have particularly high rates of kinlessness.The growing number of kinless seniors, who sometimes call themselves “elder orphans” or “solo agers,” worries researchers and advocates, because this group faces numerous disadvantages.A study of middle-aged and older adults in Canada found that those without partners or children (this study included no data on siblings) had lower levels of self-reported mental and physical health and higher levels of loneliness. They were less likely to participate in activities like sports, cultural or religious groups, or service clubs — a predictor of later cognitive impairment.Kinless Americans die earlier. Dr. Margolis and her co-authors, using data from the Health and Retirement Study, found that a decade after respondents’ initial interviews, more than 80 percent of seniors with partners and children had survived, compared with only about 60 percent of those without either.At the end of life, researchers at Mount Sinai in New York reported, people without partners and children had received fewer hours of caregiving each week and were more likely to have died in nursing homes.“Getting old is hard under the best of circumstances, and even harder if you’re going it alone or with weak social ties,” Dr. Carr said.On the other hand, meet Joan DelFattore, 76, a retired English professor at the University of Delaware. Like some solo agers, “I had a sense from an early age that I simply didn’t see myself as a wife and mother,” she said.Preferring to live alone, “I went about constructing a single life,” she said.Joan DelFattore, a retired English teacher, objects to the perception that older people without immediate family are somehow needy. Karsten Moran for The New York TimesDr. DelFattore, who is in good health, still writes and researches, and she teaches a graduate course every other fall. She stays in near-daily contact with a group of friends, walking several times a week with one of them, and remains close to cousins in New Jersey, with whom she spent Thanksgiving. She takes an active role in several local organizations.And she dislikes “the cultural perception that old people being without immediate family has to mean that you’re needy, you don’t have support.”Sociologists call that strategy “substitution” — turning to friends and neighbors for the connections and sustenance that families traditionally have provided.In Mount Lebanon, Pa., for instance, Celeste Seeman, who is divorced and childless and has lived alone for 25 years, has befriended neighbors in her apartment building. When one had surgery recently, Ms. Seeman, 65 and still working as an embroidery machine operator, walked the neighbor’s Chihuahuas, did her laundry and called her almost daily for weeks.“I hope that what goes around comes around,” Ms. Seeman said. Because she has outlived her family, after caring for her parents until their deaths, there’s no remaining relative to provide similar help if she needs it herself.“I’m frightened about it,” she acknowledged, then added, “You can’t dwell on stuff. It might not happen.”A study of sole family survivors, the last members of the families they grew up in, found that, for unclear reasons, they were also disproportionately likely to lack spouses or partners and children, and thus were doubly vulnerable.Of course, having family is no guarantee of help as people age. Estrangement, geographic distance and relatives’ own declining health can render them unwilling or unable to serve as caregivers.Still, “our system of caring for the aged has functioned, for better or worse, on the backs of spouses and, secondarily, adult children,” said Susan Brown, a sociologist at Bowling Green State University and an author of the study of sole family survivors.Ms. Ingersoll with her companion, Jesse.Jamie Kelter Davis for The New York TimesRelying on substitutes has limitations. About two-thirds of older Americans will eventually hit a rubber-meets-the-road moment and require help with the activities of daily living, such as bathing, dressing and using the toilet.“Friends and neighbors may help with meals or pick up a prescription, but they’re not going to help you in the shower,” Dr. Margolis said.Dr. DelFattore has prepared for that possibility by buying insurance for long-term care years ago, so that she can hire home care aides or afford assisted living. Few Americans have done that or can afford the costs, yet most will also be unable to pay for sufficient care out-of-pocket and don’t have incomes low enough to qualify for Medicaid.“Policies tend to lag behind reality,” Dr. Carr said. “There was the belief in past decades that older adults would be married and have children; that’s what the classic American family looked like. It no longer does.”In the absence of any broad public program, experts suggest a variety of smaller solutions to support kinless seniors.Shared housing and co-housing, providing safety and assistance in numbers and community, could grow, especially with public and philanthropic support. The village movement, which helps seniors age in place, might similarly expand.Revised family-leave policies and caregiver-support programs could include friends and neighbors, or more distant relatives like nieces and nephews.However governments, community organizations and health care systems begin to address the issue, there’s little time to waste. Projections indicate that kinlessness will increase greatly as the population cohorts behind the baby boom age.“Younger people are less likely to marry and have children, and they have fewer siblings” as family sizes shrink, Dr. Brown said. “How will they navigate health declines? We don’t have a good answer. I’m not sure people are paying attention.”