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.”

Senior move managers may spend weeks or months helping seniors and their families sort through belongings, pack and move into a new home.The four-bedroom house that Ray and Beth Nygren had lived in for 20 years in Auburn, Wash., measured about 2,400 square feet. The two-bedroom apartment that awaited them in a nearby independent- and assisted-living complex was less than half that size.They were moving — “maybe a little reluctantly,” said their daughter, Bonnie Rae Nygren — because each had undergone heart-valve replacement surgery last year, and Beth Nygren had suffered complications. The single step from living room to dining room, or down to the family room, had become difficult for her to manage using a walker.She’d already taken a fall. “They considered it a very minor thing, but it was really eye-opening for us,” said Bonnie Rae. “One more fall could make a huge difference in their lives.”The couple’s three children suggested that with Beth, 85, coping with multiple sclerosis and Ray, 87, contending with heart failure, “maybe it was time to downsize and move to a retirement community,” Bonnie Rae said.Earlier this year, the family began sorting through 65 years of possessions. “Digging in, we realized how much stuff they had,” Ms. Nygren recalled. “How many towels do you need? What dishes do you want to take? What pictures do you want on the walls? And, what about the things you can’t take?” The process felt overwhelming.The family had never heard of senior move managers until the retirement facility recommended a few, including RR Move Co. The elder Nygrens almost balked when owner Rebecca Ricards walked through their house, talked with them about their concerns, took lots of photos — and quoted a price of $5,400 for planning the move, packing their belongings and setting up the new residence, not including the moving van and movers.Bonnie Rae Nygren, left, with Rebecca Richards of RR Moving Co. in Ms. Nygren’s parents’ kitchen. Ms. Nygren said her parents were reluctant at first about the idea of hiring help for the move.Chona Kasinger for The New York TimesBut reassured by her experience and confidence, they hired her, with their son contributing a chunk of the costs.About 1,100 such companies belong to the National Association of Senior & Specialty Move Managers, which offers training and certification, and requires members to carry liability insurance and adhere to a code of ethics.Depending on the needs of clients, move managers’ services include sorting and organizing belongings, working with a moving company and using a floor plan to determine what can fit where in the new residence.They prepare the new home, from spices in the cabinets to towels on the racks; they can sell, donate or dispose of what’s left behind. Though Ms. Ricards charges by the job, most move managers charge $65 to $125 an hour, with big regional variations, said Mary Kay Buysee, the association’s co-executive director.That’s not within everyone’s means, but most clients are moving into private-pay senior living facilities, often after selling a house, and can afford the additional expense. Clients with smaller budgets may be able to purchase some services, not the whole package. Family members may also help shoulder the costs.“It’s not just packing and unpacking,” Ms. Buysee said. “It’s working with the clients and the family for weeks or months, going through a lifetime of possessions. You need to be a good listener.”Older people relocate far less frequently than younger ones. A Census Bureau report in 2022 found that from 2015 to 2019, about 6.2 percent of the population over age 65 had moved in a given year, compared with about 15 percent of the younger population. Still, senior migration topped three million adults a year. The rate increased among those over age 85 and those with a disability.The most common reasons for moving? Living closer to family members topped the list, especially among those 75 and older, according to a survey published in the Journal of the American Planning Association last year. Respondents also cited better neighborhoods and reduced housing costs.The entryway to the Nygrens’ new home.Chona Kasinger for The New York TimesThough senior move managers often work with adult children to help move their parents, the industry is seeing an uptick in younger seniors hiring managers for themselves, Ms. Buysee added.A New York native, Alissa Ballot had already downsized from a house in Florida to a Chicago apartment when, in 2021, she decided “it was time to move home.” But selling her place in Chicago while finding an apartment in New York during the pandemic became “nervous breakdown time,” said Ms. Ballot, 67, a retired lawyer. “There were all these balls up in the air — a few balls too many.”Dawson Relocation Services in Chicago charged her less than $1,000 (at $65 an hour) to coordinate the move. “I was able to set a date to get on a plane with a few suitcases and leave everything else to them,” Ms. Ballot said. “It was a miracle.”She unpacked on her own, but she didn’t have to return to clean out and close up her Chicago apartment. Marnie Dawson even helped her file claims when the movers dinged a couple of Ms. Ballot’s possessions.(Besides senior move managers, older movers may encounter real estate agents, attorneys, senior living staff and others who are “certified relocation and transition specialists.” About 1,000 individuals have passed this credentialing exam, said Donna Surges Tatum, chair of the Certified Relocation & Transition Specialist Certification Board. The National Association of Realtors also designates “senior real estate specialists.”)Relocating older adults involves particular challenges. Unlike younger movers, they’re generally shifting into smaller, not larger, spaces — after decades more time to accumulate stuff. And their families, for better or worse, are often involved.A move manager has to be a social worker in part. “We’re sometimes dealing with people with cognitive issues. Family dynamics come into play,” said Diane Bjorkman, whose company serving the Twin Cities, Gentle Transitions, is the country’s oldest and probably largest senior move management company.A nonjudgmental professional can often calm tensions. “It’s not you telling your mom, ‘Don’t take the torn recliner,’” Ms. Bjorkman said. “It’s someone else saying, ‘Maybe another chair would work better.’”Ms. Richards worked with Ray Nygren to detail where items should go in the new space. “Everything was in place,” said Ms. Nygren.Chona Kasinger for The New York TimesMy sister and I hired a senior move manager for our father, who was moving into an independent living apartment, when it became clear that discussing matters like precisely how many identical plastic flashlights he needed could consume months. We deferred to a third party.Still, in the end, the client decides. One woman who hadn’t cooked for 20 years insisted that she needed to hold on to a particular roasting pan, Ms. Bjorkman recalled. The woman also argued that, as someone who remembered the Depression, a freestanding freezer was a crucial source of comfort — even if it was full of expired food.The roasting pan could be disassembled to fit under the bed in the new apartment, Ms. Bjorkman said. The freezer — still packed with food — served as a living room side table.The Nygrens made no such unusual requests. Their children handled the weeks of sorting and paring, and Ray Nygren — a retired engineer — drew detailed schematics of the new apartment, showing where items should go.RR Move Co. did the rest, packing one day in March and moving them into their new apartment the next. At about 6 p.m., Ms. Ricards and her crew phoned the family to say they were ready for what she calls “the big reveal.”“We walked in, and it was like walking into your home,” Beth Nygren said, getting weepy on the phone. There were no boxes in sight. The move managers had made the beds, set the clocks, made sure Ray’s computer was operational.“Everything was in place: clothes in the closet, pictures on the wall, stuff in the drawers,” Ms. Nygren said. “You could just start living.”

Most have low-risk cancers and rarely benefit from treatment, a new study finds. Actively monitoring the condition is often the best choice.Last summer, Joe Loree made an appointment to see his urologist. He’d occasionally noticed blood in his urine and wanted to have that checked out. His doctor ordered a prostate-specific antigen, or P.S.A., test to measure a protein in his blood that might indicate prostate cancer — or a number of more benign conditions.“It came back somewhat elevated,” said Mr. Loree, 68, an instructional designer who lives in Berkeley, Calif. A biopsy found a few cancer cells, “a minuscule amount,” he recalled.Mr. Loree was at very low risk, but nobody likes hearing the c-word. “It’s unsettling to think there’s cancer growing within me,” he said.But because his brother and a friend had both been diagnosed with prostate cancer and had undergone aggressive treatment that he preferred to avoid, Mr. Loree felt comfortable with a more conservative approach called active surveillance.It typically means periodic P.S.A. assessments and biopsies, often with M.R.I.s and other tests, to watch for signs that the cancer may be progressing. His hasn’t, so now he can get P.S.A. tests every six months instead of every three.Research shows that a growing proportion of men with low-risk prostate cancer are opting for active surveillance, as medical guidelines now recommend.The diagnosis used to lead directly to aggressive treatment. As recently as 2010, about 90 percent of men with low-risk prostate cancer underwent immediate surgery to remove the prostate gland (a prostatectomy) or received radiation treatment, sometimes with hormone therapy.But between 2014 and 2021, the proportion of men at low risk of the cancer who chose active surveillance rose to nearly 60 percent from about 27 percent, according to a study using data from the American Urological Association’s national registry.“Definitely progress but it’s still not where we need to be,” said Dr. Matthew Cooperberg, a urologic oncologist at the University of California, San Francisco, and lead author of the study.Changing medical practice often takes a frustratingly long time. In the study, 40 percent of men with low-risk prostate cancer still had invasive treatment. And approaches vary enormously between urology practices.The proportion of men under active surveillance “ranges from 0 percent to 100 percent, depending on which urologist you happen to see,” Dr. Cooperberg said. “Which is ridiculous.”The latest results of a large British study, recently published in the New England Journal of Medicine, provide additional support for surveillance. Researchers followed more than 1,600 men with localized prostate cancer who, from 1999 to 2009, received what they called active monitoring, a prostatectomy or radiation with hormone therapy.Over an exceptionally long follow-up averaging 15 years, fewer than 3 percent of the men, whose average age at diagnosis was 62, had died of prostate cancer. The differences between the three treatment groups were not statistically significant.Although the cancer in the surveillance group was more likely to metastasize, it didn’t lead to higher mortality. “The benefit of treatment in this population is just not apparent,” said Dr. Oliver Sartor, an oncologist at the Mayo Clinic who specializes in prostate cancer and who wrote an editorial accompanying the study.“It doesn’t help people live longer,” Dr. Sartor said of the treatment, probably because of what is known as competing mortality, the likelihood of dying from something else first.Men whose P.S.A. readings and other test results indicate higher-risk tumors, or who have family histories of prostate cancer deaths, fall into a different category, experts cautioned.“The point of screening is to find the aggressive tumors — a small minority, but they kill more men than any other cancer except lung cancer,” Dr. Cooperberg said.But most prostate cancer grows so slowly, if it grows at all, that other illnesses are likely to prove lethal first, especially among older men. During the British study, one in five men died from other causes, predominantly cardiovascular or respiratory diseases and other cancers.That’s why guidelines from the U.S. Preventive Services Task Force and the American College of Physicians recommend against routine prostate cancer screening for men over 69 or 70, or for men who have less than a 10- to 15-year life expectancy. (Men ages 55 to 69 are advised to discuss the harms and benefits with health care providers before deciding to be screened.)Newly revised guidelines from the American Urological Association recommend shared decision-making after age 69, taking into account age, life expectancy, other risk factors and patients’ preferences.“If you live long enough, prostate cancer is almost a normal feature of aging,” Dr. Cooperberg explained. “By the 70s or 80s, half of all men have some cancer cells in their prostates.”Most of those tumors are deemed “indolent,” meaning that they don’t spread or cause bothersome symptoms.Nevertheless, about half of men over 70 continue P.S.A. screening, according to a new study in JAMA Network Open. Though testing declined with age, “they really shouldn’t be getting screened at this rate,” said the lead author Sandhya Kalavacherla, a medical student at the University of California, San Diego.Even among men over 80, almost 40 percent were still getting routine P.S.A. tests. An elevated P.S.A. reading can prompt a cascade of subsequent tests and treatments, because “‘cancer’ is an emotionally charged term,” Dr. Sartor acknowledged. He still sees patients, he said, whose response to very low-risk cancer is, “I want it out, now.”But treatment involves significant side effects, which often ease after the first year or two but may persist or even intensify. The British data showed, for instance, that six months after treatment, urinary leakage requiring pads affected roughly half of the men who’d had a prostatectomy, compared to 5 percent of those who underwent radiation and 4 percent of those under active surveillance.After six years, 17 percent of the prostatectomy group still needed pads; among those under active surveillance, it was 8 percent, and 4 percent in the radiation group.Similarly, men under active surveillance were more likely to retain the ability to have erections, though all three groups reported decreased sexual function with age. After 12 years, men in the radiation group were twice as likely, at 12 percent, to report fecal leakage as men in the other groups.The financial costs of unnecessary testing and treatment also run high, as an analysis of claims from a large Medicare Advantage program demonstrate. The study, recently published in JAMA Network Open, looked at payments for regular P.S.A. screening and related services for men over 70 with no pre-existing prostate problems.“The initial screening, which is unnecessary, triggers these follow-up services, a series of events catalyzed by anxiety,” said David Kim, a health economist at the University of Chicago and lead author of the study. “The further it progresses, the harder it is to stop.”From 2016 to 2018, each dollar spent on a P.S.A. test on men over 70 generated another $6 spent for additional P.S.A. tests, imaging, radiation and surgery.Extrapolated to traditional Medicare beneficiaries, Medicare could have spent $46 million for P.S.A. tests for men over 70 and $275 million in follow-up care, Dr. Kim said.“We need to change the incentives, how providers get paid,” he said.He suggested that refusing to reimburse them for procedures that receive low recommendations from the U.S. Preventive Services Task Force could mean fewer inappropriate P.S.A. tests and less aggressive treatment in their wake.Some urologists and oncologists have called for a different kind of shift — in nomenclature. “Why are we even calling it ‘cancer’ in the first place?” asked Dr. Sartor, who has argued against using the word for small, low-risk tumors in the prostate.A less frightening label — indolent lesions of epithelial origin, or I.D.L.E., was one suggestion — could leave patients less inclined to see test results as lethal portents and more willing to carefully track a common condition that might never lead to an operating room or a radiation center.

The people at the dog park, the bank teller, the regular waiter — these casual relationships may be “weak ties,” but they’re also a key to well-being.Victoria Tirondola and Lam Gong first struck up a conversation last spring at the dog run in Brookdale Park in Bloomfield, N.J., when they realized that each owned a dog named Abby. Ms. Tirondola, 65, an insurance sales representative who lives in nearby Cedar Grove, has a tiny bichon-poodle mix. Mr. Gong’s Abby, older and portlier, is a terrier-beagle.They chatted about dogs at first. Then they learned that they both cooked, so “we talked about food and restaurants,” said Mr. Gong, 67, a retiree living in Clifton.“And how much better my cooking is than his,” put in Ms. Tirondola. They were sitting on a bench, as the dogs dashed around on a warm spring afternoon, with a third member of a growing collection of regulars: Pattie Marsh, dog walker for a miniature Australian shepherd named Ollie.“All of us live alone,” Ms. Tirondola said. “My mom just passed away in July, and we were very close. Lam lost his wife a few years ago.”“It gives us companionship” to meet at the Bark Park, said Ms. Marsh, 55. She and Ms. Tirondola, who bonded as born-again Christians, come daily. Mr. Gong joins them once or twice a week. So does Lee Geanoules, 69, a part-time restaurant server from Clifton, who soon arrived with Charlie, a pug and beagle blend.Psychologists and sociologists call these sorts of connections “weak ties” or “peripheral ties,” in contrast to close ties to family members and intimate friends. Some researchers investigating weak ties include in that category classmates, co-workers, neighbors and fellow religious congregants. Others look into interactions with near-strangers at coffee shops or on transit routes.People who cross paths at the dog run, for instance, may recognize other regulars without knowing their names (though they probably know their dogs’ names) or anything much about them. Nevertheless, impromptu chats about pets or the weather often arise, and they’re important.Such seemingly trivial interactions have been shown to boost people’s positive moods and reduce their odds of depressed moods. “Weak ties matter, not just for our moods but our health,” said Gillian Sandstrom, a psychologist at the University of Sussex in England who has researched their impact.“If I asked who you confided in, you wouldn’t mention them,” she said. Yet the resulting sense of belonging that weak ties confer is “essential to thriving, feeling connected to other people” — even among introverts, which is how Dr. Sandstrom defines herself.From left, Charlie, Ollie and Abby, Ms. Geanoules’s, Ms. Marsh’s and Ms. Tirondola’s dogs, respectively. (Mr. Gong’s dog was kept home that day by a foot injury.)Bryan Anselm for The New York TimesIn her early studies, hand-held clickers were distributed to groups of undergraduate students and people over 25 to track how many classmates or others they interacted with, however minimally, over several days. Those who interacted with more weak ties reported greater happiness, and a greater sense of well-being and belonging, than those with fewer interactions.The researchers found “within-person differences,” too, showing that the effects were not a result of personalities. The same individuals reported being happier on days they had more interactions. Other studies found similar benefits when people smiled and undertook brief conversations with baristas at a Starbucks in Vancouver, British Columbia, or greeted university shuttle bus drivers in Ankara, Turkey.Most of these participants were quite young, but one study, published in 2020, followed an older sample of more than 800 adults in metropolitan Detroit over 23 years.The researchers asked subjects (average age at the start: 62) to draw three concentric circles, with “you” in the center, and to arrange people in their lives by degree of closeness. Those in the innermost circle of close ties were almost always family, said Toni Antonucci, a psychologist at the University of Michigan and senior author of the study. The weak ties in the outermost circle included friends, co-workers and neighbors.Over time, the number of weak ties more strongly predicted well-being than the number of close ties. Weak ties “provide you with a low-demand opportunity for interaction,” Dr. Antonucci said. “It’s cognitively stimulating. It’s engaging.”The Covid pandemic, striking when social scientists were already raising alarms about the health risks of loneliness and isolation for older adults, suspended many of these everyday exchanges.Seniors often kept in touch with their families, one way or another, but where were the waiters who knew their breakfast orders, the bank tellers, crossing guards and dog walkers? “I hope it made people realize how much weak ties matter,” Dr. Sandstrom said. Though they can’t replace close ones, “we missed the novelty and the spontaneity,” she said.At older ages, when social networks tend to shrink, people may have to work at expanding them. “Make the effort,” Dr. Antonucci advised. “You can’t create new children at 70, but you can create new weak ties.”The Brookdale Park dog owners have become real friends beyond the park, going to dinner, movies and comedy shows together.Bryan Anselm for The New York TimesIlze Earner, 67, retired last year after 25 years of teaching at Hunter College in Manhattan. Life in rural Claverack, N.Y., had its satisfactions and friendships, but after a few months, “I started feeling like I was missing something,” she said. She began taking herself to lunch weekly, sitting at the bar at the nearby Chatham House.Soon, the bartender had learned her name (and vice versa) and of her love of lobster rolls. Ms. Earner won a bar-top game of ice cube bocce against the highway crew who also came in for lunch. “They noticed when I disappeared because I had a knee replacement, and when I came back it was, ‘Hey, bionic woman!’” she recalled. “It’s nice.”In Placerville, Calif., David Turoff, 72, a veterinarian, chats with his mail carrier and UPS deliveryman, and sometimes drops in on the mechanic who repairs his truck just to say hello or leave a gift of firewood. “They make me feel good,” Mr. Turoff said of such brief interactions. “I like having connections with people.”Toby Gould’s day begins with a 7 a.m. visit to Chez Antoine, a bakery and coffee shop in Hyannis, Mass. Mr. Gould, 77, a retired minister, buys a takeout latte and speaks French, haltingly, with the Belgian proprietor, who bestows a slice of ham on Mr. Gould’s Australian shepherd, Layla. If the shop closed, “it would leave a hole in my life,” Mr. Gould said.Weak ties, including those developed online, don’t necessarily turn into close ones and don’t have to. Close relationships, after all, can involve conflicts, demands for reciprocity and other complications.But sometimes, weak ties do evolve.The Brookdale Park dog owners, for instance, have become real friends. They go out to dinner together and see movies and comedy shows. In bad weather, they walk in a local mall. Mr. Gong, who is handy, hung curtains for Ms. Tirondola and shellacked cabinets for Ms. Geanoules; he gave Ms. Marsh a ride home when she left her car at a garage for repairs.A bit hesitant at first to exchange phone numbers, “we took a giant step,” Ms. Geanoules said, pausing to pat and coo at one of the Abbys. “You can change a lifetime by talking to someone for 10 minutes.”

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.”