Studies found that centers provided incomplete or unbalanced information, which could lead to unnecessary screenings and health complications in older adults.Say a postcard arrives in the mail, a reminder to make an appointment for a mammogram. Or a primary care doctor orders a PSA test to screen a man for prostate cancer, or tells him that because of his years of smoking, he should be screened for lung cancer.These patients, trying to be informed customers, may look online for a cancer center to learn more about screening, when it is recommended and for whom.It might not be the best move. Medical societies and the independent U.S. Preventive Services Task Force publish guidelines about who should be screened for lung, prostate and breast cancers and how frequently, among many other prevention recommendations. But websites for cancer centers often diverge from those recommendations, according to three studies published recently in JAMA Internal Medicine.Researchers found that some sites discussed the benefits of screening but said little about the harms and risks. Some offered recommendations about the age at which to start screening but glossed over when to stop — an important piece of information for older adults.“If we acknowledge that these websites are important sources of information, based on screening according to the guidelines we have room for improvement,” said Dr. Behfar Ehdaie, a urologist at Memorial Sloan Kettering Cancer Center in New York and an author of the study on prostate cancer screening recommendations.Screening refers to tests for patients with no symptoms or evidence of disease, including prostate-specific antigen tests, mammograms, colonoscopies and CT scans.The researchers analyzed more than 600 cancer center websites that provided recommendations for prostate screening, and found that more than one-quarter recommended that all men be screened. More than three-quarters did not specify an age at which to stop routine testing.Yet guidelines from both the Preventive Services Task Force and the American Urological Association state that men over 70 should not be routinely screened, because, according to the Task Force guidelines, “the potential benefits do not outweigh the expected harms.”For men aged 55 to 69, both groups urge individual decisions after a discussion with a clinician about benefits and harms. Neither group, though, recommends routine screening for younger men at average risk.Moreover, the study reported, 62 percent of cancer center websites did not include information on the potential harms of screening. Because prostate cancer grows slowly, it often causes no problems. But detection and treatment can lead to complications from surgery or radiation, including lower quality of life from incontinence and sexual dysfunction.New Developments in Cancer ResearchCard 1 of 7Progress in the field.

Research shows that debt has risen among older people, and those who owe are more likely to have multiple diagnosed illnesses.Denise Revel had a history of developing blood clots, so in 2011, when her leg grew painfully swollen and hot to the touch, she knew what to do. She headed for the emergency room.She recovered from the clot but could not pay the medical bill. Working as a fitness instructor, she had no health insurance. “I’ve always been financially challenged,” said Ms. Revel, 62, who lives with her daughter in Stockbridge, Ga. “I was a single parent raising two children.”Four years later, when she was working as a part-time cargo agent for Delta Air Lines, a workplace accident severely injured her leg, leading to extended hospitalization and rehab. Workers’ compensation picked up most, but not all, of the medical costs. In addition to her still-unpaid E.R. bill from years before, she acquired thousands in additional medical debt.With some older people finding themselves unable to dig out from debt, such dilemmas threaten any notion of a comfortable retirement and have generated alarm among economists and other researchers.“It’s like a dark cloud over your head,” Ms. Revel said. “You get people calling you, being demanding; some can be very rude. You don’t even want to answer your phone.” She worried constantly about her debts, including monthly installments on her 2014 Toyota Camry, and about being unable to access medical care if she needed it.Now, researchers at the Urban Institute, by analyzing broad national data over nearly 20 years, have reported that indebted older adults fare measurably worse on a range of health measures: fair or poor self-rated health, depression, inability to work, impaired ability to handle everyday activities like bathing and dressing.Those in debt were also more likely to ever have had two or more doctor-diagnosed illnesses like hypertension, diabetes, cancer, heart and lung disease, heart attacks and strokes.“There seems a clear causal link between certain types of debts, especially at higher amounts, and negative health outcomes, both physical and mental,” said Stipica Mudrazija, a senior research associate at the institute.“Debt is not a bad thing in and of itself,” he said. “If it’s used cautiously, it can build up wealth over time.”Older adults typically carry less debt than younger ones because people tend to shed debt as they approach and enter retirement. But in recent decades, each cohort of seniors has been more indebted than the previous one.“There’s a group of older people in financial distress,” said Annamaria Lusardi, an economist at the George Washington University. “They’re highly leveraged; they’re carrying high-cost debt. They’re being contacted by debt collectors. They’re not going to enjoy their golden years.”Dr. Mudrazija and his co-author, Barbara Butrica, a senior fellow at the institute, used data from the national Health and Retirement Study and calculated that in 1998, about 43 percent of Americans over age 55 had debt, a median of $40,145. By 2016, about 57 percent had debt and more of it: a median $62,784, adjusted for inflation.The proportion whose debt represented 30 percent of their total assets had risen to almost 45 percent, and the proportion whose debt-to-asset ratio had reached a worrisome 80 percent nearly doubled, to 15 percent.Although seniors with any debt were more likely to encounter health problems, the kind of debt mattered, according to the study, which was published by the Boston College Center for Retirement Research.Secured debt, like mortgages and other home loans, is backed by an asset: the dwelling. Such debt rose among older borrowers as real estate prices soared and interest rates remained low. “It’s increasingly less the norm for people to pay off their mortgages before they retire, the traditional model,” Dr. Mudrazija said.But secured debt appeared less detrimental to health than unsecured debt like credit card balances, student loans and overdue medical payments, which usually charge higher interest rates. About 24 percent of older adults’ debt was unsecured in 1998; by 2016, the proportion had climbed to 35 percent.Dr. Mudrazija and Dr. Butrica found, for example, that limitations in a person’s ability to perform activities of daily living was only slightly higher for people carrying secured debt than those without debt; the difference did not reach statistical significance. But those with unsecured debt were 28 percent more likely to need help with such activities.Moreover, as the level of unsecured debt rose, their risks climbed steeply. If what they owed amounted to 30 percent of their assets, they were 65 percent more likely to have trouble with daily activities compared with those with no debt and almost twice as likely if they owed 80 percent of their assets. Other health problems showed similar associations with unsecured debt.Why would unsecured debt have such impact? The mechanism through which debt affects health remains unclear, Dr. Mudrazija said. He added that the relationship can also work in the other direction: People with poorer health might need to borrow more, especially as increases in health care costs have outpaced inflation.But “secured debt is a planned debt,” he said. “I decide I’m going to buy a house. It’s an investment, and often a well thought-out decision.”“Unsecured debt often comes as a surprise,” he added. “You lose a job and have to live off a credit card. You get sick and face a huge hospital bill. The shock and stress might translate to deteriorating health.”In a 2020 study, also using Health and Retirement Study data, Dr. Lusardi and her co-authors found that even in a relatively high-income group of 51- to 61-year-olds, whose average household income was $103,000, almost one-quarter reported being contacted by bill collectors. “I was frankly shocked,” Dr. Lusardi said. “People close to retirement should be at the peak of their wealth accumulation.”The pressures are stronger still on older people with less income and education, and on women and nonwhite people.In a study using credit bureau data, Dr. Mudrazija and Dr. Butrica documented the disparity. “In ZIP codes where people are better off, older people carry mortgages, but they pay them off,” Dr. Mudrazija said. “Where people are poorer, they seem to carry debt indefinitely.” They are also more vulnerable to predatory payday lending.What could help seniors avoid these credit traps, apart from higher incomes and more comprehensive health insurance? (In 2020, one-fifth of Medicare beneficiaries over 65 paid $2,000 or more out of pocket, beyond the premiums themselves, according to a study by The Commonwealth Fund.)Dr. Lusardi advocates financial literacy training in workplaces, where employers are more apt to emphasize retirement savings than debt management. Some borrowers don’t grasp fundamentals such as the way interest compounds, she said.“We have made it very easy to borrow,” she said. “We also need to help people make good decisions.”But regulating credit, providing clearer consumer information and reining in predatory lending practices could also reduce high levels of unsecured debt, Dr. Mudrazija said.Last fall, Ms. Revel got a call out of the blue. The nonprofit RIP Medical Debt, which uses donated dollars to buy bundled medical debt, had acquired her long-outstanding emergency room debt of $2,728.50 and erased it. “I was so grateful,” she said.Unable to work, relying on disability payments, Ms. Revel is now ensured by Medicare and Medicaid, shielding her from most future medical debt. She is down to the last three months of car payments and “I’m counting the days.”But she still owes a local group of vascular specialists $5,000. At a negotiated $25 a month, she will be nearly 80 when she pays it off.

Millions of Americans take aspirin to prevent a first heart attack or stroke. Now, doctors are advising against it — especially for people over 70.Regina Griffith was 64 when she met her new primary care doctor for a routine checkup. He recommended a daily low-dose aspirin for heart health, she recalled.It’s hard to be more fit than Ms. Griffith, the owner and chief instructor at a fitness studio in Montclair, N.J. She had a slightly elevated blood pressure at the doctor’s office (but not at home, using her own cuff); other than that, she had no significant health problems.Still, a daily aspirin didn’t seem like a big deal, and the doctor did not mention any downsides, so she took his advice. “I thought, ‘OK, I’m at a certain age,’” Ms. Griffith said. “It didn’t sound scary to take aspirin.”Millions of older Americans do likewise, and not always because of a doctor’s recommendation. Alan Turner, 64, an industrial designer in New Castle, Del., began taking aspirin on his own about five years ago, after his mother had several strokes. “I saw what that did to her,” he said. He had heard of other people his age taking prophylactic aspirin, so he “just went with it,” he said. “How much damage can you do with a baby aspirin a day?”Good question. For three decades, the United States Preventive Services Task Force, an independent and influential panel of experts, has been reviewing the growing evidence of aspirin use for preventing first heart attacks and strokes.Last month, it issued its latest recommendations on aspirin use, the first in six years. The panel warned adults over 60 against starting an aspirin regimen for primary prevention.“It carries possible serious harms” — notably, an increased risk of internal bleeding, said Dr. John Wong, a task force member. “And those harms are higher than we thought in 2016.” Dr. Wong is a primary care doctor and interim chief scientific officer at Tufts Medical Center in Boston.“Primary prevention” refers to patients who have never had a heart attack or stroke and do not have heart disease. (High blood pressure, or hypertension, is not considered heart disease.) That group is the task force’s focus.People taking aspirin for secondary prevention — because they have already had a heart attack, stroke or intervention like stenting or bypass surgery — face higher risk of subsequent cardiovascular events, and aspirin might remain part of their treatment.For adults aged 40 to 59, the net benefit of taking aspirin daily would be small, the task force concluded. They may choose to start a daily aspirin regimen if, based on widely used health calculators, they face a 10 percent or higher risk for cardiovascular disease over the next decade, but that should be an individual decision.It will take time for these new cautions to trickle down to the public. About one-third of Americans over 40 already take aspirin, a 2019 study found. Among those over 70, more than 45 percent take aspirin for primary prevention, probably representing significant overuse.“Many people don’t even think of aspirin as medication, they think of it as more like a vitamin,” said Dr. Amit Khera, the director of preventive cardiology at the University of Texas Southwestern Medical Center. “But just because it’s over-the-counter, doesn’t mean it’s not a drug with benefits and risks.”In 2019, Dr. Khera helped develop similar guidelines for the American College of Cardiology and American Heart Association, which recommended against routine aspirin use for primary prevention in people over 70. The American Geriatrics Society’s Beers Criteria, a list of medications considered inappropriate for older patients, is also considering recommending that “most older adults” avoid starting aspirin for primary prevention.The U.S. Preventive Services Task Force’s position on aspirin use for prevention has seesawed over the decades, noted Dr. Allan Brett, an internist at the University of Colorado, in a JAMA editorial accompanying the new guidelines. The task force initially recommended in 1989 that patients consider aspirin, then backed off, calling the evidence insufficient. It encouraged preventive aspirin for many adults in 2009 but had grown more skeptical by 2016.What has changed this time around? Three large, rigorous clinical trials published in 2018, following more than 47,000 older patients, “really highlighted the risks,” Dr. Khera said.Dr. Wong added: “Two didn’t find any significant reductions in heart attack or stroke, but there was an increased risk of bleeding.” The third clinical trial, which was limited to people with diabetes, a higher-risk group, found a small reduction in cardiovascular events — but with a higher bleeding risk. “The harm canceled out the benefit,” Dr. Wong said.The bleeding in question usually occurs in the gastrointestinal tract but can also include brain bleeds and hemorrhagic strokes. Although the risks are low — major bleeding occurred in 1 percent or fewer of older people taking aspirin in the 2018 studies — they increase with age. “These are serious bleeds,” Dr. Brett said. “They can require transfusions. They can put people in the hospital.”With the advent of other effective advances in preventing heart attacks and strokes — better blood pressure drugs, statins for lowering cholesterol, a reduction in smoking — the role for aspirin has narrowed, experts said.For people over 60, per the task force guidelines, or 70, per the cardiologists’ recommendations, the risks of starting aspirin now outweigh the benefits. This is particularly true for people with a history of bleeding, say from ulcers or aneurysms, or those taking medications like blood thinners, steroids or anti-inflammatories such as ibuprofen or naproxen.The 2016 task force recommendation raised the possibility that aspirin might play a role in preventing colon cancer. But, Dr. Wong said, “we’re no longer confident aspirin provides benefit for colorectal cancer. We don’t have enough evidence. We’re calling for more research.”The task force had frustratingly little to say, however, about people over 60 stopping aspirin if they have already begun taking it for primary prevention. It mentioned that people should consider stopping at about age 75 because any benefit would diminish with age, but it also said patients should not discontinue aspirin without talking to a health care professional.“There’s no urgency,” Dr. Khera said. “Put this on the agenda of things to discuss” at an upcoming appointment. But, he added, “for people generally healthy, with few risk factors, it’s reasonable to just stop.” Dr. Brett said he had been cautioning patients against routine aspirin use since 2018.Ms. Griffith, now 65, recently saw a different doctor in her new primary care practice. The doctor looked at her chart, which showed no heart disease and more than a year of aspirin use.“He said, ‘I don’t think you need to do that,’” she said.Ms. Griffith had already begun to question the practice and had cut back to an aspirin every other day. Now, she’s going to stop.

A new training tool helps to assess whether some seniors can make informed choices about their own care and well-being.During a recent Zoom conference call, four Adult Protective Services workers from California, using a tool called the Interview for Decisional Abilities, or IDA, were trying to figure out whether something fishy was going on with an 82-year-old woman they knew as Ms. K.Adult Protective Services agencies in every state receive reports of possible neglect, self-neglect, abuse or exploitation of older people and other vulnerable adults. But agency workers consistently face a bedeviling question: Does the adult in question have the capacity to make a decision about their medical care, living conditions or finances — even if it’s not the decision that the family, doctor or financial adviser thinks should be made?IDA was developed by two geriatricians to help train Adult Protective Services workers in how to handle that issue. The program helps them learn to use a structured interview procedure to gather information about a client’s decision-making ability. The two dozen California staff members taking the course had already completed 10 hours of individual online instruction; now they were practicing their new interviewing skills in small groups, role-playing with facilitators.Ms. K, a fictional character, was being played by Bess White, a special projects administrator at Weill Cornell Medicine. In the scenario, a bank manager had reported certain suspicions: Ms. K had $60,000 in a savings account but her withdrawals had increased sharply, from $600 a month to $600 a week. A younger man — her nephew, she said — had begun accompanying her to the bank, where a teller thought the man had seemed controlling and intimidating. An investigator who visited Ms. K at home learned that her only credit card had expired and that she had little cash.But Ms. K denied being financially exploited; her nephew lived with her, she said, and helped with chores and rides to doctor’s appointments. He used the bank withdrawals to buy their groceries.In the exercise, one of the A.P.S. trainees had ascertained that Ms. K grasped the basic concept of financial exploitation. Ms. K had heard about scams from the news, she said. And yes, she understood that a friend or relative might similarly take advantage.So the interviewer continued: “What do you think could happen if someone took another person’s money without their permission?”Ms. White, in the role of Ms. K, replied: “I guess the person could take it and take it until there’s nothing left.” But when the interviewer probed further to see if Ms. K understood that she herself might be facing this risk, she balked. She relied on her nephew, Ms. K said; she didn’t want to upset him.IDA was developed by Dr. Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine, and his colleagues, and by Dr. Jason Karlawish, a geriatrician and co-director of the Penn Memory Center. “People have the right to make bad decisions,” Dr. Lachs said in an interview. But, he added, the decision makers must be able to understand the risks they face and the potential consequences.Dr. Jason Karlawish, left, and Dr. Mark Lachs, who helped develop the Interview for Decisional Abilities program, in a training video.Weill Cornell Medicine“How can you walk into a brokerage office at 90 years old and say, ‘I’ve had Treasury bills for 50 years but now I want to put my last $200,000 in Bitcoin’ — and nobody raises an eyebrow?” Dr. Lachs said. “We’re going to look back at this and say, ‘What were we thinking?’”Along with applying IDA to cases of financial neglect or abuse, the California A.P.S. workers were using it to assess a range of issues including self-neglect, health and safety questions, refusal of physical care or medical treatment, and physical or psychological or sexual abuse.“It’s not meant to replace a psychiatrist, but it tells you when to contact a psychiatrist,” Dr. Lachs said. Clients whose IDA interviews reveal an inability to grasp risks or consequences should receive a full professional assessment, he added.To date, about 500 A.P.S. workers — in New York City, Massachusetts and two California regions — have taken the course and received certification. Kansas A.P.S. workers will undergo training this summer.But Drs. Lachs and Karlawish think IDA could have broader uses. Trust and estate lawyers and financial firms are already asking them about it.Hospital discharge planners might use IDA to assess whether a patient has the capacity to insist on going home instead of to rehab. A chain of assisted-living facilities contacted Dr. Lachs, wondering if IDA could help ensure that new residents understood the complicated contracts they were signing.The IDA interview attempts to answer three fundamental questions about a particular problem or risk, Dr. Karlawish said: “Do you recognize that this happens? Do you think that this could be happening to you? Can you come up with a plan to address it, reasoning through and weighing the upsides and downsides?”Depending on a problem’s complexity, people with diagnosed cognitive impairment or even dementia may still possess sufficient understanding to handle it.Someone who demonstrates that three-part understanding during the IDA interview probably has the ability to make a decision — including a decision not to address the problem. Someone without that understanding needs a more comprehensive evaluation, perhaps including consultation with family members or social service agencies. In extreme cases, it might lead to eventual guardianship or conservatorship.Trouble handling finances often serves as an early warning of incapacity, said Dr. Daniel Marson, a neuropsychologist at the University of Alabama at Birmingham who has studied the subject for 25 years.“Financial capacity is probably the first higher-order functional ability affected by neurodegenerative disorders and by normal aging,” he said. Using money proficiently requires complex thought, from “something basic like using an A.T.M. to things that are more complicated, like ‘How should I handle this call from a telemarketer?’” The consequences of diminishing financial capacity — unsafe living conditions, impoverishment, homelessness, institutionalization — can be devastating.Although the incidence of dementia has been declining in the United States and Europe, the aging of these populations means that more individuals will develop it.Moreover, in a six-year study, Dr. Marson and colleagues found that older adults who were given a diagnosis of mild cognitive impairment — often a precursor condition to dementia — also struggled increasingly. “There were diminished financial skills over time,” he said.Other institutions have attempted to tackle the issue of diminishing decisional ability. The American Bar Association last year updated its “Assessment of Older Adults with Diminished Capacities: A Handbook for Lawyers.” The Bar Association and the American Psychological Association have also published handbooks for judges and psychologists.The Financial Industry Regulatory Authority, or FINRA, has posted online courses on financial exploitation of older adults and other vulnerable investors. Its rules allow a member firm to put a temporary hold on transactions and disbursements when it believes exploitation is involved. It also allows member firms to ask investors for a “trusted contact person” to consult in the event of suspected exploitation.The IDA program is focusing on A.P.S. workers for now because “the typical agency is understaffed, underresourced and struggling,” Dr. Karlawish said. California A.P.S. agencies handle about 30,000 cases involving seniors each month, according to state data, and “are being asked to make decisions about capacity that a chair of a psychiatry department might have difficulty with,” Dr. Lachs saidThe California staff on the Zoom training session, gently asking Ms. White — as Ms. K — how she might respond to the bank manager’s suspicions, eventually concluded that she did not need a professional work-up. It appeared that she understood her options.Giving her nephew access to her savings account might not have been the wisest move. But the decision was hers to make.

Through more than three decades of research, the Yale psychologist Becca Levy has demonstrated that age discrimination can take years off one’s life.Each fall, Becca Levy asks the students in her health and aging class at the Yale School of Public Health to picture an old person and share the first five words that come to mind. Don’t think too much, she tells them.She writes their responses on the board. These include admiring words like “wisdom” and “creative” and roles such as “grandmother.” But “‘senility’ comes up a lot,” Dr. Levy said recently, “and a lot of physical infirmity and decline: ‘stooped over,’ ‘sick,’ ‘decrepit.’”Dr. Robert N. Butler, a psychiatrist, gerontologist and founding director of the National Institute on Aging, coined the term “ageism” a half-century ago. It echoes “sexism” and “racism,” describing the stereotyping of and discrimination against older adults.Among the mementos in Dr. Levy’s small office at Yale is a treasured photo of her and Dr. Butler, who died in 2010. One could argue that she is his heir.A psychologist and epidemiologist, Dr. Levy has demonstrated — in more than 140 published articles over 30 years and in a new book, “Breaking the Age Code” — that ageism results in more than hurt feelings or even discriminatory behavior. It affects physical and cognitive health and well-being in measurable ways and can take years off one’s life.“Just as we have learned in recent decades that structures are biased against women and people of color, leading to worsened health outcomes, she has shown that negative feelings about old age lead to bad outcomes in older people,” said Dr. Louise Aronson, a geriatrician at the University of California, San Francisco, and author of the best-selling book “Elderhood.”Another memento in Dr. Levy’s office is a card on her bulletin board that reads, “Ask Me About 7.5.” The souvenir came from a Wisconsin anti-ageism campaign and refers to her 2002 longevity study, which for two decades followed hundreds of residents older than 50 in a small Ohio town. The study found that median survival was seven and a half years longer for those with the most positive beliefs about aging, compared with those having the most negative attitudes.“I use that in practically every talk I give because it’s shocking,” said Tracey Gendron, who chairs the gerontology department at Virginia Tech and credits Dr. Levy’s work in “Ageism Unmasked,” her own recent book. “She’s truly been a pioneer.”Dr. Levy and her team measure attitudes about aging in a variety of ways. They use questionnaires or the same five-word exercise she gives to her students. They test subliminal biases using computer programs that flash negative or positive words about aging so quickly that participants inadvertently absorb them. They have used small experimental samples of a few dozen people and tracked health records for thousands through big national surveys. Thanks to their efforts, we know that beyond reduced longevity, ageism is also associated with:Cardiovascular events, including heart failure, strokes and heart attacks. Using health records for almost 400 participants under 50 in the Baltimore Longitudinal Study of Aging, “we’ve been able to follow people for 40 years,” Dr. Levy said in an interview. “They had twice as high a risk if, at young ages, they’d taken in negative stereotypes about aging.” Their cardiovascular events occurred at earlier ages, too.Physical function. Among 100 older people (whose average age was 81), those exposed to implicit positive age stereotypes weekly for a month scored better on tests of gait, strength and balance than control groups did. In fact, those receiving positive exposure improved more than a similar-aged experimental group that exercised for six months. In a study of New Haven residents over 70, those with positive age beliefs were also more likely to recover fully from severe disability than those with negative beliefs.Alzheimer’s disease. Some participants in the Baltimore study underwent regular brain scans, and some donated their brains for autopsies. Those who held more negative age beliefs at younger ages exhibited a sharper decline in the volume of the hippocampus, the brain region associated with memory. They also exhibited, after their deaths, more of the brain plaques and tangles that are Alzheimer’s biomarkers.Another study used data from the national Health and Retirement Survey that included whether participants carried the APOE4 gene, which increases the risk of Alzheimer’s. Those with the gene who had positive age beliefs “had as low a risk as people without the gene,” Dr. Levy said.The list goes on. Older people with positive views of aging perform better on hearing tests and memory tasks. They are less likely to develop psychiatric illnesses like anxiety, depression, post-traumatic stress disorder and suicidal thoughts.In fact, Dr. Levy and her colleagues estimate that age discrimination, negative age stereotypes and negative self-perceptions of aging lead to $63 billion in excess annual spending on common health conditions like cardiovascular and respiratory disease, diabetes and injuries.Dr. Levy, who is 55, credits her focus on aging to an after-college job at a psychiatric hospital in suburban Boston, a graduate fellowship in Japan and an errant crate in a Florida grocery store.At the hospital, she worked in a unit for older patients and, to her surprise, enjoyed it. “It inspired me to want to understand the psychology of aging,” she said.Later, she planned to spend a semester in Japan, investigating why its residents have the world’s longest life spans. “I noticed how differently older people were treated there,” she said. “They were celebrated. Centenarians were rock stars!”Before leaving for Japan, though, she visited her grandmother, a lively septuagenarian. They were shopping together when Grandma Horty fell over a crate with jagged metal corners that had been left in the aisle.The resulting cut on her leg, though bloody, proved superficial. But when her grandmother suggested to the grocery owner that he not leave crates about, he responded that old people fall all the time, and maybe they shouldn’t be walking around.“The message stayed with her, and it seemed to impact her behavior,” Dr. Levy noticed. Her grandmother appeared to question her competence, asking Dr. Levy to take over chores she normally handled herself. The incident prompted Dr. Levy to contemplate how cultural values and people’s own ideas about age might affect them.We absorb these stereotypes from an early age, through disparaging media portrayals and fairy tales about wicked old witches. But institutions — employers, health care organizations, housing policies — express a similar prejudice, enforcing what is called “structural ageism,” Dr. Levy said. Reversing that will require sweeping changes — an “age liberation movement,” she added.But she has found reason for optimism: Damaging ideas about age can change. Using the same subliminal techniques that measure stereotypical attitudes, her team has been able to enhance a sense of competence and value among older people. Researchers in many other countries have replicated their results.“You can’t create beliefs, but you can activate them,” Dr. Levy said, by exposing people to words like “active” and “full of life,” instead of “grumpy” or “helpless,” to describe older adults.Could a society undertake such a mission? How long could the benefits of such interventions last? Would people need regular boosters to help associate aging with experience and possibilities instead of with nervous jokes?The research, by Dr. Levy and other scholars, continues.“Even though toddlers already have negative stereotypes about age, they’re not set in stone,” Dr. Levy said. “They’re malleable. We can shift them.”

Two neurologists argue that calling T.I.A.s what they are — minor strokes — could prompt patients to seek the help they need more quickly.On a recent afternoon in Bastrop, Texas, Janet Splawn was walking her dog, Petunia, a Pomeranian-Chihuahua mix. She said something to her grandson, who lives with her and had accompanied her on the stroll. But he couldn’t follow; her speech had suddenly become incoherent.“It was garbled, like mush,” Ms. Splawn recalled a few days later from a hospital in Austin. “But I got mad at him for not understanding. It was kind of an eerie feeling.”People don’t take chances when 87-year-olds develop alarming symptoms. Her grandson drove her to the nearest hospital emergency room, which then transferred her to a larger hospital for a neurology consultation.The diagnosis: a transient ischemic attack, or T.I.A.For decades, patients have been relieved to hear that phrase. The sudden onset of symptoms like weakness or numbness (often on one side), loss of vision (often in one eye) and trouble with language (speaking, understanding or both) — if resolved in a few minutes — is considered “transient.” Whew.But in a recent editorial in JAMA, two neurologists called for doctors and patients to abandon the term transient ischemic attack. It’s too reassuring, they argued, and too likely to lead someone with passing symptoms to wait until the next morning to call a doctor or let a week go by before arranging an appointment. That’s dangerous.Better, they said, to call a T.I.A. what it is: a stroke. More specifically, a minor ischemic stroke. (Almost 90 percent of strokes, which afflict 795,000 Americans a year, are ischemic, meaning they result from a clot that reduces blood flow to the brain.)Until recently, T.I.A.s “were played down,” said Dr. J. Donald Easton, a neurologist recently retired from the University of California, San Francisco, and an author of the editorial. “The person thinks, ‘Oh, it’s over. It goes away, so all is well.’ But all is not well. There’s trouble to come, and it’s coming soon.”The advent of brain imaging — first CT scans in the late 1970s, then the more precise M.R.I.s in the 1990s — has shown that many T.I.A.s, sometimes called ministrokes, cause visible and permanent brain damage.“Very quickly, nerve cells and their connections start to die,” Dr. Easton explained. And the risk of a subsequent stroke, possibly a more severe one, is highest within the first 24 to 48 hours.He and his co-author on the editorial, Dr. S. Claiborne Johnston, a neurologist at the University of Texas at Austin and former dean of its medical school, want people who experience these episodes to head for an emergency room, stat.“We’re trying to get rid of a term that has comforted people in the past,” Dr. Johnston said. Because “your brain is likely injured and you don’t want it to be injured further, you need to come in right away.”Dr. Jeffrey Saver, a stroke neurologist at U.C.L.A., called the proposed change in nomenclature “an intriguing, radical and potentially good idea.” The transient ischemic attack name dates to a 1975 report from the National Institutes of Health. So, he said, “this upends 50 years of classifying low-blood-flow events in the brain.”But will health care professionals change their terminology? “The T.I.A. concept is deeply entrenched in medical thinking,” Dr. Saver said. “It’s the kind of idea that will gather adherents slowly.”He supports the change, however, because “it reflects what we’ve learned over the last two decades — even very brief episodes of low blood flow to the brain lead to damage” and because calling such episodes “minor strokes” may lead patients to respond more quickly.“The treatments for ischemic stroke are very time-dependent,” he explained. “Every minute counts towards getting a better outcome.”In an emergency room or specialized stroke center, patients undergo a brain scan to be sure their symptoms resulted from a minor stroke rather than from a condition that can mimic it, like a seizure or a migraine.Patients who have suffered minor strokes usually start taking two drugs, typically aspirin and clopidogrel, which prevent clotting. (Some may need other medications or a surgical procedure, like a stent placement.)After three weeks, when the highest risk for another stroke has passed, most continue with just one drug, usually a low-dose aspirin. “It’s easy, it’s cheap and it’s well tolerated,” Dr. Johnston said.Twenty years ago, when Dr. Johnston led an early study of stroke risk after a T.I.A., 10.5 percent of patients suffered another stroke within three months; half of those occurred within the first two days.That rate has declined substantially, thanks to improved treatments for stroke, lower smoking rates and the widespread use of cholesterol and blood pressure drugs and blood thinners. Recent studies in The New England Journal of Medicine put the risk of a subsequent stroke, coronary syndrome or death after a T.I.A. at 6.4 percent in the first year and another 6.4 percent in years two through five.For neurologists, however, that is still high, given how devastating a major stroke can be. A name change for T.I.A.s might lead to quicker responses that further reduce the rate of subsequent stroke risk.Circumstances can arise when older people or their caregivers choose not to seek immediate medical help. In 2017, Maggie Flanagan was 88 and into her seventh year with Alzheimer’s disease when Therese Flanagan, her daughter and caregiver, suddenly noticed odd physical symptoms.“She was sitting in a recliner next to me when her head tilted back a little and her eyelids started to flutter,” Ms. Flanagan said. “One eye was drooping a little. I held her hand and said, ‘Are you OK?’ There was no response at all.” Then, a couple of minutes later, “she was back.”Before, when their mother was still able to make such decisions, she had signed a do-not-resuscitate order and an advance directive instructing that “she didn’t want her life prolonged,” her daughter said. The family agreed that taking her to a hospital would only cause fear and disorientation. She and her siblings decided not to call 911.Maggie Flanagan’s doctor said that she had probably experienced a T.I.A.; she had a more serious stroke five months later and died the following year, at home in her Chicago apartment.But most people choose treatment. Ms. Splawn, the dog owner from Texas, said she was feeling fine and expected to go home to Petunia shortly.Patients treated appropriately for minor strokes will remain at a higher-than-normal risk for another stroke, especially in the first year, Dr. Saver said. But “by two or three years out, the risk is just a little higher than for folks who never had a T.I.A. or a minor stroke.”Wanda Mercer, for example, had a minor stroke four years ago, at age 66. An administrator at the University of Texas, she had donated blood during her lunch break, then fainted in an Austin restaurant. The staff called 911, but in the emergency room, everything seemed normal; she went back to work and regaled co-workers with her noontime adventure.Suddenly, “I couldn’t find my words,” Dr. Mercer said. “I couldn’t articulate.” The problem lasted only seconds, but colleagues recognized a possible stroke and sent her back to the emergency room, where an M.R.I. revealed tissue damage. She has taken a statin, a cholesterol-lowering drug, and aspirin ever since.“I’m lucky,” she said. “I haven’t had one adverse symptom since.”

Health care researchers argue that hospice facilities could better serve some terminal patients, and ease the burden on exhausted loved ones.Where do people most want to be when they die? At home, they tell researchers — in familiar surroundings, in comfort, with the people they love.That wish has become more achievable. In 2017, according to an analysis in The New England Journal of Medicine, home surpassed the hospital as the most common place of death — 30.7 percent of deaths occurred at home, compared with 29.8 percent at the hospital.“It’s probably the first time that’s happened in the United States in modern times,” said Dr. Haider Warraich, a cardiologist at the Veterans Affairs Boston Healthcare System and an author of the study, published in 2019. Technically, the proportion was even higher, since some people who died in nursing facilities (20.8 percent) were long-term residents and the nursing home effectively was their home.Dr. Warraich credited the change to the rise of hospice care, for which Congress authorized Medicare coverage 40 years ago. By 2019, more than half of Medicare beneficiaries who died were enrolled in hospice. “There’s been a cultural shift,” he said. “People don’t want to die in hospitals, and hospice helps make that possible.”But not always.When Lee Zeiontz was dying of lung cancer, she wanted to remain in her apartment on the Lower East Side of Manhattan with her cat on her bed and her neighbors stopping by. Lynda Hollander, her niece, hired a round-the-clock aide to supplement the hospice staff.But Ms. Zeiontz’s pain eventually intensified and her older relatives were uneasy about administering morphine. “I think they were afraid of her dying at home,” said Ms. Hollander, a social worker in West Orange, N.J. They moved Ms. Zeiontz to an inpatient hospice unit at Mount Sinai Beth Israel Hospital, where she died a day and a half later, at 70.Similarly, Alan Mironer had vowed to care for his wife, Lynne, with hospice help in their home in Edina, Minn., as she died of breast cancer. “He felt it was his responsibility,” their son, Mark, said. But as she weakened and became unable to walk to the bathroom, he said, “suddenly, it was so much more work to take care of her.” The elder Mr. Mironer, then 81, became overwhelmed.Neighbors told them about a small hospice facility in Edina, with room for eight patients. Ms. Mironer spent her final week there, dying at 78.Such experiences prompted an article this month in The New England Journal of Medicine that pointedly asks, “Is There Really ‘No Place Like Home’?”The lead author, Dr. Melissa Wachterman, a palliative care specialist at Harvard Medical School, and her co-authors argue that alternative locations, including free-standing inpatient hospice facilities and hospice units within hospitals, could better care for some terminal patients with difficult symptoms and provide relief for exhausted families. They also contend that financial incentives play a role in where death occurs.“There’s a lot of cultural pressure: ‘If you really loved this person, you’d keep them at home,’” Dr. Wachterman said in an interview. “We need to acknowledge that there are people whose needs are so great that families cannot manage death at home.”Ninety-eight percent of hospice patients covered by Medicare receive what is called “routine home care.” The hospice organization sends nurses, aides, a social worker and a chaplain, in addition to drugs and equipment like a hospital bed, to the patient’s home. But it can’t provide 24-hour care; that falls to family or friends, or helpers paid out of pocket.Often, that’s sufficient. But death can follow unpredictable trajectories, and some terminal conditions appear better suited to home death than others. Cancer patients have the greatest odds of dying at home, Dr. Warraich’s analysis showed. Patients with dementia are most likely to die in a nursing home, and those with respiratory disease in a hospital.Some patients “may not need someone at the bedside 24 hours a day, but they need someone available 24 hours a day,” Dr. Wachterman said.A handful of hospice patients receive “continuous home care,” which means nurses and aides are provided eight to 24 hours a day; this accounts for 0.2 percent of hospice days, according to the Medicare Payment Advisory Commission, an independent agency that advises Congress on Medicare issues. Another handful receive inpatient services in a hospice facility, hospital or nursing home.But inpatient care is hard to secure, accounting for just 1.2 percent of all hospice days in 2019. To be covered under Medicare, the patient must be diagnosed with a symptom that cannot feasibly be managed in any other setting, and “that’s a pretty high bar,” Dr. Wachterman said.The authors also argue that although Medicare pays more for inpatient care — $1,000 a day, on average, compared with $200 for home care — profit margins are higher at home. More than 70 percent of hospices are now for-profit agencies.Rankings on the quality of hospital care like those published by U.S. News & World Report may also prompt hospitals, who want to keep their mortality statistics low, to discharge patients to home hospice.Edo Banach, president and chief executive of the National Hospice and Palliative Care Organization, disputed the article’s financial assertions. “It’s not true that margins are necessarily higher for routine home care versus inpatient,” he said, attributing profit differences to the length of a patient’s stay rather than the setting.Instead, Mr. Banach primarily blamed a fear of Medicare audits, which are not uncommon, for the infrequent use of inpatient hospice care. “Providers are very reluctant to use that benefit unless it’s also clear that they won’t be hurt by the government on the back end” and forced to return contested payments, he said.Still, he said there was nothing in the authors’ recommendations that he fundamentally disagreed with, including their calls for changes like financial support for family caregivers who assist dying patients.The authors also advocate expanded access to continuous home care and lower barriers to inpatient end-of-life care, in hospice facilities (the national organization estimates that about 30 percent of hospices have them) or hospice units within nursing homes and hospitals.Of the three times I have accompanied family members to their deaths, we achieved the good-death-at-home paradigm once: My mother died at 80, with uterine cancer and after a major stroke, in her own bed. My father and I cared for her, with a hospice team. He died at 90, when sepsis overwhelmed him in a hospital before I could arrange for hospice care at home.My sister’s death in 2015 showed the possibility of a middle ground. Disabled by late-onset Tay-Sachs disease, a neurological condition, she had been hospitalized with an uncertain prognosis. I was her health care proxy.As she declined, she developed such severe pain that, between sobs, she was calling for our long-dead parents. I immediately enrolled her in hospice and began planning to move her back to her assisted-living facility, so that she could die in her own apartment.It soon became clear that would be impossible. In the hospital, hospice nurses visited twice a day, constantly raising the dose of her morphine drip before switching to more potent medications. Having staff nurses always nearby allowed us to provide comfort, relying on a team we never could have duplicated on our own.To its credit, the hospital understood our needs. It arranged for a private room with 24-hour access for my cousin and me. We turned off the TV and the intercom, dimmed the lights, played soothing music, allowed family and friends to come and kept the vigil. It wasn’t homey, but it was peaceful. My sister, just 62, died after 24 days in the hospital and 14 in hospice care.Far more hospice patients and families could probably benefit from a similar option when home care proves too difficult.“For many patients, ‘home’ isn’t the physical place,” Dr. Warraich said. “It’s a metaphor for a place that’s not medicalized, that’s comfortable and full of love.”

The Program of All-Inclusive Care for the Elderly, funded by Medicare and Medicaid, has quietly succeeded in enabling some older Americans to age in place.Felicia Biteranta was struggling when, five years ago, she enrolled in a PACE program operated by Lutheran Senior Life in Jersey City, N.J.Having suffered a stroke, she found it hard to eat without choking. She fell frequently; her diabetes was out of control; she had pulmonary disease and asthma. She might miss a medical appointment if she could not arrange or afford a taxi. Her family lived far away.She was, in short, a candidate for a nursing home. But such a move is what PACE — the Program of All-Inclusive Care for the Elderly — was designed to prevent.“The main goal is to let people age in place,” said Maria Iavarone, executive director of the PACE program that Ms. Biteranta participates in. “Nobody wants to give up their home. It’s where you’re most comfortable. It’s where you should stay.”Ms. Biteranta now receives all of her health care through PACE, which monitors her, along with 120 other seniors, meticulously. PACE supplies much of her social life, too.“Here, they schedule you for appointments,” said Ms. Biteranta, 74, a retired nurse. “They send someone to take you and bring you home.”Carpal tunnel syndrome in her wrists and arms makes personal care and household chores difficult, so PACE sends an aide to her home 12 hours a week. “She cleans and does my laundry and the shopping,” Ms. Biteranta said. “She knows the food I like.”PACE provided the portable oxygen unit that freed her from dependence on the larger oxygen tanks she uses at home. It arranged cataract surgery and regularly ferries her to a podiatrist, a cardiologist, an endocrinologist and other specialists. It delivers a host of medications at no charge, including asthma inhalers and diabetes-testing supplies. A staff social worker helped her apply for and move into an apartment in a subsidized building for seniors.As a Medicaid beneficiary, she pays nothing for this care — no co-pays, deductibles or other out-of-pocket care expenses, and no caps on benefits. Should she require more home care hours or, eventually, a nursing home, PACE will cover those costs, too.“It’s worry-free,” said Ms. Biteranta, who was preparing to have lunch at the PACE Center as she spoke. “They worry for me.”Yet both the state and federal government also save money. PACE programs receive a set amount monthly from Medicare and Medicaid to provide nearly everything for people over 55 whose needs qualify them for a nursing home but who don’t want to enter one. This includes doctors’ visits, tests, procedures, physical, occupational and speech therapy, social workers, home care, transportation, medication, dentistry and hearing aids. Participants typically visit a PACE center like the one in Jersey City several times a week for meals and social activities as well as therapy and health monitoring.That monthly payment is 15 percent lower, on average, than Medicaid would ordinarily pay to care for what are primarily low-income seniors, the National PACE Association said.Research has shown that PACE programs reduce hospitalization, emergency room visits and nursing home stays. Participants survive longer than similar patients in less comprehensive programs. A study last year by the federal Department of Health and Human Services noted that the PACE program “stands out from our analysis as a consistently ‘high performer.’”Why, then, do so few PACE programs exist — and enroll so few older Americans? Almost three decades after Medicare and Medicaid began funding PACE programs — today, there are 144, operating 272 centers in 30 states — the endeavor collectively serves fewer than 60,000 people, the National PACE Association reports.The association estimates that 1.6 million Medicare beneficiaries might meet PACE eligibility requirements. As a list of current programs shows, however, 21 states have no PACE program, and 11 have just one.Ms. Biteranta and her aide, Ms. Garcia-Reyes, on the way to lunch. Brian Fraser for The New York TimesProfessionals in elder care tend to be fans. “Every geriatrician loves this model,” said Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine.Specialists like Dr. Lachs have complained for years that traditional Medicare will cover costly surgery to repair broken hips but won’t pay to install inexpensive grab bars that might prevent falls. With PACE’s fixed payments, “there might be less money, but you spend it the way you want to, without getting on the phone for insurance company approval,” Dr. Lachs said.At the ArchCare PACE program in New York City, for instance, “if a person’s air-conditioner breaks during a heat wave, we replace it,” said Walid Michelen, the program’s chief medical officer. “If there’s a snowstorm and they need food, we send it.”With coordinated care and close observation, “you head off a urinary tract infection before it becomes sepsis,” said Jay Luxenberg, the former chief medical officer of the On Lok PACE program in San Francisco. “Or pneumonia when it can still be treated by antibiotics, before you desperately need a hospital.”Yet growth has been slow. “We’ve had a lot of headwinds over the years,” said Shawn Bloom, the association’s chief executive.Persuading state legislators to expand PACE enrollment or authorize new programs has proved challenging; such moves represent new expenditures, even if they eventually reduce costs.For individuals, the enrollment process — which involves a state assessment to determine whether their medical conditions, cognitive status and functional limitations would warrant a nursing home — can take weeks. A family needing elder care immediately may be unable to wait.Moreover, agreeing to receive all health care from PACE often means relinquishing one’s individual doctor, and some patients balk at that demand. Programs can evade that barrier by allowing PACE programs to work with community physicians.But prospective patients may not know about PACE at all. “We’re trying to expand awareness, but we don’t have a ‘Got Milk?’ budget,” Mr. Bloom said.Still, the pandemic has intensified older Americans’ desire for alternative forms of long-term care. “If people didn’t want to be in nursing homes before Covid, they really don’t want to be there now,” Dr. Lachs said. According to the association, Covid deaths among PACE participants have been about one-third those of nursing home residents.So PACE’s growth is picking up, with 45 new programs expected to begin enrollment in the next two years, in part because of higher federal incentives. Moreover, for-profit companies are starting to establish or acquire PACE programs, although skeptics worry that for-profit status will lower quality.Several bills introduced in Congress would remove barriers to growth; one would build partnerships with Veterans Affairs hospitals to make PACE more accessible to veterans.Another intriguing possibility: Encouraging middle-class patients, for whom long-term care costs can also be ruinous, to enroll in PACE. Older adults who aren’t poor enough to qualify for Medicaid can already participate, but few do because their monthly premiums would be high — in many states, $4,000 to $5,000 a month.But that is still less than they would pay for nursing homes or assisted living in many locations. Policy analysts are looking into ways to reduce costs and expand PACE eligibility for the middle class.In Jersey City, Ms. Biteranta is doing well, although she misses concerts, Zumba classes, birthday parties and other events at the PACE center. Administrators curtailed such activities during the pandemic but hope to restore them as Covid rates decline.“Oh, my God, I’d be so depressed” without PACE, Ms. Biteranta said. “It gives me a life.”

Three recent developments — incremental and undramatic but encouraging — are likely to improve the lives and health of seniors.The Covid pandemic has presented older Americans with plenty of grim news, from staffing shortages in long-term care and hospices to the punishing effects of loneliness and isolation. But there have been encouraging developments too — the kind of incremental progress that can take years to achieve, as lawsuits wend their way through courts, bills die in state legislatures and rise again, and the pandemic complicates everything.The results are not always dramatic, but they can improve lives and health for older people, especially those with low income. Here are three.A New Right to Appeal Medicare DecisionsFirst, a federal appellate court recently ruled that if Medicare declines to pay for your rehabilitation in a nursing home after you’ve left the hospital, because you were “on observation,” you can appeal the decision.This issue has boggled patients and families for years. You were in a hospital bed, doctors and nurses provided care, you were examined and perhaps received medication, but you were not actually admitted. Or you were, and then the hospital changed your status to “on observation.” Technically you were an outpatient, not an inpatientBut Medicare requires three consecutive days as an inpatient for you to be eligible for nursing home coverage. So you are left either having to pay the tab yourself (the national average nursing home cost is $260 a day) or forgoing care. In fact, if you are among the 9 percent of Medicare beneficiaries who don’t have Part B, which covers outpatient care, you must pay the hospital bill, too.Hundreds of thousands of patients discharged from hospitals have probably faced this conundrum. “You can appeal just about every issue regarding your Medicare coverage, but not that one,” said Alice Bers, litigation director at the Center for Medicare Advocacy.To change this, the center — along with Justice in Aging and a private law firm — sued the federal Department of Health and Human Services in 2011.Last month, the U.S. Court of Appeals for the Second Circuit affirmed that Medicare beneficiaries have a constitutional right to appeal if hospitals reclassify them as observation patients. If patients win their appeals, traditional Medicare will pay for up to 100 days of nursing home care, and those who were previously forced to pay out-of-pocket could receive refunds. (Medicare Advantage plans don’t generally require the three-day stay.)The Center for Medicare Advocacy answers frequent questions here.One catch: The government could still ask the Supreme Court to take the case, or seek a rehearing by the Second Circuit court. And the Medicare appeals process is no picnic. “People have the best chance of winning if they persist and work their way up through the levels,” Ms. Bers said.Repealing the three-day requirement would take Congressional action. But at least with the right to appeal, you have a fighting chance.California Eases Medicaid QualificationsIn a second promising development, California is eliminating asset limits for older people who are trying to qualify for Medicaid, and other states are considering similar moves.Medicaid, the state and federal program that provides health care for the poor and for people with disabilities, and also pays for long-term care in nursing homes and at home, sets strict ceilings on recipients’ wealth. In most states, if you are older than 65, you can amass no more than $2,000 in assets, or $3,000 for a couple (usually with a home and a car exempted).“It makes people live in very deep poverty,” unable to save for emergencies or even modest expenditures, said Amber Christ, director of health care policy and advocacy for Justice in Aging. “If you go over the limit by a dollar, you lose eligibility.”California will abolish this ceiling in two steps. In July, the asset limit rises to $130,000 for an individual and another $65,000 for each family member. In July 2024, the state will discard asset limits altogether. If you are older or disabled, you will qualify for Medi-Cal (as California calls its Medicaid program) if your income does not exceed 138 percent of the federal poverty level. The state estimates that about 17,000 residents will become newly eligible.Gov. Kathy Hochul of New York has incorporated a similar measure in her proposed state budget, eliminating asset limits as of Jan. 1, 2023; the state legislature will tackle the budget in March. Arizona eliminated asset limits in 2001, although not for long-term care, and other states are looking into the approach, Ms. Christ said.One catch: This year, 138 percent of the federal poverty level amounts to an annual income of $17,774. Medi-Cal recipients must still be poor, but less poor than before, and will be better able to hold onto their health coverage.Social Security Offices to ReopenOffices closed since the beginning of the pandemic will reopen.Fred Prouser/ReutersIn a third piece of a good news, the Social Security Administration has finally announced that it will soon reopen its 1,200 local offices.Except for limited “dire need” appointments made at the discretion of managers, offices have remained closed since the pandemic hit in March of 2020. Now, said Mark Hinkle, a spokesman for the agency, “we anticipate that local field offices will restore increased in-person service to the public, without an appointment, in early April.”This matters. “There are things that have to be done in person for Social Security,” said Kate Lang, senior staff attorney at Justice in Aging. You can apply online for retirement benefits but not for survivors’ benefits or for Supplemental Security Income, or S.S.I., which helps support seniors with very low income.These in-person requirements have meant that hundreds of thousands of applicants who would normally walk into local Social Security offices, carrying the required original documents, have been out of luck for two years.Moreover, “people already on benefits have gotten notices saying their benefits are being reduced or discontinued, and they’re unable to get in touch with anyone at Social Security to find out what’s going on,” Ms. Lang said. “There’s no way to fix these problems.”Trying to reach Social Security by phone can be an exercise in frustration. A report from the agency’s inspector general found that monthly calls to field offices rose from 4.6 million before the pandemic to 7.5 million in April through September 2020, and to 12 million in March of 2021. If you called field offices or the national 1-800 number, you often encountered busy signals or long waits; many callers abandoned the effort.Even after the Social Security Administration agreed to reopen offices, protracted negotiations with its uneasy employees followed. But the agency and its unions have reached agreements, although they are still working out the logistics of reopening.One catch: Visitors to a field office will likely face occupancy limits, and the agency must cope with huge backlogs. In an email, Mr. Hinkle said that the agency encourages the public to use its online or phone services when possible and to schedule in-person appointments in advance.Ms. Lang noted: “It’s not like everything will be hunky dory on April 1.” In fact, Justice in Aging has brought a class-action suit against the Social Security Administration on behalf of S.S.I. recipients who were unable to provide information or challenge decisions while offices were shuttered.But, Mr. Hinkle said, offices will reopen this spring “dependent on the course of the pandemic” — indisputably a good thing.

Health experts are concerned that the pandemic, in upending daily routines, has reduced mobility and physical conditioning in older adults.In normal times, Cindy Myers, an executive at a nonprofit organization, is “not a real physical person,” she said. “I work at desk jobs. I’m not a big exerciser.”Still, before the pandemic, Dr. Myers, who is 64 and has a doctorate in organization development, commuted from her home in Petaluma, Calif., to an office in San Francisco. She met friends for lunch or coffee, and she went to restaurants, theaters and lectures with her wife. “There was so much more variety in my life, more locations, more people,” she said. “You’re not cognizant of all the moves you’re making.”Like many employees, Ms. Myers has now been working remotely for two years, curtailing social and cultural events and forgoing travel. That shift, perhaps exacerbated by a bout of depression in 2020, has taken a physical toll, she said. Her limbs feel weak, her balance rocky; she has fallen several times.“Basic kinds of movement you take for granted, like walking from one end of the house to the other, are exhausting,” she said. “I’m worried about it.”Many health experts are worried about worsening physical conditioning and mobility among older adults since Covid-19 upended the daily routine. Recent research indicates that many of those who had mild to moderate infections, even some who have managed to avoid the virus altogether, may be suffering functional declines.To date, much of the attention paid to the pandemic’s effects on the older population has focused on its frightful mortality rate: Nearly three-quarters of Americans who have died have been 65 or older.Researchers have also reported that, unsurprisingly, older adults whose Covid symptoms became serious enough to require hospitalization often contended with persistent physical and mental health problems.“When you’re hospitalized and you’re older, it takes a long time to get back on your feet,” said Marla Beauchamp, who researches mobility, aging and chronic disease at McMaster University in Hamilton, Ontario. “Covid is still impacting them in a significant way months and months later.”But less severe disease can also affect their physical ability. Dr. Beauchamp led a recent study of Canadians over 50 who had confirmed, probable or suspected Covid in 2020, when testing was not widely available. The study revealed worsened mobility among those with mild to moderate illness — 93 percent of whom were never hospitalized — compared with those without Covid.Nearly half of those 65 and older who had contracted Covid reported less ability to engage in physical activity like walking and exercising than before the pandemic — but so did about one-quarter of those who did not become infected. Smaller proportions of those uninfected said their ability to move around the house, and to do housework like dishwashing and dusting, had also declined.Although some of that decline might reflect normal aging, the study measured changes over only a nine-month period. In people who did not develop Covid, “the most plausible reason for the decline is public health restrictions during the pandemic,” Dr. Beauchamp said.Declines in physical function are showing up in older Americans, too. A University of Michigan team surveyed about 2,000 American adults aged 50 to 80 in early 2021, asking about their activity levels (but not about their Covid status).It found that almost 40 percent of those over 65 reported both reduced physical activity and less daily time spent on their feet since the start of the pandemic in March 2020. In this representative national sample, those factors were associated with worsened physical conditioning and mobility.“It’s a cascade of effects,” said Geoffrey Hoffman, a health-services researcher at the university’s School of Nursing and the lead author of the study. “You start with changes in activity levels. That results in worsened function. That in turn is associated with both falls and fear of falling.”Dr. Beauchamp added: “It’s really concerning to see this decrease in mobility. This is telling us that the pandemic alone has had a significant impact on older adults.”Neither of these observational studies, in Canada or in the United States, explored reasons for the self-reported increase in physical decline. But their authors suggested that pandemic-related restrictions could have caused deconditioning, even in people who were not ill.Not only did gyms, yoga studios, pools, adult day programs, community and senior centers all close for extended periods; many older people also undertook fewer ordinary chores and errands and may have skipped recreational pastimes.“If you’re limiting visits to the grocery store or having groceries delivered, or not going to visit or help with your grandchildren, if you’re not meeting friends at a coffee shop — those all take a certain level of physical activity,” Dr. Beauchamp said.Many older people did less traveling or in-person shopping; religious services, family gatherings and medical appointments moved online. “Picture how much activity we do without even thinking about it,” Dr. Hoffman said. When that changes substantially, “it adds up over six or nine months, then you have loss of balance or muscle strength, which leads to more trips and falls.”Disparities in health and income also appear to play a role, with reduced physical conditioning and mobility more commonly reported, in both countries, by respondents in low-income categories, in fair or poor health or with multiple chronic conditions.“Relatively healthy older adults have sufficient reserve if they reduce activity,” said Neil Alexander, a geriatrician at the University of Michigan and Ann Arbor Veterans Affairs who was not involved in the study. “High-risk people may be driving these numbers.”Dr. Alexander also pointed out that early in the pandemic, older patients had less access to rehabilitation and other services. “It was difficult to get people into the home for occupational therapy and physical therapy,” he said. “The support services to keep people mobile and functioning were disrupted.” Now, work force shortages may be having a similar effect, he noted.Physical function is key to living independently — the future that a great majority of older people envision for themselves. A loss of mobility and function across a considerable proportion of the senior population could mean increasing disability, a greater need for eventual long-term care, and higher Medicare and Medicaid costs.But that is not inevitable, Dr. Hoffman said: “You can reverse deconditioning. You can recover mobility.”Dr. Hoffman would like to see Medicare, which covers hip fracture surgery and rehabilitation after serious falls, underwrite extensive “pre-habilitation,” to rebuild the strength and balance of beneficiaries and prevent falls and fractures. He hoped that doctors conducting annual Medicare wellness visits would ask about fall risks and refer deconditioned patients to occupational and physical therapy.In the interim, individuals can resume walking, enroll in yoga or tai chi classes (outdoors, online, or seated in chairs, as needed), join fall-prevention programs, even practice getting in and out of chairs and lifting small weights on their own. (People should consult a doctor or physical therapist first if they have become severely deconditioned, however.)“You want to do everything you can to be as active and mobile as possible,” Dr. Beauchamp said.Dr. Myers, having found that “simply going about my daily routine isn’t enough to bring back my stamina and strength,” has a portable exercise bike set up in front of her television. She uses it, she said, but not often enough, a pattern she wants to change.“I need an intervention,” she said. “This isn’t the way I want to live.”