The GoFundMe request jumped out at me as I was scrolling through posts on LinkedIn.

Nora Super, executive director of the 2015 White House Conference on Aging and former director of the Milken Institute’s Center for the Future of Aging, was seeking contributions after suffering a severe spinal cord injury.

“Right now, I have no feeling below the waist. I need lots of equipment to go home from the hospital and live safely and independently,” she wrote in her appeal.

Since coping with disability — and the cost of coping with disability — is an enormously important issue for older adults, I wondered if Super would discuss her experiences and try to put them in perspective.

The Institute on Disability at the University of New Hampshire ran the numbers for me: About 19 million people 65 and older in the U.S. — a third of that age group — had some type of disability in 2021, the latest year for which data is available. This includes difficulty with hearing, vision, cognition, mobility, or activities such as bathing, dressing, or shopping.

Super agreed to talk to me, but her story was more complicated than I anticipated.

First, some context. Super, 59, has been open about her struggle with major depression, an issue she’s written about. In mid-June, after being fired from the Milken Institute, she began slipping into another depression — her fifth episode since 2005.

Super’s psychiatric medications weren’t working, she said, and she sought electroconvulsive therapy (ECT), which had been effective for her in the past. But mental health services are difficult to get in a timely way, and Super couldn’t get an ECT appointment until Aug. 7.

On July 30, convinced that her life had no value, she attempted to end it. This was the event that led to her injury.

After two weeks in intensive care and a recovery unit, Super was ready to leave the hospital. But no rehabilitation facility would take her because of her mental health crisis. Without psychiatrists on staff, they claimed they couldn’t ensure her safety, said Len Nichols, her husband.

Nichols, 70, has held several high-level health policy positions during his career, among them senior adviser for health policy at the Office of Management and Budget during the Clinton administration and director of the Center for Health Policy Research and Ethics at George Mason University. 

Using every contact he could, Nichols searched for a facility in New Orleans where Super could get intensive rehab services. During the pandemic, the couple had moved there from their longtime home in Arlington, Virginia. New Orleans is where Super grew up and three of her sisters live.

It took six days to get Super admitted to rehab. And that was just one of the challenges Nichols faced.

Over the next month, he prepared for Super’s return home, at considerable expense. An elevator was installed in the couple’s three-story home (their bedroom is on the second floor) for $38,000. A metal ramp at the home’s entry cost $4,000. A lift for their Jeep cost $6,500. A bathroom renovation came to $4,000. An electronic wheelchair-style device that can be used in the shower was another $4,000.

Super’s privately purchased insurance policy covered a wheelchair, bedside commode, hospital bed, and a Hoyer lift (a device that helps people transfer in and out of bed) with a small monthly copayment.

“It’s been surprising how much stuff I’ve needed and how much all of it costs,” Super admitted when we spoke on the phone.

“Even with all our education, resources, and connections, we have had a hard time making all the arrangements we’ve needed to make,” Nichols said. “I cannot imagine how people do this with none of those three things.”

He showered praise on the physical and occupational therapists who worked with Super at the rehab facility and taught him essential skills, such as how to move her from bed to her wheelchair without straining his back or damaging her skin.

“I don’t think I ever appreciated how essential their work is before this,” he told me. “They explain what you’ll be able to do for yourself and then they help you do it. They show you a pathway back to dignity and independence.”

Still, the transition home has been difficult. “In the hospital, nothing was expected of me, everything was done for me. In rehab, you’re very goal-oriented and there are still people to take care of you,” Super told me. “Then, you come home, and that structure is gone and things are harder than you thought.”

Fortunately, Nichols is healthy and able to handle hands-on caregiving. But he soon needed a break and the couple hired home-care workers for four hours a day, five days a week. That costs $120 daily, and Super’s long-term care insurance pays $100.

They’re lucky they can afford it. Medicare typically doesn’t pay for chronic help of this kind, and only about 7% of people 50 or older have long-term care insurance.

What does Super’s future look like? She isn’t sure. Physicians have said it could take a year to know whether she can recover function below her waist.

“I’m happy to be alive and to see how I can take where I’ve ended up and do something positive with it,” she said. “I still have a voice, and I can help people understand what it is to live with physical limitations in a way that I’ve never really understood before.”

Hopefully, this sense of purpose will sustain her. But it won’t be easy. After we spoke, Super became discouraged with her prospects for recovery and her mood turned dark again, her husband said.

“Knowing her, I believe that she will make it her mission to help others better understand the enormous and multiple challenges associated with the onset of a disability, and she will press for changes in our health system to improve the lives of families who have to deal with disabilities,” said Stuart Butler, a senior fellow at the Brookings Institution who has worked with Super in the past.

Persistent accessibility problems for people with disabilities are part of what Super wants to speak out about. “I live in an old city with sidewalks that are very uneven, and just getting down the street in my chair is a big hassle,” she said. “Finding parking where we can open the door fully and get me out is a challenge.” 

Nichols has been surprised by how many medical offices have no way of lifting Super from her wheelchair to the exam table. “The default is, they ask me, ‘Can you pick her up?’ It’s stunning how poorly prepared they are to help someone like Nora.”

Then, there are reactions Super encounters when she leaves the house. “Going down the street, people look at me and then they look away. It definitely feels different than when I was able-bodied. It makes me feel diminished,” Super said.

Nichols finds himself thinking back to something a neurosurgeon said on the day Super was injured and had her first operation. “He told me, ‘Look, there’s more damage than we thought, and she won’t be what she was. You’re not going to know for six to 12 months what’s possible. But I can tell you to do as much as you can as soon as you can to move on to a new normal. Millions of people have done it, and you can too.’”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“I understood the demographic imperative and the issues facing older patients,” Gurwitz, 67 and chief of geriatric medicine at the University of Massachusetts Chan Medical School, told me. “I felt this field presented tremendous opportunities.”

But today, Gurwitz fears geriatric medicine is on the decline. Despite the surging older population, there are fewer geriatricians now (just over 7,400) than in 2000 (10,270), he noted in a recent piece in JAMA. (In those two decades, the population 65 and older expanded by more than 60%.) Research suggests each geriatrician should care for no more than 700 patients; the current ratio of providers to older patients is 1 to 10,000.

What’s more, medical schools aren’t required to teach students about geriatrics, and fewer than half mandate any geriatrics-specific skills training or clinical experience. And the pipeline of doctors who complete a one-year fellowship required for specialization in geriatrics is narrow. Of 411 geriatric fellowship positions available in 2022-23, 30% went unfilled.

The implications are stark: Geriatricians will be unable to meet soaring demand for their services as the aged U.S. population swells for decades to come. There are just too few of them. “Sadly, our health system and its workforce are wholly unprepared to deal with an imminent surge of multimorbidity, functional impairment, dementia and frailty,” Gurwitz warned in his JAMA piece.

This is far from a new concern. Fifteen years ago, a report from the National Academies of Sciences, Engineering, and Medicine concluded: “Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.” According to the American Geriatrics Society, 30,000 geriatricians will be needed by 2030 to care for frail, medically complex seniors.

There’s no possibility this goal will be met.

What’s hobbled progress? Gurwitz and fellow physicians cite a number of factors: low Medicare reimbursement for services, low earnings compared with other medical specialties, a lack of prestige, and the belief that older patients are unappealing, too difficult, or not worth the effort.

“There’s still tremendous ageism in the health care system and society,” said geriatrician Gregg Warshaw, a professor at the University of North Carolina School of Medicine.

But this negative perspective isn’t the full story. In some respects, geriatrics has been remarkably successful in disseminating principles and practices meant to improve the care of older adults.

“What we’re really trying to do is broaden the tent and train a health care workforce where everybody has some degree of geriatrics expertise,” said Michael Harper, board chair of the American Geriatrics Society and a professor of medicine at the University of California-San Francisco.

Among the principles geriatricians have championed: Older adults’ priorities should guide plans for their care. Doctors should consider how treatments will affect seniors’ functioning and independence. Regardless of age, frailty affects how older patients respond to illness and therapies. Interdisciplinary teams are best at meeting older adults’ often complex medical, social, and emotional needs.

Medications need to be reevaluated regularly, and de-prescribing is often warranted. Getting up and around after illness is important to preserve mobility. Nonmedical interventions such as paid help in the home or training for family caregivers are often as important as, or more important than, medical interventions. A holistic understanding of older adults’ physical and social circumstances is essential.

The list of innovations geriatricians have spearheaded is long. A few notable examples:

Hospital-at-home. Seniors often suffer setbacks during hospital stays as they remain in bed, lose sleep, and eat poorly. Under this model, older adults with acute but non-life-threatening illnesses get care at home, managed closely by nurses and doctors. At the end of August, 296 hospitals and 125 health systems — a fraction of the total — in 37 states were authorized to offer hospital-at-home programs.

Age-friendly health systems. Focus on four key priorities (known as the “4Ms”) is key to this wide-ranging effort: safeguarding brain health (mentation), carefully managing medications, preserving or advancing mobility, and attending to what matters most to older adults. More than 3,400 hospitals, nursing homes, and urgent care clinics are part of the age-friendly health system movement.

Geriatrics-focused surgery standards. In July 2019, the American College of Surgeons created a program with 32 standards designed to improve the care of older adults. Hobbled by the covid-19 pandemic, it got a slow start, and only five hospitals have received accreditation. But as many as 20 are expected to apply next year, said Thomas Robinson, co-chair of the American Geriatrics Society’s Geriatrics for Specialists Initiative.

Geriatric emergency departments. The bright lights, noise, and harried atmosphere in hospital emergency rooms can disorient older adults. Geriatric emergency departments address this with staffers trained in caring for seniors and a calmer environment. More than 400 geriatric emergency departments have received accreditation from the American College of Emergency Physicians.

New dementia care models. This summer, the Centers for Medicare & Medicaid Services announced plans to test a new model of care for people with dementia. It builds on programs developed over the past several decades by geriatricians at UCLA, Indiana University, Johns Hopkins University, and UCSF.

A new frontier is artificial intelligence, with geriatricians being consulted by entrepreneurs and engineers developing a range of products to help older adults live independently at home. “For me, that is a great opportunity,” said Lisa Walke, chief of geriatric medicine at Penn Medicine, affiliated with the University of Pennsylvania.

The bottom line: After decades of geriatrics-focused research and innovation, “we now have a very good idea of what works to improve care for older adults,” said Harper, of the American Geriatrics Society. The challenge is to build on that and invest significant resources in expanding programs’ reach. Given competing priorities in medical education and practice, there’s no guarantee this will happen.

But it’s where geriatrics and the rest of the health care system need to go.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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“I was stunned,” said Cooper, who lives in Pittsburgh and depends on counseling to maintain her psychological balance. “I’ve always had the best health insurance a person could have. Then I turned 65 and went on Medicare, and suddenly I had trouble getting mental health services.”

The issue: For decades, Medicare has covered only services provided by psychiatrists, psychologists, licensed clinical social workers, and psychiatric nurses. But with rising demand and many people willing to pay privately for care, 45% of psychiatrists and 54% of psychologists don’t participate in the program. Citing low payments and bureaucratic hassles, more than 124,000 behavioral health practitioners have opted out of Medicare — the most of any medical specialty.

As a result, older adults anxious about worsening health or depressed by the loss of family and friends have substantial difficulty finding professional help. Barriers to care are made more acute by prejudices associated with mental illness and by ageism, which leads some health professionals to minimize older adults’ suffering.

Now, relief may be at hand as a series of legislative and regulatory changes expand Medicare’s pool of behavioral health providers. For the first time, beginning in January, Medicare will allow marriage and family therapists and mental health counselors to provide services. This cadre of more than 400,000 professionals makes up more than 40% of the licensed mental health workforce and is especially critical in rural areas.

Medicare is also adding up to 19 hours a week of intensive outpatient care as a benefit, improving navigation and peer-support services for those with severe mental illness, and expanding mobile crisis services that can treat people in their homes or on the streets.

“As we emerge from the COVID-19 public health emergency, it is abundantly clear that our nation must improve access to effective mental health and substance use disorder treatment and care,” Meena Seshamani, deputy administrator of the Centers for Medicare & Medicaid Services, said in a July statement.

Organizations that have advocated for years for improvements in Medicare’s mental health coverage applaud the changes. “I think we are, hopefully, at a turning point where we’ll start seeing more access to mental health and substance use disorder care for older adults,” said Deborah Steinberg, senior health policy attorney at the Legal Action Center in Washington, D.C.

For years, seniors in need of mental health aid have encountered obstacles. Although 1 in 4 Medicare recipients — including nearly 8 million people under 65 with serious disabilities — have some type of mental health condition, up to half don’t receive treatment.

Cooper, now 68 and a behavioral health policy specialist at the Pennsylvania Association of Area Agencies on Aging, bumped up against Medicare’s limitations when she tried to find a new therapist in 2020: “The first problem I had was finding someone who took Medicare. Many of the providers I contacted weren’t accepting new patients.” When Cooper finally discovered a clinical social worker willing to see her, the wait for an initial appointment was six months, a period she describes as “incredibly stressful.”

The new Medicare initiatives should make it easier for people in Cooper’s position to get care.

Advocates also note the importance of expanded Medicare coverage for telehealth, including mental health care. Since the pandemic, older adults have been able to get these previously restricted services at home by phone or via digital devices anywhere in the country, and requirements for in-person appointments every six months have been waived. But some of these flexibilities are set to expire at the end of next year.

Robert Trestman, chair of the American Psychiatric Association’s Council on Healthcare Systems and Financing, called on lawmakers and regulators to maintain those expansions and continue to reimburse mental health telehealth visits at the same rate as in-person visits, another pandemic innovation.

Older adults who seek psychiatric care tend to have more complex needs than younger adults, with more medical conditions, more disabilities, more potential side effects from medications, and fewer social supports, making their care time-consuming and challenging, he said.

Several questions remain open as Medicare enacts these changes. The first is, “Will CMS pay mental health counselors and marriage and family therapists enough so they actually accept Medicare patients?” asked Beth McGinty, chief of health policy and economics at Weill Cornell Medicine in New York City. That’s by no means guaranteed.

A second: Will Medicare Advantage plans add marriage and family therapists, mental health counselors, and drug addiction specialists to their networks of authorized mental health providers? And will federal regulators do more to guarantee that Medicare Advantage plans provide adequate access to mental health services? This kind of oversight has been spotty at best.

In July, researchers reported that Medicare Advantage plans include, on average, only 20% of psychiatrists within a geographic area in their networks. (Similar data is not available for psychologists, social workers, and psychiatric nurses.) When older adults have to go out-of-network for mental health care, 60% of Medicare Advantage plans don’t cover those expenses, KFF reported in April. With high costs, many seniors just skip services.

Another key issue: Will legislation proposing mental health parity for Medicare advance in Congress? Parity refers to the notion that mental health benefits available through insurance plans should be comparable to medical and surgical benefits in key respects. Although parity is required for private insurance plans under the 2008 Mental Health Parity and Addiction Equity Act, Medicare is excluded.

One of the most egregious examples of Medicare’s lack of parity is a 190-day lifetime limit on psychiatric hospital care, a feature that deeply affects members with serious conditions such as schizophrenia, severe depression, or post-traumatic stress, who often require repeated hospitalization. There is no similar curb on hospital use for medical conditions.

An upcoming Government Accountability Office report examining differences between the cost and use of behavioral health services and medical services in traditional Medicare and Medicare Advantage plans may give Congress some guidance, suggested Steinberg, of the Legal Action Center. That investigation is underway, and a date for the report’s release hasn’t been set.

But Congress can’t do anything about the all-too-common assumption that seniors feeling overwhelmed or depressed should “just grin and bear it.” Kathleen Cameron, chair of the executive committee for the National Coalition on Mental Health and Aging, said “there’s a lot more that we need to do” to address biases surrounding the mental health of older adults.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This might seem appealing on the surface, but the development has Alzheimer’s researchers and clinicians up in arms.

The Quest Diagnostics blood test, AD-Detect, measures elevated levels of amyloid-beta proteins, a signature characteristic of Alzheimer’s. Introduced in late July, the test is targeted primarily at people 50 and older who suspect their memory and thinking might be impaired and people with a family history of Alzheimer’s or genetic risks for the condition.

Given Alzheimer’s is among the most feared of all medical conditions, along with cancer, this could be a sizable market, indeed. Nearly 7 million older adults in the U.S. have Alzheimer’s, and that number is expected to double by 2060 if medical breakthroughs don’t occur.

But Alzheimer’s researchers and clinicians aren’t convinced the Quest test is backed by sound scientific research. The possibility of false-positive results is high, as is the likelihood that older adults won’t understand the significance of their results, they say. The test should be taken only under a physician’s supervision, if at all, they advise. And, priced originally at $399 (recently discounted to $299) and not covered by insurance, it isn’t cheap.

Though blood tests for Alzheimer’s are likely to become common in the years ahead, the Alzheimer’s Association said it’s premature to offer a test of this kind directly to consumers.

For its part, Quest, which also sells direct-to-consumer tests for sexually transmitted diseases and various other conditions, suggests older adults can be trusted to respond responsibly to AD-Detect results. The test is not meant to diagnose Alzheimer’s, the company stressed; instead, it’s meant to help assess an individual’s risk of developing the condition. But under a new, proposed biological definition of Alzheimer’s, excess amyloid could automatically trigger a diagnosis of “preclinical” Alzheimer’s.

Michael Racke, Quest’s medical director of neurology, said individuals who test positive might be inspired to talk to their physicians about cognitive symptoms and seek comprehensive evaluations from dementia specialists. Others may just want to adopt behaviors associated with brain health, such as exercising more and maintaining healthy blood pressure, blood sugar, and cholesterol levels.

“People who do consumer-initiated testing are often very motivated to figure out what they can do to help reduce the risk of disease,” he said.

To get the test, a person first needs to go to the AD-Detect test’s website and report that they’re experiencing mild cognitive decline and have at least one other risk factor. (Self-reported complaints of this kind are often unreliable, experts note.) The order then goes automatically to a doctor paid by Quest, who will order a blood test to be drawn at a Quest laboratory.

Results classifying a person as low, medium, or high risk will be provided on a secure patient portal. Post-test counseling isn’t mandatory, but individuals can speak to a physician paid by Quest, if they like. (There is a separate $13 “physician service fee.”)

A new poll from the University of Michigan confirms that older adults will take results seriously: Ninety-seven percent of seniors said they would take steps to improve brain health upon receiving a positive result from a blood test, while 77% said they would consider changes to financial or end-of-life plans.

But research scientists and clinicians worry that Quest hasn’t published any peer-reviewed studies documenting the test’s validity. The company’s preliminary data released at the 2022 Alzheimer’s Association International Conference in San Diego suggests there’s a relatively high chance of false-positive results, said Suzanne Schindler, an associate professor of neurology at Washington University School of Medicine in St. Louis.

That’s a significant problem because telling someone they have biological changes associated with Alzheimer’s disease is a “big deal and you want to be as accurate as possible,” Schindler noted.

Racke said at least three scientific studies giving more details about the AD-Detect test have been submitted to medical journals and might be published by the end of this year.

Experts also question the usefulness of the test since a positive result (indicating abnormal levels of amyloid in the blood) doesn’t mean an individual will definitely develop Alzheimer’s disease. Amyloid in the brain accumulates slowly over the course of decades, typically beginning in middle age, and becomes more common as people age.

“This test gives you a fuzzy answer. We don’t know whether you’re going to get dementia, or when symptoms might begin, or, really, how high the risk is for any individual,” said Meera Sheffrin, medical director of the Senior Care clinic at Stanford Healthcare.

Also, cognitive symptoms that prompt someone to take the test might be due to a wide variety of other causes, including mini-strokes, sleep apnea, thyroid problems, vitamin B12 deficiency, or medication interactions. If an older adult becomes anxious, depressed, or hopeless upon learning they’re at risk for Alzheimer’s — another source of concern — “they may not go for further evaluation and seek appropriate care,” said Rebecca Edelmayer, senior director of scientific engagement at the Alzheimer’s Association.

The University of Michigan poll confirms the potential for misunderstanding. Upon receiving a positive result from a blood test, 74% of seniors said they would believe they were likely to develop Alzheimer’s and 64% said they would be likely to experience significant distress.

Because the science behind blood tests for Alzheimer’s is still developing and because “patients may not really understand the uncertainty of test results,” Edelmayer said, the Alzheimer’s Association “does not endorse the use of the AD-Detect test by consumers.”

Quest’s blood test is one of several developments altering the landscape of Alzheimer’s care in the United States. In early July, the FDA granted full approval to Leqembi, an anti-amyloid therapy that slightly slows cognitive decline in people with mild cognitive impairment and early-stage Alzheimer’s. Early detection of cognitive symptoms and diagnosis of cognitive dysfunction have assumed greater importance now that this disease-modifying drug is available.

Also in July, a work group convened by the National Institute on Aging and the Alzheimer’s Association proposed a new definition of Alzheimer’s disease to be used in clinical practice.

Previously, Alzheimer’s could be diagnosed only when there was evidence of underlying brain pathology (amyloid plaques and tau tangles) as well as cognitive symptoms (memory loss, poor judgment, disorientation, among others) and accompanying impairments (difficulty with managing finances, wandering, problems with self-care, and more). Under the new definition, Alzheimer’s would be defined purely on a biological basis, as a “continuum that is first evident with the appearance of brain pathologic changes” including amyloid accumulation, according to a draft of the work group’s report.

That would mean “you can get a positive result from the Quest test and be diagnosed with Alzheimer’s disease if these guidelines are adopted, even if you’re cognitively normal,” cautioned Eric Widera, a professor of medicine at the University of California-San Francisco.

Demand for follow-up evaluations by dementia specialists is likely to be high and contribute to already-long waits for care, he suggested.

Additional concerns about the test relate to safeguarding privacy and the potential for discrimination. No federal laws protect people who receive Alzheimer’s biomarker results from discriminatory practices, such as employment discrimination or the denial of life, disability, or long-term care insurance. (The Genetic Information Nondiscrimination Act applies only to genetic tests.) And “laws that normally protect the privacy of health information do not apply in this space,” said Emily Largent, an assistant professor of medical ethics and health policy at the University of Pennsylvania’s Perelman School of Medicine.

Notably, HIPAA, the Health Insurance Portability and Accountability Act, doesn’t extend to laboratory tests marketed directly to consumers.

The bottom line: Before taking a test, “older adults need to ask themselves, ‘Why do I want to know this? What will I do with the information? How will I react? What would I change in the future?’” said C. Munro Cullum, a neuropsychologist and distinguished professor of clinical psychology at the University of Texas Southwestern Medical Center. “This test needs to be used very cautiously and with great forethought.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Creating a work of this kind is challenging. For one thing, aging gradually alters people over decades, a long period shaped by individuals’ economic and social circumstances, their behaviors, their neighborhoods, and other factors. Also, while people experience common physiological issues in later life, they don’t follow a well-charted, developmentally predetermined path.

“Predictable changes occur, but not necessarily at the same time or in the same sequence,” said Rosanne Leipzig, vice chair for education at the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai in New York. “There’s no more heterogeneous a group than older people.”

I called Leipzig, 72, who works full time teaching medical residents and fellows and seeing patients, after reading her new 400-plus-page, information-packed book, “Honest Aging: An Insider’s Guide to the Second Half of Life.” It’s the most comprehensive examination of what to expect in later life I’ve come across in a dozen years covering aging.

Leipzig told me she had two goals in writing this guide: “to overcome all the negatives that are out there about growing older” and “to help people understand that there are lots of things that you can do to adapt to your new normal as you age and have an enjoyable, engaged, meaningful life.”

Why call it “Honest Aging”? “Because so much of what’s out there is dishonest, claiming to teach people how to age backwards,” Leipzig said. “I think it’s time we say, ‘This is it; this is who we are,’ and admit how lucky we are to have all these years of extra time.”

The doctor was referring to extraordinary gains in life expectancy achieved in the modern era. Because of medical advances, people over age 60 live far longer than people at the dawn of the 20th century. Still, most of us lack a good understanding of what happens to our bodies during this extended period after middle age.

Several months ago, a medical student asked Leipzig whether references to age should be left out of a patient’s written medical history, as references to race have been eliminated. “I told her no; with medicine, age is always relevant,” Leipzig said. “It gives you a sense of where people are in their life, what they’ve lived through, and the disorders they might have, which are different than those in younger people.”

What questions do older adults tend to ask most often? Leipzig rattled off a list: What can I do about this potbelly? How can I improve my sleep? I’m having trouble remembering names; is this dementia? Do I really need that colonoscopy or mammogram? What should I do to get back into shape? Do I really need to stop driving?

Underlying these is a poor understanding of what’s normal in later life and the physical and mental alterations aging brings.

Can the stages of aging be broken down, roughly, by decade? No, said Leipzig, noting that people in their 60s and 70s vary significantly in health and functioning. Typically, predictable changes associated with aging “start to happen much more between the ages of 75 and 85,” she told me. Here are a few of the age-related issues she highlights in her book:

• Older adults often present with different symptoms when they become ill. For instance, a senior having a heart attack may be short of breath or confused, rather than report chest pain. Similarly, an older person with pneumonia may fall or have little appetite instead of having a fever and cough.
• Older adults react differently to medications. Because of changes in body composition and liver, kidney, and gut function, older adults are more sensitive to medications than younger people and often need lower doses. This includes medications that someone may have taken for years. It also applies to alcohol.
• Older adults have reduced energy reserves. With advancing age, hearts become less efficient, lungs transfer less oxygen to the blood, more protein is needed for muscle synthesis, and muscle mass and strength decrease. The result: Older people generate less energy even as they need more energy to perform everyday tasks.
• Hunger and thirst decline. People’s senses of taste and smell diminish, lessening food’s appeal. Loss of appetite becomes more common, and seniors tend to feel full after eating less food. The risk of dehydration increases.
• Cognition slows. Older adults process information more slowly and work harder to learn new information. Multitasking becomes more difficult, and reaction times grow slower. Problems finding words, especially nouns, are typical. Cognitive changes related to medications and illness are more frequent.
• The musculoskeletal system is less flexible. Spines shorten as the discs that separate the vertebrae become harder and more compressed; older adults typically lose 1 to 3 inches in height as this happens. Balance is compromised because of changes in the inner ear, the brain, and the vestibular system (a complex system that regulates balance and a person’s sense of orientation in space). Muscles weaken in the legs, hips, and buttocks, and range of motion in joints contracts. Tendons and ligaments aren’t as strong, and falls and fractures are more frequent as bones become more brittle.
• Eyesight and hearing change. Older adults need much more light to read than younger people. It’s harder for them to see the outlines of objects or distinguish between similar colors as color and contrast perception diminishes. With changes to the cornea, lens, and fluid within the eye, it takes longer to adjust to sunlight as well as darkness.
• Because of accumulated damage to hair cells in the inner ear, it’s harder to hear, especially at high frequencies. It’s also harder to understand speech that’s rapid and loaded with information or that occurs in noisy environments.
• Sleep becomes fragmented. It takes longer for older adults to fall asleep, and they sleep more lightly, awakening more in the night.

This is by no means a complete list of physiological changes that occur as we grow older. And it leaves out the many ways people can adapt to their new normal, something Leipzig spends a great deal of time discussing.

A partial list of what she suggests, organized roughly by the topics above: Don’t ignore sudden changes in functioning; seek medical attention. At every doctor’s visit, ask why you’re taking medications, whether doses are appropriate, and whether medications can be stopped. Be physically active. Make sure you eat enough protein. Drink liquids even when you aren’t thirsty. Cut down on multitasking and work at your own pace. Do balance and resistance exercises. Have your eyes checked every year. Get hearing aids. Don’t exercise, drink alcohol, or eat a heavy meal within two to three hours of bedtime.

“Never say never,” Leipzig said. “There is almost always something that can be done to improve your situation as you grow older, if you’re willing to do it.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

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Crear esta hoja de ruta no es fácil. El envejecimiento altera a las personas por décadas, un largo período influenciado por circunstancias sociales y económicas, conductas, el lugar en donde se vive, y otros factores. E impacta en la fisiología, pero no de manera uniforme para todos.

“Ocurren cambios predecibles, pero no necesariamente al mismo tiempo y en la misma secuencia”, dijo Rosanne Leipzig, vice presidenta de educación del Departamento de Geriatría y Medicina Paliativa Brookdale de la Facultad de Medicina Icahn de Mount Sinai, en Nueva York. “No hay grupo más heterogéneo que el de las personas mayores”, afirmó Leipzig.

Leipzig, de 72 años, trabaja a tiempo completo enseñando a residentes y becarios médicos y atendiendo pacientes y es autora de “Honest Aging: An Insider’s Guide to the Second Half of Life”, un completo análisis sobre qué esperar en la vejez.

Los objetivos del libro fueron “superar todos los aspectos negativos que existen sobre el envejecimiento” y “ayudar a las personas a comprender que hay muchas cosas que puedes hacer para adaptarte a la nueva normalidad a medida que envejeces, y tener una vida placentera, comprometida y significativa”.

Leipzig se refiere a los extraordinarios avances en la esperanza de vida. Gracias a estos logros médicos, los mayores de 60 años viven mucho más que las personas de principios del siglo XX. Hay más vida, pero no hay una comprensión cabal de lo que ocurre en esta etapa.

Hace unos meses, un estudiante de medicina le preguntó a Leipzig si las referencias a la edad deberían excluirse del historial médico escrito de un paciente, ya que se han eliminado las referencias a la raza. “Le dije que no; en medicina, la edad siempre es relevante”, dijo Leipzig. “Te da una idea de dónde se encuentran las personas en su vida, lo que han vivido y los trastornos que podrían tener, que son diferentes a los de los más jóvenes”.

¿Qué preguntas suelen hacer los adultos mayores con más frecuencia? Leipzig recitó una lista: ¿Qué puedo hacer con esta barriga? ¿Cómo puedo mejorar mi sueño? Tengo problemas para recordar nombres; ¿Es esto demencia? ¿Realmente necesito esa colonoscopía o mamografía? ¿Qué debo hacer para volver a estar en forma? ¿Realmente necesito dejar de conducir?

Detrás de esto se encuentra una mala comprensión de lo que es normal en la vejez y de las alteraciones físicas y mentales que trae consigo el envejecimiento.

Los siguientes son algunos de los problemas relacionados con la edad que destaca en su libro:

Los adultos mayores suelen presentar diferentes síntomas cuando enferman. Por ejemplo, una persona mayor que sufre un ataque cardíaco puede tener dificultad para respirar o sentirse confundida, en lugar de decir que siente dolor en el pecho. Una persona mayor con neumonía puede caerse o tener poco apetito en lugar de fiebre y tos.

Los adultos mayores reaccionan de manera diferente a los medicamentos. Debido a los cambios en la composición corporal y en la función hepática, renal e intestinal, son más sensibles a los medicamentos que las personas más jóvenes y, a menudo, necesitan dosis más bajas. Esto incluye medicamentos que alguien pudo haber tomado durante años. También se aplica al alcohol.

Los adultos mayores tienen reservas de energía reducidas. A medida que avanza la edad, los corazones se vuelven menos eficientes, los pulmones transfieren menos oxígeno a la sangre, se necesita más proteína para la síntesis muscular, y la masa y la fuerza muscular disminuyen. El resultado: las personas mayores generan menos energía incluso cuando necesitan más energía para realizar las tareas cotidianas.

El hambre y la sed disminuyen. Los sentidos del gusto y el olfato de las personas disminuyen, lo que reduce el atractivo de los alimentos. La pérdida de apetito se vuelve más común y las personas mayores tienden a sentirse llenas después de comer menos alimentos. El riesgo de deshidratación aumenta.

La cognición se ralentiza. Los adultos mayores procesan la información más lentamente y tardan más en decodificar nueva información. Las tareas múltiples se vuelven más difíciles y los tiempos de reacción, más lentos. Son típicos los problemas para encontrar palabras, especialmente sustantivos. Los cambios cognitivos relacionados con los medicamentos y las enfermedades son más frecuentes.

El sistema musculoesquelético es menos flexible. La columna se acorta a medida que los discos que separan las vértebras se vuelven más duros y comprimidos; los adultos mayores suelen perder de 1 a 3 pulgadas de altura cuando esto sucede. El equilibrio se ve comprometido. Los músculos de las piernas y las caderas se debilitan y la amplitud de movimiento de las articulaciones se contrae. Los tendones y ligamentos no son tan fuertes, y las caídas y fracturas son más frecuentes a medida que los huesos se vuelven más frágiles.

Cambios en la vista y el oído. Los adultos mayores necesitan mucha más luz para leer que los más jóvenes. Les resulta más difícil ver los contornos de los objetos o distinguir entre colores similares a medida que disminuye la percepción del color y el contraste. Con cambios en la córnea, el cristalino y el líquido dentro del ojo, se necesita más tiempo para adaptarse a la luz del sol y a la oscuridad.

El sueño se fragmenta. Los adultos mayores tardan más en conciliar el sueño, tienen el sueño más ligero y se despiertan más durante la noche.

Además de los consejos sobre comer bien y hacer ejercicio, Leipzig recomienda hablar mucho con el médico, sobre los medicamentos que se consumen, si hay que tomarlos de por vida o no, si logran controlar la afección. Y empezar a hacer las cosas en la vida cotidiana y el trabajo al propio ritmo.

“Nunca digas nunca”, enfatiza Leipzig. “Casi siempre hay algo que se puede hacer para mejorar tu situación a medida que envejeces, si estás dispuesto a hacerlo”.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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LaTurner, 71, had been diagnosed with early-onset dementia seven years before. For two years, she’d been living with LaFleur, who managed insulin injections for her mother’s Type 1 diabetes, helped her shower and dress, dealt with her incontinence, and made sure she was eating well.

In the hospital after her mother’s hip replacement, LaFleur was told her mother would never walk again. When LaTurner came home, two emergency medical technicians brought her on a stretcher into the living room, put her on the bed LaFleur had set up, and wished LaFleur well.

That was the extent of help LaFleur received upon her mother’s discharge.

She didn’t know how to change her mother’s diapers or dress her since at that point LaTurner could barely move. She didn’t know how to turn her mother, who was spending all day in bed, to avoid bedsores. Even after an occupational therapist visited several days later, LaFleur continued to face caretaking tasks she wasn’t sure how to handle.

“It’s already extremely challenging to be a caregiver for someone living with dementia. The lack of training in how to care for my mother just made an impossible job even more impossible,” said LaFleur, who lives in Auburn, Washington, a Seattle suburb. Her mother passed away in March 2022.

A new proposal from the Centers for Medicare & Medicaid Services addresses this often-lamented failure to support family, friends, and neighbors who care for frail, ill, and disabled older adults. For the first time, it would authorize Medicare payments to health care professionals to train informal caregivers who manage medications, assist loved ones with activities such as toileting and dressing, and oversee the use of medical equipment.

The proposal, which covers both individual and group training, is a long-overdue recognition of the role informal caregivers — also known as family caregivers — play in protecting the health and well-being of older adults. About 42 million Americans provided unpaid care to people 50 and older in 2020, according to a much-cited report.

“We know from our research that nearly 6 in 10 family caregivers assist with medical and nursing tasks such as injections, tube feedings, and changing catheters,” said Jason Resendez, president and CEO of the National Alliance for Caregiving. But fewer than 30% of caregivers have conversations with health professionals about how to help loved ones, he said.

Even fewer caregivers for older adults — only 7% — report receiving training related to tasks they perform, according to a June 2019 report in JAMA Internal Medicine.

Nancy LeaMond, chief advocacy and engagement officer for AARP, experienced this gap firsthand when she spent six years at home caring for her husband, who had amyotrophic lateral sclerosis, a neurological condition also known as Lou Gehrig’s disease. Although she hired health aides, they weren’t certified to operate the feeding tube her husband needed at the end of his life and couldn’t show LeaMond how to use it. Instead, she and her sons turned to the internet and trained themselves by watching videos.

“Until very recently, there’s been very little attention to the role of family caregivers and the need to support caregivers so they can be an effective part of the health delivery system,” she told me.

Several details of CMS’ proposal have yet to be finalized. Notably, CMS has asked for public comments on who should be considered a family caregiver for the purposes of training and how often training should be delivered.

(If you’d like to let CMS know what you think about its caregiving training proposal, you can comment on the CMS site until 5 p.m. ET on Sept. 11. The expectation is that Medicare will start paying for caregiver training next year, and caregivers should start asking for it then.)

Advocates said they favor a broad definition of caregiver. Since often several people perform these tasks, training should be available to more than one person, Resendez suggested. And since people are sometimes reimbursed by family members for their assistance, being unpaid shouldn’t be a requirement, suggested Anne Tumlinson, founder and chief executive officer of ATI Advisory, a consulting firm in aging and disability policy.

As for the frequency of training, a one-size-fits-all approach isn’t appropriate given the varied needs of older adults and the varied skills of people who assist them, said Sharmila Sandhu, vice president of regulatory affairs at the American Occupational Therapy Association. Some caregivers may need a single session when a loved one is discharged from a hospital or a rehabilitation facility. Others may need ongoing training as conditions such as heart failure or dementia progress and new complications occur, said Kim Karr, who manages payment policy for AOTA.

When possible, training should be delivered in a person’s home rather than at a health care institution, suggested Donna Benton, director of the University of Southern California’s Family Caregiver Support Center and the Los Angeles Caregiver Resource Center. All too often, recommendations that caregivers get from health professionals aren’t easy to implement at home and need to be adjusted, she noted.

Nancy Gross, 72, of Mendham, New Jersey, experienced this when her husband, Jim Kotcho, 77, received a stem cell transplant for leukemia in May 2015. Once Kotcho came home, Gross was responsible for flushing the port that had been implanted in his chest, administering medications through that site, and making sure all the equipment she was using was sterile.

Although a visiting nurse came out and offered education, it wasn’t adequate for the challenges Gross confronted. “I’m not prone to crying, but when you think your loved one’s life is in your hands and you don’t know what to do, that’s unbelievably stressful,” she told me.

For her part, Cheryl Brown, 79, of San Bernardino, California — a caregiver for her husband, Hardy Brown Sr., 80, since he was diagnosed with ALS in 2002 — is skeptical about paying professionals for training. At the time of his diagnosis, doctors gave Hardy five years, at most, to live. But he didn’t accept that prognosis and ended up defying expectations.

Today, Hardy’s mind is fully intact, and he can move his hands and his arms but not the rest of his body. Looking after him is a full-time job for Cheryl, who is also chair of the executive committee of California’s Commission on Aging and a former member of the California State Assembly. She said hiring paid help isn’t an option, given the expense.

And that’s what irritates Cheryl about Medicare’s training proposal. “What I need is someone who can come into my home and help me,” she told me. “I don’t see how someone like me, who’s been doing this a very long time, would benefit from this. We caregivers do all the work, and the professionals get the money? That makes no sense to me.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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It’s a fraught moment, with hope running high for families and other promising therapies such as donanemab on the horizon. Still, medical providers are cautious. “This is an important first step in developing treatments for complex neurodegenerative diseases, but it’s just a first step,” said Ronald Petersen, director of the Mayo Clinic’s Alzheimer’s Disease Research Center in Rochester, Minnesota.

Unanswered questions abound as this new era of treatment begins for mild cognitive impairment and early-stage Alzheimer’s. Will Leqembi’s primary benefit — a slight slowing of decline in cognition and functioning — make a significant difference to patients and family members or will it be difficult to discern? Will its effects accelerate, decelerate, or flatten out over time?

Will demand for Leqembi (the brand name for lecanemab), a monoclonal antibody that requires infusions every two weeks, be robust or restrained? How many older adults in their 70s and 80s will be able and willing to travel to medical centers for infusions twice a month and have regular MRI scans and physician visits to monitor for potential side effects such as brain bleeds or swelling?

Even with Medicare coverage, how many people will be able to afford the suite of medical services required, including cognitive tests, infusions, doctors’ appointments, MRI scans, genetic tests, and spinal taps or PET scans to verify the presence of amyloid plaques, a hallmark of Alzheimer’s and a precondition for receiving this therapy?

Will primary care physicians start routinely screening older adults for mild cognitive impairment, something that doesn’t happen currently?

These questions aren’t surprising, given that these dementia treatments are opening uncharted territory. Here’s some of what people should know:

Leqembi basics. Leqembi is very effective at removing amyloid plaques (a protein that clumps between neurons) from people’s brains. But it doesn’t reverse cognitive decline or prevent future deterioration.

In a briefing document, Eisai, the company that makes Leqembi, said clinical trials showed a 27% slower rate of decline for people taking the drug. But when raw scores on the cognitive scale used to measure results are considered (4.41 for the Leqembi group at the end of 18 months versus 4.86 for the placebo group), the rate of improvement was 9%, according to Lon Schneider, a professor of psychiatry, neurology, and gerontology at the University of Southern California’s Keck School of Medicine.

Benefits may be hard to detect. Research suggests that patients notice a “clinically meaningful” change in cognitive performance — a noticeable alteration in their ability to think, remember, and perform daily tasks — when scores rise at least 1 point on an 18-point scale used to measure Leqembi’s impact. But the change detected after 18 months for patients taking this medication was only 0.45.

“That’s a minimal difference, and people are unlikely to perceive any real alteration in cognitive functioning,” said Alberto Espay, a professor of neurology at the University of Cincinnati College of Medicine.

Petersen has a different perspective since many patients have told him they’d be happy to put off getting worse. “If we can keep these patients stable for a somewhat longer period of time, that’s meaningful,” he told me.

Side effects are common. The drugmaker reported 17% of patients taking Leqembi experienced swelling in the brain and 13% had brain bleeds. Most of these side effects occurred during the first three months of treatment and resolved without serious consequences four months later.

In slightly more than 1 in 4 cases, there were also infusion-related side effects — chills, aches, nausea, vomiting, a spike or drop in blood pressure, and more.

A little-discussed side effect is a reduction in brain volume associated with Leqembi and other anti-amyloid therapies. “We don’t know what this will mean to patients long term, and that’s concerning,” Espay said.

Because people with the APOE4 gene variant, which raises the risk of Alzheimer’s, are also at higher risk of Leqembi side effects, physicians at major medical centers will recommend genetic testing as they evaluate potential patients.

Not all patients will qualify. “I’m very carefully selecting the patients I think will be appropriate, focusing on people with mild cognitive symptoms who are otherwise healthy,” said Erik Musiek, an associate professor of neurology at the Washington University School of Medicine in St. Louis.

He has about 20 patients ready to start treatment once Washington University starts offering Leqembi, perhaps by early autumn. Delivering this therapy “is going to be challenging, and I think we need to err on the side of caution,” he said.

In Los Angeles, UCLA Health has set up a multidisciplinary group of specialists, similar to a cancer tumor board, to undertake comprehensive reviews of patients who want to take Leqembi, said Keith Vossel, director of UCLA’s Mary S. Easton Center for Alzheimer’s Research and Care. They will disqualify people with evidence of more than four microbleeds on brain MRIs, those taking blood thinners, and those with a history of seizures.

At the Mayo Clinic in Minnesota, a new Alzheimer’s therapeutics clinic will carefully assess potential patients over three to four days and treat only people who live within a 100-mile radius. “We’ll start with patients who are fairly healthy and follow them very closely,” Petersen said.

At Mount Sinai School of Medicine in New York City, Mary Sano, director of Alzheimer’s Disease Research, is concerned about older patients with mild cognitive impairment who want to take Leqembi but don’t have evidence of amyloid plaque accumulation in their brains. “We’ll only treat people who are amyloid-positive, and I’m afraid this could lead to people feeling like we’re not taking care of them,” she said. About 40% to 60% of patients 58 and older with mild cognitive impairment are amyloid-positive, research indicates.

Also of concern are patients who have moderate Alzheimer’s or early-stage cognitive impairment due to vascular dementia or various metabolic causes. They, too, would not be able to take Leqembi and may well be disappointed, Sano noted.

Costs could be considerable. Costs for Leqembi are difficult to calculate since Medicare officials haven’t announced what the government will pay for services. But the University of Southern California estimates that a year’s worth of care, including the $26,500 cost of the medication, could total about $90,000, according to Schneider.

A separate analysis by the Institute for Clinical and Economic Review suggests that all the medical services necessary to administer the drug, monitor patients, and undertake needed testing could total an average of $82,500 yearly on top of Leqembi’s direct cost.

Assuming a patient copayment of 20%, that would mean at least $18,000 in out-of-pocket spending. While many older adults have supplemental insurance (a Medigap plan or employer-sponsored retiree coverage) to cover these costs, nearly 1 in 10 Medicare beneficiaries lack this type of protection. And it remains to be seen what policies private Medicare Advantage plans will put in place for this medication.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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After her weight began climbing in high school, she spent years losing 50 or 100 pounds then gaining it back. Morris, 78, was at her heaviest in her mid-40s, standing 5 feet 10½ inches and weighing 310 pounds. The Pittsburgh resident has had diabetes for more than 40 years.

Managing her weight was a losing battle until Morris’ doctor prescribed a Type 2 diabetes medication, Ozempic, four months ago. It’s one in a new category of medications changing how ordinary people as well as medical experts think about obesity, a condition that affects nearly 4 in 10 people 60 and older.

The drugs include Ozempic’s sister medication, Wegovy, a weight loss drug with identical ingredients, which the FDA approved in 2021, and Mounjaro, approved as a diabetes treatment in 2022. (Ozempic was approved for diabetes in 2017.) Several other drugs are in development.

The medications reduce feelings of hunger, generate a sensation of fullness, and have been shown to help people lose an average of 15% or more of their weight.

“It takes your appetite right away. I wasn’t hungry at all and I lost weight like mad,” said Morris, who has shed 40 pounds.

But how these medications will affect older adults in the long run isn’t well understood. (Patients need to remain on the drugs permanently or risk regaining the weight they’ve lost.)

Will they help prevent cardiovascular disease and other chronic illnesses in obese older adults? Will they reduce rates of disability and improve people’s ability to move and manage daily tasks? Will they enhance people’s lives and alleviate symptoms associated with obesity-related chronic illnesses?

Unfortunately, clinical trials of the medications haven’t included significant numbers of people ages 65 and older, leaving gaps in the available data.

While the drugs appear to be safe — the most common side effects are nausea, diarrhea, vomiting, constipation, and stomach pain — “they’ve only been on the market for a few years and caution is still needed,” said Mitchell Lazar, founding director of the Institute for Diabetes, Obesity and Metabolism at the University of Pennsylvania Perelman School of Medicine.

Given these uncertainties, how are experts approaching the use of the new obesity medications in older people? As might be expected, opinions and practices vary. But several themes emerged in nearly two dozen interviews.

The first was frustration with limited access to the drugs. Because Medicare doesn’t cover weight loss medications and they can cost more than $10,000 a year, seniors’ ability to get the new drugs is restricted.

There is an exception: Medicare will cover Ozempic and Mounjaro if an older adult has diabetes, because the insurance program pays for diabetes therapies.

“We need Medicare to cover these drugs,” said Shauna Matilda Assadzandi, a geriatrician at the University of Pittsburgh who cares for Morris. Recently, she said, she tried to persuade a Medicare Advantage plan representative to authorize Wegovy for a patient with high blood pressure and cholesterol who was gaining weight rapidly.

“I’m just waiting for this patient’s blood sugar to rise to a level where diabetes can be diagnosed. Wouldn’t it make sense to intervene now?” she remembered saying. The representative’s answer: “No. We have to follow the rules.”

Seeking to change that, a bipartisan group of lawmakers has reintroduced the Treat and Reduce Obesity Act, which would require Medicare to cover weight loss drugs. But the proposal, which had been considered previously, has languished amid concerns over enormous potential costs for Medicare.

If all beneficiaries with an obesity diagnosis took brand-name semaglutide drugs (the new class of medications), annual costs would top $13.5 billion, according to a recent analysis in The New England Journal of Medicine. If all older obese adults on Medicare — a significantly larger population — took them, the cost would exceed the total spent on Medicare’s Part D drug program, which was $145 billion in 2019.

Laurie Rich, 63, of Canton, Massachusetts, was caught off guard by Medicare’s policies, which have applied to her since she qualified for Social Security Disability Insurance in December. Before that, Rich took Wegovy and another weight loss medication — both covered by private insurance — and she’d lost nearly 42 pounds. Now, Rich can’t get Wegovy and she’s regained 14 pounds.

“I haven’t changed my eating. The only thing that’s different is that some signal in my brain is telling me I’m hungry all the time,” Rich told me. “I feel horrible.” She knows that if she gains more weight, her care will cost much more.

While acknowledging difficult policy decisions that lie ahead, experts voiced considerable agreement on which older adults should take these drugs.

Generally, the medications are recommended for people with a body mass index over 30 (the World Health Organization’s definition of obesity) and those with a BMI of 27 or above and at least one obesity-related condition, such as diabetes, high blood pressure, or high cholesterol. There are no guidelines for their use in people 65 and older. (BMI is calculated based on a person’s weight and height.)

But those recommendations are problematic because BMI can under- or overestimate older adults’ body fat, the most problematic feature of obesity, noted Rodolfo Galindo, director of the Comprehensive Diabetes Center at the University of Miami Health System.

Dennis Kerrigan, director of weight management at Henry Ford Health in Michigan, a system with five hospitals, suggests physicians also examine waist circumference in older patients because abdominal fat puts them at higher risk than fat carried in the hips or buttocks. (For men, a waist over 40 inches is of concern; for women, 35 is the threshold.)

Fatima Stanford, an obesity medicine scientist at Massachusetts General Hospital, said the new drugs are “best suited for older patients who have clinical evidence of obesity,” such as elevated cholesterol or blood sugar, and people with serious obesity-related conditions such as osteoarthritis or heart disease.

Since going on Mounjaro three months ago, Muriel Branch, 73, of Perryville, Arkansas, has lost 40 pounds and stopped taking three medications as her health has improved. “I feel real good about myself,” she told me.

When adults with obesity lose weight, their risk of dying is reduced by up to 15%, according to Dinesh Edem, Branch’s doctor and the director of the medical weight management program at the University of Arkansas for Medical Sciences.

Still, weight loss alone should not be recommended to older adults, because it entails the loss of muscle mass as well as fat, experts agree. And with aging, the shrinkage of muscle mass that starts earlier in life accelerates, contributing to falls, weakness, the loss of functioning, and the onset of frailty.

Between ages 60 and 70, about 12% of muscle mass falls away, researchers estimate; after 80, it reaches 30%.

To preserve muscle mass, seniors losing weight should be prescribed physical activity — both aerobic exercise and strength training, experts agree.

Also, as older adults taking weight loss drugs eat less, “it’s critically important that their diet includes adequate protein and calcium to preserve bone and muscle mass,” said Anne Newman, director of the Center for Aging and Population Health at the University of Pittsburgh.

Ongoing monitoring of older adults having gastrointestinal side effects is needed to ensure they’re getting enough food and water, said Jamy Ard, co-director of Wake Forest Baptist Health’s Weight Management Center.

Generally, the goal for older adults should be to lose 1 to 2 pounds a week, with attention to diet and exercise accompanying medication management.

“My concern is, once we put patients on these obesity drugs, are we supporting lifestyle changes that will maintain their health? Medication alone won’t be sufficient; we will still need to address behaviors,” said Sukhpreet Singh, system medical director at Henry Ford’s weight management program.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Should they lose this modest extra weight to optimize their health? This question has come to the fore with a new category of diabetes and weight loss drugs giving people hope they can shed excess pounds.

For years, experts have debated what to advise older adults in this situation. On one hand, weight gain is associated with the accumulation of fat. And that can have serious adverse health consequences, contributing to heart disease, diabetes, arthritis, and a host of other medical conditions.

On the other hand, numerous studies suggest that carrying some extra weight can sometimes be protective in later life. For people who fall, fat can serve as padding, guarding against fractures. And for people who become seriously ill with conditions such as cancer or advanced kidney disease, that padding can be a source of energy, helping them tolerate demanding therapies.

Of course, it depends on how heavy someone is to begin with. People who are already obese (with a body mass index of 30 or over) and who put on extra pounds are at greater risk than those who weigh less. And rapid weight gain in later life is always a cause for concern.

Making sense of scientific evidence and expert opinion surrounding weight issues in older adults isn’t easy. Here’s what I learned from reviewing dozens of studies and talking with nearly two dozen obesity physicians and researchers.

Our bodies change with age. As we grow older, our body composition changes. We lose muscle mass — a process that starts in our 30s and accelerates in our 60s and beyond — and gain fat. This is true even when our weight remains constant.

Also, less fat accumulates under the skin while more is distributed within the middle of the body. This abdominal fat is associated with inflammation and insulin resistance and a higher risk of cardiovascular disease, diabetes, and stroke, among other medical conditions.

“The distribution of fat plays a major role in determining how deleterious added weight in the form of fat is,” said Mitchell Lazar, director of the Institute for Diabetes, Obesity and Metabolism at the University of Pennsylvania’s Perelman School of Medicine. “It’s visceral [abdominal] fat [around the waist], rather than peripheral fat [in the hips and buttocks] that we’re really concerned about.”

Activity levels diminish with age. Also, with advancing age, people tend to become less active. When older adults maintain the same eating habits (energy intake) while cutting back on activity (energy expenditure), they’re going to gain weight.

According to the Centers for Disease Control and Prevention, 27% of 65- to 74-year-olds are physically inactive outside of work; that rises to 35% for people 75 or older. For older adults, the health agency recommends at least 150 minutes a week of moderately intense activity, such as brisk walking, as well as muscle-strengthening activities such as lifting weights at least twice weekly. Only 27% to 44% of older adults meet these guidelines, according to various surveys.

Concerns about muscle mass. Experts are more concerned about a lack of activity in older adults who are overweight or mildly obese (a body mass index in the low 30s) than about weight loss. With minimal or no activity, muscle mass deteriorates and strength decreases, which “raises the risk of developing a disability or a functional impairment” that can interfere with independence, said John Batsis, an obesity researcher and associate professor of medicine at the University of North Carolina School of Medicine in Chapel Hill.

Weight loss contributes to inadequate muscle mass insofar as muscle is lost along with fat. For every pound shed, 25% comes from muscle and 75% from fat, on average.

Since older adults have less muscle to begin with, “if they want to lose weight, they need to be willing at the same time to increase physical activity.” said Anne Newman, director of the Center for Aging and Population Health at the University of Pittsburgh School of Public Health.

Ideal body weight may be higher. Epidemiologic research suggests that the ideal body mass index (BMI) might be higher for older adults than younger adults. (BMI is a measure of a person’s weight, in kilograms or pounds, divided by the square of their height, in meters or feet.)

One large, well-regarded study found that older adults at either end of the BMI spectrum — those with low BMIs (under 22) and those with high BMIs (over 33) — were at greater risk of dying earlier than those with BMIs in the middle range (22 to 32.9).

Older adults with the lowest risk of earlier deaths had BMIs of 27 to 27.9. According to World Health Organization standards, this falls in the “overweight” range (25 to 29.9) and above the “healthy weight” BMI range (18.5 to 24.9). Also, many older adults whom the study found to be at highest mortality risk — those with BMIs under 22 — would be classified as having “healthy weight” by the WHO.

The study’s conclusion: “The WHO healthy weight range may not be suitable for older adults.” Instead, being overweight may be beneficial for older adults, while being notably thin can be problematic, contributing to the potential for frailty.

Indeed, an optimal BMI for older adults may be in the range of 24 to 29, Carl Lavie, a well-known obesity researcher, suggested in a separate study reviewing the evidence surrounding obesity in older adults. Lavie is the medical director of cardiac rehabilitation and prevention at Ochsner Health, a large health care system based in New Orleans, and author of “The Obesity Paradox,” a book that explores weight issues in older adults.

Expert recommendations. Obesity physicians and researchers offered several important recommendations during our conversations:

• Maintaining fitness and muscle mass is more important than losing weight for overweight older adults (those with BMIs of 25 to 29.9). “Is losing a few extra pounds going to dramatically improve their health? I don’t think the evidence shows that,” Lavie said.
• Unintentional weight loss is associated with several serious illnesses and is a danger signal that should always be attended to. “See your doctor if you’re losing weight without trying to,” said Newman of the University of Pittsburgh. She’s the co-author of a new paper finding that “unanticipated weight loss even among adults with obesity is associated with increased mortality” risk.
• Ensuring diet quality is essential. “Older adults are at risk for vitamin deficiencies and other nutritional deficits, and if you’re not consuming enough protein, that’s a problem,” said Batsis of the University of North Carolina. “I tell all my older patients to take a multivitamin,” said Dinesh Edem, director of the Medical Weight Management program at the University of Arkansas for Medical Sciences.
• Losing weight is more important for older adults who have a lot of fat around their middle (an apple shape) than it is for people who are heavier lower down (a pear shape). “For patients with a high waist circumference, we’re more aggressive in reducing calories or increasing exercise,” said Dennis Kerrigan, director of weight management at Henry Ford Health in Michigan.
• Maintaining weight stability is a good goal for healthy older adults who are carrying extra weight but who don’t have moderate or severe obesity (BMIs of 35 or higher). By definition, “healthy” means people don’t have serious metabolic issues (overly high cholesterol, blood sugar, blood pressure, and triglycerides), obesity-related disabilities (problems with mobility are common), or serious obesity-related illnesses such as diabetes or heart disease. “No great gains and no great losses — that’s what I recommend,” said Katie Dodd, a geriatric dietitian who writes a blog about nutrition.

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