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.

USE OUR CONTENT

This story can be republished for free (details).

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.

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.

USE OUR CONTENT

This story can be republished for free (details).

Can negotiation and dispute resolution techniques used in the business world help defuse these kinds of conflicts?

Yes, say a group of researchers at Northwestern University. And they’re on to something.

These experts have developed a training curriculum on negotiation and dispute resolution for social workers, care managers, and health care professionals who regularly work with resistant older adults. Materials for family caregivers are being developed, too.

Instead of avoiding difficult issues or simply telling people what to do (“You’ll need home health aides several times a week for the foreseeable future”), professionals learn to elicit what’s most important to older adults and approach arranging care as a collaboration, not an edict from on high.

“People get into so many arguments when they get older. It’s something I see every day in my work,” said Lee Lindquist, chief of geriatrics at Northwestern University’s Feinberg School of Medicine, who’s leading the project. Its goal is to de-escalate conflicts and make it easier for older people to receive needed support, she said.

In May, Lindquist and her team planned to launch another part of the project: a trial of a computer-based training program for family caregivers of people with mild cognitive impairment or early-stage dementia. The program, called NegotiAge, features avatars of older adults and allows caregivers to practice negotiation techniques under different scenarios.

“You get thrown different situations, different emotions, and you get to play the game of negotiation as often as you want,” Lindquist said. Nearly $4 million in funding for the project comes from the National Institutes of Health. After evaluating the program’s effectiveness, Lindquist hopes to make NegotiAge widely available.

In the meantime, there are several steps family caregivers can take to forestall or resolve conflicts with older parents.

Prepare

Preparation is essential for any type of negotiation, advised Jeanne Brett, professor emerita of dispute resolution and organizations at Northwestern’s Kellogg School of Management and a member of the NegotiAge team. “You want to think through answers to several fundamental questions: What issues need to be addressed? Who are the parties invested in these issues? What are the parties’ positions on each of these issues? Why do you believe they’re taking those positions? And what’s going to happen if we can’t reach an agreement?”

It’s helpful to write down answers to these questions in a planning document. Be sure to include yourself among the parties and spell out your goals for the conversations to come.

What might this look like in practice? Let’s say you want your father, who’s in his early 90s, to stop driving, because he’s started getting lost and his vision isn’t great. The people with a stake in the discussion include your father, your elderly mother, you, your two siblings, and your father’s physician.

Your mom may be concerned about your father’s safety but hesitant to raise the issue for fear of provoking an argument. One of your siblings may agree it’s time to take away the car keys, while the other may think Dad is still fine on the road. The doctor may recommend a driving evaluation and subsequently offer his professional opinion.

Look for Common Interests

Your job is to find areas where these parties’ interests intersect and work from there. Everyone wants your father to remain active and see his friends on a regular basis. Everyone wants to ensure he doesn’t injure himself or anyone else on the road. Everyone wants to respect his desire for independence. No one wants to label him incompetent.

Brett distinguishes between positions, such as “I’m not going to stop driving,” and interests, or the reasons why someone takes a position. In this case, Dad may be afraid of becoming isolated, losing autonomy, or giving up control over his affairs. But he, too, may worry about hurting somebody else unintentionally.

Negotiations have the best chance of success when they address the interests of all the parties involved, Brett noted. Don’t adopt an adversarial approach. Rather, emphasize that you’re on the same team. The goal isn’t for one side to win; it’s for people to work together to find a solution to the issue at hand.

Ask Questions

Don’t assume you know why your parent is taking a certain position (“I don’t want to go to the doctor”). Instead, ask follow-up questions, such as “Why?” or “Why not?”

If an older person snaps, “I don’t want to talk about it,” don’t back away. Acknowledge their discomfort by saying, “I understand this is difficult,” while adding, “I care about you and I want to know more.”

Lindquist favors starting difficult discussions with patients with open-ended questions: “What are some things you’re having issues with? What are you doing that you wish you could be doing differently? What would make your life easier?”

Listening carefully and making the person you’re negotiating with feel heard and respected is essential. If one of Lindquist’s patients tells her, “I make my own choices, and this is what I want,” she might respond, “I agree you’re the boss, but we’re both here to make your life better, and I’m worried about you.”

Brainstorm Strategies

Negotiations with family members are often charged with emotions that can easily spiral out of control. But don’t reciprocate if someone gets angry and lashes out.

“When you’re buying a car, if you can’t agree with the dealer you’re talking to, you can go to another dealer. When you’re in a conflict with a family member, you don’t have this option. You’ve got more stubbornness and more defensiveness about disabilities,” Brett said, “and preserving relationships is even more important.”

Redirect your focus to brainstorming strategies that can help solve the problem at hand. Get creative and put lots of options on the table. Invite your parent to respond and ask “Why?” or “Why not?” again as needed.

If you find yourself going round and round without making progress, try saying something like, “We could argue about this all afternoon, but neither one of us is going to give in. Let’s set aside our arguments and come up with five ways that you can get to activities without your car,” Brett said.

Don’t expect to agree on a strategy right away. “You can say, ‘Let’s bring in Mom and talk about this later,’ or, ‘Let’s think about this and check in with each other next week,’” Lindquist suggested, noting that many negotiations take time and can’t be rushed.

Bring In a Third Party

If all else fails, appeal to a third party. This was Brett’s strategy when her husband, who has Parkinson’s disease and compromised vision, wanted to resume driving in 2021 after recovering from a serious fall. Brett and the couple’s daughter couldn’t convince him this might be risky, but the older man, then 89, agreed to get a driving evaluation at a facility associated with a Chicago hospital. When they recommended he stop driving, he gave up the car keys.

Brett later hired a neighbor in the small town in France where they now live to ferry her husband to appointments several times a week. Twice a week, she drives him to a nearby village where he has coffee with friends. He gets out into the world and she doesn’t worry about safety — an outcome both can live with.

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.

USE OUR CONTENT

This story can be republished for free (details).

The estimates are sobering: By 2060, the prevalence of ischemic heart disease (a condition caused by blocked arteries and also known as coronary artery disease) is projected to rise 31% compared with 2025; heart failure will increase 33%; heart attacks will grow by 30%; and strokes will increase by 34%, according to a team of researchers from Harvard and other institutions. The greatest increase will come between 2025 and 2030, they predicted.

The dramatic expansion of the U.S. aging population (cardiovascular disease is far more common in older adults than in younger people) and rising numbers of people with conditions that put them at risk of heart disease and stroke — high blood pressure, diabetes, and obesity foremost among them — are expected to contribute to this alarming scenario.

Because the risk factors are more common among Black and Hispanic populations, cardiovascular illness and death will become even more common for these groups, the researchers predicted. (Hispanic people can be of any race or combination of races.)

“Disparities in the burden of cardiovascular disease are only going to be exacerbated” unless targeted efforts are made to strengthen health education, expand prevention, and improve access to effective therapies, wrote the authors of an accompanying editorial, from Stony Brook University in New York and Baylor University Medical Center in Texas.

“Whatever focus we’ve had before on managing [cardiovascular] disease risk in Black and Hispanic Americans, we need to redouble our efforts,” said Clyde Yancy, chief of cardiology and vice dean for diversity and inclusion at Northwestern University’s Feinberg School of Medicine in Chicago, who was not involved with the research.

Of course, medical advances, public health policies, and other developments could alter the outlook for cardiovascular disease over the next several decades.

More than 80% of cardiovascular deaths occur among adults 65 or older. For about a dozen years, the total number of cardiovascular deaths in this age group has steadily ticked upward, as the ranks of older adults have expanded and previous progress in curbing fatalities from heart disease and strokes has been undermined by Americans’ expanding waistlines, poor diets, and physical inactivity.

Among people 65 and older, cardiovascular deaths plunged 22% between 1999 and 2010, according to data from the National Heart, Lung, and Blood Institute — a testament to new medical and surgical therapies and treatments and a sharp decline in smoking, among other public health initiatives. Then between 2011 and 2019, deaths climbed 13%.

The covid-19 pandemic has also added to the death toll, with coronavirus infections causing serious complications such as blood clots and millions of seniors avoiding seeking medical care out of fear of becoming infected. Most affected have been low-income individuals, and older non-Hispanic Black and Hispanic people, who have died from the virus at disproportionately higher rates than non-Hispanic white people.

“The pandemic laid bare ongoing health inequities,” and that has fueled a new wave of research into disparities across various medical conditions and their causes, said Nakela Cook, a cardiologist and executive director of the Patient-Centered Outcomes Research Institute, an independent organization authorized by Congress.

One of the most detailed examinations yet, published in JAMA Cardiology in March, examined mortality rates in Hispanic, non-Hispanic Black, and non-Hispanic white populations from 1990 to 2019 in all 50 states and the District of Columbia. It showed that Black men remain at the highest risk of dying from cardiovascular disease, especially in Southern states along the Mississippi River and in the northern Midwest. (The age-adjusted mortality rate from cardiovascular disease for Black men in 2019 was 245 per 100,000, compared with 191 per 100,000 for white men and 135 per 100,000 for Hispanic men. Results for women within each demographic were lower.)

Progress stemming deaths from cardiovascular disease in Black men slowed considerably between 2010 and 2019. Across the country, cardiovascular deaths for that group dropped 13%, far less than the 28% decline from 2000 to 2010 and 19% decline from 1990 to 2000. In the regions where Black men were most at risk, the picture was even worse: In Mississippi, for instance, deaths of Black men fell only 1% from 2010 to 2019, while in Michigan they dropped 4%. In the District of Columbia, they actually rose, by nearly 5%.

While individual lifestyles are partly responsible for the unequal burden of cardiovascular disease, the American Heart Association’s 2017 scientific statement on the cardiovascular health of African Americans notes that “perceived racial discrimination” and related stress are associated with hypertension, obesity, persistent inflammation, and other clinical processes that raise the risk of cardiovascular disease.

Though Black people are deeply affected, so are other racial and ethnic minorities who experience adversity in their day-to-day lives, several experts noted. However, recent studies of cardiovascular deaths don’t feature some of these groups, including Asian Americans and Native Americans.

What are the implications for the future? Noting significant variations in cardiovascular health outcomes by geographic location, Alain Bertoni, an internist and professor of epidemiology and prevention at Wake Forest University School of Medicine, said, “We may need different solutions in different parts of the country.”

Gregory Roth, a co-author of the JAMA Cardiology paper and an associate professor of cardiology at the University of Washington School of Medicine, called for a renewed effort to educate people in at-risk communities about “modifiable risk factors” — high blood pressure, high cholesterol, obesity, diabetes, smoking, inadequate physical activity, unhealthy diet, and insufficient sleep. The American Heart Association has suggestions on its website for promoting cardiovascular health in each of these areas.

Michelle Albert, a cardiologist and the current president of the American Heart Association, said more attention needs to be paid in medical education to “social determinants of health” — including income, education, housing, neighborhood environments, and community characteristics — so the health care workforce is better prepared to address unmet health needs in vulnerable populations.

Natalie Bello, a cardiologist and the director of hypertension research at the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles, said, “We really need to be going into vulnerable communities and reaching people where they’re at to increase their knowledge of risk factors and how to reduce them.” This could mean deploying community health workers more broadly or expanding innovative programs like ones that bring pharmacists into Black-owned barbershops to educate Black men about high blood pressure, she suggested.

“Now, more than ever, we have the medical therapies and technologies in place to treat cardiovascular conditions,” said Rishi Wadhera, a cardiologist and section head of health policy and equity research at the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center in Boston. What’s needed, he said, are more vigorous efforts to ensure all older patients, including those from disadvantaged communities, are connected with primary care physicians and receive appropriate screening and treatment for cardiovascular risk factors, and high-quality, evidence-based care in the event of heart failure, a heart attack, or a stroke.

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.

USE OUR CONTENT

This story can be republished for free (details).

Her 80-year-old mother, Harriet Burkel, had fallen at her home in Raleigh, North Carolina, fractured her pelvis, and gone to a rehabilitation center to recover. It was only days after the death of Burkel’s 82-year-old husband, who’d moved into a memory care facility three years before.

With growing distress, Sylvester had watched her mother, who had emphysema and peripheral artery disease, become increasingly frail and isolated. “I would say, ‘Can I help you?’ And my mother would say, ‘No, I can do this myself. I don’t need anything. I can handle it,’” Sylvester told me.

Now, Sylvester had a chance to get some more information. She let herself into her mother’s home and went through all the paperwork she could find. “It was a shambles — completely disorganized, bills everywhere,” she said. “It was clear things were out of control.”

Sylvester sprang into action, terminating her mother’s orders for anti-aging supplements, canceling two car warranty insurance policies (Burkel wasn’t driving at that point), ending a yearlong contract for knee injections with a chiropractor, and throwing out donation requests from dozens of organizations. When her mother found out, she was furious.

“I was trying to save my mother, but I became someone she couldn’t trust — the enemy. I really messed up,” Sylvester said.

Dealing with an older parent who stubbornly resists offers of help isn’t easy. But the solution isn’t to make an older person feel like you’re steamrolling them and taking over their affairs. What’s needed instead are respect, empathy, and appreciation of the older person’s autonomy.

“It’s hard when you see an older person making poor choices and decisions. But if that person is cognitively intact, you can’t force them to do what you think they should do,” said Anne Sansevero, president of the board of directors of the Aging Life Care Association, a national organization of care managers who work with older adults and their families. “They have a right to make choices for themselves.”

That doesn’t mean adult children concerned about an older parent should step aside or agree to everything the parent proposes. Rather, a different set of skills is needed.

Cheryl Woodson, an author and retired physician based in the Chicago area, learned this firsthand when her mother — whom Woodson described as a “very powerful” woman — developed mild cognitive impairment. She started getting lost while driving and would buy things she didn’t need then give them away.

Chastising her mother wasn’t going to work. “You can’t push people like my mother or try to take control,” Woodson told me. “You don’t tell them, ‘No, you’re wrong,’ because they changed your diapers and they’ll always be your mom.”

Instead, Woodson learned to appeal to her mother’s pride in being the family matriarch. “Whenever she got upset, I’d ask her, ‘Mother, what year was it that Aunt Terri got married?’ or ‘Mother, I don’t remember how to make macaroni. How much cheese do you put in?’ And she’d forget what she was worked up about and we’d just go on from there.”

Woodson, author of “To Survive Caregiving: A Daughter’s Experience, a Doctor’s Advice,” also learned to apply a “does it really matter to safety or health?” standard to her mother’s behavior. It helped Woodson let go of her sometimes unreasonable expectations. One example she related: “My mother used to shake hot sauce on pancakes. It would drive my brother nuts, but she was eating, and that was good.”

“You don’t want to rub their nose into their incapacity,” said Woodson, whose mother died in 2003.

Barry Jacobs, a clinical psychologist and family therapist, sounded similar themes in describing a psychiatrist in his late 70s who didn’t like to bend to authority. After his wife died, the older man stopped shaving and changing his clothes regularly. Though he had diabetes, he didn’t want to see a physician and instead prescribed medicine for himself. Even after several strokes compromised his vision, he insisted on driving.

Jacobs’ take: “You don’t want to go toe-to-toe with someone like this, because you will lose. They’re almost daring you to tell them what to do so they can show you they won’t follow your advice.”

What’s the alternative? “I would employ empathy and appeal to this person’s pride as a basis for handling adversity or change,” Jacobs said. “I might say something along the lines of, ‘I know you don’t want to stop driving and that this will be very painful for you. But I know you have faced difficult, painful changes before and you’ll find your way through this.’”

“You’re appealing to their ideal self rather than treating them as if they don’t have the right to make their own decisions anymore,” he explained. In the older psychiatrist’s case, conflict with his four children was constant, but he eventually stopped driving.

Another strategy that can be useful: “Show up, but do it in a way that’s face-saving,” Jacobs said. Instead of asking your father if you can check in on him, “Go to his house and say, ‘The kids really wanted to see you. I hope you don’t mind.’ Or, ‘We made too much food. I hope you don’t mind my bringing it over.’ Or, ‘I wanted to stop by. I hope you can give me some advice about this issue that’s on my mind.’”

This psychiatrist didn’t have any cognitive problems, though he wasn’t as sharp as he used to be. But encroaching cognitive impairment often colors difficult family interactions.

If you think this might be a factor with your parent, instead of trying to persuade them to accept more help at home, try to get them medically evaluated, said Leslie Kernisan, author of “When Your Aging Parent Needs Help: A Geriatrician’s Step-by-Step Guide to Memory Loss, Resistance, Safety Worries, and More.”

“Decreased brain function can affect an older adult’s insight and judgment and ability to understand the risks of certain actions or situations, while also making people suspicious and defensive,” she noted.

This doesn’t mean you should give up on talking to an older parent with mild cognitive impairment or early-stage dementia, however. “You always want to give the older adult a chance to weigh in and talk about what’s important to them and their feelings and concerns,” Kernisan said.

“If you frame your suggestions as a way of helping your parent achieve a goal they’ve said was important, they tend to be much more receptive to it,” she said.

A turning point for Sylvester and her mother came when the older woman, who developed dementia, went to a nursing home at the end of 2021. Her mother, who at first didn’t realize the move was permanent, was furious, and Sylvester waited two months before visiting. When she finally walked into Burkel’s room, bearing a Valentine’s Day wreath, Burkel hugged her and said, “I’m so glad to see you,” before pulling away. “But I’m so mad at my other daughter.”

Sylvester, who doesn’t have a sister, responded, “I know, Mom. She meant well, but she didn’t handle things properly.” She learned the value of what she calls a “therapeutic fiblet” from Kernisan, who ran a family caregiver group Sylvester attended between 2019 and 2021.

After that visit, Sylvester saw her mother often, and all was well between the two women up until Burkel’s death. “If something was upsetting my mother, I would just go, ‘Interesting,’ or, ‘That’s a thought.’ You have to give yourself time to remember this is not the person you used to know and create the person you need to be for your parent, who’s changed so much.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Su madre, Harriet Burkel, de 80 años, se había caído en su casa en Raleigh, Carolina del Norte. Se fracturó la pelvis y fue a un centro de rehabilitación para recuperarse. Ocurrió pocos días después de la muerte del esposo de Burkel, de 82, quien había ingresado a un centro de atención de la memoria tres años antes.

Con una angustia creciente, Sylvester veía como su madre, quien padecía de enfisema y enfermedad arterial periférica, se volvía cada vez más frágil y aislada. “Yo le decía: ‘¿Puedo ayudarte?’ Y mi madre me respondía: ‘No, puedo hacer sola. No necesito nada. Puedo manejarlo'”, me contó Sylvester.

Finalmente, halló la oportunidad de obtener más información. Entró sin ser vista en la casa de su madre y revisó toda la documentación que pudo encontrar. “Era un desastre, completamente desorganizado, facturas por todas partes”, dijo. “Era claro que las cosas estaban fuera de control”.

Sylvester actuó de inmediato, cancelando los pedidos de suplementos anti envejecimiento de su madre, anulando dos pólizas de seguro de garantía para automóviles (Burkel ya no conducía), terminando un contrato de un año para inyecciones de rodilla con un quiropráctico, y desechando solicitudes de donación de docenas de organizaciones.

Cuando su madre se enteró, se puso furiosa.

“Estaba tratando de salvarla, pero me convertí en alguien en quien no podía confiar, en el enemigo. Realmente metí la pata”, dijo Sylvester.

Lidiar con un padre mayor que se resiste obstinadamente a aceptar ayuda no es fácil. Pero la solución no es que los padres sientan que se está pasando por encima de ellos, tomando el control de sus asuntos. En cambio, lo que se necesita es respeto, empatía y aprecio por la autonomía de la persona mayor.

“Es difícil cuando ves que una persona mayor toma decisiones y elecciones equivocadas. Pero si esa persona tiene sus facultades cognitivas intactas, no puedes obligarla a hacer lo que crees que debería hacer”, dijo Anne Sansevero, presidenta de la junta directiva de la Aging Life Care Association, una organización nacional de administradores de atención que trabajan con adultos mayores y sus familias. “Tienen derecho a tomar decisiones por sí mismos”.

Eso no significa que los hijos adultos preocupados por un padre mayor deban apartarse o aceptar todo lo que propone el padre. Más bien, se requiere un conjunto de habilidades especial.

Cheryl Woodson, autora y médica jubilada de la zona de Chicago, aprendió esto de primera mano cuando su madre, a quien describió como una mujer “muy poderosa”, desarrolló un deterioro cognitivo leve. Empezó a perderse mientras conducía, y compraba cosas que no necesitaba para luego regalarlas.

Retar a su madre no iba a funcionar. “No puedes presionar a personas como mi madre o tratar de controlarlas”, me dijo Woodson. “No les dices ‘Estás equivocada’, porque ellas te cambiaron los pañales y siempre serán tu mamá”.

En cambio, Woodson aprendió a apelar al orgullo de su madre como matriarca de la familia. “Cuando se enojaba, le preguntaba: ‘Madre, ¿en qué año se casó la tía Terri?’ o ‘Mamá, no recuerdo cómo hacer macarrones. ¿Cuánto queso se usa?’ Y ella olvidaba por qué estaba alterada y seguíamos adelante”.

Woodson, autora de “To Survive Caregiving: A Daugther’s Experience, a Doctor’s Advice”, también aprendió a aplicar un estándar de “¿realmente importa para la seguridad o la salud?” al comportamiento de su madre.

Esto la ayudó a dejar de lado sus expectativas a veces irracionales. Un ejemplo que mencionó fue: “Mi madre solía poner salsa picante en los panqueques. A mi hermano lo volvía loco, pero ella estaba comiendo, y eso era bueno”.

“No quieres echarles en cara su incapacidad”, dijo Woodson, cuya madre falleció en 2003.

Barry Jacobs, psicólogo clínico y terapeuta familiar, expresó ideas similares al describir a un psiquiatra de unos 70 años al que no le gustaba ceder ante la autoridad. Después de que su esposa falleciera, el hombre mayor dejó de afeitarse y cambiar de ropa regularmente. A pesar de tener diabetes, no quería ver a un médico y, en cambio, se recetaba medicamentos a sí mismo. Incluso después de varios accidentes cerebrovasculares que comprometieron su visión, insistía en seguir conduciendo.

La opinión de Jacobs es: “No debes enfrentarte directamente a alguien así, porque perderás. Casi te están desafiando para que les digas qué hacer y así demostrarte que no seguirán tu consejo”.

¿Cuál es la alternativa? “Yo emplearía la empatía y apelaría al orgullo de esta persona como base para enfrentar la adversidad o el cambio”, dijo Jacobs. “Podría decir algo así como: ‘Sé que no quieres dejar de conducir y que te causará mucho dolor. Pero has enfrentado cambios difíciles y dolorosos antes, y encontrarás la manera de superarlo'”.

“Estás apelando a su ‘ego’ en lugar de tratarlos como si no tuvieran derecho a tomar sus propias decisiones”, explicó. En el caso del psiquiatra mayor, el conflicto con sus cuatro hijos era constante, pero finalmente dejó de conducir.

Otra buena estrategia es presentarte por sorpresa, pero haciéndolo de una manera que mantenga la dignidad de tu padre. En lugar de preguntarle directamente si puedes visitarlo, puedes ir a su casa y decir algo como: “Los niños realmente querían verte. Espero que no te importe”. o “Hicimos demasiada comida. Espero que no te importe que la traiga”; o “Quería pasar por aquí. Espero que puedas darme algún consejo sobre este tema que me preocupa”.

Si crees que el deterioro cognitivo podría ser un factor en el comportamiento de tu padre, en lugar de tratar de persuadirlo para que acepte más ayuda en casa, intenta que tenga una evaluación médica, como sugiere Leslie Kernisan, autora de “When Your Aging Parent Needs Help: A Geriatrician’s Step-by-Step Guide to Memory Loss, Resistance, Safety Worries, and More”.

“La disminución de la función cerebral puede afectar la percepción, el juicio y la capacidad de comprender los riesgos de ciertas acciones o situaciones en un adulto mayor, lo que puede hacer que se pongan sospechosos y a la defensiva”, señala Kernisan.

Sin embargo, esto no significa que debas renunciar a hablar con un padre mayor que tenga un deterioro cognitivo leve o demencia en etapa inicial. “Si enmarcas tus sugerencias como una forma de ayudar a tu padre a alcanzar una meta que él considera importante, es más probable que las acepte”, afirma Kernisan.

Un punto de inflexión para Sylvester y su madre ocurrió cuando la mujer mayor, que desarrolló demencia, ingresó a una residencia a fines de 2021. Al principio, no se dio cuenta de que el traslado era permanente y estaba furiosa, por lo que Sylvester esperó dos meses antes de visitarla. Cuando finalmente entró en la habitación de Burkel llevando un regalo de San Valentín, su madre la abrazó y dijo: “Me alegra verte”, antes de alejarse y decir: “Pero estoy muy enojada con mi otra hija”.

Sylvester, que no tiene una hermana, respondió: “Lo sé, mamá. Ella tenía buenas intenciones, pero no manejó las cosas correctamente”. Aprendió el valor de un “pequeño engaño terapéutico”, como lo llama Kernisan, quien dirigió un grupo de cuidadores familiares al que Sylvester asistió entre 2019 y 2021.

Después de esa visita, Sylvester vio a su madre con frecuencia y todo se mantuvo bien entre las dos mujeres hasta la muerte de Burkel. “Si algo perturbaba a mi madre, simplemente decía: ‘Interesante’ o ‘Eso es algo para pensar’. Debes darte tiempo para recordar que esta no es la persona que solías conocer y simplemente es alguien que ha cambiado tanto”.

Nos gustaría escuchar de los lectores las preguntas que pueden tener, los problemas que han tenido con su atención y los consejos que necesitan para lidiar con el sistema de atención médica. Visita kffhealthnews.org/columnists para enviar tus solicitudes o sugerencias.

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.

USE OUR CONTENT

This story can be republished for free (details).

For years, Carole Leskin, 78, enjoyed this close camaraderie with five women in Moorestown, New Jersey, a group that took classes together, gathered for lunch several times a week, celebrated holidays with one another, and socialized frequently at their local synagogue.

Leskin was different from the other women — unmarried, living alone, several years younger — but they welcomed her warmly, and she basked in the feeling of belonging. Although she met people easily, Leskin had always been something of a loner and her intense involvement with this group was something new.

Then, just before the covid-19 pandemic struck, it was over. Within two years, Marlene died of cancer. Lena had a fatal heart attack. Elaine succumbed to injuries after a car accident. Margie died of sepsis after an infection. Ruth passed away after an illness.

Leskin was on her own again, without anyone to commiserate or share her worries with as pandemic restrictions went into effect and waves of fear swept through her community. “The loss, the isolation; it was horrible,” she told me.

What can older adults who have lost their closest friends and family members do as they contemplate the future without them? If, as research has found, good relationships are essential to health and well-being in later life, what happens when connections forged over the years end?

It would be foolish to suggest these relationships can easily be replaced: They can’t. There’s no substitute for people who’ve known you a long time, who understand you deeply, who’ve been there for you reliably in times of need, and who give you a sense of being anchored in the world.

Still, opportunities to create bonds with other people exist, and “it’s never too late to develop meaningful relationships,” said Robert Waldinger, a clinical professor of psychiatry at Harvard Medical School and director of the Harvard Study of Adult Development.

That study, now in its 85th year, has shown that people with strong connections to family, friends, and their communities are “happier, physically healthier, and live longer than people who are less well connected,” according to The Good Life: Lessons From the World’s Longest Scientific Study of Happiness, a new book describing its findings, co-written by Waldinger and Marc Schulz, the Harvard study’s associate director.

Waldinger’s message of hope involves recognizing that relationships aren’t only about emotional closeness, though that’s important. They’re also a source of social support, practical help, valuable information, and ongoing engagement with the world around us. And all these benefits remain possible, even when cherished family and friends pass on.

Say you’ve joined a gym and you enjoy the back-and-forth chatter among people you’ve met there. “That can be nourishing and stimulating,” Waldinger said. Or, say, a woman from your neighborhood has volunteered to give you rides to the doctor. “Maybe you don’t know each other well or confide in each other, but that person is providing practical help you really need,” he said.

Even casual contacts — the person you chat with in the coffee shop or a cashier you see regularly at the local supermarket — “can give us a significant hit of well-being,” Waldinger said. Sometimes, the friend of a friend is the person who points you to an important resource in your community you wouldn’t otherwise know about.

After losing her group of friends, Leskin suffered several health setbacks — a mild stroke, heart failure, and, recently, a nonmalignant brain tumor — that left her unable to leave the house most of the time. About 4.2 million people 70 and older are similarly “homebound” — a figure that has risen dramatically in recent years, according to a study released in December 2021.

Determined to escape what she called “solitary confinement,” Leskin devoted time to writing a blog about aging and reaching out to readers who got in touch with her. She joined a virtual travel site and found a community of people with common interests, including five (two in Australia, one in Ecuador, one in Amsterdam and one in New York) who’ve become treasured friends.

“Between [Facebook] Messenger and email, we write like old-fashioned pen pals, talking about the places we’ve visited,” she told me. “It has been lifesaving.”

Still, Leskin can’t call on these long-distance virtual friends to come over if she needs help, to share a meal, or to provide the warmth of a physical presence. “I miss that terribly,” she said.

Research confirms that virtual connections yield mixed results. On one hand, older adults who routinely connect with other people via cellphones and computers are less likely to be socially isolated than those who don’t, several studies suggest. Shifting activities for older adults such as exercise classes, social hours, and writing groups online has helped many people remain engaged while staying safe during the pandemic, noted Kasley Killam, executive director of Social Health Labs, an organization focused on reducing loneliness and fostering social connections.

But when face-to-face contact with other people diminishes significantly — or disappears altogether, as was true for millions of older adults in the past three years — seniors are more likely to be lonely and depressed, other studies have found.

“If you’re in the same physical location as a friend or family member, you don’t have to be talking all the time: You can just sit together and feel comfortable. These low-pressure social interactions can mean a lot to older adults and that can’t be replicated in a virtual environment,” said Ashwin Kotwal, an assistant professor of medicine in the division of geriatrics at the University of California-San Francisco who has studied the effects of engaging with people virtually.

Meanwhile, millions of seniors — disproportionately those who are low-income, represent racial and ethnic minorities, or are older than 80 — can’t afford computers or broadband access or aren’t comfortable using anything but the phone to reach out to others.

Liz Blunt, 76, of Arlington, Texas, is among them. She hasn’t recovered from her husband’s death in September 2021 from non-Hodgkin lymphoma, a blood cancer. Several years earlier, Blunt’s closest friend, Janet, died suddenly on a cruise to Southeast Asia, and two other close friends, Vicky and Susan, moved to other parts of the country.

“I have no one,” said Blunt, who doesn’t have a cellphone and admitted to being “technologically unsavvy.”

When we first spoke in mid-March, Blunt had seen only one person she knows fairly well in the past 4½ months. Because she has several serious health issues, she has been extremely cautious about catching covid and hardly goes out. “I’m not sure where to turn to make friends,” she said. “I’m not going to go somewhere and take my mask off.”

But Blunt hadn’t given up altogether. In 2016, she’d started a local group for “elder orphans” (people without spouses or children to depend on). Though it sputtered out during the pandemic, Blunt thought she might reconnect with some of those people, and she sent out an email inviting them to lunch.

On March 25, eight women met outside at a restaurant and talked for 2½ hours. “They want to get together again,” Blunt told me when I called again, with a note of eagerness in her voice. “Looking in the mirror, I can see the relief in my face. There are people who care about me and are concerned about me. We’re all in the same situation of being alone at this stage of life — and we can help each other.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Initially, Johnson, now 77, thought she was depressed. She could barely summon the energy to get dressed in the morning. Some days, she couldn’t get out of bed.

But as she began to get her affairs in order, Johnson realized something else was going on. However long she slept the night before, she woke up exhausted. She felt depleted, even if she didn’t do much during the day.

“People would tell me, ‘You know, you’re getting old.’ And that wasn’t helpful at all. Because then you feel there’s nothing you can do mentally or physically to deal with this,” she told me.

Fatigue is a common companion of many illnesses that beset older adults: heart disease, cancer, rheumatoid arthritis, lung disease, kidney disease, and neurological conditions like multiple sclerosis, among others. It’s one of the most common symptoms associated with chronic illness, affecting 40% to 74% of older people living with these conditions, according to a 2021 review by researchers at the University of Massachusetts.

This is more than exhaustion after an extremely busy day or a night of poor sleep. It’s a persistent whole-body feeling of having no energy, even with minimal or no exertion. “I feel like I have a drained battery pretty much all of the time,” wrote a user named Renee in a Facebook group for people with polycythemia vera, a rare blood cancer. “It’s sort of like being a wrung-out dish rag.”

Fatigue doesn’t represent “a day when you’re tired; it’s a couple of weeks or a couple of months when you’re tired,” said Dr. Kurt Kroenke, a research scientist at the Regenstrief Institute in Indianapolis, which specializes in medical research, and a professor at Indiana University’s School of Medicine.

When he and colleagues queried nearly 3,500 older patients at a large primary care clinic in Indianapolis about bothersome symptoms, 55% listed fatigue — second only to musculoskeletal pain (65%) and more than back pain (45%) and shortness of breath (41%).

Separately, a 2010 study in the Journal of the American Geriatrics Society estimated that 31% of people 51 and older reported being fatigued in the past week.

The impact can be profound. Fatigue is the leading reason for restricted activity in people 70 and older, according to a 2001 study by researchers at Yale. Other studies have linked fatigue with impaired mobility, limitations in people’s abilities to perform daily activities, the onset or worsening of disability, and earlier death.

What often happens is older adults with fatigue stop being active and become deconditioned, which leads to muscle loss and weakness, which heightens fatigue. “It becomes a vicious cycle that contributes to things like depression, which can make you more fatigued,” said Dr. Jean Kutner, a professor of medicine and chief medical officer at the University of Colorado Hospital.

To stop that from happening, Johnson came up with a plan after learning her lung cancer had returned. Every morning, she set small goals for herself. One day, she’d get up and wash her face. The next, she’d take a shower. Another day, she’d go to the grocery store. After each activity, she’d rest.

In the three years since her cancer came back, Johnson’s fatigue has been constant. But “I’m functioning better,” she told me, because she’s learned how to pace herself and find things that motivate her, like teaching a virtual class to students training to be teachers and getting exercise under the supervision of a personal trainer.

When should older adults be concerned about fatigue? “If someone has been doing OK but is now feeling fatigued all the time, it’s important to get an evaluation,” said Dr. Holly Yang, a physician at Scripps Mercy Hospital in San Diego and incoming board president of the American Academy of Hospice and Palliative Medicine.

“Fatigue is an alarm signal that something is wrong with the body but it’s rarely one thing. Usually, several things need to be addressed,” said Dr. Ardeshir Hashmi, section chief of the Center for Geriatric Medicine at the Cleveland Clinic.

Among the items physicians should check: Are your thyroid levels normal? Are you having trouble with sleep? If you have underlying medical conditions, are they well controlled? Do you have an underlying infection? Are you chronically dehydrated? Do you have anemia (a deficiency of red blood cells or hemoglobin), an electrolyte imbalance, or low levels of testosterone? Are you eating enough protein? Have you been feeling more anxious or depressed recently? And might medications you’re taking be contributing to fatigue?

“The medications and doses may be the same, but your body’s ability to metabolize those medications and clear them from your system may have changed,” Hashmi said, noting that such changes in the body’s metabolic activity are common as people become older.

Many potential contributors to fatigue can be addressed. But much of the time, reasons for fatigue can’t be explained by an underlying medical condition.

That happened to Teresa Goodell, 64, a retired nurse who lives just outside Portland, Oregon. During a December visit to Arizona, she suddenly found herself exhausted and short of breath while on a hike, even though she was in good physical condition. At an urgent care facility, she was diagnosed with an asthma exacerbation and given steroids, but they didn’t help.

Soon, Goodell was spending hours each day in bed, overcome by profound tiredness and weakness. Even small activities wore her out. But none of the medical tests she received in Arizona and subsequently in Portland — a chest X-ray and CT scan, blood work, a cardiac stress test — showed abnormalities.

“There was no objective evidence of illness, and that makes it hard for anybody to believe you’re sick,” she told me.

Goodell started visiting long covid web sites and chat rooms for people with chronic fatigue syndrome. Today, she’s convinced she has post-viral syndrome from an infection. One of the most common symptoms of long covid is fatigue that interferes with daily life, according to the Centers for Disease Control and Prevention.

There are several strategies for dealing with persistent fatigue. In cancer patients, “the best evidence favors physical activity such as tai chi, yoga, walking, or low-impact exercises,” said Dr. Christian Sinclair, an associate professor of palliative medicine at the University of Kansas Health System. The goal is to “gradually stretch patients’ stamina,” he said.

With long covid, however, doing too much too soon can backfire by causing “post-exertional malaise.” Pacing one’s activities is often recommended: doing only what’s most important, when one’s energy level is highest, and resting afterward. “You learn how to set realistic goals,” said Dr. Andrew Esch, senior education advisor at the Center to Advance Palliative Care.

Cognitive behavioral therapy can help older adults with fatigue learn how to adjust expectations and address intrusive thoughts such as, “I should be able to do more.” At the University of Texas MD Anderson Cancer Center, management plans for older patients with fatigue typically include strategies to address physical activity, sleep health, nutrition, emotional health, and support from family and friends.

“So much of fatigue management is about forming new habits,” said Dr. Ishwaria Subbiah, a palliative care and integrative medicine physician at MD Anderson. “It’s important to recognize that this doesn’t happen right away: It takes time.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Ms. Green stays home most of the time and sometimes goes a week without seeing people. But she’s in frequent touch by phone with friends and relatives, and she takes a virtual class with a discussion group from a nearby college.

Ms. Smith also stays home, but rarely talks to anyone. She has lost contact with friends, stopped going to church, and spends most of her time watching TV.

Ms. Johnson has a wide circle of friends and a busy schedule. She walks with neighbors regularly, volunteers at a school twice a week, goes to church, and is in close touch with her children, who don’t live nearby.

Three sets of social circumstances, three levels of risk should the women experience a fall, bout of pneumonia, or serious deterioration in health.

Of the women, Ms. Johnson would be most likely to get a ride to the doctor or a visit in the hospital, experts suggest. Several people may check on Ms. Green and arrange assistance while she recovers.

But Ms. Smith would be unlikely to get much help and more likely than the others to fare poorly if her health became challenged. She’s what some experts would call “socially vulnerable” or “socially frail.”

Social frailty is a corollary to physical frailty, a set of vulnerabilities (including weakness, exhaustion, unintentional weight loss, slowness, and low physical activity) shown to increase the risk of falls, disability, hospitalization, poor surgical outcomes, admission to a nursing home, and earlier death in older adults.

Essentially, people who are physically frail have less physiological strength and a reduced biological ability to bounce back from illness or injury.

Those who are socially frail similarly have fewer resources to draw upon, but for different reasons — they don’t have close relationships, can’t rely on others for help, aren’t active in community groups or religious organizations, or live in neighborhoods that feel unsafe, among other circumstances. Also, social frailty can entail feeling a lack of control over one’s life or being devalued by others.

Many of these factors have been linked to poor health outcomes in later life, along with so-called social determinants of health — low socioeconomic status, poor nutrition, insecure housing, and inaccessible transportation.

Social frailty assumes that each factor contributes to an older person’s vulnerability and that they interact with and build upon each other. “It’s a more complete picture of older adults’ circumstances than any one factor alone,” said Dr. Melissa Andrew, a professor of geriatric medicine at Dalhousie University in Halifax, Nova Scotia, who published one of the first social vulnerability indices for older adults in 2008.

This way of thinking about older adults’ social lives, and how they influence health outcomes, is getting new attention from experts in the U.S. and elsewhere. In February, researchers at Massachusetts General Hospital and the University of California-San Francisco published a 10-item “social frailty index” in the Proceedings of the National Academy of Sciences journal.

Using data from 8,250 adults 65 and older who participated in the national Health and Retirement Study from 2010 to 2016, the researchers found that the index helped predict an increased risk of death during the period studied in a significant number of older adults, complementing medical tools used for this purpose.

“Our goal is to help clinicians identify older patients who are socially frail and to prompt problem-solving designed to help them cope with various challenges,” said Dr. Sachin Shah, a co-author of the paper and a researcher at Massachusetts General Hospital.

“It adds dimensions of what a clinician should know about their patients beyond current screening instruments, which are focused on physical health,” said Dr. Linda Fried, an internationally known frailty researcher and dean of the Mailman School of Public Health at Columbia University.

Beyond the corridors of medicine, she said, “we need society to build solutions” to issues raised in the index — the ability of seniors to work, volunteer, and engage with other people; the safety and accessibility of neighborhoods in which they live; ageism and discrimination against older adults; and more.

Meanwhile, a team of Chinese researchers recently published a comprehensive review of social frailty in adults age 60 and older, based on results from dozens of studies with about 83,900 participants in Japan, China, Korea, and Europe. They determined that 24% of these older adults, assessed both in hospitals and in the community, were socially frail — a higher portion than those deemed physically frail (12%) or cognitively frail (9%) in separate studies. Most vulnerable were people 75 and older.

What are the implications for health care? “If someone is socially vulnerable, perhaps they’ll need more help at home while they’re recovering from surgery. Or maybe they’ll need someone outside their family circle to be an advocate for them in the hospital,” said Dr. Kenneth Covinsky, a geriatrician at UCSF and co-author of the recent Proceedings of the National Academy of Sciences article.

“I can see a social frailty index being useful in identifying older adults who need extra assistance and directing them to community resources,” said Jennifer Ailshire, an associate professor of gerontology and sociology at the University of Southern California Leonard Davis School of Gerontology.

Unlike other physicians, geriatricians regularly screen older adults for extra needs, albeit without using a well-vetted or consistent set of measures. “I’ll ask, who do you depend on most and how do you depend on them? Do they bring you food? Drive you places? Come by and check on you? Give you their time and attention?” said Dr. William Dale, the Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope, a comprehensive cancer center in Duarte, California.

Depending on the patients’ answers, Dale will refer them to a social worker or help modify their plan of care. But, he cautioned, primary care physicians and specialists don’t routinely take the time to do this.

Oak Street Health, a Chicago-based chain of 169 primary care centers for older adults in 21 states and recently purchased by CVS Health, is trying to change that in its clinics, said Dr. Ali Khan, the company’s chief medical officer of value-based care strategy. At least three times a year, medical assistants, social workers, or clinicians ask patients about loneliness and social isolation, barriers to transportation, food insecurity, financial strain, housing quality and safety, access to broadband services, and utility services.

The organization combines these findings with patient-specific medical information in a “global risk assessment” that separates seniors into four tiers of risk, from very high to very low. In turn, this informs the kinds of services provided to patients, the frequency of service delivery, and individual wellness plans, which include social as well as medical priorities.

The central issue, Khan said, is “what is this patient’s ability to continue down a path of resilience in the face of a very complicated health care system?” and what Oak Street Health can do to enhance that.

What’s left out of an approach like this, however, is something crucial to older adults: whether their relationships with other people are positive or negative. That isn’t typically measured, but it’s essential in considering whether their social needs are being met, said Linda Waite, the George Herbert Mead Distinguished Service Professor of sociology at the University of Chicago and director of the National Social Life, Health, and Aging Project.

For seniors who want to think about their own social vulnerability, consider this five-item index, developed by researchers in Japan.

(1) Do you go out less frequently now than last year?

(2) Do you sometimes visit your friends?

(3) Do you feel you are helpful to friends or family?

(4) Do you live alone?

(5) Do you talk to someone every day?

Think about your answers. If you find your responses unsatisfactory, it might be time to reconsider your social circumstances and make a change.

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.

USE OUR CONTENT

This story can be republished for free (details).

Yet, when the U.S. Preventive Services Task Force, an independent, influential panel of experts, suggested last year that adults be screened for anxiety, it left out one group — people 65 and older.

The major reason the task force cited in draft recommendations issued in September: “the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety” in all older adults. (Final recommendations are expected later this year.)

The task force noted that questionnaires used to screen for anxiety may be unreliable for older adults. Screening entails evaluating people who don’t have obvious symptoms of worrisome medical or psychological conditions.

“We recognize that many older adults experience mental health conditions like anxiety” and “we are calling urgently for more research,” said Lori Pbert, associate chief of the preventive and behavioral medicine division at the University of Massachusetts Chan Medical School and a former task force member who worked on the anxiety recommendations.

This “we don’t know enough yet” stance doesn’t sit well with some experts who study and treat seniors with anxiety. Dr. Carmen Andreescu, an associate professor of psychiatry at the University of Pittsburgh, called the task force’s position “baffling” because “it’s well established that anxiety isn’t uncommon in older adults and effective treatments exist.”

“I cannot think of any danger in identifying anxiety in older adults, especially because doing so has no harm and we can do things to reduce it,” said Dr. Helen Lavretsky, a psychology professor at UCLA.

In a recent editorial in JAMA Psychiatry, Andreescu and Lavretsky noted that only about one-third of seniors with generalized anxiety disorder — intense, persistent worry about everyday matters — receive treatment. That’s concerning, they said, considering evidence of links between anxiety and stroke, heart failure, coronary artery disease, autoimmune illness, and neurodegenerative disorders such as dementia.

Other forms of anxiety commonly undetected and untreated in seniors include phobias (like a fear of dogs), obsessive-compulsive disorder, panic disorder, social anxiety disorder (a fear of being assessed and judged by others), and post-traumatic stress disorder.

The smoldering disagreement over screening calls attention to the significance of anxiety in later life — a concern heightened during the covid-19 pandemic, which magnified stress and worry among seniors. Here’s what you should know.

Anxiety is common. According to a book chapter published in 2020, authored by Andreescu and a colleague, up to 15% of people 65 and older who live outside nursing homes or other facilities have a diagnosable anxiety condition.

As many as half have symptoms of anxiety — irritability, worry, restlessness, decreased concentration, sleep changes, fatigue, avoidant behaviors — that can be distressing but don’t justify a diagnosis, the study noted.

Most seniors with anxiety have struggled with this condition since earlier in life, but the way it manifests may change over time. Specifically, older adults tend to be more anxious about issues such as illness, the loss of family and friends, retirement, and cognitive declines, experts said. Only a small fraction develop anxiety after turning 65.

Anxiety can be difficult to identify in older adults. Older adults often minimize symptoms of anxiety, thinking “this is what getting older is like” rather than “this is a problem that I should do something about,” Andreescu said.

Also, seniors are more likely than younger adults to report “somatic” complaints — physical symptoms such as dizziness, fatigue, headaches, chest pain, shortness of breath, and gastrointestinal problems — that can be difficult to distinguish from underlying medical conditions, according to Gretchen Brenes, a professor of gerontology and geriatric medicine at Wake Forest University School of Medicine.

Some types of anxiety or anxious behaviors — notably, hoarding and fear of falling — are much more common in older adults, but questionnaires meant to identify anxiety don’t typically ask about those issues, said Dr. Jordan Karp, chair of psychiatry at the University of Arizona College of Medicine in Tucson.

When older adults voice concerns, medical providers too often dismiss them as normal, given the challenges of aging, said Dr. Eric Lenze, head of psychiatry at Washington University School of Medicine in St. Louis and the third author of the recent JAMA Psychiatry editorial.

Simple questions can help identify whether an older adult needs to be evaluated for anxiety, he and other experts suggested: Do you have recurrent worries that are hard to control? Are you having trouble sleeping? Have you been feeling more irritable, stressed, or nervous? Are you having trouble with concentration or thinking? Are you avoiding things you normally like to do because you’re wrapped up in your worries?

Stephen Snyder, 67, who lives in Zelienople, Pennsylvania, and was diagnosed with generalized anxiety disorder in March 2019, would answer “yes” to many of these queries. “I’m a Type A personality and I worry a lot about a lot of things — my family, my finances, the future,” he told me. “Also, I’ve tended to dwell on things that happened in the past and get all worked up.”

Treatments are effective. Psychotherapy — particularly cognitive behavioral therapy, which helps people address persistent negative thoughts — is generally considered the first line of anxiety treatment in older adults. In an evidence review for the task force, researchers noted that this type of therapy helps reduce anxiety in seniors seen in primary care settings.

Also recommended, Lenze noted, is relaxation therapy, which can involve deep breathing exercises, massage or music therapy, yoga, and progressive muscle relaxation.

Because mental health practitioners, especially those who specialize in seniors’ mental health, are extremely difficult to find, primary care physicians often recommend medications to ease anxiety. Two categories of drugs — antidepressants known as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors) — are typically prescribed, and both appear to help to older adults, experts said.

Frequently prescribed to older adults, but to be avoided by them, are benzodiazepines, a class of sedating medications such as Valium, Ativan, Xanax, and Klonopin. The American Geriatrics Society has warned medical providers not to use these in older adults, except when other therapies have failed, because they are addictive and significantly increase the risk of hip fractures, falls and other accidents, and short-term cognitive impairments.

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.

USE OUR CONTENT

This story can be republished for free (details).