Even when physicians determine these patients need to be admitted to the hospital, they often wait for hours — sometimes more than a day — in the ER in pain and discomfort, not getting enough food or water, not moving around, not being helped to the bathroom, and not getting the kind of care doctors deem necessary.

“You walk through ER hallways, and they’re lined from end to end with patients on stretchers in various states of distress calling out for help, including a number of older patients,” said Hashem Zikry, an emergency medicine physician at UCLA Health.

Physicians who staff emergency rooms say this problem, known as ER boarding, is as bad as it’s ever been — even worse than during the first years of the covid-19 pandemic, when hospitals filled with desperately ill patients.

While boarding can happen to all ER patients, adults 65 and older, who account for nearly 20% of ER visits, are especially vulnerable during long waits for care. Also, seniors may encounter boarding more often than other patients. The best estimates I could find, published in 2019, before the covid-19 pandemic, suggest that 10% of patients were boarded in ERs before receiving hospital care. About 30% to 50% of these patients were older adults.

“It’s a public health crisis,” said Aisha Terry, an associate professor of emergency medicine at George Washington University School of Medicine and Health Sciences and the president of the board of the American College of Emergency Physicians, which sponsored a summit on boarding in September.

What’s going on? I spoke to almost a dozen doctors and researchers who described the chaotic situation in ERs. They told me staff shortages in hospitals, which affect the number of beds available, are contributing to the crisis. Also, they explained, hospital administrators are setting aside more beds for patients undergoing lucrative surgeries and other procedures, contributing to bottlenecks in ERs and leaving more patients in limbo.

Then, there’s high demand for hospital services, fueled in part by the aging of the U.S. population, and backlogs in discharging patients because of growing problems securing home health care and nursing home care, according to Arjun Venkatesh, chair of emergency medicine at the Yale School of Medicine.

The impact of long ER waits on seniors who are frail, with multiple medical issues, is especially serious. Confined to stretchers, gurneys, or even hard chairs, often without dependable aid from nurses, they’re at risk of losing strength, forgoing essential medications, and experiencing complications such as delirium, according to Saket Saxena, a co-director of the geriatric emergency department at the Cleveland Clinic.

When these patients finally secure a hospital bed, their stays are longer and medical complications more common. And finds that the risk of dying in the hospital is significantly higher for older adults when they stay in ERs overnight, as is the risk of adverse events such as falls, infections, bleeding, heart attacks, strokes, and bedsores.

Ellen Danto-Nocton, a geriatrician in Milwaukee, was deeply concerned when an 88-year-old relative with “strokelike symptoms” spent two days in the ER a few years ago. Delirious, immobile, and unable to sleep as alarms outside his bed rang nonstop, the older man spiraled downward before he was moved to a hospital room. “He really needed to be in a less chaotic environment,” Danto-Nocton said.

Several weeks ago, Zikry of UCLA Health helped care for a 70-year-old woman who’d fallen and broken her hip while attending a basketball game. “She was in a corner of our ER for about 16 hours in an immense amount of pain that was very difficult to treat adequately,” he said. ERs are designed to handle crises and stabilize patients, not to “take care of patients who we’ve already decided need to be admitted to the hospital,” he said.

How common is ER boarding and where is it most acute? No one knows, because hospitals aren’t required to report data about boarding publicly. The Centers for Medicare & Medicaid Services retired a measure of boarding in 2021. New national measures of emergency care capacity have been proposed but not yet approved.

“It’s not just the extent of ED boarding that we need to understand. It’s the extent of acute hospital capacity in our communities,” said Venkatesh of Yale, who helped draft the new measures.

In the meantime, some hospital systems are publicizing their plight by highlighting capacity constraints and the need for more hospital beds. Among them is in Boston, which announced in January that ER boarding had risen 32% from October 2022 to September 2023. At the end of that period, patients admitted to the hospital spent a median of 14 hours in the ER and 26% spent more than 24 hours.

Maura Kennedy, Mass General’s chief of geriatric emergency medicine, described an 80-something woman with a respiratory infection who languished in the ER for more than 24 hours after physicians decided she needed inpatient hospital care.

“She wasn’t mobilized, she had nothing to cognitively engage her, she hadn’t eaten, and she became increasingly agitated, trying to get off the stretcher and arguing with staff,” Kennedy told me. “After a prolonged hospital stay, she left the hospital more disabled than she was when she came in.”

When I asked ER doctors what older adults could do about these problems, they said boarding is a health system issue that needs health system and policy changes. Still, they had several suggestions.

“Have another person there with you to advocate on your behalf,” said Jesse Pines, chief of clinical innovation at US Acute Care Solutions, the nation’s largest physician-owned emergency medicine practice. And have that person speak up if they feel you’re getting worse or if staffers are missing problems.

Alexander Janke, a clinical instructor of emergency medicine at the University of Michigan, advises people, “Be prepared to wait when you come to an ER” and “bring a medication list and your medications, if you can.”

To stay oriented and reduce the possibility of delirium, “make sure you have your hearing aids and eyeglasses with you,” said Michael Malone, medical director of senior services for Advocate Aurora Health, a 20-hospital system in Wisconsin and northern Illinois. “Whenever possible, try to get up and move around.”

Friends or family caregivers who accompany older adults to the ER should ask to be at their bedside, when possible, and “try to make sure they eat, drink, get to the bathroom, and take routine medications for underlying medical conditions,” Malone said.

Older adults or caregivers who are helping them should try to bring “things that would engage you cognitively: magazines, books … music, anything that you might focus on in a hallway where there isn’t a TV to entertain you,” Kennedy said.

“Experienced patients often show up with eye masks and ear plugs” to help them rest in ERs with nonstop stimulation, said Zikry of UCLA. “Also, bring something to eat and drink in case you can’t get to the cafeteria or it’s a while before staffers bring these to you.”

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  to submit your requests or tips.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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Pain shot through her left knee and ankle. After summoning her husband on her phone, with difficulty she made it back to the house.

And then began the run-around that so many people face when they interact with America’s uncoordinated health care system.

Gilliam’s orthopedic surgeon, who managed previous difficulties with her left knee, saw her that afternoon but told her “I don’t do ankles.”

He referred her to an ankle specialist who ordered a new set of X-rays and an MRI. For convenience’s sake, Gilliam asked to get the scans at a hospital near her home in Sudbury, Massachusetts. But the hospital didn’t have the doctor’s order when she called for an appointment. It came through only after several more calls.

Coordinating the care she needs to recover, including physical therapy, became a part-time job for Gilliam. (Therapists work on only one body part per session, so she has needed separate visits for her knee and for her ankle several times a week.)

“The burden of arranging everything I need — it’s huge,” Gilliam told me. “It leaves you with such a sense of mental and physical exhaustion.”

The toll the American health care system extracts is, in some respects, the price of extraordinary progress in medicine. But it’s also evidence of the poor fit between older adults’ capacities and the health care system’s demands.

“The good news is we know so much more and can do so much more for people with various conditions,” said Thomas H. Lee, chief medical officer at Press Ganey, a consulting firm that tracks patients’ experiences with health care. “The bad news is the system has gotten overwhelmingly complex.”

That complexity is compounded by the proliferation of guidelines for separate medical conditions, financial incentives that reward more medical care, and specialization among clinicians, said Ishani Ganguli, an associate professor of medicine at Harvard Medical School.

“It’s not uncommon for older patients to have three or more heart specialists who schedule regular appointments and tests,” she said. If someone has multiple medical problems — say, heart disease, diabetes, and glaucoma — interactions with the health care system multiply.

Ganguli is the author of a showing that Medicare patients spend about three weeks a year having medical tests, visiting doctors, undergoing treatments or medical procedures, seeking care in emergency rooms, or spending time in the hospital or rehabilitation facilities. (The data is from 2019, before the covid pandemic disrupted care patterns. If any services were received, that counted as a day of health care contact.)

That study found that slightly more than 1 in 10 seniors, including those recovering from or managing serious illnesses, spent a much larger portion of their lives getting care — at least 50 days a year.

“Some of this may be very beneficial and valuable for people, and some of it may be less essential,” Ganguli said. “We don’t talk enough about what we’re asking older adults to do and whether that’s realistic.”

Victor Montori, a professor of medicine at the Mayo Clinic in Rochester, Minnesota, has for many years raised an alarm about the “treatment burden” that patients experience. In addition to time spent receiving health care, this burden includes arranging appointments, finding transportation to medical visits, getting and taking medications, communicating with insurance companies, paying medical bills, monitoring health at home, and following recommendations such as dietary changes.

Four years ago — in a paper titled “” — Montori and several colleagues found that 40% of patients with chronic conditions such as asthma, diabetes, and neurological disorders “considered their treatment burden unsustainable.”

When this happens, people stop following medical advice and report having a poorer quality of life, the researchers found. Especially vulnerable are older adults with multiple medical conditions and low levels of education who are economically insecure and socially isolated.

Older patients’ difficulties are compounded by medical practices’ increased use of digital phone systems and electronic patient portals — both frustrating for many seniors to navigate — and the time pressures afflicting physicians. “It’s harder and harder for patients to gain access to clinicians who can problem-solve with them and answer questions,” Montori said.

Meanwhile, clinicians rarely ask patients about their capacity to perform the work they’re being asked to do. “We often have little sense of the complexity of our patients’ lives and even less insight into how the treatments we provide (to reach goal-directed guidelines) fit within the web of our patients’ daily experiences,” several physicians wrote in a on reducing treatment burden.

Consider what Jean Hartnett, 53, of Omaha, Nebraska, and her eight siblings went through after their 88-year-old mother had a stroke in February 2021 while shopping at Walmart.

At the time, the older woman was looking after Hartnett’s father, who had kidney disease and needed help with daily activities such as showering and going to the bathroom.

During the year after the stroke, both of Hartnett’s parents — fiercely independent farmers who lived in Hubbard, Nebraska — suffered setbacks, and medical crises became common. When a physician changed her mom’s or dad’s plan of care, new medications, supplies, and medical equipment had to be procured, and new rounds of occupational, physical, and speech therapy arranged.

Neither parent could be left alone if the other needed medical attention.

“It wasn’t unusual for me to be bringing one parent home from the hospital or doctor’s visit and passing the ambulance or a family member on the highway taking the other one in,” Hartnett explained. “An incredible amount of coordination needed to happen.”

Hartnett moved in with her parents during the last six weeks of her father’s life, after doctors decided he was too weak to undertake dialysis. He passed away in March 2022. Her mother died months later in July.

So, what can older adults and family caregivers do to ease the burdens of health care?

To start, be candid with your doctor if you think a treatment plan isn’t feasible and explain why you feel that way, said Elizabeth Rogers, an assistant professor of internal medicine at the University of Minnesota Medical School. 

“Be sure to discuss your health priorities and trade-offs: what you might gain and what you might lose by forgoing certain tests or treatments,” she said. Ask which interventions are most important in terms of keeping you healthy, and which might be expendable.

Doctors can adjust your treatment plan, discontinue medications that aren’t yielding significant benefits, and arrange virtual visits if you can manage the technological requirements. (Many older adults can’t.)

Ask if a social worker or a patient navigator can help you arrange multiple appointments and tests on the same day to minimize the burden of going to and from medical centers. These professionals can also help you connect with community resources, such as transportation services, that might be of help. (Most medical centers have staff of this kind, but physician practices do not.)

If you don’t understand how to do what your doctor wants you to do, ask questions: What will this involve on my part? How much time will this take? What kind of resources will I need to do this? And ask for written materials, such as self-management plans for asthma or diabetes, that can help you understand what’s expected.

“I would ask a clinician, ‘If I chose this treatment option, what does that mean not only for my cancer or heart disease, but also for the time I’ll spend getting care?’” said Ganguli of Harvard. “If they don’t have an answer, ask if they can come up with an estimate.”

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  to submit your requests or tips.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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Sintió una punzada de dolor en la rodilla y el tobillo de la pierna izquierda. Después de llamar a su marido por teléfono, logró regresar a su casa con dificultad.

Y así comenzó el vaivén interminable que tantas personas enfrentan cuando tienen que navegar el desorganizado sistema de salud de Estados Unidos.

El cirujano ortopédico de Gilliam, que la había tratado antes por problemas en la misma rodilla, la vio esa tarde pero le aclaró: “Yo no me ocupo de tobillos”.

La derivó a un especialista en tobillos que ordenó nuevas radiografías y una resonancia magnética. Gilliam pidió hacerse las pruebas en un hospital cerca de su casa en Sudbury, Massachusetts, que le resultaba más conveniente. Pero cuando llamó para pedir una cita, el hospital no tenía la orden del doctor, que finalmente llegó después de varias llamadas más.

Coordinar la atención que necesita para recuperarse, incluyendo sesiones de fisioterapia, se convirtió en un trabajo de medio tiempo para Gilliam. (Los terapeutas trabajan solo en una parte del cuerpo por sesión, y por lo tanto Gilliam requiere visitas separadas para su rodilla y su tobillo, varias veces a la semana).

“El peso de organizar todo lo que necesito es enorme”, dijo Gilliam. “Te queda una sensación de agotamiento físico y mental”.

En algunos casos, las deficiencias del sistema de salud son el precio que se paga por avances extraordinarios en el campo de la medicina. Pero también ponen en evidencia las incoherencias entre las capacidades de los adultos mayores y las demandas del sistema.

“La buena noticia es que sabemos mucho más y podemos hacer mucho más por las personas con distintas afecciones”, dijo Thomas H. Lee, director médico de Press Ganey, una consultoría que hace seguimiento de las experiencias de los pacientes con el sistema de salud. “La mala noticia es que el sistema se ha vuelto tremendamente complejo”.

Esto se agrava por las múltiples guías para tratar afecciones, la super especialización médica, y los incentivos financieros que hacen que los pacientes reciban cada vez más atención, dijo Ishani Ganguli, profesora asociada en la Escuela de Medicina de Harvard.

“No es raro que pacientes mayores tengan tres o más cardiólogos que les programan citas y pruebas regulares”, dijo. Si alguien tiene varios problemas de salud (por ejemplo, enfermedades cardíacas, diabetes y glaucoma), las interacciones con el sistema se multiplican.

Ganguli es la autora de un que muestra que los pacientes de Medicare dedican aproximadamente tres semanas al año a hacerse pruebas médicas, ver a doctores, someterse a tratamientos o procedimientos médicos, buscar atención en salas de emergencia o pasar tiempo en el hospital o en centros de rehabilitación. (Los datos son de 2019, antes de la pandemia de covid, que alteró   los patrones de atención médica. Cada servicio recibido se contó como un día de contacto con el sistema de salud).

El estudio determinó que poco más de 1 de cada 10 personas mayores, incluyendo las que se estaban haciendo controles o recuperándose de enfermedades graves, pasaban más tiempo recibiendo atención médica: al menos 50 días al año.

“Hay aspectos de esto que son muy beneficiosos y valiosos para las personas, pero hay otros que son menos esenciales”, dijo Ganguli. “No hablamos lo suficiente sobre lo que les pedimos a los adultos mayores que hagan, y si tiene sentido”.

Victor Montori, profesor de medicina de la Clínica Mayo en Rochester, Minnesota, lleva muchos años advirtiendo sobre lo que llama la “carga de tratamiento” que enfrentan los pacientes.

Esto incluye el tiempo que dedican a recibir atención médica, programar citas, encontrar transporte para las visitas médicas, obtener y tomar medicamentos, comunicarse con las aseguradoras, pagar facturas médicas, monitorear su salud en casa y seguir consejos como cambios en la dieta.

Hace cuatro años, en un artículo titulado “¿?”, Montori y sus colegas descubrieron que el 40% de los pacientes con enfermedades crónicas como asma, diabetes y trastornos neurológicos “sentían que su carga de tratamiento era insostenible”.

Cuando la carga de tratamiento es excesiva, las personas dejan de seguir las recomendaciones médicas y dicen que su calidad de vida empeora, según los investigadores. Los adultos mayores con múltiples afecciones médicas y bajo nivel de educación son especialmente vulnerables, ya que experimentan inseguridad económica y aislamiento social.

El uso cada vez más frecuente de sistemas telefónicos digitales y portales electrónicos para pacientes en los consultorios y la falta de tiempo por parte de los doctores profundizan las barreras. “Cada vez es más difícil para los pacientes acceder a doctores que puedan pasar tiempo con ellos, para ayudarlos a resolver problemas y responder sus preguntas”, dijo Montori.

Mientras tanto, los médicos rara vez preguntan a los pacientes sobre su capacidad para realizar las tareas que se les pide. “A menudo tenemos poca idea de qué tan compleja es la vida de nuestros pacientes”, escribieron médicos en un sobre cómo reducir la carga de tratamiento.

Un ejemplo es lo que vivieron Jean Hartnett, de 53 años de Omaha, Nebraska, y sus ocho hermanos después que su madre de 88 años sufriera un derrame cerebral en febrero de 2021, mientras hacían compras en Walmart.

En ese momento, su madre estaba cuidando al padre de Hartnett, quien sufría de una enfermedad renal y necesitaba ayuda con las tareas diarias, como ducharse o ir al baño.

Durante el año posterior al derrame cerebral, los padres de Hartnett, ambos trabajadores agrícolas extremadamente independientes que vivían en Hubbard, Nebraska, sufrieron varios achaques y las crisis médicas se volvieron comunes.

Cuando un médico cambiaba el plan de atención de su mamá o su papá, eran necesarios nuevos medicamentos, suministros y equipos médicos, y programar nuevas sesiones de terapia ocupacional, física y del habla.

Ninguno de los padres podía quedarse solo si el otro necesitaba atención médica.

“No era inusual para mí estar llevando a uno de mis padres a su casa después del hospital o de la visita al médico y pasar una ambulancia o un familiar transportando al otro al doctor”, explicó Hartnett. “Se necesitaba muchísima coordinación”.

Hartnett se mudó a la casa de sus padres durante las últimas seis semanas de vida de su padre, cuando  los médicos decidieron que estaba demasiado débil como para someterse a diálisis. Falleció en marzo de 2022. Su madre murió meses después, en julio.

Entonces, ¿qué pueden hacer los adultos mayores y sus cuidadores y familiares para aliviar la carga de la atención médica?

Para empezar, es importante sincerarse  con el médico si el plan de tratamiento que recomienda no resulta factible, y explicarle por qué, dijo Elizabeth Rogers, profesora asistente de medicina interna en la Escuela de Medicina de la Universidad de Minnesota.

Recomendó preguntar sobre cuáles intervenciones serían las más importantes para mantenerse saludable y cuáles podrían ser prescindibles.

Los médicos pueden ajustar los planes, suspender los medicamentos que no producen beneficios significativos y programar visitas virtuales, en caso de que las personas puedan manejar la tecnología necesaria (muchos adultos mayores no pueden).

Pregunte también si un asistente de pacientes (también llamados navegadores) puede ayudarle a programar varias citas y exámenes en el mismo día, para minimizar la carga de ir y venir de los centros médicos. Estos profesionales también pueden ayudarlo a conectarse con recursos comunitarios, como servicios de transporte. (La mayoría de los centros médicos tienen personal de este tipo, pero los consultorios médicos no).

Si no entiende cómo hacer lo que su médico pide, pregunte: ¿Qué implicaría esto de mi parte? ¿Cuánto tiempo llevaría? ¿Qué necesitaré? Y pida materiales escritos, como guías de autocontrol del asma o la diabetes, que puedan ayudarle a comprender mejor los requisitos.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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Every time my husband called his father, who was 94 when he died in 2022, he’d wait for his dad to find his hearing aids and put them in before they started talking.

Even then, my father-in-law could barely hear what my husband was saying. “What?” he’d ask over and over.

Then, there were the problems my father-in-law had replacing the devices’ batteries. And the times he’d end up in the hospital, unable to understand what people were saying because his hearing aids didn’t seem to be functioning. And the times he’d drop one of the devices and be unable to find it.

How many older adults have problems of this kind?

There’s no good data about this topic, according to Nicholas Reed, an assistant professor of epidemiology at Johns Hopkins Bloomberg School of Public Health who studies hearing loss. He did a literature search when I posed the question and came up empty.

Reed co-authored the to date of hearing issues in older Americans, published in JAMA Open Network last year. Previous studies excluded people 80 and older. But data became available when a 2021 survey by the National Health and Aging Trends Study included hearing assessments conducted at people’s homes.

The results, based on a nationally representative sample of 2,803 people 71 and older, are eye-opening. Hearing problems become pervasive with advancing age, exceeding 90% in people 85 and older, compared with 53% of 71- to 74-year-olds. Also, hearing worsens over time, with more people experiencing moderate or severe deficits once they reach or exceed age 80, compared with people in their 70s.

However, only 29% of those with hearing loss used hearing aids. Multiple studies have documented barriers that inhibit use. Such devices, which Medicare doesn’t cover, are pricey, from nearly $1,000 for a good over-the-counter set (OTC hearing aids became available in 2022) to more than $6,000 for some prescription models. In some communities, hearing evaluation services are difficult to find. Also, people often associate hearing aids with being old and feel self-conscious about wearing them. And they tend to underestimate hearing problems that develop gradually.

Barbara Weinstein, a professor of audiology at the City University of New York Graduate Center and author of the textbook “Geriatric Audiology,” added another concern to this list when I reached out to her: usability.

“Hearing aids aren’t really designed for the population that most needs to use them,” she told me. “The move to make devices smaller and more sophisticated technologically isn’t right for many people who are older.”

That’s problematic because hearing loss raises the risk of cognitive decline, dementia, falls, depression, and social isolation.

What advice do specialists in hearing health have for older adults who have a hard time using their hearing aids? Here are some thoughts they shared.

Consider larger, customized devices. Many older people, especially those with arthritis, poor fine motor skills, compromised vision, and some degree of cognitive impairment, have a hard time manipulating small hearing aids and using them properly.

Lindsay Creed, associate director of audiology practices at the American Speech-Language-Hearing Association, said about half of her older clients have “some sort of dexterity issue, whether numbness or reduced movement or tremor or a lack of coordination.” Shekinah Mast, owner of Mast Audiology Services in Seaford, Delaware, estimates nearly half of her clients have vision issues.

For clients with dexterity challenges, Creed often recommends “behind-the-ear hearing aids,” with a loop over the ear, and customized molds that fit snugly in the ear. Customized earpieces are larger than standardized models.

“The more dexterity challenges you have, the better you’ll do with a larger device and with lots of practice picking it up, orienting it, and putting it in your ear,” said Marquitta Merkison, associate director of audiology practices at ASHA.

For older people with vision issues, Mast sometimes orders hearing aids in different colors for different ears. Also, she’ll help clients set up stands at home for storing devices, chargers, and accessories so they can readily find them each time they need them.

Opt for ease of use. Instead of buying devices that require replacing tiny batteries, select a device that can be charged overnight and operate for at least a day before being recharged, recommended Thomas Powers, a consultant to the Hearing Industries Association. These are now widely available.

People who are comfortable using a smartphone should consider using a phone app to change volume and other device settings. Dave Fabry, chief hearing health officer at Starkey, a major hearing aid manufacturer, said he has patients in their 80s and 90s “who’ve found that being able to hold a phone and use larger visible controls is easier than manipulating the hearing aid.”

If that’s too difficult, try a remote control. GN ReSound, another major manufacturer, has designed one with two large buttons that activate the volume control and programming for its hearing aids, said Megan Quilter, the company’s lead audiologist for research and development.

Check out accessories. Say you’re having trouble hearing other people in restaurants. You can ask the person across the table to clip a microphone to his shirt or put the mike in the center of the table. (The hearing aids will need to be programmed to allow the sound to be streamed to your ears.)

Another low-tech option: a hearing aid clip that connects to a piece of clothing to prevent a device from falling to the floor if it becomes dislodged from the ear.

Wear your hearing aids all day. “The No. 1 thing I hear from older adults is they think they don’t need to put on their hearing aids when they’re at home in a quiet environment,” said Erika Shakespeare, who owns Audiology and Hearing Aid Associates in La Grande, Oregon.

That’s based on a misunderstanding. Our brains need regular, not occasional, stimulation from our environments to optimize hearing, Shakespeare explained. This includes noises in seemingly quiet environments, such as the whoosh of a fan, the creak of a floor, or the wind’s wail outside a window.

“If the only time you wear hearing aids is when you think you need them, your brain doesn’t know how to process all those sounds,” she told me. Her rule of thumb: “Wear hearing aids all your waking hours.”

Consult a hearing professional. Everyone’s needs are different, so it’s a good idea to seek out an audiologist or hearing specialist who, for a fee, can provide guidance.

“Most older people are not going to know what they need” and what options exist without professional assistance, said Virginia Ramachandran, the head of audiology at Oticon, a major hearing aid manufacturer, and a past president of the American Academy of Audiology.

Her advice to older adults: Be “really open” about your challenges.

If you can’t afford hearing aids, ask a hearing professional for an appointment to go over features you should look for in over-the-counter devices. Make it clear you want the appointment to be about your needs, not a sales pitch, Reed said. Audiology practices don’t routinely offer this kind of service, but there’s good reason to ask since once-a-year audiologist consultations last year.

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  to submit your requests or tips.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

The death toll was shocking, as were reports of chaos in nursing homes and seniors suffering from isolation, depression, untreated illness, and neglect. Around 900,000 older adults have died of covid-19 to date, accounting for 3 of every 4 Americans who have perished in the pandemic.

But decisive actions that advocates had hoped for haven’t materialized. Today, most people — and government officials — appear to accept covid as a part of ordinary life. Many seniors at high risk aren’t getting antiviral therapies for covid, and most older adults in nursing homes aren’t getting updated vaccines. Efforts to strengthen care quality in nursing homes and assisted living centers have stalled amid debate over costs and the availability of staff. And only a small percentage of people are masking or taking other precautions in public despite a new wave of covid, flu, and respiratory syncytial virus infections hospitalizing and killing seniors.

In the last week of 2023 and the first two weeks of 2024 alone, 4,810 people 65 and older lost their lives to covid — a group that would fill more than 10 large airliners — according to data provided by the CDC. But the alarm that would attend plane crashes is notably absent. (During the same period, the flu killed an additional 1,201 seniors, and RSV killed 126.)

“It boggles my mind that there isn’t more outrage,” said Alice Bonner, 66, senior adviser for aging at the Institute for Healthcare Improvement. “I’m at the point where I want to say, ‘What the heck? Why aren’t people responding and doing more for older adults?’”

It’s a good question. Do we simply not care?

I put this big-picture question, which rarely gets asked amid debates over budgets and policies, to health care professionals, researchers, and policymakers who are older themselves and have spent many years working in the aging field. Here are some of their responses.

The pandemic made things worse. Prejudice against older adults is nothing new, but “it feels more intense, more hostile” now than previously, said Karl Pillemer, 69, a professor of psychology and gerontology at Cornell University.

“I think the pandemic helped reinforce images of older people as sick, frail, and isolated — as people who aren’t like the rest of us,” he said. “And human nature being what it is, we tend to like people who are similar to us and be less well disposed to ‘the others.’”

“A lot of us felt isolated and threatened during the pandemic. It made us sit there and think, ‘What I really care about is protecting myself, my wife, my brother, my kids, and screw everybody else,’” said W. Andrew Achenbaum, 76, the author of nine books on aging and a professor emeritus at Texas Medical Center in Houston.

In an environment of “us against them,” where everybody wants to blame somebody, Achenbaum continued, “who’s expendable? Older people who aren’t seen as productive, who consume resources believed to be in short supply. It’s really hard to give old people their due when you’re terrified about your own existence.”

Although covid continues to circulate, disproportionately affecting older adults, “people now think the crisis is over, and we have a deep desire to return to normal,” said Edwin Walker, 67, who leads the Administration on Aging at the Department of Health and Human Services. He spoke as an individual, not a government representative.

The upshot is “we didn’t learn the lessons we should have,” and the ageism that surfaced during the pandemic hasn’t abated, he observed.

Ageism is pervasive. “Everyone loves their own parents. But as a society, we don’t value older adults or the people who care for them,” said Robert Kramer, 74, co-founder and strategic adviser at the National Investment Center for Seniors Housing & Care.

Kramer thinks boomers are reaping what they have sown. “We have chased youth and glorified youth. When you spend billions of dollars trying to stay young, look young, act young, you build in an automatic fear and prejudice of the opposite.”

Combine the fear of diminishment, decline, and death that can accompany growing older with the trauma and fear that arose during the pandemic, and “I think covid has pushed us back in whatever progress we were making in addressing the needs of our rapidly aging society. It has further stigmatized aging,” said John Rowe, 79, professor of health policy and aging at Columbia University’s Mailman School of Public Health.

“The message to older adults is: ‘Your time has passed, give up your seat at the table, stop consuming resources, fall in line,’” said Anne Montgomery, 65, a health policy expert at the National Committee to Preserve Social Security and Medicare. She believes, however, that baby boomers can “rewrite and flip that script if we want to and if we work to change systems that embody the values of a deeply ageist society.”

Integration, not separation, is needed. The best way to overcome stigma is “to get to know the people you are stigmatizing,” said G. Allen Power, 70, a geriatrician and the chair in aging and dementia innovation at the Schlegel-University of Waterloo Research Institute for Aging in Canada. “But we separate ourselves from older people so we don’t have to think about our own aging and our own mortality.”

The solution: “We have to find ways to better integrate older adults in the community as opposed to moving them to campuses where they are apart from the rest of us,” Power said. “We need to stop seeing older people only through the lens of what services they might need and think instead of all they have to offer society.”

That point is a core precept of the National Academy of Medicine’s 2022 report . Older people are a “natural resource” who “make substantial contributions to their families and communities,” the report’s authors write in introducing their findings.

Those contributions include financial support to families, caregiving assistance, volunteering, and ongoing participation in the workforce, among other things.

“When older people thrive, all people thrive,” the report concludes.

Future generations will get their turn. That’s a message Kramer conveys in classes he teaches at the University of Southern California, Cornell, and other institutions. “You have far more at stake in changing the way we approach aging than I do,” he tells his students. “You are far more likely, statistically, to live past 100 than I am. If you don’t change society’s attitudes about aging, you will be condemned to lead the last third of your life in social, economic, and cultural irrelevance.”

As for himself and the baby boom generation, Kramer thinks it’s “too late” to effect the meaningful changes he hopes the future will bring.

“I suspect things for people in my generation could get a lot worse in the years ahead,” Pillemer said. “People are greatly underestimating what the cost of caring for the older population is going to be over the next 10 to 20 years, and I think that’s going to cause increased conflict.”

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  to submit your requests or tips.

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El documento indicará que se alejará del volante cuando sus hijos se lo pidan.

“Es posible que, llegado el momento, no sea capaz de tomar la mejor decisión sobre conducir, y quiero dejar claro que confío en mis hijos para asumir esa responsabilidad”, dijo Morgenstern, profesor de neurología, neurocirugía y medicina de emergencia en la Universidad de Michigan.

Su esposa, de 59, tiene la intención de firmar un documento similar a los 65.

Morgenstern ha reflexionado mucho sobre el tema controversial de cuándo dejar de conducir. Fue coautor de reciente publicado en el Journal of the American Geriatrics Society que reveló que el 61% de los adultos mayores con deterioro cognitivo seguían manejando a pesar de que el 36% de sus cuidadores estaban preocupados por su capacidad para hacerlo.

Muchos de estos adultos mayores probablemente se hayan adaptado siendo precavidos y recurriendo a una amplia experiencia detrás del volante, dijo Morgenstern. Pero remarcó que “indudablemente hay un grupo de personas que están conduciendo y no deberían hacerlo porque representan un riesgo para sí mismos y para los demás”.

Pocos estudios han examinado cuántos adultos mayores con deterioro cognitivo leve o demencia continúan conduciendo, y no hay estándares nacionales sobre cuándo las personas deberían “colgar las llaves”. Pero es una preocupación creciente a medida que aumenta la población de adultos mayores de 70, 80 y 90 años, el grupo de edad más propenso a tener deterioro cognitivo.

Casi 50 millones de personas de 65 años o más tenían licencias de conducir en 2021, un aumento del 38% desde 2012, según datos de la American Automobile Association (AAA). Casi 19 millones tenían 75 años o más, un aumento del 31%. Durante este período, las muertes por accidentes de vehículos entre personas de 65 años o más aumentaron un 34%: fueron 7,489 en 2021. El número de personas mayores lesionadas en accidentes de tráfico ese año superó las 266,000.

En su mayoría, los seniors conducen de manera segura. Usan el cinturón de seguridad con más frecuencia, beben menos, y son menos propensos a conducir a alta velocidad que los más jóvenes.

En comparación con los adultos más jóvenes y de mediana edad, están involucrados en menos accidentes automovilísticos fatales cada año. Y son más propensos a restringir dónde y cuándo conducen, siguiendo rutas familiares, evitando calles con mucho tráfico y no manejando de noche.

Sin embargo, los riesgos para los conductores mayores aumentan con la edad y el desarrollo de afecciones como la artritis, el glaucoma y el Parkinson. Y cuando ocurren accidentes, los adultos mayores son más propensos a sufrir heridas graves o morir porque son físicamente más vulnerables.

El deterioro cognitivo y la demencia plantean desafíos especialmente preocupantes porque la toma de decisiones, la atención, el juicio y la evaluación del riesgo se ven comprometidos en las personas con estas afecciones.

En este contexto, “conducir es un gran desafío, porque las personas no reaccionan adecuadamente y no pueden controlarse a sí mismas”, dijo Emmy Betz, profesora de medicina de emergencia en la Escuela de Medicina de la Universidad de Colorado, que ha estudiado las directivas anticipadas sobre el manejo.

Este fue el caso del suegro de Morgenstern, quien desarrolló Alzheimer moderado en sus 70s pero seguía convencido de que podía conducir. Después de perderse un día, su esposa le sacó las llaves del auto, y “él no entendía por qué. Estaba muy infeliz”, contó Morgenstern.

El interés de Morgenstern en las directivas anticipadas de manejo, una opción que recomienda en su artículo, surgió de esta experiencia.

Existen varios tipos de directivas. Una pide a una persona que nombre a un familiar o amigo que, en el futuro, hablará con ellos sobre si es seguro seguir conduciendo. La AAA y la American Occupational Therapy Association han respaldado , que no es legalmente vinculante (básicamente es poner por escrito un acuerdo de palabra).

También los familiares deben comprometerse a ayudar a la persona a explorar si es posible seguir conduciendo, o a intentar el transporte público o programas de conductores voluntarios. Uber y Lyft, que han creado programas para personas mayores, son nuevas opciones que se utilizan con frecuencia.

Otra , respaldada por la Asociación de Alzheimer, reconoce que las personas con demencia no podrán conducir a medida que avanza su enfermedad. También nombra a personas que deberían expresar preocupación sobre el manejo cuando sea relevante. Pero va más allá declarando: “Comprendo que puedo olvidar que ya no puedo conducir y puedo intentar seguir conduciendo. Si esto sucede, apoyo todas las acciones tomadas, incluido el retiro o desactivación de mi automóvil, para ayudar a garantizar mi seguridad y la de los demás”.

En la Universidad de South Florida Health, Lori Dee Grismore, terapeuta ocupacional y especialista certificada en rehabilitación del manejo, dijo que hasta el 75% de los adultos mayores que evalúa tienen algún tipo de deterioro cognitivo.

Esto es evidente durante la primera parte de su evaluación integral: una entrevista sobre los hábitos de manejo de la persona y problemas recientes; una revisión de su historial médico; un examen de la vista; una evaluación física; y una batería de seis pruebas cognitivas. “Si alguien no tiene perspicacia, que es común, no entienden por qué estas pruebas tienen algo que ver con conducir”, dijo.

Si lo considera seguro, Grismore lleva a los adultos mayores a la calle, verificando su capacidad para seguir direcciones, girar, mantenerse en sus carriles y conducir a velocidades apropiadas e interpretar señales, entre otras medidas de desempeño.

Si bien la mayoría con deterioro cognitivo leve aprueban estos tests, Grismore generalmente recomienda volver a evaluar a intervalos regulares e imponer restricciones como conducir solo cerca de casa y evitar autopistas. Pero reconoció que no hay garantía de que los adultos mayores recuerden estas restricciones.

La evaluación de tres horas de Grismore cuesta $420. Medicare no la paga, una barrera para los adultos mayores con ingresos bajos. Los adultos mayores y las familias interesadas en encontrar un proveedor de rehabilitación de manejo pueden consultar un directorio de la American Occupational Therapy Association en .

Elin Schold Davis, quien coordina la Older Driver Initiative en la asociación de terapia ocupacional, recomienda tener una evaluación de este tipo cuando hay un diagnóstico de deterioro cognitivo o cuando los familiares comienzan a notar problemas.

“Todos deberíamos estar planificando nuestras cambiantes necesidades de transporte en nuestros 70, 80 y 90 años”, dijo. “La parte difícil es que conducir está asociado con la independencia, y este es un problema muy emocional. Por eso, cuanto más se planee, más opciones y control se podrá tener”.

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The directive will say that when his children want him to stop getting behind the wheel, Morgenstern will follow their advice.

“I recognize that I might not be able to make the best decision about driving at a certain point, and I want to make it clear I trust my children to take over that responsibility,” said Morgenstern, a professor of neurology, neurosurgery, and emergency medicine at the University of Michigan.

His wife, 59, intends to sign a similar document at 65.

Morgenstern has given a lot of thought to the often-divisive issue of when to stop driving. He co-authored a in the Journal of the American Geriatrics Society that found 61% of older adults with cognitive impairment continued to drive even though 36% of their caregivers were concerned about their performance.

Many of these seniors probably adapted by exercising caution and drawing on extensive experience behind the wheel, Morgenstern said. But, he noted, “there is undoubtedly a group of people who are driving and shouldn’t be because they’re a risk to themselves and to others.”

Relatively few studies have looked at how many older adults with mild cognitive impairment or dementia continue to drive, and there aren’t any national standards on when people should hand over the car keys. But the issue is a growing concern as the ranks of seniors in their 70s, 80s, and 90s — the age group most likely to have cognitive impairment — expand.

Nearly 50 million people 65 and older held driver’s licenses in 2021, a 38% increase from 2012, according to data compiled by the American Automobile Association. Almost 19 million were 75 or older, a rise of 31%. During this period, motor vehicle deaths for people 65 and older increased 34%, reaching 7,489 in 2021. The number of seniors injured in vehicle crashes that year exceeded 266,000.

For the most part, older adults drive safely. They use seat belts more often, are intoxicated less often, and are less likely to speed than younger adults. Compared with younger and middle-aged adults, they’re involved in fewer fatal car crashes each year. And they’re more likely to restrict where and when they drive — following familiar routes, avoiding heavily trafficked streets, and not driving at night.

Still, risks for older drivers rise with advancing age and the onset of medical conditions such as arthritis, glaucoma, and Parkinson’s disease. And when crashes occur, seniors are more likely to be severely injured or die because they’re more vulnerable physically.

Cognitive impairment and dementia pose especially worrisome challenges because decision-making, attention, judgment, and risk assessment are compromised in people with these conditions. 

“This is a big challenge when it comes to driving, because people don’t react appropriately and self-regulate,” said Emmy Betz, a professor of emergency medicine at the University of Colorado School of Medicine who has studied advance driving directives.

This was the case for Morgenstern’s beloved father-in-law, who developed moderate Alzheimer’s disease in his 70s but remained convinced he was fit to drive. After he got badly lost one day, Morgenstern’s mother-in-law took away the car keys, and “he didn’t understand why. He was very unhappy,” Morgenstern said.

Morgenstern’s interest in advance directives for driving, an option he recommends in his paper, springs from this experience.

Several types of directives exist. One asks a person to name a family member or friend who will talk to them about whether it’s safe to continue driving. AAA and the American Occupational Therapy Association have of this kind, which is not legally binding.

Obligations also run in the other direction, with family members agreeing to help the person explore ways to keep driving, if possible. If not, family members agree to help the person find other ways to get out and about by offering rides and helping them use public transportation, carpooling services, or volunteer-driver programs. Uber and Lyft, which have created programs for seniors, are newer options frequently used.

, endorsed by the Alzheimer’s Association, recognizes that people with dementia will not be able to drive as their illness progresses. It, too, names people who should raise concerns about driving when it becomes important. But it goes further by stating: “I understand that I may forget that I cannot drive anymore and may try to continue driving. If this happens, please know that I support all actions taken, including removing or disabling my car, to help ensure my safety and the safety of others.”

At the University of South Florida Health, Lori Dee Grismore, an occupational therapist and certified driving rehabilitation specialist, said up to 75% of the seniors she evaluates have some type of cognitive impairment.

This becomes evident during the first part of Grismore’s comprehensive evaluation: an interview about the person’s driving habits and recent problems; a review of their medical history; a vision exam; a physical assessment; and a battery of six cognitive tests. “If someone doesn’t have insight, which is common, they don’t understand why these tests have anything to do with driving,” she told me.

If she thinks it’s safe, Grismore then takes older adults out on the road, checking their ability to follow directions, make turns, stay in their lanes, maintain appropriate speeds, and interpret signs, among other performance measures.

While most older adults with mild cognitive impairment pass these tests, Grismore usually recommends retesting at regular intervals and imposing restrictions such as driving only close to home and staying off highways. But she acknowledged there’s no guarantee seniors will remember these restrictions.

Grismore’s three-hour assessment costs $420. Medicare doesn’t pay — a barrier to seniors with low or fixed incomes. Older adults and families interested in finding a driving rehab provider can consult an American Occupational Therapy Association directory at .

Elin Schold Davis, who coordinates the Older Driver Initiative at the occupational therapy association, recommends getting an evaluation of this kind when someone is diagnosed with cognitive impairment or when family members begin to notice problems.

“We should all be planning for our changing transportation needs in our 70s, 80s, and 90s,” she said. “The hard part is that driving is associated with independence, and this is such an emotional issue. But the more people look ahead, the more choice and control they can have.”

Steering Older Drivers to Resources

Many people with cognitive impairment continue to drive and don’t want to stop. There are no standards for when they should give up their car keys, but planning ahead is recommended. Here are some resources that offer guidance.

For basic information:Alzheimer’s Association: “”National Highway Traffic Safety Administration: “”

Hitting the milestone:Healthwise: “Is It Time to Stop Driving?”

A conversation guide:The Hartford Center for Mature Market Excellence: “.”

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But the health care system isn’t ready to address their needs.

That became painfully obvious during the covid-19 pandemic, when older adults with disabilities had trouble getting treatments and hundreds of thousands died. Now, the and the are targeting some failures that led to those problems.

One initiative strengthens access to medical treatments, equipment, and web-based programs for people with disabilities. The other recognizes that people with disabilities, including older adults, are a separate population with special health concerns that need more research and attention.

Lisa Iezzoni, 69, a professor at Harvard Medical School who has lived with multiple sclerosis since her early 20s and is widely considered the godmother of research on disability, called the developments “an important attempt to make health care more equitable for people with disabilities.”

“For too long, medical providers have failed to address change in society, changes in technology, and changes in the kind of assistance that people need,” she said.

Among Iezzoni’s notable findings published in recent years:

Most doctors are biased. In survey results , 82% of physicians admitted they believed people with significant disabilities have a worse quality of life than those without impairments. Only 57% said they welcomed disabled patients.

“It’s shocking that so many physicians say they don’t want to care for these patients,” said Eric Campbell, a co-author of the study and professor of medicine at the University of Colorado.

While the findings apply to disabled people of all ages, a larger proportion of older adults live with disabilities than younger age groups. About one-third of people 65 and older — nearly 19 million seniors — have a disability, according to the Institute on Disability at the University of New Hampshire.

Doctors don’t understand their responsibilities. In 2022, Iezzoni, Campbell, and colleagues had little to no knowledge of their responsibilities under the 1990 Americans With Disabilities Act, indicating a concerning lack of training. The ADA requires medical practices to provide equal access to people with disabilities and accommodate disability-related needs.

Among the practical consequences: Few clinics have height-adjustable tables or mechanical lifts that enable people who are frail or use wheelchairs to receive thorough medical examinations. Only a small number have scales to weigh patients in wheelchairs. And most diagnostic imaging equipment can’t be used by people with serious mobility limitations.

Iezzoni has experienced these issues directly. She relies on a wheelchair and can’t transfer to a fixed-height exam table. She told me she hasn’t been weighed in years.

Among the medical consequences: People with disabilities receive less preventive care and than other people, as well as more coexisting medical conditions. Physicians too often rely on incomplete information in making recommendations. There are and patients are they do get.

Egregiously, during the pandemic, when crisis standards of care were developed, people with disabilities and older adults were deemed low priorities. These standards were meant to ration care, when necessary, given shortages of respirators and other potentially lifesaving interventions.

There’s no starker example of the deleterious confluence of bias against seniors and people with disabilities. Unfortunately, older adults with disabilities routinely encounter these twinned types of discrimination when seeking medical care.

Such discrimination would be explicitly banned in September. For the first time in 50 years, it would update Section 504 of the Rehabilitation Act of 1973, a landmark statute that helped establish civil rights for people with disabilities.

The new rule sets specific, enforceable standards for accessible equipment, including exam tables, scales, and diagnostic equipment. And it requires that electronic medical records, medical apps, and websites be made usable for people with various impairments and prohibits treatment policies based on stereotypes about people with disabilities, such as covid-era crisis standards of care.

“This will make a really big difference to disabled people of all ages, especially older adults,” said Alison Barkoff, who heads the HHS Administration for Community Living. She expects the rule to be finalized this year, with provisions related to medical equipment going into effect in 2026. Medical providers will bear extra costs associated with compliance.

Also in September, NIH designated people with disabilities as a population with health disparities that deserves further attention. This makes a new funding stream available and “should spur data collection that allows us to look with greater precision at the barriers and structural issues that have held people with disabilities back,” said Bonnielin Swenor, director of the Johns Hopkins University Disability Health Research Center.

One important barrier for older adults: Unlike younger adults with disabilities, many seniors with impairments don’t identify themselves as disabled.

“Before my mom died in October 2019, she became blind from macular degeneration and deaf from hereditary hearing loss. But she would never say she was disabled,” Iezzoni said.

Similarly, older adults who can’t walk after a stroke or because of severe osteoarthritis generally think of themselves as having a medical condition, not a disability.

Meanwhile, seniors haven’t been well integrated into the disability rights movement, which has been led by young and middle-aged adults. They typically don’t join disability-oriented communities that offer support from people with similar experiences. And they don’t ask for accommodations they might be entitled to under the ADA or the 1973 Rehabilitation Act.

Many seniors don’t even realize they have rights under these laws, Swenor said. “We need to think more inclusively about people with disabilities and ensure that older adults are fully included at this really important moment of change.”

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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 . 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  to submit your requests or tips.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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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 . (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, 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.

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