Women are more likely to develop osteoporosis than men are, but that doesn’t mean men are in the clear. As journalist Pamela Span explains in this article, it does mean that they’re seldom screened for the disease or treated for it in time to make a difference. KFF Health News posted Span’s piece on October 14, 2025; it also ran in the New York Times. Funding from the Silver Century Foundation helps KFF Health News produce articles (like this one) on longevity and related health and social issues. 

Ronald Klein was biking around his neighborhood in North Wales, PA, in 2006 and tried to jump a curb. “But I was going too slow—I didn’t have enough momentum,” he recalled.

As the bike toppled, he thrust out his left arm to break the fall. It didn’t seem like a serious accident, yet “I couldn’t get up,” he said.

At the emergency room, X-rays showed that he had fractured both his hip, which required surgical repair, and his shoulder. Klein, a dentist, went back to work in three weeks, using a cane. After about six months and plenty of physical therapy, he felt fine.

But he wondered about the damage the fall had caused. “A 52-year-old is not supposed to break a hip and a shoulder,” he said. At a follow-up visit with his orthopedist, “I said, ‘Maybe I should have a bone density scan.’”

As Klein suspected, the test showed he had developed osteoporosis, a progressive condition, increasing sharply with age, that thins and weakens bones and can lead to serious fractures. Klein immediately began a drug regimen and, now 70, remains on one.

Osteoporosis occurs so much more commonly in women, for whom medical guidelines recommend universal screening after age 65,  that a man who was not a health care professional might not have thought about getting a scan. The orthopedist didn’t raise the prospect.

But about one in five men over age 50 will suffer an osteoporotic fracture in their remaining years, and among older adults, about a quarter of hip fractures occur in men. 

When they do, “men have worse outcomes,” said Cathleen Colón-Emeric, MD, a geriatrician at the Durham VA Health Care System and Duke University and the lead author of a recent study of osteoporosis treatment in male veterans.

“Men don’t do as well in recovery as women,” she said, with higher rates of death (25 to 30 percent within a year), disability and institutionalization. “A 50-year-old man is more likely to die from the complications of a major osteoporotic fracture than from prostate cancer,” she said.

(What’s “major”? Fractures of the wrist, hip, femur, humerus, pelvis or vertebra.)

Should some (or all) older men be screened for osteoporosis, as women are? 

In her study of 3,000 veterans ages 65 to 85, conducted at Veterans Affairs health centers in North Carolina and Virginia, only 2 percent of those assigned to the control group had undergone bone-density screening.

“Shockingly low,” said Douglas Bauer, MD, a clinical epidemiologist and osteoporosis researcher at the University of California-San Francisco, who published an accompanying commentary in JAMA Internal Medicine. “Abysmal. And that’s at the VA, where it’s paid for by the government.”

But establishing a bone health service—overseen by a nurse who entered orders, sent frequent appointment reminders and explained results—led to dramatic changes in the intervention group, who had at least one risk factor for the condition.

Forty-nine percent of them said yes to a scan. Half of those tested had osteoporosis or a forerunner condition, osteopenia. Where appropriate, most of them began medications to preserve or rebuild their bones.

“We were pleasantly surprised that so many agreed to be screened and were willing to initiate treatment,” Colón-Emeric said.

After 18 months, bone density had increased modestly for those in the intervention group, who were more likely to stick to their drug regimens than osteoporosis patients of either sex in real-world conditions.

The study didn’t continue long enough to determine whether bone density increased further or fractures declined, but the researchers plan a secondary analysis to track that.

The results revive a longtime question: given how life-altering, even deadly, such fractures can be, and the availability of effective drugs to slow or reverse bone loss, should older men be screened for osteoporosis, as women are? If so, which men and when?

Men would like to believe they’re indestructible, so a fracture doesn’t have the implication that it should. 

—Eric Orwoll, MD

Such issues mattered less when lifespans were shorter, Bauer explained. Men have bigger and thicker bones and tend to develop osteoporosis five to 10 years later than women do. “Until recently, those men died of heart disease and smoking” before osteoporosis could harm them, he said.

“Now, men routinely live into their 70s and 80s, so they have fractures,” he added. By then, they have also accumulated other chronic conditions that impair their ability to recover.

With osteoporosis testing and treatment, “a man could see a clear-cut improvement in mortality and, more importantly, his quality of life,” Bauer said.

Both patients and many doctors still tend to regard osteoporosis as a women’s disease, however. “There’s a bit of a Superman idea,” said Eric Orwoll, MD, an endocrinologist and osteoporosis researcher at Oregon Health & Science University.

“Men would like to believe they’re indestructible, so a fracture doesn’t have the implication that it should,” he added.

One patient, for example, for years resisted entreaties from his wife, a nurse, to “see someone” about his visibly rounded upper back.

Bob Grossman, 74, a retired public school teacher in Portland, blamed poor posture instead and told himself to straighten up. “I thought, ‘It can’t be osteoporosis—I’m a guy,’” he said. But it was.

Another obstacle to screening: “Clinical practice guidelines are all over the place,” Colón-Emeric said.

Professional associations like the Endocrine Society and the American Society for Bone and Mineral Research recommend that men 50 and older who have a risk factor, and all men over 70, should seek screening. 

As osteoporosis develops, it typically produces no symptoms, so without screening, men don’t know their bones have deteriorated until one breaks. 

But the American College of Physicians and the U.S. Preventive Services Task Force have deemed the evidence for screening of men “insufficient.” Clinical trials have found that osteoporosis drugs increase bone density in men, as in women, but most male studies have been too small or lacked enough follow-up to show whether fractures also declined.

The task force’s position means that Medicare and many private insurers generally won’t cover screening for men who haven’t had a fracture, though they will cover care for men diagnosed with osteoporosis.

“Things have been stalled for decades,” Orwoll said.

So it may fall to older men themselves to ask their doctors about a DXA (pronounced DECKS-ah) scan, widely available at $100 to $300 out-of-pocket. Otherwise, because osteoporosis is typically asymptomatic, men (and women, who are also undertested and undertreated) don’t know their bones have deteriorated until one breaks.

“If you had a fracture after age 50, you should have a bone scan—that’s one of the key indicators,” Orwoll advised.

Other risk factors: falls, a family history of hip fractures, and a fairly long list of other health conditions including rheumatoid arthritis, hyperthyroidism and Parkinson’s disease. Smoking and excessive alcohol use increase the odds of osteoporosis as well.

“A number of medications also do a number on your bone density,” Colón-Emeric added, notably steroids and prostate cancer drugs.

When a scan reveals osteoporosis, depending on its severity, doctors may prescribe oral medications like Fosamax or Actonel, intravenous formulations like Reclast, daily self-injections of Forteo or Tymlos, or twice-annual injections of Prolia.

Lifestyle changes like exercising, taking calcium and vitamin D supplements, stopping smoking, and drinking only moderately will help but aren’t sufficient to stop or reverse bone loss, Colón-Emeric said.

Although guidelines don’t universally recommend it, at least not yet, she would like to see all men age 70 and up be screened, because the odds of disability after hip fractures are so high—two-thirds of older people will not regain their prior mobility, she noted—and the medications that treat it are effective and often inexpensive.

But informing patients and health care professionals that osteoporosis threatens men too has progressed “at a snail’s pace,” Orwoll said.

Klein remembers attending a seminar to instruct patients like him in using the drug Forteo. “I was the only male there,” he said.

Researchers have found that, not only are the main vaccines recommended for older people effective, but a pair of them also reduce the risk of dementia. Journalist Paula Span sums up what you need to know in this piece that appeared in Kaiser Health News on June 23, 2025. It also ran in the New York Times. Funding from the Silver Century Foundation helps KFF Health News produce articles (like this one) on longevity and related health and social issues. 

Kim Beckham, an insurance agent in Victoria, TX, had seen friends suffer so badly from shingles that she wanted to receive the first approved shingles vaccine as soon as it became available, even if she had to pay for it out of pocket. 

Her doctor and several pharmacies turned her down because she was below the recommended age at the time, which was 60. So, in 2016, she celebrated her 60th birthday at her local CVS.

“I was there when they opened,” Beckham recalled. After getting her Zostavax shot, she said, “I felt really relieved.” She has since received the newer, more effective shingles vaccine, as well as a pneumonia shot, an RSV vaccine to guard against respiratory syncytial virus, annual flu shots and all recommended COVID-19 vaccinations.

Some older people are really eager to be vaccinated.

Robin Wolaner, 71, a retired publisher in Sausalito, CA, has been known to badger friends who delay getting recommended shots, sending them relevant medical studies. “I’m sort of hectoring,” she acknowledged.

Deana Hendrickson, 66, who provides daily care for three young grandsons in Los Angeles, sought an additional MMR shot, though she was vaccinated against measles, mumps and rubella as a child, in case her immunity to measles had waned.

For older adults who express more confidence in vaccine safety than younger groups, the past few months have brought welcome research. Studies have found important benefits from a newer vaccine and enhanced versions of older ones, and one vaccine may confer a major bonus that nobody foresaw.

The new studies are coming at a fraught political moment. The nation’s health secretary, Robert F. Kennedy Jr., has long disparaged certain vaccines, calling them unsafe and saying that the government officials who regulate them are compromised and corrupt.

Studies show that enhanced flu vaccines are more effective than standard flu shots. 

On June 9, Kennedy fired a panel of scientific advisers to the Centers for Disease Control and Prevention and later replaced them with some who have been skeptical of vaccines. But so far, Kennedy has not tried to curb access to the shots for older Americans.

The evidence that vaccines are beneficial remains overwhelming.

The phrase “Vaccines are not just for kids anymore” has become a favorite for William Schaffner, MD, an infectious diseases specialist at Vanderbilt University Medical Center.

“The population over 65, which often suffers the worst impact of respiratory viruses and others, now has the benefit of vaccines that can prevent much of that serious illness,” he said.

Take influenza, which annually sends from 140,000 to 710,000 people to hospitals, most of them seniors, and is fatal to 10 percent of hospitalized older adults. 

For about 15 years, the CDC has approved several enhanced flu vaccines for people 65 and older. More effective than the standard formulation, they either contain higher levels of the antigen that builds protection against the virus or incorporate an adjuvant that creates a stronger immune response. Or they’re recombinant vaccines, developed through a different method, with higher antigen levels.

In a meta-analysis in the Journal of the American Geriatrics Society, “all the enhanced vaccine products were superior to the standard dose for preventing hospitalizations,” said Rebecca Morgan, PhD, a health research methodologist at Case Western Reserve University and an author of the study.

Compared with the standard flu shot, the enhanced vaccines reduced the risk of hospitalization from the flu in older adults by at least 11 percent and up to 18 percent. The CDC advises adults 65 and older to receive the enhanced vaccines, as many already do.

The RSV vaccine is 75 percent effective in protecting you from an illness serious enough that you need to see a doctor. 

More good news: vaccines to prevent respiratory syncytial virus in people 60 and older are performing admirably.

RSV is the most common cause of hospitalization for infants, and it also poses significant risks to older people. “Season in and season out,” Schaffner said, “it produces outbreaks of serious respiratory illness that rivals influenza.”

Because the FDA first approved an RSV vaccine in 2023, the 2023-24 season provided “the first opportunity to see it in a real-world context,” said Pauline Terebuh, MD, an epidemiologist at Case Western Reserve School of Medicine and an author of a recent study in the journal JAMA Network Open.

In analyzing electronic health records for almost 800,000 patients, the researchers found the vaccines to be 75 percent effective against acute infection, meaning illness that was serious enough to send a patient to a health care provider.

The vaccines were 75 percent effective in preventing emergency room or urgent care visits, and 75 percent effective against hospitalization, both among those ages 60 to 74 and those older.

Immunocompromised patients, despite having a somewhat lower level of protection from the vaccine, will also benefit from it, Terebuh said. As for adverse effects, the study found a very low risk for Guillain-Barré syndrome, a rare condition that causes muscle weakness and that typically follows an infection, in about 11 cases per 1 million doses of vaccine. That, she said, “shouldn’t dissuade people.”

The CDC now recommends RSV vaccination for people 75 and older, and for those 60 to 74 if they’re at higher risk of severe illness (from, say, heart disease).

As data from the 2024-25 season becomes available, researchers hope to determine whether the vaccine will remain a one-and-done or whether immunity will require repeated vaccination.

Shingles vaccines protect you against shingles and also reduce the risk that you’ll develop dementia. 

People 65 and up express the greatest confidence in vaccine safety of any adult group, a KFF survey found in April. More than 80 percent said they were “very “or “somewhat confident” about MMR, shingles, pneumonia and flu shots.

Although the COVID vaccine drew lower support among all adults, more than two-thirds of older adults expressed confidence in its safety.

Even skeptics might become excited about one possible benefit of the shingles vaccine: this spring, Stanford researchers reported that over seven years, vaccination against shingles reduced the risk of dementia by 20 percent, a finding that made headlines.

Biases often undermine observational studies that compare vaccinated with unvaccinated groups. “People who are healthier and more health-motivated are the ones who get vaccinated,” said Pascal Geldsetzer, PhD, an epidemiologist at the Knight Initiative for Brain Resilience at Stanford and lead author of the study.

“It’s hard to know whether this is cause and effect,” he said, “or whether they’re less likely to develop dementia anyway.”

So the Stanford team took advantage of a “natural experiment” when the first shingles vaccine, Zostavax, was introduced in Wales. Health officials set a strict age cutoff: People who turned 80 on or before Sept. 1, 2013, weren’t eligible for vaccination, but those even slightly younger were eligible.

In the sample of nearly 300,000 adults whose birthdays fell close to either side of that date, almost half of the eligible group received the vaccine, but virtually nobody in the older group did.

“Just as in a randomized trial, these comparison groups should be similar in every way,” Geldsetzer explained. A substantial reduction in dementia diagnoses in the vaccine-eligible group, with a much stronger protective effect in women, therefore constitutes “more powerful and convincing evidence,” he said.

The team also found reduced rates of dementia after shingles vaccines were introduced in Australia and other countries. “We keep seeing this in one dataset after another,” Geldsetzer said.

In the United States, where a more potent vaccine, Shingrix, became available in 2017 and supplanted Zostavax, Oxford investigators found an even stronger effect. 

By matching almost 104,000 older Americans who received a first dose of the new vaccine (full immunization requires two) with a group that had received the earlier formulation, they found delayed onset of dementia in the Shingrix group.

How a shingles vaccine might reduce dementia remains unexplained. Scientists have suggested that viruses themselves may contribute to dementia, so suppressing them could protect the brain. Perhaps the vaccine revs up the immune system in general or affects inflammation.

“I don’t think anybody knows,” said Paul Harrison, MD, a psychiatrist at Oxford and a senior author of the study. But, he added, “I’m now convinced there’s something real here.”

Shingrix, now recommended for adults over 50, is 90 percent effective in preventing shingles and the lingering nerve pain that can result. In 2021, however, only 41 percent of adults 60 and older had received one dose of either shingles vaccine.

A connection to dementia will require further research, and Geldsetzer is trying to raise philanthropic funding for a clinical trial.

And “if you needed another reason to get this vaccine,” Schaffner said, “here it is.”

Rajiv Roy is semi-retired from venture capital, but he’s not slowing down. At age 66, he spends about half his time traveling—just in the past six months, he’s been to Colombia, China, India, Japan and Iceland—to capture birds and other wildlife through his camera lens. 

Roy took up wildlife photography about eight years ago, and he’s convinced it’s helping him age more healthfully. When he’s in nature, he’s mentally engaged and physically active. He’s often out by sunrise, scanning the horizon for wildlife, tracking and observing their behavior and moving constantly to position himself for a perfect shot.

“I’ve never had a bad day outdoors,” said Roy. “It gets you away from doomscrolling or stuffing your face mindlessly as you are triggered by political news.” 

A growing body of research confirms Roy’s observation: spending time in nature can help older adults stay physically active, mentally engaged, emotionally balanced, socially connected and even spiritually grounded. 

Compelling evidence is piling up for the health benefits of nature. A 2019 study of nearly 20,000 participants found that those who spent at least 120 minutes per week in nature were significantly more likely to report good health and well-being compared to those with no contact with nature. The positive association was consistent across different age groups and health statuses. 

Similarly, a systematic review of studies through 2017 found that exposure to green space (such as parks or trails) was associated with wide-ranging health benefits, including reduced diastolic blood pressure, heart rate, salivary cortisol, incidence of Type 2 diabetes and stroke, and mortality. Those who live in urban areas with more green spaces are also less likely to have cardiovascular disease, obesity, diabetes, asthma hospitalization or mental distress. 

The benefits are so significant that initiatives like PaRx are cropping up to encourage physicians to write “park prescriptions,” instructing patients to spend more time outdoors. PaRx, offered by the BC Parks Foundation in British Columbia, offers practical resources like quick tips and patient handouts to make prescribing time in nature easy and effective. 

“Health care providers are always looking for simple, practical interventions they can make to improve their patients’ lives,” according to the PaRx website. “The beauty of PaRx is that almost anyone can increase the time they spend in nature, no matter what their physical abilities are or where they live.”

Spiritual Ground

Many cultures have long recognized the value of the natural world to human health. Scandinavians embrace friluftsliv or “open-air living,” which can range from spending days in a remote mountain hut to simply taking a lunchtime run in the forest. In Finland, saunas are a weekly or daily ritual, involving meditative sessions in heated spaces, sometimes alternated with dips in cold water or a quick roll in the snow. 

In Japan, shinrin-yoku, or “forest bathing,” emerged in the 1980s as a kind of ecotherapy promoting mental and physical health. The practice involves spending time mindfully in the forest; other Asian countries, as well as Native American cultures, observe similar practices. 

John Dattilo, PhD, professor emeritus in Penn State University’s recreation, park and tourism management department, was part of a team that surveyed older adult forest bathers in Taiwan. The researchers found that fostering social connections around nature-based activities could improve health and quality of life for older adults.

“Nature seems to provide a platform for connecting with other people and for cultivating a sense of meaning and purpose in life,” he said. 

You hear the river running, the birds singing, and you smell the foliage or the flowers. There’s the sensation of snow or rain on your face. You don’t get that when you’re inside.

—Carol Hatch, MD

When they spend time in nature, Dattilo said, older adults often experience awe and wonder, which promotes a sense of appreciation and gratitude. 

“Gratitude is such an important aspect of healthy aging,” he said. “As we cultivate a sense of gratitude, we tend to be happier and healthier and to age more meaningfully.” 

Many older outdoor enthusiasts report experiencing spiritual connection and meaning outdoors. 

Carol Hatch, MD, 74, a retired pediatric neurologist, finds spiritual nourishment on a hiking trail near her home in Connecticut. Now that they’re retired, she and her husband help maintain the trails as volunteers. Over the decades, she has spent many hours on the trails—sometimes alone, in reflection, and sometimes with friends, talking about what’s going on in their lives. 

“It offers the possibility for introspection or for socialization, depending on how you choose to do it,” she said. “Being on the trail is a symphony of sensory delight. You can feel the sun on your skin and the wind cooling you off. You hear the river running, the birds singing, and you smell the foliage or the flowers. There’s the sensation of snow or rain on your face. You don’t get that when you’re inside.” 

Nature-Deficit Disorder

In 2005, author Richard Louv coined the term “nature-deficit disorder,” identifying “the human costs of alienation from nature,” such as behavioral and physical problems affecting children who never spend time outside. Louv noted that many children born in recent decades were among the first in human history to spend all their time indoors. 

Louv’s research focused on children, but many people who work with older adults observe that those who are confined indoors—whether due to isolation, mobility or health challenges—may suffer similar effects. 

“Small-world syndrome” was the term that Maureen McFadden, senior services manager in Marquette, MI, and her colleagues coined for the negative effects they’ve observed among older adults who never venture outside. 

“They develop a very consistent routine, they become more fearful, and they’re not exposed to new experiences or opportunities to build resilience and confidence,” she said.  

Barriers to Getting Out 

Since retiring about 15 years ago, outdoor activities have kept Don and Kay Wendell on the move. They chalk up about 3,000 miles a year on their bikes and spend time canoeing, skiing, snowshoeing and hiking.  

“It gets your heart rate up,” said Don Wendell, 77. “And I do some of my best thinking when I’m out biking or hiking.”

But having spent his career in recreation—he was director of parks and recreation in Plano, TX, when he retired in 2009—Wendell acknowledges that many older adults don’t get out to enjoy the outdoors. He thinks that many simply don’t know where to go or how to take advantage of outdoor recreation opportunities in their area. 

“I have a saying: ‘It is fun to have fun, but you have to know how,’” he said. 

Other barriers that may keep older adults from venturing out, according to McFadden, include lack of transportation to safe and accessible outdoor spaces; limited physical ability or fear of falling or injury, particularly without guidance or adaptive equipment; social isolation, which can reduce motivation to try new things or venture out alone; and financial constraints, which may make equipment rentals, park entry fees or guided tours inaccessible.

To help overcome those barriers, Marquette’s Senior Center created Silver Sampler, a program to encourage people 50 and older to try a variety of outdoor recreational activities at no cost. Since 2015, Silver Sampler has offered a long list of events, including winter sports like ice skating, cross-country skiing, snow biking and snowshoeing, as well as summer activities like kayaking, stand-up paddleboarding, hiking, rowing, tour biking, trail running, mountain biking, rock climbing and disc golf.   

Participants undergo an interview before joining the program. That serves two purposes, McFadden says: to assess their capabilities and to ensure their safety, but also to gently encourage participants to try new things. For example, McFadden worked with a 76-year-old woman who was hesitant to try kayaking. The woman could swim and was physically up to the challenge, so McFadden reassured her that she would stay near her and teach her paddling techniques. Not only did the woman enjoy kayaking, she came back for another kayaking trip, and with her confidence boosted, joined other Silver Sampler outings. 

Silver Sampler participant Carol Steinhaus says she tried activities through the program she never would have otherwise. 

“I would’ve never been on a fat-tire bike at this age,” she said. “I would not have tried downhill skiing. And I met people I would probably not have met otherwise, and I have really gained a lot from that. I’ve made lots of connections and it’s helped my life in many ways.” 

Overcoming Barriers

Getting outdoors has always been a challenge for Marjorie Turner, 69. In her 30s, brain surgery left her totally paralyzed on one side of her body. She’s able to walk now, using hiking poles, but the experience inspired her to publish a series of regional trail guides for hikers with mobility challenges. She says that getting outdoors may take a little more upfront research for older adults, especially those with mobility challenges. 

“It’s not always easy to gauge the accessibility of a trail before visiting,” she said. Most online sources are written for able-bodied people and often neglect to provide key information about trail surfaces or the availability of parking, benches and bathrooms. A trail rated as “easy” might be level but littered with rocks or roots, posing a fall hazard for an older person with foot drop or neuropathy.  

Turner notes that rail trails—hiking trails built along former railway routes—are often a good bet for older adults. Most are fairly level, paved and handicapped-accessible. Most are located near populated areas, with access to parking and bathrooms. (Find rail trails in your state at the Rails to Trails Conservancy website.) 

Turner advises older people who are venturing out into nature to never hike alone and to bring a cell phone, water and a fanny pack or light backpack. While it may take more planning to find safe, accessible places to enjoy nature, Turner says, it’s worth the effort. 

“As soon as I step outside, my heart is lighter,” she said. 

Transformations 

McFadden says outdoor recreation can transform the lives of older adults. She witnessed that with the Silver Sampler program. One participant, Don Bode, joined shortly after retiring and moving to Marquette. He was overweight, struggled with joint pain, had been physically inactive for many years and didn’t know anyone in the area. 

Bode started kayaking and hiking. He met new people and lost 60 pounds. He discovered asahi, a Finnish fitness practice, and even went to Finland to become a certified instructor. Now he teaches asahi at the Senior Center in Marquette. 

Joining Silver Sampler, Bode said, made him feel part of a community and gave him a sense of purpose. 

“You can wake up every morning and say to yourself, ‘What am I going to do today that’s going to keep me from aging in a poor manner?’” he said. “Or I can do something that the Silver Sampler taught me.’” 

The symptoms of a TIA can be so mild that it’s tempting to ignore them. Journalist Paula Span describes the symptoms and reports on the latest research on ministrokes and the consequences of ignoring them. KFF Health News posted her story on May 27, 2025. It also ran in the New York Times. Funding from the Silver Century Foundation helps KFF Health News produce articles (like this one) on longevity and related health and social issues. 

Kristin Kramer woke up early on a Tuesday morning 10 years ago because one of her dogs needed to go out. Then, a couple of odd things happened.

When she tried to call her other dog, “I couldn’t speak,” she said. As she walked downstairs to let them into the yard, “I noticed that my right hand wasn’t working.”

But she went back to bed, “which was totally stupid,” said Kramer, now 54, an office manager in Muncie, IN, “it didn’t register that something major was happening,” especially because, reawakening an hour later, “I was perfectly fine.”

So she “just kind of blew it off” and went to work.

It’s a common response to the neurological symptoms that signal a TIA, a transient ischemic attack or ministroke. At least 240,000 Americans experience one each year, with the incidence increasing sharply with age. 

Because the symptoms disappear quickly, usually within minutes, people don’t seek immediate treatment, putting them at high risk for a bigger stroke.

Kramer felt some arm tingling over the next couple of days and saw her doctor, who found nothing alarming on a CT scan. But then she started “jumbling” her words and finally had a relative drive her to an emergency room.

By then, she could not sign her name. After an MRI, she recalled, “my doctor came in and said, ‘You’ve had a small stroke.’”

Did those early-morning aberrations constitute a TIA? Might a 911 call and an earlier start on anticlotting drugs have prevented her stroke? “We don’t know,” Kramer said. She’s doing well now, but faced with such symptoms again, “I would seek medical attention.”

A TIA can cause a cognitive decline that shows up years afterward. 

Now, a large epidemiological study by researchers at the University of Alabama-Birmingham and the University of Cincinnati, published in JAMA Neurology, points to another reason to take TIAs seriously: over five years, study participants’ performance on cognitive tests after a TIA drops as steeply as it does among victims of a full-on stroke.

“If you have one stroke or one TIA, with no other event over time and no other change in your medical status, the rate of cognitive decline is the same,” said Victor Del Bene, PhD, a neuropsychologist and lead author of the study.

An accompanying editorial by Eric Smith, MD, a neurologist at the University of Calgary, was pointedly headlined, “Transient Ischemic Attack — Not So Transient After All!”

The study showed that even if the symptoms resolve—typically within 15 minutes to an hour—TIAs set people on a different cognitive slope later in life, Smith said in an interview, “a long-lasting change in people’s cognitive ability, possibly leading to dementia.”

The study, analyzing findings from data on more than 30,000 participants, followed three groups of adults age 45 or older with no history of stroke or TIA. “It’s been a hard group to study because you lack the baseline data of how they were functioning prior to the TIA or stroke,” Del Bene said.

With this longitudinal study, however, researchers could separate those who went on to have a TIA from a group who went on to suffer a stroke and also from an asymptomatic control group. The team adjusted their findings for a host of demographic variables and health conditions.

Immediately after a TIA, “we don’t see an abrupt change in cognition,” as measured by cognitive tests administered every other year, Del Bene said. The stroke group showed a steep decline, but the TIA and control group participants “were more or less neck and neck.”

Five years later, the picture was different. People who had experienced TIAs were cognitively better off than those who had suffered strokes. But both groups were experiencing cognitive decline, and at equally steep rates.

After accounting for various possible causes, the researchers concluded that the cognitive drop reflected not demographic factors, chronic illnesses or normal aging, but the TIA itself.

We know a lot more about how to prevent a stroke, as long as people get to a hospital.

—Tracy Madsen, MD 

“It’s not dementia,” Del Bene said of the decline after a TIA. “It may not even be mild cognitive impairment. But it’s an altered trajectory.”

Of course, most older adults do have other illnesses and risk factors, like heart disease, diabetes or smoking. “These things together work synergistically to increase the risk for cognitive decline and dementia over time,” he said.

The findings reinforce long-standing concerns that people experiencing TIAs don’t respond quickly enough to the incident. “These events are serious, acute and dangerous,” said Claiborne Johnston, PhD, MD, a neurologist and chief medical officer of Harbor Health in Austin, TX. 

After a TIA, neurologists put the risk of a subsequent stroke within 90 days at 5 percent to 20 percent, with half that risk occurring in the first 48 hours.

“Feeling back to normal doesn’t mean you can ignore this, or delay and discuss it with your primary care doctor at your next visit,” Johnston said. The symptoms should prompt a 911 call and an emergency room evaluation.

How to recognize a TIA? Tracy Madsen, MD, an epidemiologist and emergency medicine specialist at the University of Vermont, promotes the BE FAST acronym: balance loss, eyesight changes, facial drooping, arm weakness, speech problems. The “T” is for time, as in don’t waste any.

“We know a lot more about how to prevent a stroke, as long as people get to a hospital,” said Madsen, vice chair of an American Heart Association committee that, in 2023, revised recommendations for TIAs. 

The statement called for more comprehensive and aggressive testing and treatment, including imaging, risk assessment, anticlotting and other drugs, and counseling about lifestyle changes that reduce stroke risk.

Unlike other urgent conditions, a TIA may not look dramatic or even be visible; patients themselves have to figure out how to respond.

Karen Howze, 74, a retired lawyer and journalist in Reno, NV, didn’t realize that she’d had several TIAs until after a doctor noticed weakness on her right side and ordered an MRI. Years later, she still notices some effect on “my ability to recall words.”

Perhaps “transient ischemic attack” is too reassuring a label, Johnston and a co-author argued in a 2022 editorial in JAMA. They suggested that giving a TIA a scarier name, like “minor ischemic stroke,” would more likely prompt a 911 call.

The experts interviewed for this column all endorsed the idea of a name that includes the word “stroke.”

Changing medical practice is “frustratingly slow,” Johnston acknowledged. But whatever the nomenclature, keeping BE FAST in mind could lead to more examples like Wanda Mercer, who shared her experience in a previous column. 

In 2018, she donated at the bloodmobile outside her office in Austin, where she was a systems administrator for the University of Texas, then walked two blocks to a restaurant for lunch. “Waiting in line, I remember feeling a little lightheaded,” she said. “I woke up on the floor.”

Reviving, she assured the worried restaurant manager that she had merely fainted after giving blood. But the manager had already called an ambulance—this was smart move No. 1.

The ER doctors ran tests, saw no problems, gave Mercer intravenous fluids and discharged her. “I began to tell my colleagues, ‘Guess what happened to me at lunch!’” she recalled. But, she said, she had lost her words, “I couldn’t articulate what I wanted to say.”

Smart move No. 2: Co-workers, suspecting a stroke, called the EMTs for the second time. “I was reluctant to go,” Mercer said. “But they were right.” This time, emergency room doctors diagnosed a minor stroke.

Mercer has had no recurrences. She takes a statin and a baby aspirin daily and sees her primary care doctor annually. Otherwise, at 73, she has retired to an active life of travel, pickleball, running, weight lifting and book groups.

“I’m very grateful,” she said, “that I have a happy story to tell.

Before she landed in the hospital, Wilma Jones (not her real name) was living independently and generally managing well, despite some mild cognitive impairment. But one day, when an insurance assessor came to her home, Jones answered in her underwear, in a state of confusion, and fell. 

Hospital staff determined that Jones, in her late 80s, was taking two medications for insomnia: clonazepam (Klonopin), prescribed by her physician, along with Advil PM, an over-the-counter (OTC) medication she had self-prescribed.

“The combination of these medications had a significant effect on her cognition and her ability to maintain safety, causing her to fall multiple times,” said Katie Pescatello, a nurse practitioner and hospitalist who helped care for Jones. “After those medications were removed, she returned to her normal cognitive status.” 

Jones’s ordeal is far from rare. As many as one-third of emergency hospital admissions among people 75 or older may be in part due to medication-related problems. Those with cognitive impairment are especially vulnerable. 

To help address the problem, the Journal of the American Geriatrics Society (AGS) maintains the Beers Criteria, a directory of drugs that are potentially harmful for older adults. In July 2025, the AGS published new recommendations for treating common symptoms affecting older adults that list alternative medications as well as nonpharmacological treatments. 

But many patients and caregivers aren’t aware of the Beers Criteria—or that it includes common OTC medications that many older adults self-prescribe. 

“People assume they’re benign, but over-the-counter medications can be very harmful, depending on your age, your concurrent medications, and your kidney and liver function,” said Dominick Trombetta, PharmD, associate professor at Wilkes University School of Pharmacy in Wilkes-Barre, PA.

The Beers Criteria was developed in 1991 by the late Mark Beers, MD, and colleagues, originally as a guide to prevent improper use of medications in nursing home settings. The list gained popularity and was eventually expanded to include all older adults. The AGS has maintained the Beers Criteria since 2011 with periodic updates, most recently in 2023. 

Until recently, the Beers Criteria only flagged drugs whose potential for harm outweighed their intended benefits. A panel of experts would hammer out specific recommendations to guide physicians in handling common conditions that affect older adults and are often treated with Beers Criteria medications, including allergic rhinitis, pruritus (itching), pain, diabetes, involuntary weight loss, atrial fibrillation (Afib), anxiety, insomnia, delirium, gastroesophageal reflux (GERD) and recurrent urinary tract infections. 

The current publication also recommends alternative medications and nonpharmacological interventions, such as cognitive behavioral therapy for sleeplessness, or exercise, physical therapy and psychological interventions for pain.  

Problematic OTC Medications

Among the most common OTC medications on the list are sedating antihistamines, including Benadryl (diphenhydramine), Unisom (doxylamine) and Bonine/Dramamine (meclizine). These medications are used to treat allergies or to aid with sleep, since they cause drowsiness in many patients. (They are sometimes called “first-generation” antihistamines, distinguishing them from second- and third-generation antihistamines, which are less likely to cause sleepiness and less likely to cause interactions with other medications.)

With these medications, older adults have increased risk of side effects, which may include dry mouth, constipation, overheating (especially during the warm summer months) and short-term confusion, according to Man-Khoi Nguyen, PharmD, director of clinical pharmacy at Archwell Health in Nashville, TN.   

“The risk increases even further with regular use,” he said. “The drugs are also linked with increased risk of falls and dementia.” 

Many older adults aren’t aware of these potential dangers. 

“Patients and caregivers often know about issues like the potential for aspirin to cause stomach bleeding, for example,” said Pescatello. “But not many people are aware that antihistamines, or any medicine with ‘PM’ in the name, pose extra risks for older adults.” 

Another common class of OTC medications included in the Beers Criteria: nonsteroidal anti-inflammatory drugs—or NSAIDs—such as Motrin and Advil (ibuprofen) and Aleve (naproxen.) These may increase blood pressure, increase risk of ulcers or stomach bleeding or may worsen heart failure or kidney disease in patients with these conditions.

“We see older patients, almost on a weekly basis, who’ve taken NSAIDs and who come to the hospital because of either acute stomach bleeding or even acute kidney injury,” said Trombetta.

The Beers Criteria also cautions against prolonged use of proton pump inhibitors such as Prilosec (omeprazole) or Nexium (esomeprazole) for heartburn or acid reflux. When taken for longer than eight weeks, PPIs are associated with an increased risk of bone loss, fractures and a severe type of diarrhea called C. diff.   

Common Problems, Alternative Interventions

The July update lists medication alternatives that are generally considered safer than Beers Criteria drugs. For example, for allergic rhinitis (hay fever or seasonal allergies), instead of first-generation antihistamines, the update recommends nasal sprays (which are absorbed into the bloodstream less than oral medications and have fewer adverse effects). For those taking oral antihistamines, second- or third-generation antihistamines (such as loratadine (Claritin) or cetirizine (Zyrtec)) are preferred. 

The July update also details nonpharmacological interventions for several common symptoms, many of which, it says, “are often safer or equally or more effective than the potentially inappropriate medications they are replacing.”   

Examples include: 

• Allergic rhinitis: Avoid allergens, when possible; irrigate nasal passages with distilled saline, using a neti pot or similar system. 
• GERD: Make lifestyle changes, such as smoking cessation, avoiding trigger foods, not eating within two to three hours before bedtime and elevating the head of the bed. 
• Constipation: Increase fluid and fiber intake, exercise. 
• Arthritis-related pain: Exercise, physical therapy, education and psychological interventions such as cognitive behavioral therapy. 

Insomnia—the condition that ultimately sent Jones to the hospital—illustrates the need for nonpharmacological interventions and why they are so often challenging to implement.

The American Academy of Sleep Medicine recommends nonpharmacologic interventions as the first line of treatment for insomnia. However, older adults often self-prescribe potentially risky OTC medications. According to the 2017 National Poll on Healthy Aging, about one in four older adults use OTC medications for sleep either regularly or occasionally. 

Several classes of prescription drugs included in the Beers Criteria are also sometimes prescribed for insomnia, including benzodiazepines (such as Xanax, Valium or Klonopin), Z-drugs (such as zolpidem or Ambien,) tricyclic antidepressants and barbiturates. 

But cognitive behavioral therapy, combined with good sleep hygiene, has been shown to be more effective in the long term than medications. So why aren’t physicians prescribing those? Jones’ situation provides some clues. After just two days, the medications cleared her system, and she was alert and cognitively functional. 

“But she remained worried about sleep,” said Pescatello. “Much of our education during her hospitalization focused on avoiding dangerous medication combinations and avoiding Advil PM altogether.”

Drugs listed in the Beers Criteria are potentially harmful—but not in all cases or for everyone. 

Nonpharmacological interventions often require spending more time with patients—a challenge for time-pressed general practitioners. They don’t work if patients don’t comply, a big hurdle for those with cognitive impairment. Sometimes patients insist on medications. 

To help address these challenges, the July update also includes links to resources that physicians can share with patients and their caregivers, such as a one-page patient infographic on managing GERD and digital apps like Insomnia Coach, which allow patients to self-administer cognitive behavioral therapy for sleep problems. 

The addition of nonmedicinal options reflects a general trend in geriatric medicine: deprescribing—discontinuing drugs that are either potentially harmful or no longer required, or reducing the dosage or frequency, always with medical supervision. 

Medications pose additional risks for older adults for a variety of reasons, according to Nguyen.

“As we age, physiological changes take place that affect how our bodies metabolize, or process, medications,” he said. “For example, the liver decreases in size and blood flow to the liver also reduces. Medications that pass through the liver may not be cleared as quickly.” That, in turn, increases the risk of adverse effects, which can range from mild to life-threatening. 

The Beers list is primarily a tool for medical providers. But patients can take steps to ensure their medications are being managed appropriately.

First, understand that Beers Criteria identifies drugs that are potentially harmful for older adults. That doesn’t mean that physicians should never prescribe them, Trombetta cautions. In some cases, patients and their physicians may decide jointly to accept the risks associated with a medication, if that’s the best option.

Some drugs on the list should be avoided only by older adults with specific health conditions, such as reduced kidney function; some should be avoided in combination with other drug treatments; and some must be dosed differently for older adults. The Beers list doesn’t apply to older adults in hospice and palliative care settings.  

Tips for Older Adult Patients

If you are taking a Beers Criteria medication, ask your physician if there are safer or more effective therapies. 

“Patients should never discontinue any medication without talking to their doctors first,” said Trombetta. “Ideally, the Beers list is a starting point to have a conversation.” 

Be sure you are clear on why you need each medication and why it was prescribed. Inform your physician if you suspect a medication is not working or if you experience side effects. 

Pharmacists can also serve as a helpful, and often readily available, resource. 

“If you’re experiencing side effects, and your physician is not immediately available, you can seek a quick consult with your pharmacist,” Nguyen said. “Likely, they can advise whether a reaction could be mild or needs medical attention right away. Pharmacists are still one of the most highly accessible health care providers, with extensive training to recognize significant drug interactions and potential inappropriate use.” 

Carefully review the information provided by your pharmacy for every drug you take, or consult a trusted source such as Medline Plus. 

Always consult your physician or pharmacist before taking any new OTC medication. Here again, the pharmacist can be a good resource. 

“Older people often see many different specialists, but most people use just one pharmacy,” said Trombetta. “If you’re just talking to a doctor, and he only knows what he prescribed, he doesn’t necessarily know what the specialist across town prescribed. The pharmacist gets to see the big picture.” 

Finally, understand that the Beers Criteria is a tool for medical providers, not a guideline for self-prescribing or self-deprescribing any medication. 

“The key is to be engaged in your own care,” said Trombetta. “Understand the things that you can do that don’t require medication, like lifestyle modifications. They don’t cost you anything; they just require a little motivation. If you can avoid taking a medication, in the long run you’re going to be much better off.”