That’s a shame because accommodations of all kinds are available for those willing to ask for them. Many are required by law. Journalist Paula Span reports on the situation in this column, posted on KFF Health News on December 11, 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. 

In her house in Ypsilanti, MI, Barbara Meade said, “there are walkers and wheelchairs and oxygen and cannulas all over the place.”

Barbara, 82, has chronic obstructive pulmonary disease, so a portable oxygen tank accompanies her everywhere. Spinal stenosis limits her mobility, necessitating the walkers and wheelchairs and considerable help from her husband, Dennis, who serves as her primary caregiver.

“I know I need hearing aids,” Barbara added. “My hearing is horrible.” She acquired a pair a few years ago but rarely uses them.

Dennis Meade, 86, is more mobile, despite arthritis pain in one knee, but contends with his own hearing problems. Similarly dissatisfied with the hearing aids he once bought, he said, “I just got to the point where I say, ‘Talk louder.’”

But if you ask either of them a question included on a recent University of Michigan survey—“Do you identify as having a disability?”—the Meades answer promptly: No, they don’t.

Disability “means you can’t do things,” Dennis said. “As long as you can work with it and it’s not affecting your life that much, you don’t consider yourself disabled.”

Their daughter Michelle Meade, a rehabilitation psychologist and the director of the Center for Disability Health and Wellness at the university, accompanies her parents to medical appointments and tends to roll her eyes at their reluctance to acknowledge needing support.

Working with other researchers on the recent national poll has shown her how often older adults feel that they are not disabled despite ample evidence to the contrary.

Many people still feel like ‘disability’ is a dirty word.

— Megan Morris, PhD

The survey looked at nearly 3,000 Americans aged 50 and older and found that only a minority—fewer than 18 percent of participants over 65—saw themselves as having a disability.

Yet their responses to the six questions that the Census Bureau’s American Community Survey uses to track disability rates told a different story.

The survey asks whether respondents have difficulty seeing or hearing, limitations in walking or climbing stairs, difficulty concentrating or remembering, trouble dressing or bathing, difficulty working or problems leaving the home.

In the university’s survey, about a third of those aged 65 to 74 reported difficulty with one or more of those functions. Among those over 75, the figure was more than 44 percent.

Moreover, when respondents were asked about several additional health conditions that would require accommodations under the Americans with Disabilities Act, including respiratory problems or speech disorders, the proportion climbed even higher. Half the 65-to-74 group reported disabilities, as did about two-thirds of those over 75.

Yet only a sliver—fewer than one in five—of older adults had ever received an accommodation from their health care providers to which they are legally entitled under the ADA.

Even among the small minority who identified as disabled, only a quarter had asked for an accommodation (though a third received one, whether they asked or not).

“It’s a familiar story,” said Megan Morris, PhD, a rehabilitation researcher at NYU Langone Health and director of the Disability Equity Collaborative. When it comes to the way people describe themselves, “many people still feel like ‘disability’ is a dirty word,” she said.

It’s almost an American value to decline to seek help, even when the law requires that it be available, Michelle Meade added. Faced with a disability, she said, “we’re supposed to toughen up and battle through it.”

In health care settings, it helps a lot if you tell providers you have a disability and ask for help. 

That may be particularly true among older Americans whose attitudes formed before the landmark ADA became law in 1990, or even before the 50-year-old Individuals with Disabilities Education Act, which guaranteed access to public education.

“It’s going to be hard for that older generation,” Morris said. “Disability was something that was locked away. Younger folks are more open to seeing disability as being part of a community.”

In the University of Michigan survey, for instance, among people over 65 who had two or more disabilities, about half identified as a person with a disability. In the younger cohort, aged 50 to 64, it was 68 percent.

Why does that matter? “It greatly assists in health care settings if you disclose a disability and know to request an accommodation and support,” said Anjali Forber-Pratt, PhD, the research director at the American Association of Health and Disability.

Such accommodations “can make a stressful situation easier,” she added. They include mammography and X-ray machines that allow patients to remain seated, scales that wheelchair users can roll onto, examination tables that rise and lower so that patients don’t have to step onto a footstool and swivel around.

Health care providers may also offer amplification devices for people with hearing loss, as well as magnifiers and large print materials for the visually impaired. Buildings themselves must be accessible. Practices can send a staff member with a wheelchair to help patients traverse long distances.

Even with a disability parking placard, “you hike in, you wait for the elevator, you hike to the office,” said Emmie Poling, 75, a retired teacher in Menlo Park, CA.

Because of arthritis and spinal stenosis, “I can’t walk with an upright posture for more than a few minutes” without pain, she said. “I basically live on Tylenol.” Yet when she makes an appointment and the scheduler asks if she will need assistance, Poling replies that she won’t.

“My personal voice says, ‘Come on, you can do it,’” she said.

Patients who identify as disabled feel less depressed and anxious than those who don’t, according to research. 

Identifying as a person with a disability provides other benefits, advocates say. It can mean avoiding isolation and “being part of a community of people who are good problem-solvers, who figure things out and work in partnership to do things better,” Meade said.

Government programs and private organizations like the National Disability Rights Network,  the Americans with Disabilities Act National Network and the National Association of Councils on Developmental Disabilities help connect people with services and supports in their communities.

Several studies have found too that patients who identify as disabled have less depression and anxiety, higher self-esteem and a greater sense of “self-efficacy” than disabled people who don’t.

For years, despite a lifetime of surgeries for congenitally dislocated hips, as well as joint replacements and cancer treatment, Glenna Mills, an artist in Oakland, CA, told herself that she was not disabled.

“I suffered a lot by denying that I couldn’t walk very far,” she recalled. Although walking caused pain in her knees, hips and shoulders, “I didn’t want people to see me as someone who couldn’t keep up,” she added.

But about 10 years ago, “I stopped worrying about that,” said Mills, 82. “I was more willing to say, ‘I can’t do that activity. I can’t walk that far.’” She bought a scooter that allowed her to take walks with her husband and dog and to spend time in museums. “I’m happier now,” she said.

More often, older Americans resist a label that could help improve their care. Even those who do request accommodations may find that enforcement of the ADA remains spotty, in part because patients don’t always report violations.

The Meades, after years of pleading from their children, have made appointments to see an audiologist about new hearing aids.

But Poling intends to struggle on without seeking or accepting assistance. “I know that point will come,” she said. “I’ll attempt to surrender as gracefully as possible, given my personality.”

Until then, she said, “the mental picture that’s acceptable to me is not wanting to look like I’m disabled.”

For the past 14 years, Darrell Rodenbaugh has played the lead in Scrooge – The Musical, an annual production by North Texas Performing Arts in Plano. The role is a marathon for 62-year-old Rodenbaugh: the company performs more than a dozen shows on consecutive nights, plus matinees on the weekends, with Rodenbaugh on stage, singing, dancing and speaking, for nearly the entire two-and-a-half-hour show. 

All of which he managed to handle until about five years ago, when his voice began to falter. 

“It was getting a little more raspy,” he said. “I was struggling to enunciate and hit some of the higher notes.” 

Rodenbaugh was noticing presbyphonia, or “aging voice,” changes in vocal quality that occur with aging. As people reach older adulthood, their voices tend to become breathy, weak or hoarse. They may lose the ability to project, and the voice may tire more easily. 

Rodenbaugh relies on his voice professionally, but voice problems can affect any older adult—and they are common. Research suggests that 19-29 percent of adults 64 and older experience a voice disorder at any given time, and for many, it impairs daily function and satisfaction with life. 

“The most common complaints I hear are, ‘People can’t hear me’ or ‘I have to repeat myself all the time,’” said Karen Goins, a speech pathologist who works with older adults in Dallas.

Often folks have no idea that there are voice doctors and things we can do that are specifically geared to helping older patients.

—Lesley Childs, MD

When voice issues make it harder to communicate and to socialize, that can lead to isolation and, in turn, depression and cognitive decline, according to Angela Van Sickle, PhD, a speech pathologist at Texas Tech University Health Sciences Center in Lubbock. 

“If friends or family can’t hear them, or can’t understand them, it’s frustrating, and it’s more work to communicate,” she said. “Some people start to feel like it’s too much work. They start to kind of close in and become more and more isolated.” 

Similarly, older adults who remain in the workforce may feel that voice issues hamper their professional productivity. 

However, while age-related changes may be inevitable, experts say older adults have options for keeping their voices strong, ranging from voice therapy and good health habits to medical interventions like injections and surgery. 

“Often, folks have no idea that there are voice doctors and things we can do that are specifically geared to helping older patients,” said Lesley Childs, MD, medical director at the Clinical Center for Voice Care at UT Southwestern Medical Center in Dallas.  

How Voices Change

The voice functions like a musical instrument. Sound emanates from the vocal folds, or vocal cords, housed in the larynx. Air pumped up from the lungs causes the folds to vibrate, creating sound that resonates in the open spaces inside the mouth, behind the nose and the back of the throat. 

Like the rest of the body, the larynx, vocal cords and lungs change with age. The larynx can become stiff. The vocal folds can atrophy, losing muscle tone, elasticity and moisture. The lungs, which act like a respiratory bellows to power the voice, lose capacity. With these changes, the voice starts to sound raspy, weak or breathy. That’s why it is often easy to tell that you’re talking to an older person on the telephone, just by the sound of their voice. 

Men’s and women’s voices tend to age differently, said Childs, who is also associate professor of laryngology, neurolaryngology and professional voice at UT Southwestern. 

“In men, the vocal folds become thin and slightly bowed, causing the voice to sound more breathy and weaker,” she said. “In females, the vocal folds become more dense, causing the voice to deepen.” 

Hormonal changes—lowered estrogen levels in women, falling androgen levels in men —seem to contribute.

Older people may develop a tremor, making the voice shaky. Neurogenic conditions such as Parkinson’s can impair the vocal cords or cause tremors. A stroke may trigger vocal cord paralysis or affect the part of the brain that controls speech. (Speech, the ability to articulate words, is differentiated from the voice, which produces the sound generated in the vocal cords.) Older adults also take more medications and have more health conditions, both of which can affect voices. 

Age-related voice problems occur at the same time many older adults experience hearing loss, making two-way communication even more difficult. Hearing loss can also contribute to voice issues. A person with impaired hearing may have difficulty calibrating their volume—either causing them to speak too loudly or too softly, depending on how they perceive their own voice. 

How Voice Therapy Works

For those with vocal disorders, the first line of treatment is voice therapy with a speech language pathologist. 

“The exercises aim to restore vocal strength by rebuilding muscle tone,” said Van Sickle.

Just as the abs and glutes need regular exercise to stay strong, so do the muscles in the voice. Voice therapy helps patients learn proper breathing techniques and find ways to optimize volume and reduce strain. Van Sickle often prescribes a series of exercises developed by voice-therapy pioneer Joseph Stemple, with separate regimens for male and female voices. Similar to vocal warm-ups that singers and actors follow, these involve holding a single note or pitch glides—starting low and sliding to a higher note, and vice versa.

Specialized voice-therapy programs are also available for people with Parkinson’s and other age-related voice issues.

“Patients with Parkinson’s may feel like they’re yelling, because they have to put in extra effort to speak, but they’re actually talking too softly,” Van Sickle said. “These programs help people to recalibrate the volume of their voices.” 

Other Interventions

Even at the age of 88, Jan Steele says her voice hasn’t changed much. She credits her 42 years as a member of the Rich-Tones, an 80-person women’s barbershop chorus in Dallas. The group rehearses for three hours each week and performs in concerts and international competitions, three of which they’ve won. 

“I’m very disciplined about my vocal exercise,” Steele said. “I sing in the shower and around the house. I practice scales and repertoire, and of course go to weekly rehearsals. I think a mature voice needs to sing every day. If you don’t use it, you lose it.”

Experts agree: singing can be a form of natural voice therapy. 

“The folks that we see that are doing really well are generally using their voice a fair amount, without overusing it,” said Childs. “Singing is good for expansion of the breath support. We actually recommend singing to a lot of our patients.”  

Here are other steps experts recommend for vocal health and longevity.

Stay hydrated. Drink plenty of water, especially when exercising. Childs likes caffeine-free teas, served warm, not hot. She advises patients to avoid alcohol and caffeine, or to balance intake of either with additional water. 

Practice “external hydration.” A home humidifier, especially in winter or dry climates, can be helpful. (Thirty percent humidity is recommended.) For professionals who use their voices, Childs also recommends a portable saline nebulizer designed specifically for voice support, such as Vocal Mist, to add moisture to the throat. 

Address bad habits. A persistent cough can lead to vocal problems. Some people develop a habit of frequently clearing their throats, for example, which irritates the vocal folds. Van Sickle helps patients in that situation learn to swallow or take other steps when the urge to clear their throat crops up. 

Manage allergies and allergy medicine. Allergies can cause inflammation in the larynx, leading to hoarseness. Antihistamines may dry out the nasal and breathing passages. For people with congestion or post-nasal drip, Childs prefers guaifenesin (Mucinex is a popular brand), an expectorant that helps loosen and clear mucus from the airways. Avoid pseudoephedrine (D) or dextromethorphan (DM) formulations, which can cause dryness.

Use assistive devices. Van Sickle never teaches class for more than an hour or two, even in a small classroom, without a microphone. Personal amplification devices can be used in situations where a public address system is not available. 

Exercise regularly. Exercise increases stamina and muscle tone, as well as improves posture and breathing. 

Practice good breathing techniques. Support the voice with deep breaths from the chest. 

Socialize in quiet places. Trying to talk over a noisy room can cause frustration and strain the voice. Childs encourages patients to consider acoustics when making plans. “If they go out to dinner at a restaurant, for example, I advise them to choose a quiet restaurant, or a booth in the corner, next to a wall, where it’s likely to be easier to hear and be heard,” she said. 

Maintain good posture. Goins works with patients’ posture, because good posture can facilitate better breath support, which helps in speaking. Van Sickle also encourages patients to always face the person they’re speaking with. “There are so many important cues that we get from a speaker’s facial expressions,” she said.

Rest the voice. While exercising is helpful, resting is important, too, especially for anyone who uses their voice extensively. Avoid vocal extremes, such as screaming or whispering. Childs notes that vocal strain is dose related. The longer a person speaks, and the louder, the more likely they are to strain the voice. It’s important to take breaks before and after any challenging speaking situations. 

Medical Interventions 

Most age-related voice issues are not serious and respond well to therapy. But for persistent symptoms, it’s a good idea to see an otolaryngologist or ear, nose and throat (ENT) specialist for a medical evaluation to rule out other medical conditions such as gastroesophageal reflux (GERD) or cancer of the larynx.

Typically, a medical workup for voice issues begins with an examination of the larynx and the vocal folds. This may involve a videostroboscopy, which Childs calls the “gold standard” for a thorough workup. A scope, inserted through the mouth or nose, uses strobe lights to examine vocal tissue. 

For those struggling with atrophy (thinning), Childs may inject fillers to “fatten up” the vocal cords. For a more permanent solution, she can surgically place implants (usually made of Gore-Tex) into the vocal cords to bulk them up. Botox injections may help calm vocal tremors by relaxing overactive muscles. If GERD is diagnosed, dietary changes or medications are recommended to help reduce flare-ups and minimize irritation in the throat. 

“I’m hopeful more people will realize that there are some options for them,” Childs said, adding that most large cities in the United States with major academic medical centers offer voice centers—multidisciplinary teams of fellowship-trained otolaryngologists, speech pathologists and other specialists focused on voice therapies.  

Scrooge’s Redemption 

When his voice issues arose, Rodenbaugh began working with a vocal coach who prescribed voice and breathing exercises. He started exercising with a trainer, adding cardio to boost his breath support. To help prevent sinus infections and inflammation, he irrigates his nasal passages regularly with saline. When he’s performing, he hydrates constantly before, during and after each show. 

Now, Rodenbaugh says, his voice is as strong as ever—he’s even hitting a few high notes he couldn’t hit before. This fall, he’ll return as Scrooge in NTPA’s 15th season, marking the troupe’s record-setting 125th performance of Scrooge: The Musical. 

“At this age, singing is not about pushing harder, it’s about being smarter,” he said. “Caring for your voice really means caring for yourself and your whole body.” 

Every year, millions of older adults roll up their sleeves for an annual physical. Blood is drawn, a cuff tightens around the arm, and a stethoscope taps against the chest. A few days later, a patient portal pings with test results, unleashing a barrage of numbers: cholesterol levels, blood pressure readings, blood glucose, creatinine and more. 

It’s like receiving a report card in a language you don’t speak.

What do all these numbers mean? Is it important for patients to understand and track them from one year to the next? And if a lab test produces an abnormal result, should you worry, wait or push your physician for action? 

“There are so many tests out there that it’s very confusing for patients,” acknowledged Darshan Kapadia, MD, senior internist at Texas Health Plano in Plano, TX. 

Understanding your numbers can help you ask informed questions, advocate for your own health care and partner more effectively with your health care provider. At the same time, health care professionals caution, it’s important to put numbers in context. No single lab result tells the whole story. And determining what’s normal for each patient’s personal health situation is more complicated than it looks. Numbers alone don’t determine diagnoses; they’re data points that must be weighed along with a patient’s health history and physical exam.

“There’s more to the story than just those numbers on the lab sheet,” said Rebekah Mulligan, MD, an internal and geriatric medicine physician at Texas Health Harris Methodist Hospital in Southlake, TX. 

More Isn’t Always Better

Understanding your personal numbers is more important than ever, now that many patients have direct access to test results. The growth in health information technology, especially patient portals, means more and more data is relayed straight to patients, sometimes in bewildering detail, often without medical guidance. 

But more information isn’t always a good thing. This windfall of data to patients comes at a time when primary care physicians are increasingly in short supply and pressed for time to explain those results.

“Clinicians have expressed concern that patients often experience great difficulty in comprehending, interpreting, and correctly responding to personalized health information,” according to a 2020 study published in the Israel Journal of Health Policy Research. “In particular, misunderstanding test results leads to confusion, frustration, and disruptions in healthcare processes, including delays in seeking care, overutilization of services, medication errors, and inappropriate healthcare decision-making.” 

At the same time, in most states, patients can now take advantage of “DIY diagnostics” by ordering their own blood tests at medical labs, without guidance or orders from medical professionals. At-home medical and wellness testing is exploding; it’s now a $5 billion market in the United States. 

Advocates say this expanded pool of available information gives patients more options when they’re looking for answers to hard-to-diagnose health issues or waiting for months for medical appointments. But medical professionals argue that it can be risky for patients to interpret their own results. Some may panic over an out-of-normal-range result that isn’t necessarily concerning—or assume that a blood workup with only normal results means they’re healthy. 

Normal vs. Abnormal

In reviewing their lab results, one common assumption many patients make is viewing the numbers as either “normal” or “abnormal.” But physicians take a more nuanced view. Even the term “normal” can be misleading. 

“It’s important for patients to understand how the medical profession comes up with what is considered the normal range,” said Diana Cardona, MD, professor and chair of the department of pathology at Wake Forest University School of Medicine. For example, a white blood count (WBC) of 4,500—11,000 cells/mcL is considered within normal range. Researchers developed that range by looking at data from large groups of healthy individuals. The range of numbers where 95 percent of those patients landed is designated as normal. 

“But that’s really just a statistical number,” Cardona said. “There’s the 5 percent on either end of the range who are still healthy people, but now we’ve called them abnormal.” 

Cardona prefers the term “reference range” rather than “normal range” for that 95 percent. 

Context is important too. Two patients with the same borderline cholesterol numbers, for example, might need totally different treatment approaches.  

“If a patient has diabetes and high blood pressure, I need them at a much lower cholesterol level to control their risk, compared to a patient without diabetes or high blood pressure,” said Donald Lloyd-Jones, MD, director of the Framingham (MA) Center for Population and Prevention Science and chief of preventive medicine at the Chobanian & Avedisian School of Medicine and Boston Medical Center.  

Doctors take into account how much a number on a test changes from year to year and how quickly.

Almost every number comes with asterisks—exceptions to the rule when it comes to interpretation. Body mass index (BMI) seems like a straightforward way to determine whether a patient is at a healthy weight: a BMI of 19-24 is considered healthy; 25 or higher is overweight; over 30 is obese. 

But according to the American Heart Association, a BMI number should be “interpreted with caution” among persons of Asian ancestry, older adults and muscular individuals. For adults 65 and older, recent studies link somewhat higher BMI numbers to better health and higher chances of survival. Similarly, a weight lifter with very little body fat could have a higher body weight that yields a BMI that labels them “obese.” The Heart Association also recommends factoring in waist circumference, which helps determine how much body fat has accumulated around the middle section, which is associated with higher cardiovascular risk. 

Doctors also look at individual trends—how much a number changes, and how quickly, from one year to the next. That can be especially important for lab tests like the prostate specific antigen (PSA), which helps detect prostate cancer in men. 

“It’s really important to keep an eye on the rate of change,” Mulligan said. “Say you go to a new doctor, and you have some abnormal numbers. The doctor will want to know, ‘Is this where you’ve always been, or is this a new thing?’ Because if it’s a new thing, it’s a bigger deal in some instances.”  

Tracking Your Numbers

Any time new test results come in, Kapadia goes over the written report and encourages the patient to scan or photograph the report for their own records. Keeping track of your numbers can prove useful in a medical emergency or if you change providers.

“Have a folder somewhere in your cell phone titled, ‘My health record’ and keep your reports in there,” he advised. “Then make sure you can find it in your phone—not in the cloud—so that you don’t need the internet to retrieve the information. So, if you’re traveling, and, say, you’re on a safari in Africa and something happens, you’ve got the data to look at right there. You don’t have to remember it or understand it, because the physician on duty can review it from your phone.” 

Patients can also take advantage of a growing body of tools designed to help patients interpret their own key medical metrics in context. Lloyd-Jones and the American Heart Association created Life’s Essential 8, a checklist to help patients understand key numbers (cholesterol, blood pressure, blood sugar and body weight) in combination with lifestyle factors (exercise, sleep, diet and nicotine exposure) to assess and manage their cardiovascular health. The American Heart Association also offers “Know Your Numbers” fact sheets for patients with diabetes and for women concerned about their heart health. 

Researchers are also working on making the lab results and other reports easier for patients to understand. Cardona is part of a College of American Pathologists research project exploring ways to make pathology reports more patient-friendly. In focus groups with cancer patients, she was surprised to learn that they didn’t want the information summarized in plain language. Learning the medical terminology helped them speak more easily with their care team. But they did want more explanation, such as a glossary of terms. 

Handling Abnormal Results

If a number is somewhat out of normal range, and your physician says, “Don’t worry” or “Let’s wait and see,” should you question that?   

“That’s the art of medicine—understanding when those red flags are a big deal and when they’re not,” said Mulligan. “Sometimes patients can get hung up on an [out-of-range result] and ask for more intense testing that’s not clinically applicable. I try to explain why that number is OK in this situation.” 

But tell your doctor if a test result worries you, Mulligan added. 

“Keep asking questions,” she said. “You can say, ‘I hear what you’re saying, and I’m not trying to second-guess you, but can you show me what it says in the literature so that I can educate myself?’ I would much rather have a patient do that than worry for the next 12 months.” 

Remember that any lab result is a snapshot of a particular day and time. Many factors can skew the results of a test on a particular day. An abnormal kidney function number might indicate the patient has kidney disease—or is mildly dehydrated, which is common in hot weather. Certain medications or supplements may affect the results of kidney or liver function tests. Mulligan often sees that in patients who take biotin or hair-growth supplements like Nutrafol. 

When is blood pressure too low? There’s no accepted number. Low blood pressure is diagnosed by symptoms instead. 

“That’s why it’s so important to tell your physician if you’re taking anything—including supplements or over-the-counter medications—that may not be on your medications list,” Mulligan said. “And don’t assume the information in the [medical practice’s] computer is up to date. Always bring a written list to your appointment.” 

Conversely, understand that even a complete battery of tests with entirely normal results doesn’t guarantee that a patient is healthy. Kapadia recently diagnosed a patient with lymphoma; that patient’s blood work was 100 percent normal. An imaging test revealed the presence of cancer. 

Also, know that some numbers have clear cut-off levels; others do not. 

“Optimal blood pressure is defined as less than 120 on the top number and less than 80 on the bottom number,” said Lloyd-Jones. “But there’s no hard-and-fast number for blood pressure that’s too low. For many patients, a top number in the 90s may be normal and healthy and certainly means they’re at lower risk for strokes or heart failure. But if the patient gets light-headed when they stand up, that’s too low for them. The lower limit on blood pressure is defined by symptoms rather than a specific number.” 

Changing Interpretations

Another caveat: as new research emerges, medicine changes. For example, the numbers you’ve heard for years for healthy cholesterol levels may no longer apply. 

Until recently, physicians typically assessed cardiovascular health with a lipid panel that calculated total cholesterol as a combination of “good” (HDL) and “bad” (LDL) cholesterol along with triglycerides. Today, those numbers are still considered, but as part of more-complex algorithms that also factor in other metrics (such as blood sugar and blood pressure) as well as gender, age, smoking status and family history in determining whether to prescribe medications for high cholesterol or high blood pressure. 

“We want the LDL to be as low as possible, but we’ve de-emphasized HDL as a target of therapy, because medications don’t really help move that number,” Lloyd-Jones said. “And there’s more focus on triglycerides, which are more sensitive to diet and exercise and a better indicator of current metabolic health.” 

That complexity makes it even more important for patients to ask questions and engage in back-and-forth as needed with their primary care physicians. 

“A good relationship with your physician is worth its weight in gold,” said Kapadia. “That’s why it’s so important to find someone you like and trust and to start developing that relationship with them. So you can work together to understand and personalize those numbers for your own situation.”

At 81, Hélène Bertrand, MD, and her 90-year-old husband continue to enjoy a fulfilling sex life. Once every week or two, they share intimate moments that lead to orgasm and, as Bertrand puts it, “a very good night’s sleep.”

“Over 36 years of marriage, we’ve learned the moves that our partners like and delight in giving each other pleasure,” said Bertrand, a retired physician. “Our satisfying sex life improves the quality of our marriage. You don’t have to be 20 years old to have a good sex life.” 

Research shows that many older adults maintain active sex lives well beyond 65. According to a 2018 National Poll on Healthy Aging, 40 percent of those aged 65 to 80 are sexually active. Among respondents with a romantic partner, more than half reported engaging in sexual activity.  

Yet as the population ages, medical care has not kept pace with this reality. Gaps in knowledge and understanding persist. Senior living communities often lack policies that respect sexual expression, particularly for LGBTQ residents. Even health care professionals frequently underestimate or neglect the sexual needs of older adults, influenced by stereotypes that dismiss them as asexual or deem sex “unnecessary” after reproductive age. 

“Sexuality is a critical aspect of quality of life, yet it’s rarely discussed,” said Sivan Perdue, LCPAT, an art therapist certified in dementia care and sexual health.

The Longevity of Love

Several factors explain why older adults are enjoying more sexual longevity. Many are living longer, healthier lives. Those shaped by the sexual revolution often retain more open attitudes toward sexuality as they age. Medical advances, including treatments for erectile dysfunction, and hormonal therapies, have extended the potential for satisfying sex lives. 

For those seeking connections after the death of a partner or divorce, dating apps like OurTime and SeniorMatch open a wider pool of possible partners for romance and intimacy. One in six Americans ages 50 and older (17 percent) have tried using a dating site or app at least once, according to research from the Pew Research Center. 

“Today, older adults are more likely to participate in the hook-up culture of casual encounters and condomless sex,” according to a 2023 report in The Lancet, “Sexual activity of older adults: let’s talk about it.”

Positive portrayals of later-life romance in pop culture also play a role. Movies like It’s Complicated and TV series like Grace and Frankie show older adults embracing active sex lives and candidly discussing intimacy. Even reality TV, with shows like The Golden Bachelor, portrays romance as ageless.

Bertrand credits hormone therapy and a healthy lifestyle for the enduring intimacy she and her husband enjoy. Both have taken hormones since their 50s. She started using an estrogen patch in her 50s to counter menopause symptoms like depression, insomnia and hot flashes. Hormone therapy poses potential downsides—including a higher risk for breast cancer—but Bertrand thinks it’s worth the risk.

“Life’s too short,” she said.

Decreasing Libido

While 40 percent of older adults report they are sexually active, that leaves 60 percent who are not. It’s common for men and women to experience a gradual decline in libido beginning in their 50s, often triggered by factors like hormonal changes and chronic disease or disability. 

Sagging skin and other age-related physical changes may make some feel more inhibited sexually. Many medications prescribed to older adults can also dampen desire or affect functioning, including blood pressure medications, pain medications, statins and others. Obesity can interfere with sexual function, both at the hormonal and psychological level.

Some older adults simply lack partners. More than one-third of Baby Boomers aren’t currently married. Compared to previous generations, fewer Boomers got married in the first place, and among those who did, more ended up divorced or separated. Also, as people are living longer, the divorce rate for those 50 or older is rising. 

Some older adults lose partners to death. Jo McCormack (not her real name), 72, grew up during the sexual revolution and made the most of it, enjoying multiple liaisons with men in her youth. She never married but entered a long-term, monogamous relationship in her 30s that lasted 33 years, until her partner’s death.

“We had a very satisfying sex life, but when he died, my libido died with him,” she said. “I’ve always had a lot of men in my life, but now, I have no desire.” 

Online dating does widen the pool of potential love matches for older adults—if they’re comfortable using dating apps. Some find the technology too daunting. And online dating can be frustrating. 

“Many of us [people over 50] have to swim through a dispiriting sea of hundreds of people, most of whom we are unlikely to ever want to date,” writes Maggie Jones in the New York Times. “That includes profiles that are fake, created by scammers to try to lure private information from users. And while most profiles are real, sometimes their photos are not so much. More than one person told me that photos can be so outdated or filtered that they barely recognized their date when they met.”

Rising Risks

Increased sexual activity among older adults has coincided with a surge in STIs [sexually transmitted infections]. Between 2010 and 2023, STI rates among adults over 65 skyrocketed, with chlamydia tripling, gonorrhea increasing sixfold, and syphilis, nearly tenfold. Overall, STI rates among those 55 and older climbed from three to five cases per 100,000 in 2010 to 17.2 per 100,000 in 2020.

Despite these trends, older adults often lack basic STI knowledge. Few health care providers address sexual health with patients over 65 proactively. Among sexually active older adults, only 17.3 percent reported discussing sexual health with a provider in the past two years, and in most cases, patients initiated the conversation. 

Maggie Syme, PhD, a research psychologist at Massachusetts General Hospital, noted that the US Preventive Services Task Force only recommends STI screening for patients up to age 65. By contrast, doctors routinely ask younger patients about their sexual health and habits. For people ages 16-25, sex education is readily available in schools and colleges.

“But there are very few resources for older cohorts,” Syme said. “So, we have more older people engaging in sexual relations with new partners but lacking the resources and information to help them minimize risk.” 

Syme would like to see more public health campaigns aimed at older adults, such as the “Age is not a condom” social media campaign launched by ACRIA, an HIV-related nonprofit in New York state. 

If there’s one man with multiple partners in an assisted living community, that’s a recipe to start an STI outbreak.

—Martha Kempner

Condoms aren’t a foolproof solution, however. Condom use can pose practical challenges for older couples, cautions Leanna Wolfe, PhD, author of 177 Lovers and Counting: My Life as a Sex Researcher (Rowman and Littlefield, 2024.) 

“An older man needs a certain amount of stimulation, and a condom may not allow for that,” she said. Also, it’s difficult to apply a condom when the male isn’t fully erect, or if the couple is employing lubricants for vaginal dryness, a common problem for older women. (If condoms aren’t fail-safe, other preventive options include regular testing for STIs, limiting sexual partners to a mutually monogamous relationship, and possibly getting relevant vaccinations, such as HPV.)  

Many senior living communities lack policies that ensure residents’ safety while supporting their right to sexual expression. Sivan Perdue helps communities craft guidelines that address the reality of residents enjoying sexual activity. 

“It’s a matter of educating staff that sexuality is completely normal, that residents have a right to their privacy and that staff should not impose their beliefs,” she said.  “Policies should also ensure inclusivity for LGBTQ residents. No one should feel they have to go back into the closet in their later years.”

Residents living with dementia pose special issues. People with dementia have the right to sexual relationships if they desire them, Perdue adds. But whether an individual has the capacity to give consent is a complex question that requires careful, case-by-case consideration. 

The gender imbalance among older adults may also contribute to the rise in STIs, according to Martha Kempner, author of the Sex on Wednesday newsletter and co-author with Pepper Schwartz of 50 Great Myths of Human Sexuality (Wiley-Blackwell, 2015.) Because women live nearly six years longer than men, on average, there are fewer male partners available for older women. 

“If there’s one man with multiple partners in an assisted living community, that’s a recipe to start an STI outbreak,” Kempner said.  

Waning Desire

While more people are enjoying longer sex lives, sexual activity does change as people age. 

“I think the common misconception is that nothing works after a certain age,” Kempner said. “Things get a little more complicated as we age, but there are ways around that. Viagra and other performance enhancing treatments can help address erectile dysfunction in men. Lubricants can combat vaginal dryness.”

Developing a satisfying sex life in later life often means expanding one’s sexual vocabulary. 

“Many older adults have limited ideas of what constitutes ‘sex,’” according to Leanna Wolfe. “They think sex is only sex if it’s penile-vaginal intercourse.”

Partnered sex and intercourse may not be possible due to age-related issues such as arthritis, mobility limitations, effects of medication or serious health conditions. Oral sex, for example, often works better for older adults, according to Wolfe.  

Good communication, always key to a good sex life, is essential for older adults. However, sex is often a difficult topic to broach with a romantic partner, according to the National Poll on Healthy Aging. Only one in three respondents indicated they would talk to their partner about sexual health problems. 

But communication is critical for couples navigating changes in sexual desire. If both partners lose interest in sex in a relationship, that’s not necessarily a problem, but couples whose levels of interest and desire become unequal must negotiate those changes. Good communication can lead to effective compromises—like scheduling times for intimacy or agreeing to “maintenance sex” to enhance the relationship, even if one partner isn’t necessarily in the mood.  

To keep the spark alive, one woman sends her partner flirtatious text messages and makes sure he knows what “stokes the fire” for her.

When couples have unequal sex drives, it’s important not to sweep the issue under the rug, advises Maryon Stewart, author of Manage Your Menopause Naturally (New World Library, 2020.) 

“When your libido is low, expecting your partner to understand what is going on, without explaining, is an easy trap to fall into,” she said. 

Waning desire hasn’t happened with Lynn Johnson, 62, and her 77-year-old male partner. They’ve been together 15 years.  

“We’re both a bit baffled by it,” she said. “That’s a long time to want someone badly. The best way I can describe it is chemistry.” 

Johnson was in a long marriage previously, which was sexless for many years. “I was determined never to be in a relationship again where that was the case,” she said. “I’m just really cognizant of how to keep that alive.” 

To keep the spark alive, Johnson incorporates playful gestures, like sending flirtatious text messages. She’s vocal with her partner about what “stokes the fire” for her, as well as what turns her off. If her partner spends too much time on his phone, or in his own head, she reminds him that that “dims the flame.”

That’s how good communication keeps the spark alive, Bertrand notes, and it’s important to be specific.  

“Tell your partner what pleases you and how you like it done,” she said. “Sex is a two-way street.”

In his early 40s, Vinny Minchillo noticed he needed to work harder in the gym just to maintain his usual level of strength. Then, when he turned 60 a few years ago, he noticed a big change in flexibility. 

“I started making noises whenever I bent down to pick something up, or get up or down on the floor,” he said. “And it seemed like these changes occurred in just a week.” 

So when Minchillo read about a new Stanford Medicine study indicating that aging may occur in “bursts” around ages 44 and 60, he felt seen. “It blew me away. That’s exactly what happened to me.”

The study, published in Nature Aging in August 2024, tracked changes in 135,000 molecules and microbes collected from 108 healthy volunteers ages 25 to 75. Researchers observed that participants seemed to undergo dramatic waves of changes at the molecular level, or “aging bursts,” clustered around two distinct times: at age 44 and age 60.

The study assessed thousands of different molecules as well as participants’ microbiomes—the bacteria, viruses and fungi that live inside the body and on the skin. More than 80 percent of the molecules studied showed rapid changes, which are likely to impact health, surging at certain ages. The study’s cohort consisted of people under 75, but a previous study similarly noted spikes of changes in blood proteins occurring around ages 34, 60 and 78.  

“We expected to see changes in the 60s because we know people’s immune systems decline and disease risks go way up at that time,” said Michael Snyder, PhD, professor of genetics and the study’s senior author. “But the burst in the 40s was a bit unexpected.” 

Among participants in their 40s, the Stanford Medicine study noted significant changes in molecules related to caffeine, alcohol and lipid (fat) metabolism, as well as in molecules linked to the cardiovascular system, skin and muscles. For those in their 60s, changes related to carbohydrate and caffeine metabolism, immune regulation, kidney function, and the cardiovascular system, skin and muscle were observed.

At the molecular level, people don’t seem to age gradually and evenly over time. 

Many people experience major life changes or stresses around 44 and 60, which could contribute to the molecular changes, noted Pooja Patel, DrOT, an occupational therapist and elder care consultant. 

“People start retiring around age 60, for example,” she said. “They may not be as active as they were, or they may become more socially isolated. They may start feeling older because they’ve experienced a loss of purpose.”   

Similarly, women typically reach perimenopause in the mid-to-late 40s, and men undergo hormonal changes, including a drop in testosterone levels, around that age. 

However, changes at the molecular level don’t always lead to immediate changes in a person’s health status. 

“Just because something is happening at the biochemical level doesn’t necessarily translate into meaningful life changes,” said Hesan Fernando, PhD, a neuropsychologist at Corewell Health in Grand Rapids, MI. “We see this in individuals who show Alzheimer’s disease pathology in the brain but don’t actually develop Alzheimer’s clinically.” 

More research is needed to make definitive conclusions, including looking at participants’ health status and surveying a larger, more diverse cohort. But the key takeaway remains: people don’t seem to age in gradual, chronological fashion. Instead, they undergo two periods of rapid change. 

Mirrored in Experience 

Medical professionals and others who work with older adults say, anecdotally, that the research reflects their clinical experience. 

“I frequently see patients experience notable shifts in their health around their mid-40s and early 60s,” said Takyrbashev Kubanych, MD, an internal medicine physician. “There may be a sudden drop in stamina, or a new onset of health issues around these ages, despite leading generally healthy lifestyles. And they seem to emerge suddenly rather than developing gradually over time.”

Erin Williams, PhD, and her husband both noticed abrupt changes when their older friends reached the 60-year milestone. 

“They suddenly looked so much older,” said Williams, a psychologist specializing in treating older adults. “Then when it was our turn, it happened to us.”

Williams vividly remembers her 60th birthday a few years ago. She looked in the mirror and fought back tears and feelings of hopelessness. She had worked in health care through the pandemic, and her sleep was fractured. In the previous six years, three close family members had died, and several others struggled with health setbacks. The toll was showing. She had gained weight. Her energy was depleted, and her mind felt foggy.  

That birthday moment spurred Williams to make lifestyle changes: exercising and moving more throughout the day, cutting back on carbs and devoting more time to rest and self-care. She’s feeling more energetic and optimistic now. While she couldn’t stop the aging process, she said, understanding it has helped her cope. 

Managing the Changes

While the reality of aging bursts is sobering, it could also prove reassuring, according to Susan Rebillet, PhD, a psychologist specializing in older adults. She thinks the Stanford Medicine study could help them better understand and manage the changes that come with aging.

“Things can change dramatically as you get older,” she said. “When patients experience big health setbacks, some assume things will go back to ‘normal’ if they just follow the doctor’s orders, or if they exercise more or eat better.” The research, Rebillet said, helps clients understand that some change is inevitable. 

Similarly, Fernando says he often hears from patients who’ve just been diagnosed with a neurodegenerative disease, like Alzheimer’s or Parkinson’s, who ask, “What did I do wrong?” Understanding that changes are happening at the molecular level, and not always within the patient’s realm of control, might reduce the self-blame. 

While good health habits can help slow aging, Fernando added, “We also know that certain genetic factors will override anything we do environmentally or in terms of lifestyle. And some changes are just an inevitable part of life.”  

Preventive Potential 

The Stanford Medicine study doesn’t change the standard recommendations for maintaining good health later in life: eat healthy, exercise regularly, don’t smoke or overindulge in alcohol. But it does point to possibilities for managing patients’ preventative health care more precisely and more proactively. 

Snyder says that might mean increasing exercise to protect the heart, emphasizing strength training to maintain muscle mass or decreasing alcohol consumption in the 40s, as the ability to metabolize alcohol slows. Similarly, while staying hydrated is always important, it becomes even more critical when kidney function tends to decline in the 60s. 

Snyder believes the research points to ways for treating developing issues more proactively. He was also the lead researcher for a 2020 study that determined that people generally age along certain biological pathways in the body: metabolic, immune, hepatic (liver) and nephrotic (kidney). His team dubbed these “ageotypes.” Those who were metabolic ageotypes, for example, might be at a higher risk for diabetes; those with an immune ageotype, on the other hand, might be more prone to immune-related diseases as they age. 

Determining which ageotype applies might allow physicians to tailor more precise and targeted preventive interventions. For example, currently, doctors don’t treat high blood pressure or high cholesterol until levels reach a particular threshold. As aging bursts and ageotypes are better understood, physicians might prescribe medications or other interventions earlier, to prevent systemic, long-term damage. 

As further research is done, more sophisticated interventions are likely to emerge down the road. In the meantime, the Stanford Medicine study’s results are valuable, Fernando said, because they “highlight these potentially vulnerable times in our lives when we need to be extra careful about the decisions that we’re making.”

Minchillo, who’s still in good health and still working, hopes further research might provide clues to help him stay active as long as possible.  

“I need to stay in shape so that I can play on the floor and roughhouse with my grandson,” he said. “I want to be able to do that as long as I can.” 

Every time Jodie Pepin’s mother saw another physician, it seemed like she was prescribed yet another medication. Each time Pepin wondered, “Why are they giving her that? She already has dementia.”

Pepin, clinical pharmacy program director at Harbor Health in Austin, TX, knew the medications could exacerbate dementia, cause drowsiness and affect gait. When her mother fell, multiple times, she blamed the drugs. 

“These medications just kept making it worse,” said Pepin, PharmD, who is also a clinical assistant professor at the College of Pharmacy at the University of Texas at Austin. “It frustrated me to no end.” 

Pepin lived in another state, so she reviewed her mother’s medications and had many conversations with doctors over the phone. Each time, the doctor would stop one or two drugs. Then another health issue would arise for her mother, who would see another doctor, who would prescribe yet another medication. 

That kind of medical doom loop is not uncommon among older people, particularly those with multiple chronic conditions. Polypharmacy—taking five or more medications—is associated with increased hospital admissions, falls and premature mortality.  

The problem has led to a growing movement among medical schools and hospital systems toward “deprescribing” medications: discontinuing drugs that are either potentially harmful or no longer required, or reducing the dosage or frequency, always with medical supervision. 

Almost 90 percent of adults 65 and up take at least one prescription drug regularly; 54 percent of older adults report taking four or more prescription drugs. As the number of medicines goes up, medication management becomes more complex, and the risk of adverse reactions grows.  

As people age, kidney and liver functioning decrease, along with lean body mass, affecting the way drugs are metabolized. Medications may stay in an older person’s system longer, increasing the risk and severity of side effects. 

Troubles with the System

The fragmented nature of the US health care system also contributes to the problem.  

“Many older people see multiple doctors in multiple specialties,” said DeLon Canterbury, PharmD, founder of GeriatRx, a concierge telehealth service. “One is focused on the kidney, the other is focused on the heart, and so on. These providers are following their guidelines but not thinking about the whole picture.” 

As a result, patients may end up with duplicate prescriptions for similar medications or medications that interact. 

Older patients are also at risk for what medical professionals call a “prescribing cascade,” according to Dominick Trombetta, PharmD, associate professor of pharmacy practice (geriatrics/internal medicine) at Wilkes University School of Pharmacy in Wilkes-Barre, PA. 

A common scenario: a doctor prescribes amlodipine, a medication for high blood pressure. It’s generally safe but can cause a patient’s feet to swell. Instead of trying a different blood pressure medication or adjusting the dosage, the provider assumes the edema is yet another age-related condition and prescribes a diuretic. 

The diuretic, in turn, creates an electrolyte imbalance, which leads to a prescription for a potassium supplement, which causes heartburn, which leads to a prescription for antacids.

Some whole categories of drugs carry special risks for older people. 

Some medications can be dangerous for older people or patients with certain health conditions. Canterbury saw this with his grandmother, Mildred, who had mild dementia. When she began declining rapidly, the family moved Mildred out of assisted living. But she didn’t improve. 

“She was wandering around the house, hiding her dentures, hiding her glasses and not remembering us,” Canterbury said. “It was heartbreaking.”  

A medication review by the family’s pharmacist revealed that Mildred was taking an antipsychotic with a “Black Box Warning” (the Food and Drug Administration’s highest safety-related warning). The drug was associated with “increased mortality in elderly patients with dementia-related psychosis.” 

Mildred returned to her baseline level of functioning after she stopped the meds.

Trombetta notes that some drug categories tend to be inappropriately prescribed for older patients. Proton pump inhibitors, such as omeprazole, omeprazole or pantoprazole, are often prescribed in hospitals to prevent gastrointestinal bleeding. That’s appropriate while the patient is in the hospital, but the patient may no longer need it after discharge, and continued use increases the risk for fractures, severe diarrhea, pneumonia or B12 deficiency. 

Diabetes medications are also frequently prescribed inappropriately. For younger or middle-aged patients, doctors prescribe for tight control of blood sugar levels, because high blood sugar can harm the heart and pose other long-term risks. For older people, it often makes sense to relax the control of blood sugar levels and reduce or change medications accordingly. The goal is to minimize the risk of hypoglycemia (dangerously low blood sugar), which can lead to falls or even death.    

Taking Precautions

To help avoid polypharmacy issues, the American Geriatrics Society publishes the Beers List, a database that flags medicines that health care providers should either avoid or prescribe with caution for older patients. The list is updated every three years, most recently in 2023.

The Beer’s List includes seemingly innocuous, over-the-counter medications like diphenhydramine (Benadryl), which may lead to confusion or falls for older patients, and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, which should be avoided by older people with kidney disease. Other cautions on the list include antibiotics like Cipro, which may interact with blood thinners, and benzodiazepines like Valium, which can impair cognitive function and cause an unsteady gait. Doctors may still choose to prescribe these medications, but the list helps them proceed with caution. 

Some hospitals are implementing programs to avoid over-prescribing medications or to encourage physicians to consider deprescribing. 

Pepin was involved in one such effort at a trauma unit. Working with trauma surgeons, she designed an admission order for older patients. Previously, doctors were prescribing the same doses of sleep or pain meds regardless of patients’ ages. Following the Beers criteria, the orders were customized for older patients, which led to a decrease in oversedation or respiratory depression.

Safety Is an Utmost Concern

More than 80 percent of adults aged 50 to 80 would be open to stopping one or more of their prescription drugs, according to the University of Michigan National Poll on Healthy Aging. 

Some patients are taking matters into their own hands. More than a third of those polled said they stopped taking a medication without consulting a medical professional—in some cases, due to concerns about cost. 

But self-deprescribing is risky, said Sarah Vordenberg, PharmD, a clinical associate professor at the University of Michigan College of Pharmacy, who worked on the poll.

“In our research, we found that the types of medications that older adults are interested in stopping are not always the types that health care professionals think are best to stop,” she said. A patient who discontinues a cholesterol medication, for example, may not notice any changes, but their risk of heart attacks or stroke may be increased.”

Bottom line: deprescribing should always be done in consultation with a physician or other primary care provider. 

Taking Charge

Patients and their caregivers can take a proactive role in managing their medications. Start by always keeping an updated list of all medications, including over-the-counter drugs, supplements and vitamins—even non-oral medications like eye drops—with the actual doses being taken, even if not as prescribed. If the cost of a medication is an issue, tell the provider that too. 

Bring that list to every doctor visit. Don’t assume the provider has a correct list.  

Patients may request a comprehensive medication review by a pharmacist or other provider. Most retail pharmacists can provide this service, which is covered by Medicare and other insurance, but an appointment is usually required. If possible, patients should get all their prescriptions filled at the same pharmacy. Those who use more than one pharmacy, or take nonprescription drugs or supplements, should be sure the reviewing pharmacist has that information. 

Medications should also be reviewed at every annual checkup, with an eye toward deprescribing. If a physician does recommend cutting some medications, be sure to get detailed instructions on how. Some medications need to be tapered rather than stopped cold turkey. And always ask how long new medications should be taken. 

In addition to the annual checkup, experts advise having all medications reviewed at every medical transition, including: 

• After a fall
• Any time there’s a change in medical condition or health needs
• Upon entering or leaving a long term care facility, such as rehab or skilled nursing
• Before and after a hospitalization

“Any time a person is discharged from the hospital, they should follow up with their primary care provider within a week,” said HaVy Ngo-Hamilton, PharmD, a hospital pharmacist and clinical consultant at BuzzRx, a free prescription discount service. 

Some older adults aren’t comfortable questioning their doctors, according to Vondenberg. She suggests asking, “Can we talk through all of my medications so I can better understand why I’m taking each one?’” 

“That naturally leads to the conversation of, why are you taking the medication, and is it still needed?” she said. 

Family members, too, may hesitate to broach the issue of deprescribing for an older family member, fearing they’ll be perceived as pinching pennies or withholding care. To help start the conversation, Vonderberg and fellow researchers created a patient handout, Polypharmacy and Deprescribing, available online on the JAMA Network website. 

“At the end of the day, you’re the one taking these medications and they’re impacting your health,” Vondenberg said. “Make sure that they are right for you and align with your health goals.” 

For most of her life, Jenny Anne Horst-Martz’s mother worked hard to stay slender. But now, at age 90, her mother struggles to keep enough weight on. 

The problem started a few years ago when her mother was injured in a fall and then diagnosed soon after with a recurrence of lung cancer. Between the cancer itself, the multiple hospital stays, an array of new medications and the slowdown in her activity level, her mother’s appetite disappeared. Her weight dipped to 104 pounds—too low for her 5’6” frame. 

“We were really worried,” Horst-Martz said. 

Horst-Martz’s mother faces a common struggle among older adults: malnutrition. The Alliance for Aging Research calls malnutrition a “hidden epidemic in the United States,” one that is underrecognized and undertreated. An estimated 25 percent of older Americans are malnourished or at risk of malnutrition, and not all are at risk due to poverty or lack of access to healthy food. 

“We see this all the time: people who have very good means and good caregiver support, but they’re struggling with malnutrition,” said Alex Foxman, MD, president of Mobile Physician Associates in Beverly Hills, CA.

Malnutrition triggers a vicious cycle, weakening the immune system and causing sarcopenia (loss of muscle mass), which can lead to frailty and falls. Malnutrition rates are especially high among older adults who are hospitalized, leading to longer hospital stays, higher infection rates, poor wound healing, higher readmission rates, poorer outcomes and death. The Alliance for Aging Research estimates the resulting increased economic burden due to malnutrition among older adults in the United States at more than $51 billion each year. 

How the Cycle Begins

A host of factors make older adults more prone to malnutrition. 

Many of the chronic medical problems affecting older adults can contribute. Some, like cancer, diabetes and Alzheimer’s disease, can depress the appetite, as can many medications or combinations of medications. Other diseases—and even normal age-related changes, such as lower stomach acidity—lessen the body’s ability to absorb nutrients. 

“Sometimes it’s not that people are not eating, it is that they are not absorbing the nutritional value of foods through their gastrointestinal system,” Foxman said. 

People with dementia can lose the ability to handle daily activities, including feeding themselves. Older adults may develop dental problems, dry mouth or difficulty handling tableware, chewing or swallowing food. Age-related changes may alter the ability to smell and taste food.  

“If you were a big meat eater when you were younger, and now suddenly chewing and swallowing meat becomes a challenge, you might end up just eating cheese and crackers all day long,” said Suzannah Gerber, a nutrition epidemiology researcher at Tufts Friedman School of Nutrition Science and Policy.

Isolation, leading to depression, can shrink a person’s appetite.

Older adults with mobility challenges may not be able to prepare meals. Others may lack transportation to get to the grocery store regularly. 

“Altogether, this means that older adults may choose more convenient, processed foods because they are accessible, easier to cook, available in [single-serving] packages and easy to swallow and digest,” said Gerber. “This means more empty calories.”

Psychological factors can contribute too. Eating is a social activity that loses its appeal for an isolated older adult. And many older adults are isolated; according to the 2023 University of Michigan National Poll on Healthy Aging, one in three older adults (ages 50–80) reported feeling isolated from others in the past year.  

“Isolation and loneliness lead to depression, which can have a negative impact on appetite,” said Michelle Rauch, MNutr, a registered dietician for the Actors Fund Home, a senior living community in Englewood, NJ, for retired members of the entertainment community. 

Food Insecurity Plays a Role

For a significant number of older adults, malnutrition stems from an inability to afford healthy food. According to a 2021 survey, 5.5 million Americans over age 60 are food insecure. 

Older adults with functional limitations or chronic disease are especially prone to food insecurity. People with two or more chronic conditions, for example, were two to three times more likely to be food insecure compared to those with no chronic conditions. 

Food insecurity especially affects people of color. 

“Food insecurity is caused by financial insecurity, which is rooted in systemic racial, gender and health inequities.” said Gretchen Dueñas-Tanbonliong, MS, a registered dietician and associate director of health and wellness at the National Council on Aging (NCOA.) “Black older adult households are over three times more likely to experience food insecurity compared to white households.” Similarly, Latino older adults are three times as likely to experience food insecurity compared to white older adults

Food insecure older adults often resort to harmful coping strategies. They may skip medication, forgo medical care or choose cheap, unhealthy foods to stretch their budgets, according to a Food Research & Action Center (FRAC) study. 

In addition, many older adults who are eligible for Supplemental Nutrition Assistance Program (SNAP) benefits aren’t getting them. A 2016 NCOA study showed that 79 percent of older adults have heard of SNAP, but only one in six who were eligible are actually enrolled. Survey respondents said the application process was too tedious, or they didn’t know how to apply or they were worried that, by accepting benefits, they’d deprive people who needed the help more. 

Some advocates want programs like Medicaid expanded to cover food and nutrition.

To help older adults navigate benefits more easily, NCOA created a website, BenefitsCheckup.org. Visitors enter their zip codes and other information to determine their eligibility for SNAP and a variety of other government programs.

Many older adults who receive Social Security are eligible for only the minimum SNAP payments, according to LaMonika Jones, interim director of state initiatives for FRAC. Rules and minimum amounts vary by state, but in Washington, DC, where Jones is based, the minimum is only $30 a month, which doesn’t go far in funding a healthy diet. 

Older adults with diabetes or hypertension should take particular care in choosing healthy foods, Jones said. “But that’s a challenge because the cost of fresh foods is high.” 

Some hunger advocates propose expanding Medicaid and similar programs to cover food and nutrition, as part of a movement broadly called “Food is Medicine.”

“We’d like to see medically tailored meals as an option, as well as the potential to purchase fresh fruit and vegetables, to treat those diet-related diseases,” Jones said. 

Assessment and Diagnosis

While malnutrition is prevalent, diagnosing it is not always easy. 

“An older adult who is overweight can still be malnourished,” said Dueñas-Tanbonliong. “If they aren’t getting enough important vitamins and minerals, that can result in nutrient deficiencies.” 

Even the definition of malnutrition varies. Medical researchers typically define malnutrition as a lack of nutrient quality, or nutrient quantity or both. By contrast, other agencies, including the World Health Organization, consider malnutrition more broadly to include any “deficit, excess or imbalance of protein, energy and other nutrients” that adversely affects health. By that definition, obesity is counted as a form of malnutrition.

Common symptoms of malnutrition include loss of appetite, unexplained weight loss, weakness, fatigue or edema (swelling). Sunken eyes or protruding bones are other clues. Blood tests can detect anemia, an iron or protein deficiency. Screening tools assess factors such as appetite, dietary intake, weight loss, appetite and body mass index (BMI). 

“Health care teams must be vigilant in promptly diagnosing and treating malnourished patients in the hospital,” wrote Dueñas-Tanbonliong in an article she co-authored. “It is equally important, however, for patients and their families to be knowledgeable and to speak up when they feel something is amiss.” 

Improving Nutrition

Interventions to combat malnutrition vary depending on the older adult’s situation. 

Medically, a physician might begin by treating any underlying conditions that are contributing to malnutrition and reviewing the older adult’s medications to reduce or replace any that suppress appetite or cause gastrointestinal side effects. Doctors may also prescribe appetite-inducing medication or, in extreme cases, a feeding tube. 

“You start by trying to figure out what nutrients the person is lacking, and then you try to supply that in the form of real food, if possible,” Rauch said. 

That may mean helping the older adult prepare or obtain tempting meals with plenty of fresh fruits and vegetables, lean meats or other proteins, and whole grains. This could mean in-home assistance with meal preparation, Meals on Wheels or arranging for the individual to eat meals at a local senior center. 

Some interventions focus on simply upping a person’s calorie or protein intake. While meal-replacement supplements like Ensure or Boost are often loaded with sugar or corn syrup, they still may be a good option for people who need more calories or who can’t eat solid food.

Those who have had an eating disorder in the past sometimes struggle with malnutrition in their later years.

Sometimes tackling malnutrition means educating the older adult or caregiver on healthier food choices, according to Tina Baxter, GNP, a nurse practitioner in Anderson, IN, and a parish nurse in her church. In a home visit, she discovered a parishioner was surviving on frozen dinners and sodium-packed processed foods after suffering a stroke. 

“I was able to get her refrigerator stocked with healthier versions of ready-made food, donated by the church, contact her family for assistance for future needs and show her how to make simple meals using the microwave, as she was not able to stand long due to the stroke,” Baxter said. 

Psychological factors may also need to be addressed. Rauch occasionally sees retired dancers or performers with a history of eating disorders. When they move into the Actors Fund Home, where meals are provided, Rauch said, “The family may be thinking that I can just fatten them up, but there’s a big psychological component with eating disorders. With malnutrition, there really needs to be a multidisciplinary approach.” 

Several different strategies have helped Jenny Anne Horst-Martz’s mother make progress. Thankfully, immunotherapy has kept the cancer at bay. Today, at 112 pounds, she is still underweight, but her appetite is improving. To up her calorie intake, she snacks on protein drinks between meals, slathers her apple slices with nut butter at lunch and enjoys a dish of vanilla bean ice cream at night. Her doctors seem pleased with her nutritional status, and her blood work is good.  

“Mom eats nutritiously, tries to exercise and enjoys food at least some of the time,” said Jenny Anne Horst-Martz. “She’s doing much better.”