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.” 

For three years, Lil Banchero’s 86-year-old mother struggled with pain due to advanced arthritis. She tried yoga. Doctors prescribed medications and tried injections. Nothing worked. The pain got worse, and her mother became depressed. 

“Months passed,” said Banchero. “Nobody was paying attention anymore.”

Finally, Banchero accompanied her mother to a doctor’s appointment and insisted, “There’s got to be something else out there we can try.” 

The doctor prescribed another medication, and that—combined with meditation, walking and yoga—finally made the pain manageable.

“My mother is a different person now,” Banchero said. “She went out and got a pedicure today. It’s been life changing.” 

Banchero knew how to advocate for her mother because she’s a nurse and program coordinator for the Institute for Healthy Aging at the Luminis Health Anne Arundel Medical Center in Annapolis, MD. But more and more older adults who are not medical professionals will need to learn that skill, too. That’s because, just as the population of older Americans is ballooning, several factors are conspiring to make getting good medical care even harder.

Older adults often have multiple chronic conditions involving a multitude of specialists. (A third of older adults see at least five different specialty medical providers each year.) The fragmented, siloed nature of the American health care system delegates the task of coordinating that care to primary care physicians (PCPs), who are overworked, pressed for time and in short supply. There’s an even greater dearth of geriatricians, who specialize in caring for older adults. And projections say it’s only going to get worse.

The bottom line: just showing up for appointments and following doctors’ orders doesn’t guarantee good care.

Said Banchero: “You’re the pilot of your own care.”

 Quarterbacking Care

That reality shocked Tina Sadarangani, PhD, an assistant professor at New York University’s Rory Meyers College of Nursing. When her parents developed serious health conditions, she discovered how much responsibility falls on patients and their families. Even though she’s always treated patients, and although both parents are retired physicians, quarterbacking their care has proven exhausting. 

Spurred by her experiences, Sadarangani created CareMobi, an app for coordinating care, and the Enlightened Caregiver, an Instagram with tips for patients and their care partners.

“We may not be able to fix the broken system, but we can figure out how to work within the system,” she said. 

Her advice: make the most of medical visits, which may run only five minutes. Consider recording conversations with the doctor to help remember details. Bring a family member or friend to the appointment.

“Plan your story ahead,” she said. “Lead with your most pressing problem and get the timeline of your symptoms straight with as many specifics as possible. It makes a big difference to your doctor if your cough has been going on for several months instead of two weeks, for example.” ⠀

When describing a symptom, Sadarangani said, tell the doctor how it’s affecting your ability to function. Instead of just saying “My back hurts,” be specific: “I was playing golf five times a week until this back pain started, and now I can’t get out of bed.” 

Keep track of basics, like your numbers if you have high cholesterol, and what direction they’re moving in. 

Specific information helps ensure the doctor doesn’t dismiss your symptoms as “just getting old,” Sadarangani added. 

“If you want the doctors to be proactive and to help you maintain the level of functioning you want, you need to be clear about that,” she said. “You need to say, ‘I want to be back in my golf game. What can you do to help me get there?’”  

If you have questions, write them down in advance and frame them carefully. 

“If you’re not precise with an ask, the physician is probably not going to pay attention,” Banchero said. 

Before leaving a doctor’s office, make sure you are clear on your next steps. If the doctor ordered a test, for example, ask: How and when will you get the results?  Depending on the test results, will you need another test, or to schedule another appointment? If you’ve seen the doctor for a new symptom or acute illness, ask when you should expect improvement, and what new or continued symptoms warrant a call to the doctor’s office or even a trip to the ER. Find out the best way to contact the doctor or a nurse after hours, if the need arises. Assume the ball is always in your court because, in most situations, it is. 

Consider yourself the central repository for your medical records. In theory, after an exam, each specialist sends the records to your primary care physician. Don’t count on that. If you see a specialist, follow up with your PCP’s office to confirm that the record was received and reviewed. Keep your own record of each visit, too.

Banchero encourages patients to educate themselves on some medical basics. For example, if you have high cholesterol, keep track of your numbers and understand what they mean. That way you’ll know whether you’re improving or getting worse and can discuss that with your doctor if needed. 

Many experts noted that patients can ask for an annual Wellness Visit—an extended, 45-minute visit, covered by Medicare, that includes a review of your medical and family history and current prescriptions, as well as advance care planning and a cognitive assessment. That in-depth visit can ensure that your health care plan is personalized. 

Managing Multiple Meds

In her previous job as executive director of a senior living community, Jenni Knutson, CDP, always made sure that residents were prepared for medical emergencies. Any time a resident was taken to the ER, Knutson handed paramedics a list of the person’s medications, insurance information and other documents. 

But that didn’t always work, as Knutson discovered when visiting a resident who’d been taken to the hospital in an ambulance and admitted. Family members were puzzled because the patient hadn’t eaten in days. When Knutson asked the nurse on duty at the hospital to check, they discovered that the patient’s medication record wasn’t updated in the hospital system. No one at the hospital was aware that the patient had been taking a strong anti-psychotic medication daily before she was admitted. As a result, the patient had gone “cold turkey” during the six days she’d been in the hospital, which explained the appetite loss. 

“Likely a doctor in the ER reviewed her medication list, then set it down on a counter, and no one updated the computer system,” said Knutson, who is now a senior life care manager with Olive Branch Seniors based in the Dallas, TX, area. 

Knutson said that many missteps in medical care for older adults relate to medications. About half of adults 65 and older report taking four or more prescription drugs daily. One study showed that one in seven cases of emergency department visits by older adults were medication related—and over three-quarters of them were preventable. Medication-related problems included adverse drug events (side effects) as well as those due to noncompliance—taking too much or too little of the medication, or stopping the drug entirely without medical supervision.

To help avoid these missteps, keep an updated list of all medications, including the name, dosage, date, number of refills and instructions (such as whether to take with or without food). That list should include prescriptions, over-the-counter medications, supplements and herbal remedies. 

Also, know that it’s also up to you to make sure every provider has the most updated list.

As you grow older, medication side effects can become more common or severe. Ask your doctors whether you really need all the drugs you’re taking. 

“Share your medication list with all of your health care providers, especially when you see a new doctor, get a new prescription or have a change in your condition,” said Erin Inman, PharmD, vice president of Corewell Health in Grand Rapids, MI. Ask the doctor to review the list for possible interactions. 

Pharmacists can also serve as an excellent resource between doctor visits, Inman adds. 

“Your pharmacist can answer any questions you may have,” she said. “You can request a review of your complete medication list for potential interactions or duplications. This is what pharmacists are trained to do.” (Call ahead to make sure the pharmacist has time to review the medications or to schedule a time.)

Inman recommends filling all your prescriptions at a single pharmacy, if possible. Anytime a new medication is prescribed, she advised, ask the doctor: “Is this medicine additive or is it replacing something else? How long do I need to take it—for a period of time or is it going to be lifelong?” 

Geriatricians review patients’ medication lists with an eye toward “deprescribing,” because side effects may become more common or severe as patients get older. Don’t hesitate to ask your doctor about this.

“You can ask your providers about de-prescribing, especially if you suspect a medication or medication interaction is causing an adverse symptom or no longer helping,” said Kylie Meyer, PhD, assistant professor at Bolton School of Nursing at Case Western Reserve University in Cleveland, OH. 

Enlisting Care Partners

Many experts advise bringing a care partner—a trusted friend or family member—along on appointments to serve as a second set of eyes and ears. That’s especially important for patients who may have cognitive impairment. Care partners can work with the primary provider to keep the dots connected, said Denise Lucas, PhD, clinical associate professor and chair of advanced practices at Duquesne University’s School of Nursing in Pittsburgh, PA.       

The care partner should also obtain access to the patient’s online medical records. Banchero can log onto her mother’s account for MyChart, the health care system’s patient portal, to check on test results and other developments. (Patients are permitted to share their log-in info if they so choose.) 

A care partner can be especially helpful for older patients who aren’t comfortable asking questions, said Erica Stevens, DO, department chief of primary care at Corewell Health in Grand Rapids, MI.

“[Older adult patients] may feel like asking questions is disrespectful,” she said. “But it’s actually welcomed, from a provider’s lens, because I don’t know what’s happening in your home.” If a patient is forgetting things, or having trouble getting out of a chair, she wants to know, especially if the problem has worsened recently. 

For older adults without family nearby, some community agencies may be able to help with this role. “Contact your local Area Agency on Aging and request help from publicly funded Care Coordination Services,” said Dennis Meyers, PhD, chair for the residential care of older adults at Baylor University’s Garland School of Social Work in Waco, TX. “Organizations such as the Alzheimer’s Association and American Heart Association also offer guidance on how to access care.” 

Becoming Age-Friendly 

Some hospitals and clinics are working to improve care for older adults by becoming certified Age-Friendly Health Systems. That involves adopting practices centered on the “4Ms” of good geriatric care: What Matters, Medication, Mentation and Mobility: 

• “What Matters” involves considering the older adult’s priorities in making treatment decisions—for example, honoring a 90-year-old patient’s desire to forego aggressive cancer treatment. Don’t hesitate to express your wishes to your doctor. 
• “Medication” means considering your medicine and supplement needs and issues, as described earlier in this article.
• “Mentation” issues, such as forgetfulness, can be dismissed by primary care physicians as part of normal aging. Ask for an assessment if you’re experiencing cognitive issues. 
• “Mobility” is another area that primary care physicians might brush aside. If you’re having trouble getting around, ask about the possibility of physical therapy (which may help you regain or maintain physical function) or occupational therapy (which can help you adapt to changes in mobility and optimize functioning). 

As more hospitals adopt age-friendly measures, which Banchero’s hospital helped develop, more older patients will get the care they need in the future. But until they do, the onus falls on older adults and their care partners to be smart, educated and empowered. 

“We really do need to be advocates for ourselves,” she said. “There are so many phenomenal advancements in medicine today. I would never [accept], ‘It’s just because you’re old.’”

 

Even though he’s at retirement age, T.S. Dharmarajan, MD, continues to care for older patients as the clinical director of geriatrics at Montefiore Medical Center in Bronx, NY.  But he’s terrified of the possibility of becoming a patient himself one day.  

“I’m healthy now, but I’m scared to death when I think of the time when I’m going to be admitted to a hospital and taken care of by a hospitalist who has no [geriatric training],” he said. 

Dharmarajan knows he’s unlikely to receive care from a physician with geriatric expertise, because there aren’t enough of them now—and it’s only going to get worse. 

While the population of adults over 65 in the United States has exploded, the number of geriatric specialists has decreased, from 10,270 in 2000 to 7,300 in 2019, according to The Looming Geriatrician Shortage, a 2019 report that Dharmarajan co-authored with Paula Lester, MD, and Ele Weinstein, MD. 

The American Geriatrics Society estimates that about 30,000 geriatricians will be needed to provide high-quality care for the most vulnerable elderly by 2030. Yet about half of all fellowships in geriatrics in the United States continue to go unfilled every year, and there’s no sign the trend will reverse. 

“The need for expertly trained and passionate geriatric physicians is clear,” according to the 2019 report. 

Why Geriatricians Matter

Geriatricians are trained in caring for older patients, particularly those with frailty, cognitive decline (Alzheimer’s or other forms of dementia) or multiple medical issues. 

“The knowledge base that geriatricians have is very different than that of practitioners who are just taking care of older people,” said Dharmarajan, who is also a professor of medicine at Albert Einstein College of Medicine. “There’s a huge difference.” 

One reason why geriatricians are so essential: they understand the ways that physiology changes as people age. Most older people expect to eventually lose bone density and muscle mass and to experience a measure of vision and hearing loss. But other, more subtle changes occur with aging. As the COVID-19 pandemic demonstrated, aging is associated with lowered immune function and greater susceptibility to infection. Kidney function also declines with age. 

“One of the main drawbacks of not having robust geriatric training is the lack of understanding of the aging physiology,” said Diane Kerwin, MD, a geriatrician and Alzheimer’s researcher in Dallas, TX. “And usually in geriatrics, you are managing several chronic disease states as well as the aging body, with the focus on maintenance of function and independence.”

Many older adults live with multiple health issues, like hypertension, diabetes or heart disease. 

“If you have a 40-year-old patient who has pneumonia, you can just give them antibiotics, but if you have an 80-year-old with pneumonia and 10 other conditions, that’s much more complicated,” said Paula Lester, MD, director of the fellowship program in geriatric medicine at NYU Grossman Long Island School of Medicine and chair of the geriatrics task force for the New York chapter of the American College of Physicians.

Managing a chronic condition with an older patient is more complex. For younger patients with diabetes, for example, doctors typically focus on tightly controlling blood sugar levels, because high blood sugar can cause long-term problems like blindness, kidney problems and neuropathy. But that strategy doesn’t necessarily work for older patients, according to Barry Wu, MD, professor of medicine at Yale School of Medicine.

Older people respond to medications differently and sometimes develop different symptoms than those who are younger. 

“With an older person, if you have such tight control, you may put that person at more risk for low blood sugar, and low sugar can kill you,” he said. Plus, the long-term effects of high blood sugar may not take priority for a patient who’s unlikely to live another 10 or 20 years. 

Older patients metabolize medications differently and may experience more severe side effects. They may have difficulty taking medication according to directions. 

“You’ve got to weigh the risks and the benefits of the medicines,” Wu said. 

Without specialized care, older patients may be misdiagnosed, and treatable problems may be overlooked. Kerwin says it’s not uncommon for her to see patients whose cognitive impairment was previously dismissed by medical providers as normal aging and left untreated.

“It’s possible that the cognitive impairment could’ve been due to a thyroid problem, a B12 deficiency, a urinary tract infection or a series of small strokes,” she said. “These are treatable conditions.” 

Patients with undiagnosed Alzheimer’s or dementia may miss the benefits of early interventions, like medication that could have helped slow disease progression. 

Another subtlety of treating older patients: “Older adults have atypical presentations of conditions,” said Ele Weinstein, MD, associate professor of medicine at Albert Einstein College of Medicine. “There are differences in patterns of illness, and differences in conditions that older adults present with.”

For example, a younger patient with a urinary tract infection (UTI) will likely report classic symptoms like burning, pain or frequent urination. An older adult with a UTI might instead exhibit confusion or lethargy. 

Managing Multiple Conditions

Geriatricians follow the “Geriatric 5Ms,” their key focus issues: mind, mobility, medications, multi-complexity, and matters most. 

“Mind” refers to the importance of assessing mental acuity and recognizing conditions like dementia, delirium and depression. “Mobility” relates to fall prevention and optimizing gait and balance. “Medications” includes reducing polypharmacy (multiple medications), de-prescribing, and recognizing harmful side effects of medications. 

“Multi-complexity” involves managing multiple illnesses and conditions, as well as living environments and social concerns. “Matters most” refers to guiding patients’ care based on their values and priorities. 

Many geriatricians consider “de-prescribing” medications to be one of the most valuable functions of geriatricians. Patients with multiple health problems typically see several specialists who each prescribe medications. Geriatricians are trained to spot potential drug interactions—which are more common and more severe with older patients—and to weigh the benefits against the risks of each medication. 

“When you go to a doctor with a complaint, they give you a pill,” said Lester. “But if you go to a geriatrician with a complaint, they may take away a pill. It’s just a very different philosophy.” 

Lester adds that geriatricians are much better at prognostication.

“That’s basically looking at a patient and their lives and their condition and their whole situation and figuring out, ‘Are they going to get better? Are they safe to go back to where they were before? Are they going to recover from this illness? Do they need hospice?’” said Lester. “I do that somehow in my head, quickly and accurately. In general, geriatricians are much, much better at prognosticating. That is so important for the people who want to know what their life expectancy is, what that time will look like, and then they can decide how they want to spend it.”

Why the Shortage

Since the publication of their 2019 report, the co-authors say they have not seen sufficient change to increase the supply of geriatricians. Dharmarajan noted that he created the geriatric medicine fellowship program in 1991 at Our Lady of Mercy Medical Center in the Bronx, currently Montefiore Medical Center (Wakefield Campus), where he also serves as professor of medicine. “In the first 10 to 15 years, there was no problem filling those fellowships, but we have seen a very clear decline in the number of applicants in the last 15 years,” he said. 

Lester said geriatrics has a “PR problem” that discourages medical students from choosing the field. Most students complete their geriatric rotations in hospitals, where patients are typically very ill and unlikely to recover. However, geriatricians themselves report some of the highest levels of social satisfaction among medical specialties, citing the relationships they build with their older adult patients, the more holistic approach of geriatric medicine and even the challenge of handling medically complex cases.

Geriatricians spend more time with each patient. Because virtually all their patients are on Medicare, geriatricians are paid at Medicare rates—generally lower than regular health insurance. As a result, geriatrics ranks as the fourth-lowest-paid medical specialty, only slightly more than pediatrics, medical genetics and family medicine. 

Another factor is the rise in the number of hospitalist positions. Hospitalists are doctors who provide primary care for patients while they’re hospitalized. The term was coined in 1996 when there were a few thousand hospitalists in the United States. Now there are more than 50,000. 

“It’s easy now for a medical student to finish three years of residency and just become a hospitalist with fixed hours and a very attractive salary,” Dharmarajan said. “Why waste one more year for a fellowship for geriatric medicine, and then deal with all the very complex illnesses that older people have and work for less money?” 

Facing the Future 

Some medical schools are looking to help fill the gap by adding geriatric training as part of their medical education. 

“We won’t be able to train enough geriatricians, so the goal is to train other professionals throughout medical school in geriatrics,” said Wu, who directs the introductory and final courses at Yale School of Medicine. 

In the intro course, students take their first medical history on older adult patients, beginning with an assessment of the patient’s values. Students are introduced to basic concepts of geriatrics, including patient priorities care—identifying patients’ goals and values, which ultimately guide their care.

Lester also hopes that hospital administrators will recognize the cost-savings potential of geriatric expertise.  

“What do hospitals worry about?” Lester said. “They don’t like falls. They don’t like readmissions. They don’t like people dying [outside of] hospice. They don’t like pressure ulcers or delirium. Those are all geriatric things. That’s literally what we do.” 

Even after a diagnosis of vascular dementia, Laura Brancato’s father was able to stay in his own home for years. But as his condition worsened, that started to become problematic.

Her father started to wander out of the house. His sleep became disrupted, keeping his wife up at night and leaving her constantly sleep deprived. His medications frequently needed adjustments, which meant Brancato—who has young children and a 70-hour-a-week career as an elder law attorney—had to drive him to the doctor’s office. Part-time caregivers were hard to find and unreliable, especially once the COVID-19 pandemic began.

Finally, Brancato’s family decided to move her father into a memory care community in 2020. He was safer there but unhappy. Visits were limited, because of the pandemic, and her father didn’t understand. 

“He thought we had abandoned him,” she said. 

The decision to move into senior living is one that many older adults and their families will wrestle with, sooner or later. On average, someone turning 65 today has almost a 70 percent chance of needing some type of long term care in their remaining years, and 37 percent will require residential care in an assisted living or skilled nursing facility, according to LongTermCare.gov.  

Determining the best time to make the move often creates conflicts. Siblings may fight over the best course of action. Older adults may resist making a move, even when their adult children feel it’s clearly time.  

“The older person is saying, ‘Why? I’m perfectly fine. I can take care of myself,’” according to Dianne Savastano, a patient advocate and founder of HealthAssist in Manchester, MA. 

Aging in Place

Most older adults want to remain in their own homes as long as possible. Realistically, however, some will reach the point when that’s no longer safe or comfortable. A person living with dementia may wander and get lost, or leave the stove on and start a fire. Mobility issues may pose a high risk for a fall or make it impossible to handle basic daily chores like cooking, cleaning, dressing or bathing.  

When counseling older adults and their families grappling with this question, Kimberly Knight focuses on activities of daily living (ADLs). 

“It’s all about ADLs,” said Knight, director of caregiver-support programs at the Senior Source in Dallas. “Consider whether the older adult is still able to navigate the home and care for themselves safely.” 

She asks questions: Can the person get up out of bed, toilet and dress themselves in the morning? Are they able to stand long enough to prepare meals? Do they remember to take their medications on schedule? 

Knight also urges family members to look for signs the older adult isn’t coping. Are they losing weight? Is there spoiled food in the refrigerator, or no food at all? Are bills and mail piling up? Is the home cluttered? Is the person skipping basic grooming tasks? If a spouse or other older adult is the caregiver, is that person showing signs of fatigue or burnout?

Not all of these signs automatically mean it’s time to make a move, but they all do usually mean that the older adult needs more help. 

Older people without family support need to plan ahead for the care they’ll need someday

For those who want to stay in their own homes, the first strategy is to explore options to make staying there safer and more manageable. A life-alert device, for example, could ensure that an older adult can get help quickly in the event of a fall. A part-time, paid caregiver might be able to help with meals, shopping, getting dressed or other ADLs.  

Another key factor in the timing decision is the availability—or lack of availability—of family support, according to Jenny Munro, a gerontologist. She advises older adults and their families every day on the question of “When is it time?” as response team manager at Home Instead, an in-home caregiving agency.

She sees this with her own father, who’s now 98. He wants to remain in the house where he has lived for more than 60 years. His cognitive condition is still excellent, but he’s frail and weak.

Family support is plentiful: Munro is one of nine adult children. After her mother died a few years ago, all stepped in to handle some aspect of his care. A brother who is a banker, for example, is handling his finances. Four of the siblings live nearby, and used to take turns staying with him, a week at a time. That worked until her father began experiencing incontinence. Now, three, full-time, care professionals provide round-the-clock care, and the siblings visit often.

“It’s very expensive,” Munro said. “Thankfully, he saved and invested and has the ability to pay for that.” 

Family support may not be an option, especially for solo agers and older adults without children or spouses. They must plan to handle their care needs on their own.

Solo agers especially may want to hire a professional to help with caregiving decisions.

Like Munro, Carol Marak pitched in, along with her two sisters, to care for her mother, who had several chronic health issues, and her father, who had Alzheimer’s. The couple lived in a rural area and needed help with rides to the doctor, cooking, cleaning and managing their finances. 

The experience was an eye-opener for Marak, 72, who was divorced, childless and had little savings.  

“It scared the heck out of me,” she said. “It took all three of us to take care of Mom and Dad. Who’s going to do that for me?”  

After her parents passed away, Marak began focusing on improving her health and adjusting her lifestyle. She moved from her suburban home to a high-rise apartment building in Dallas that functions as an informal retirement community. Many of the residents are older and support each other. She can walk to errands or catch a bus. 

She also wrote a book, Solo and Smart: The Roadmap for a Supportive and Secure Future (2022). And she’s making plans for when she’s no longer able to care for herself on her own. 

To do that, Marak urges solo agers to hire a professional who can help weigh caregiving decisions, such as an aging-life-care professional or geriatric care manager. Solo agers may want to undergo a cognitive function evaluation before signs of memory loss occur. The test can serve as a baseline and can be repeated regularly as part of their routine health care, to provide objective information on the older person’s cognitive status in the future. 

“You need to have your team of professionals who are looking out for you and who will take notice if you’re starting to decline,” said Marak. 

An Iterative Process

Don’t be surprised if the decision to make a move turns into a series of decisions stretching over several years, Savastano advises. 

“I call it ‘iterative decision-making,’” she said. “You’re constantly adjusting to the older adult’s level of abilities and what they need help with.” 

She worked for 13 years as an advocate for a client named Rosalie, guiding her through knee replacement surgery and then a move into an independent living apartment in a continuing care retirement community (CCRC).  

Rosalie loved her apartment and made new friends. The move was such a success that, even though the CCRC offered sections for higher levels of care, “Rosalie made it truly clear to both me and her children, over and over again, that she intended to live there through the end of her life,” Savastano said.  

Those who delay moving until they’re in poor health may be turned away by some senior living facilities.

When Rosalie’s cognitive abilities began to decline, the staff wanted to move her into the community’s memory care unit. Savastano negotiated for a way to honor Rosalie’s wishes. 

“We gradually increased the use of private, in-home assistance, ultimately involving 24/7 care in her home, which thankfully she was able to afford,” Savastano said. 

Savastano cautions that while older adults may wish to stay at home as long as possible, later isn’t always better than sooner. An older adult’s condition can decline to the point that their options become limited to skilled nursing or long term care. 

“If you wait too long, you may not have as many choices,” she said. Some assisted living or memory care communities, for example, may accept an older adult with dementia, knowing their condition will decline. Most will make accommodations to allow a longtime resident to stay until the end of life. But the same community likely won’t accept someone in that later stage as a new resident. 

Sooner, Rather than Later

A “sooner, rather than later” strategy worked well for Larry and Marilyn Comstock, both in their 80s.

After visiting eight communities, the Comstocks moved into an independent living apartment in 2018. Even though both were—and still are—healthy, active and cognitively sharp, and even though it meant leaving behind their beloved home and many treasured possessions, they felt it was time. They chose Highland Springs Senior Living in Dallas, which has on-site medical care and offers assisted living, memory care and long term care, should their needs change. 

“It was the hardest decision we’ve ever made,” Marilyn Comstock said. “But we didn’t want our children to have the burden of finding someplace for us to move. We wanted to make the decision ourselves.” 

A few months later, the couple felt affirmed in their decision when Marilyn fell and broke her hip. Thanks to the community’s alert system, she was able to get help in minutes. Marilyn recovered, and today they’re both thriving, serving on resident committees and socializing with the many new friends they’ve made.

“We’re glad we moved when we did, because we still have the ability to enjoy the facilities and the people here,” said Marilyn Comstock. 

When the Older Adult Resists

The decision to move into senior living becomes more complicated when family members think it’s time for a move—but the older adult is unwilling. If cognitive decline is present, family members may question whether the older adult is capable of making the right decision. 

“It’s a tricky situation when the older adult is resistant to a move,” said Hannah De George, elder advocate at St. John’s Senior Services in Rochester, NY.  

De George recently sat in on a family meeting with some close friends. The adult children all agreed it was time for their parents to move into assisted living; the parents were unwilling. 

“They felt ganged up on,” said De George. “No one wants to be told, ‘You can’t live in your own home anymore.’” 

Family members can’t force an older adult to move, unless the person has been declared unable to make their own decisions and placed under guardianship by a court order. But that doesn’t mean families should immediately accept “no” as the answer if it’s clear the older adult needs more help. 

“When it’s safety versus autonomy, you have to err on the side of safety,” Knight said. 

Savastano sometimes coaches adult children on different strategies for making their case with a parent resisting a move.

“But in reality, sometimes you end up waiting until a crisis occurs,” she said. 

Family Conflict

The decision to move an older adult into senior living often sparks conflicts among the adult children. 

“This is an issue that can break up families and cause siblings to stop talking to each other for years,” said Knight. 

An adult child living out of state might think the parent is fine living alone at home, whereas a nearby sibling, who visits every day, may be convinced that’s not an option. 

One adult child may want to move the parent sooner, rather than later, and sell the aging parent’s home or dip into their nest egg to provide the best available care. A sibling who’s counting on inheriting that money may disagree. Feelings of guilt, sibling rivalry or other emotional baggage add to the morass. 

Older adults can help ward off conflicts by communicating their wishes in advance, before a crisis hits, and having the legal documentation in place for a trusted person to handle the financial aspects of paying for senior living, should they become unable to do so. 

If it’s too late for that option, experts advise bringing in a third party—a geriatric care manager or physician, for example—who can weigh in with a neutral opinion on the need for residential care.

A Good Decision

Laura Brancato’s father was initially unhappy after moving into memory care. But the regularity of the community’s daily schedule—important for people with dementia—made him feel comfortable. Medical staff on site adjusted his medications quickly when needed, avoiding the need for frequent trips to the doctor. Soon, her father embraced the place as home.

He stayed there until his death in December 2023. Looking back, Brancato’s family feels they made the right move at the right time. 

“He forgot he had ever lived anywhere else,” Brancato said. “Instead of bringing him home for celebrations, we started bringing the family to him. He really was thriving in that environment.” 

Jane’s adult children worried she was sinking into dementia. Her behavior had changed. She wasn’t taking care of her physical appearance. She was forgetful and missing appointments. Maybe it was time, family members wondered, to move her into assisted living. 

Then they discovered the real problem: at the age of 89, Jane was an alcoholic. 

She’d struggled with alcoholism earlier in life but had been sober since age 70. She had taken sobriety seriously, attending Alcoholics Anonymous meetings and sponsoring others who struggled. But after a series of setbacks—her husband of 57 years died, she had to stop driving, and worsening arthritis meant she couldn’t swim anymore—Jane relapsed. 

“I think she was lonely, and felt a lot of loss, and thought, ‘I haven’t drank in 20 years; maybe I can just have a glass of wine,’” said Diana Santiago, MSW, clinical supervisor of the Older Adult Program at Caron Treatment Centers, where Jane eventually underwent treatment. “After a couple of months, she was right back where she started.” 

Jane’s story isn’t uncommon. Substance addiction is on the rise among older adults. 

“Nearly one million adults 65 and up in the United States are living with a substance abuse disorder,” said Lisa Stern, LCSW, assistant vice president, Senior & Adult Services at Family & Children’s Association (FCA), a human services agency on Long Island, NY. From 2002 to 2021, the rate of overdose deaths, accidental or intentional, quadrupled among older adults, according to a research letter published in the March 2023 JAMA Psychiatry. 

Alcohol and prescription painkillers top the list of substances most commonly abused by people 60 and up. Most older people admitted to treatment facilities are addicted to alcohol. Approximately 20 percent of all adults ages 60 to 64, and around 11 percent over age 65, report they are currently binge drinking, according to the National Institute on Alcohol Abuse and Alcoholism.

In later life, people are more likely to use alcohol or drugs to relieve pain than to get high. 

Opioid abuse is rising among older people too. While the US population of adults 55 and older rose by about 6 percent between 2013-2015, the proportion of people in that age group seeking treatment for opioid use disorder increased nearly 54 percent. The proportion of older adults using heroin more than doubled between 2013-2015 (in part due to those who switched to heroin—an illicit opioid—after misusing prescription opioids). One study estimated that the prevalence of prescription drug abuse among older adults may be as high as 11 percent.

Marijuana use is also on the rise among older people in the United States. However, experts suspect that’s due to Boomers, the first generation to widely accept marijuana use, reaching older age. Admission to treatment facilities for marijuana alone is rare, although it can often be part of the mix of drugs and/or alcohol that led to addiction.

Older addicts tend to follow different patterns than those who are younger. They include “hardy survivors”—people like Jane, who struggled with addiction for years off and on or continuously. Others first become addicts in their later years. Use of illicit drugs, like cocaine or meth, declines after young adulthood. But common challenges in later life—isolation, depression and anxiety, financial worries, family conflict, the loss of a spouse or other loved ones, physical or mental decline, adapting to retirement—can turn into triggers for abuse. 

“Older adults are less likely to use drugs or alcohol to get high,” said Jeremy Klemanski, MBA, CEO of Gateway Foundation, one of the nation’s largest addiction treatment organizations. “Instead, they tend to use these substances to reduce pain or handle emotional difficulties.” 

Many older adults experience chronic pain, anxiety or insomnia, all of which may be treated with highly addictive medications like opioids or benzodiazepines (“benzos”), like alprazolam (Xanax), diazepam (Valium) and lorazepam (Ativan.) Older people may be even more prone to abuse these drugs than their younger counterparts. Plus, many older adults must manage multiple health conditions with an assortment of medications prescribed by several specialists, usually without careful coordination, making misuse or overuse more likely. 

“These prescriptions are often not monitored closely, as seniors who cannot get out easily do not follow up regularly with their physicians,” said Stern. “Doctors should be making patients aware of drugs that can be highly addictive, but often they don’t have these conversations. The older adult may be taking the medication incorrectly, or taking too much, but not considering it abusive.” 

Physiological changes that occur with aging can make substance use riskier and misuse more deadly. The ability to metabolize drugs or alcohol declines with age. Someone who could have a beer or two in their 30s with no consequences, for example, is more likely to become impaired in their 60s or 70s. 

Addiction Can Be Easily Missed

Substance abuse is often overlooked or misdiagnosed in older adults. Many of the symptoms of abuse—forgetfulness, drowsiness, confusion, mood swings or shaky hands—are easily dismissed as signs of aging. Even when addiction is recognized, family members are often prone to minimize it.

“People may think the older adult isn’t working or driving, so what’s the harm?” said Klemanski. “The harm is that the substance is harmful physically, and addiction is often a sign of loneliness and lack of connectedness. Both can lead to premature death.” 

Santiago cited a patient in his early 60s who’d been prescribed Aricept for dementia. 

“His medical records indicated that he had Alzheimer’s,” she said. “When he came in for treatment, he was confused and his memory was bad.” 

As it turned out, the patient had been taking a variety of stimulants, opioids and benzodiazepines, along with alcohol. After four weeks without the drugs and alcohol, the man scored within normal range in a follow-up cognitive screening. 

That scenario is not uncommon, Santiago added.

“Once we’re able to clear the substances away, we’re able to see what’s really going on, and nine times out of 10, those older adult patients have their cognition improved significantly,” she said. 

Confronting Trauma 

The telltale sign that Tim, 68, had a problem was his credit card statements. Family members discovered he was “drunk buying” guitars online, ultimately spending more than $100,000, which he couldn’t afford. His daughter referred him to FCA Long Island for treatment. 

In counseling, Tim shared how his mother had walked out on his family when he was 14 and was never heard from again. For the first time, he realized that trauma had affected his relationships for more than 50 years. 

Unresolved trauma is a common factor contributing to addiction among older adults, according to Chris Walter, a certified recovery peer advocate at FCA. 

“Often the Boomers don’t want to talk about these things,” he said. “That wasn’t a generation that went to therapy or talked about their problems. If we can get that [childhood trauma] out, it does help them to free up demons.”  

People who have had a successful life can become isolated as they age, with time on their hands, and fill that vacuum with alcohol or drugs. 

Older adulthood, of course, can also bring new trauma and loss. Friends and family members die. A move from a longtime home to assisted living can feel like a death. Retirement, or an unplanned job loss, may leave an older adult at loose ends. 

That’s what happened with Dan, 63, when he lost his job 17 years ago. He spiraled from a social drinker into an alcoholic. 

“When you go from being a workaholic, and your professional career to a large extent defines you, to being undecided about your future and with whom you fit in, it leads to self-questioning, and for some of us, self-medicating,” he said.  

“It’s very typical to have an older adult [with addiction] who has had a successful life,” said Klemanski. “They’ve raised children. They’ve had a career or contributed something positive to their community. But as they got older, some of the things that helped define life are pulled away from them. They may have more time on their hands or feel isolated. A vacuum occurs, and that’s filled with alcohol or drugs.”  

Getting Treatment

Drinking got Francisco, 68, banned from the local senior center. He’d shown up intoxicated, behaved aggressively and fell in the parking lot. He was referred for treatment at FCA Long Island. Counselors discovered that he was not only drinking a pint of vodka a day but also taking clonazepam (Klonopin) prescribed by his doctor for anxiety. 

In treatment, counselors helped Francisco to better manage his drinking and to address a root cause of the problem: isolation. His case manager set up a meal delivery service, so he’d eat more nutritious meals more regularly, and provided him with a tablet computer and Amazon Echo device, along with lessons on how to use both. 

“He was able to learn how to access YouTube and the internet, which allowed him to enjoy his passions of cars and music in a new way and socialize virtually to reduce his isolation,” said Christiana Mangiapane, LMSW, director of senior mental health services at FCA Long Island. “As a result, he had something to look forward to every day besides a drink.” 

Francisco’s treatment seems to be helping. But as the numbers of older adults struggling with addiction increase, many worry that treatment facilities and programs can’t keep up. Researchers for the JAMA Psychiatry report on overdoses urged policy makers to pursue proposals applying mental health parity rules within Medicare, so that older adults will have better mental health and substance-use disorder coverage and more options. Medicare has covered opioid treatment programs such as methadone clinics since 2020 and will cover a broader range of outpatient treatments beginning in January 2024. However, it does not cover residential treatment.

When older people who are addicted get treatment, they have a better chance of recovering than people who are younger. 

Models of care for treating substance abuse in older people are still evolving. Inpatient treatment typically begins with detox—a period of medical observation while the patient withdraws from the substance, sometimes with the aid of medication. Because older adults tend to metabolize drugs more slowly, most need longer periods of detox. 

Other treatment approaches might include individual counseling, cognitive behavioral therapy, support groups, medication and building connections with other people. Ideally, treatment is tailored to individual needs. Older adults with other medical or mental health issues must have those managed while in residential treatment. Support groups with peers, rather than with people in their 20s and 30s, are more effective. 

“A 74-year-old man who’s retired and whose wife just died isn’t going to relate to a bunch of 30-year-olds with small children and jobs, whose struggles might relate more to drinking too much when they’re with friends,” said Santiago. 

On the plus side, recovery rates tend to be higher among older adults who seek treatment compared to younger adults, according to Klemanski. 

“Their positive life experiences help them focus on the benefits of rehab, which can make them more disciplined in their recovery,” he said.   

Finding Sobriety

Still, the first hurdle is motivating the older adult to seek help. For Dan, that motivation came in the form of a health scare. His drinking finally led to liver disease; doctors told him he’d need a transplant or he’d die within three months.  

“Treatment for me was literally a life-or-death decision,” he said. 

Dan enrolled in a program at Gateway and cobbled together his own recovery strategy, combining the support of friends and family with daily prayer and attending Mass four times a week at his church. He’s been sober for more than a year now. To his doctor’s surprise, his liver disease seems to be in remission. 

For him, the AA principle of “one day at a time” was his key coping strategy.

“Anyone who has [quit drinking] knows it’s more like 10 or 20 minutes at a time,” he said. “Everyone has to develop the tricks, skills and tools that work for them.”

For Jane, an intervention staged by her adult children spurred her to travel from Florida to Wernersville, PA, to undergo residential treatment at Caron Treatment Centers. By age 90, Jane was once again sober. A follow-up cognitive screening showed that Jane didn’t have dementia after all.  

“Her memory came back, and she was able to live independently again,” said Santiago. “Even though she may only have a few years left on this earth, she’s enjoying a better quality of life during those years.”