During procedures, he seemed “hesitant, not sure of how to go on to the next step without being prompted” by assistants, said Mark Katlic, director of the Aging Surgeon Program at Sinai Hospital in Baltimore.

The chief of surgery, concerned about the doctor’s cognition, “would not sign off on his credentials to practice surgery unless he went through an evaluation,” Katlic said.

Since 2015, when Sinai inaugurated a screening program for surgeons 75 and older, about 30 from around the country have undergone its comprehensive two-day physical and cognitive assessment. This surgeon “did not come of his own accord,” Katlic recalled.

But he came. The tests revealed mild cognitive impairment, often but not necessarily a precursor to dementia. The neuropsychologist’s report advised that the surgeon’s difficulties were “likely to impact his ability to practice medicine as he is doing presently, e.g. conducting complex surgical procedures.”

That didn’t mean the surgeon had to retire; a variety of accommodations would allow him to continue in other roles. “He retained a lifetime of knowledge that had not been impacted by cognitive changes,” Katlic said. The hospital “took him out of the OR, but he continued to see patients in the clinic.”

Such incidents are likely to become more common as America’s physician workforce ages rapidly. In 2005, more than 11% of doctors who were seeing patients were 65 or older, the American Medical Association said. Last year, the proportion reached 22.4%, with nearly 203,000 older practitioners.

Given physician shortages, especially in rural areas and key specialties like primary care, nobody wants to drive out veteran doctors with skills and experience.

Yet researchers have documented “a gradual decline in physicians’ cognitive abilities starting in their mid-60s,” said Thomas Gallagher, an internist and bioethicist at the University of Washington who has studied late-career trajectories.

At older ages, reaction times slow; knowledge can become outdated. Cognitive scores vary greatly, however. “Some practitioners continue to do as well as they did in their 40s and 50s, and others really start to struggle,” Gallagher said.

A few health organizations have responded by establishing late-career practitioner programs mandating that older doctors be screened for cognitive and physical deficits.

UVA Health at the University of Virginia began its program in 2011 and has screened about 200 older practitioners. Only in four cases did the results significantly change a doctor’s practice or privileges.

Stanford Health Care launched its late-career program the following year. Penn Medicine at the University of Pennsylvania also put in place a testing program.

Nobody has tracked how many exist; Gallagher guesstimated as many as 200. But given that the United States has more than 6,000 hospitals, those with late-career programs constitute “a vast minority,” he said.

The number may actually have shrunk. A federal lawsuit, along with the profession’s lingering reluctance, appears to have put the effort to regularly assess older doctors’ abilities in limbo.

Late-career programs typically require those 70 and older to be evaluated before their privileges and credentials are renewed, with confirmatory testing for those whose initial results indicate problems. Thereafter, older doctors undergo regular rescreening, usually every year or two.

It’s fair to say such efforts proved unpopular among their intended targets. Doctors frequently insist that “‘I’ll know when it’s time to stand down,’” said Rocco Orlando, senior strategic adviser to Hartford HealthCare, which operates eight Connecticut hospitals and began its late-career practitioner program in 2018. “It turns out not to be true.”

When Hartford HealthCare published data from the first two years of its late-career program, it reported that of the 160 practitioners 70 and older who were screened, 14.4% showed some degree of cognitive impairment.

That mirrored results from Yale New Haven Hospital, which instituted mandatory cognitive screening for medical staff members starting at age 70. Among the first 141 Yale clinicians who underwent testing, 12.7% “demonstrated cognitive deficits that were likely to impair their ability to practice medicine independently,” a study reported.

Proponents of late-career screening argued that such programs could prevent harm to patients while steering impaired doctors to less demanding assignments or, in some cases, toward retirement.

“I thought as we got the word out nationally, this would be something we could encourage across the country,” Orlando said, noting that Hartford’s program cost only $50,000 to $60,000 a year.

Instead, he has seen “zero progress” in recent years. “Probably we’ve gone backward,” he said.

A key reason: In 2020, the federal Equal Employment Opportunity Commission sued Yale New Haven over its testing efforts, charging age and disability discrimination. The legal action continues (the EEOC declined to comment on its status), as does the hospital’s late-career program.

But the suit led several other organizations to pause or shut down their programs, including those at Hartford HealthCare and at Driscoll Children’s Hospital in Corpus Christi, Texas, while few new ones have emerged.

“It made lots of organizations uncomfortable about sticking their necks out,” Gallagher said.

Instituting later-career programs has always been an uphill effort. “Doctors don’t like to be regulated,” Katlic acknowledged. Late-career programs have “in some cases been very controversial, and they’ve been blocked by influential physicians,” he said.

As health systems wait to see what happens in federal court, most national medical organizations have recommended only voluntary screening and peer reporting.

“Neither works very well at all,” Gallagher said. “Physicians are hesitant to share their concerns about their colleagues,” which can involve “challenging power dynamics.”

As for voluntary evaluation, since cognitive decline can affect doctors’ (or anyone’s) self-awareness, “they’re the last to know that they’re not themselves,” he added.

In a recent commentary in The New England Journal of Medicine, Gallagher and his co-authors recommended procedural policies to promote fairness in late-career screening, based on an analysis of such programs and interviews with their leaders.

“How can we design these programs in a way that’s fair and that therefore physicians are more apt to participate in?” he said. The authors emphasized the need for confidentiality and safeguards, such as an appeals process.

“There are all sorts of accommodations” for doctors whose assessments indicate the need for different roles, Gallagher noted. They could adopt less onerous schedules or handle routine procedures while leaving complex six-hour surgeries to their colleagues. They might transition to teaching, mentoring, and consulting.

Yet a substantial number of older doctors head for the exits and retire rather than face a mandated evaluation, he said.

The future, therefore, might involve programs that regularly screen every practitioner. That would be inefficient (few doctors in their 40s will flunk a cognitive test) and, with current tests, time-consuming and consequently expensive. But it would avoid charges of age discrimination.

Faster reliable cognitive tests, reportedly in the research pipeline, may be one way to proceed. In the meantime, Orlando said, changing the culture of health care organizations requires encouraging peer reporting and commending “the people who have the courage to speak up.”

“If you see something, say something,” he continued, referring to health care professionals who witness doctors (of any age) faltering. “We are overly protective of our own. We need to step back and say, ‘No, we’re about protecting our patients.’”

The New Old Age is produced through a partnership with The New York Times.

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Finally, after decades of advocacy, the Biden administration in 2023 tackled the problem of perennial understaffing of long-term care facilities. Officials backed a Medicare regulation that would mandate at least 3.48 hours of care from nurses and aides per resident, per day, and would require a registered nurse on-site 24 hours a day, seven days a week.

The mandated hours were lower than supporters hoped for, said Hunter, who directs Washington state’s long-term care ombudsman program. But “I’m a pragmatic person, so I thought, this is a good start,” she said. “It would be helpful, for enforcement, to have a federal law.”

In 2024, when the Centers for Medicare & Medicaid Services adopted the standards, advocates celebrated. But industry lawsuits soon blocked most of the rule, with two federal district courts finding that Medicare had exceeded its regulatory authority.

And after the 2024 elections, Hunter said, “I was concerned about the changing of the guard.” Her concerns proved well founded.

In July, as part of Republicans’ One Big Beautiful Bill Act, Congress prohibited Medicare from implementing the staffing standards before 2034. Last month, CMS repealed the standards altogether. They never took effect.

“It was devastating,” Hunter said.

As with environmental law and consumer protections, the Trump administration’s enthusiasm for deregulation has undone long-sought rules to improve care for the aged. And it has introduced a Medicare experiment for prior authorizations, now getting underway in six states, that has alarmed advocates, congressional Democrats, and a good number of older Americans.

Taken together, the moves will affect many of the facilities and workers providing care and introduce complications in health coverage in several states.

On the nursing home front, “it’s clear CMS has no interest in ensuring adequate staffing,” said Sam Brooks, the director of public policy for the National Consumer Voice for Quality Long-Term Care.

“They’re repealing a regulation that could have saved 13,000 lives a year,” he added, citing an analysis by University of Pennsylvania researchers.

Industry groups argued that nursing homes, with high rates of staff turnover, were already struggling to fill vacancies.

The staffing mandate “was requiring nursing homes to hire an additional 100,000 caregivers that simply don’t exist,” said Holly Harmon, a senior vice president at the American Health Care Association.

The organization had brought one of the suits that largely vacated the rule. “Facilities would have been forced to limit admissions or downsize to comply with the requirements, or close altogether,” Harmon said.

For supporters, the action is now likely to shift to updating requirements in 35 states, along with the District of Columbia, that have already established some nursing home staff standards, and to developing them in those that haven’t.

Rules for Home Help

A second rescinded regulation, this one more unexpected, brought about upheaval in July, when the Labor Department announced a return to a policy excluding home care workers from the federal Fair Labor Standards Act.

Some history: Dating back to the New Deal, the FLSA mandated that workers receive the federal minimum wage (currently $7.25 an hour) and overtime pay. It exempted most “domestic service workers” until 1975, when a new Labor Department regulation included them — with the exception of home care workers.

“There was a misinterpretation of home care work as being casual, nonprofessional, non-skilled,” the equivalent of teenage babysitting, said Kezia Scales, a vice president at PHI, a national research and advocacy organization. “Just someone popping into your mother’s house now and then and keeping her company.”

For almost 40 years, workers and their supporters lobbied to change the rule, seeing it as a contributor to the low wages and meager benefits of a swiftly growing workforce, one made up primarily of women and minority groups, with many immigrants.

In 2013, the Labor Department responded with a rule that brought home care workers under the labor act, entitled to minimum wage, time and a half for overtime work, and payment for travel time between clients.

After industry lawsuits failed to overturn it, “everything settled down,” Scales said. “It was in place successfully for a decade.”

Home care workers brought hundreds of compliance complaints annually. In 87% of them, the Labor Department found violations of the labor act, according to a 2020 Government Accountability Office report.

Since 2013, home care agencies have paid about $158 million in back wages, PHI has calculated.

Then in July, the Labor Department abruptly announced that it would return to the 1975 regulations and stop enforcing the 2013 rule, which it said “had negative effects on the ground” and hindered consumer access to care.

The agencies employing most home care workers, primarily funded through Medicaid, would agree. “Many workers never got any benefit from this,” said Damon Terzaghi, a vice president at the National Alliance for Care at Home.

“States made a lot of moves to essentially absolve themselves of any responsibility,” he said. A 2020 federal report, for example, found that 16 states had capped Medicaid-covered home care hours at 40, thus averting overtime payment.

The alliance, which estimates that the number of impacted agencies and businesses has declined by 30% since 2013, supported the rescission. Scales, who hopes for congressional action, called it “a shocking step backward.”

Where they concur is that the United States has never really committed to sufficiently funding long-term care at home. With the July legislation setting the stage for a $914 billion cut to Medicaid over the coming decade, that seems unlikely to change anytime soon.

Medicare’s AI Referee

Beyond rolling back policies for care of the aged, the Trump administration has established a pilot program to introduce one to traditional Medicare: prior authorization, using artificial intelligence and machine learning technologies.

Touting it as a boon to taxpayers, Medicare calls it WISeR — Wasteful and Inappropriate Service Reduction.

Prior authorization, in which private insurers review proposed treatments before agreeing to pay for them, is widely used in Medicare Advantage plans despite its unpopularity with patients, doctors, and health care organizations. It has rarely been used in traditional Medicare.

This month, however, WISeR debuts in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington) in a six-year trial to determine whether review by tech companies can reduce costs and improve efficiency, while maintaining or improving quality of care.

Initially, WISeR targets 17 items and services that CMS said “historically have had a higher risk of waste, fraud and abuse.” The list includes knee arthroscopy for arthritis, electrical nerve stimulation devices for several conditions, and treatment for impotence.

The pilot program excludes emergency services and inpatient hospital care, or care where delay poses “a substantial risk.” Algorithmic denials will trigger review by “an appropriately licensed human clinician.” The tech companies get “a share of averted expenditures.”

“It injects some of the worst of Medicare Advantage into traditional Medicare,” said David Lipschutz, co-director of the Center for Medicare Advocacy. The six vendors that approve or reject treatments “have a financial stake in the outcomes,” he said, and therefore “an incentive to deny care.”

Moreover, the CMS Innovation Center overseeing the pilot could theoretically bypass Congress and expand prior authorization to include more medical services in more states.

The agency did not respond to questions about what kind of human clinicians would review denials, except to say that they would have “relevant experience” and that tech companies would be “financially penalized for inappropriate denials, high appeal rates or poor performance.”

It plans an “independent, federally funded evaluation” and will release public reports annually.

Democrats in Congress have introduced bills in both houses to repeal WISeR. “We should be reducing red tape in Medicare, not creating new hurdles that second-guess health care providers,” said Rep. Suzan DelBene of Washington, one of the bill’s sponsors.

For now, though, WISeR has opened for business, receiving prior authorization requests through its electronic portals.

“The New Old Age” is produced through a partnership with The New York Times.

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Finalmente, después de décadas de lucha y presión, en 2023 la administración Biden abordó el problema crónico de la falta de personal en los centros de cuidado a largo plazo.

Las autoridades respaldaron una norma de Medicare que exigía que cada residente recibiera al menos 3,48 horas diarias de atención, brindada por enfermeras y asistentes. Además, establecía que debía haber una enfermera calificada en el lugar durante las 24 horas del día, los siete días de la semana.

Sin embargo, las horas obligatorias de cuidado resultaron ser menos de lo que esperaban quienes apoyaron la medida, dijo Hunter, directora del programa de defensoría de cuidados a largo plazo del estado de Washington. Pero explicó: “Soy una persona pragmática, así que pensé que era un buen comienzo. Y que tener una ley federal ayudaría a hacer cumplir la norma”.

En 2024, cuando los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés) adoptaron estos estándares, los defensores celebraron. Sin embargo, luego, demandas de la industria bloquearon la mayor parte de la ley: dos cortes federales dictaminaron que Medicare se había excedido en sus atribuciones regulatorias.

Tras las elecciones de 2024, “me preocupaba el cambio de mando”, dijo Hunter. Sus preocupaciones estaban justificadas.

En julio, como parte de la ley republicana conocida como One Big Beautiful Bill Act, el Congreso prohibió que Medicare implementara los estándares de personal antes de 2034. En diciembre, los CMS revocaron los estándares por completo. Nunca llegaron a entrar en vigencia.

“Fue devastador”, lamentó Hunter.

Como ocurrió con la legislación medioambiental y la protección de los consumidores, el entusiasmo de la administración Trump por la desregulación ha deshecho normas para mejorar la atención a las personas mayores que se estaban esperando hacía tiempo.

Además, introdujo un programa experimental de Medicare con autorizaciones previas, que ya se está llevando a cabo en seis estados y ha generado alarma entre defensores, legisladores demócratas del Congreso y muchas personas mayores.

En conjunto, estas decisiones afectarán a muchos centros de cuidado y a trabajadores que prestan servicios de salud, y complicarán la cobertura médica en varios estados.

En lo que respecta a los hogares de adultos mayores, “está claro que los CMS no tienen interés en garantizar una dotación adecuada de personal”, dijo Sam Brooks, director de políticas públicas de National Consumer Voice for Quality Long-Term Care.

“Están derogando una regulación que podría haber salvado 13.000 vidas al año”, agregó Brooks, citando un análisis de investigadores de la Universidad de Pennsylvania.

Los grupos de la industria argumentaron que los hogares de adultos mayores, que tienen altas tasas de rotación de personal, ya se veían en dificultades para cubrir las vacantes.

El mandato exigía “que los hogares de adultos mayores contrataran a 100.000 cuidadores adicionales que simplemente no existen”, sostuvo Holly Harmon, vicepresidenta sénior de la American Health Care Association.

Esa organización fue una de las que presentaron las demandas que, en gran medida, terminaron anulando la norma. “Para cumplir con los requisitos, los centros se habrían visto obligados a limitar las admisiones, reducir su tamaño o incluso cerrar por completo”, agregó Harmon.

Para quienes apoyan la regulación, ahora la atención se centrará en actualizar los requisitos sobre el personal de estos hogares en los 35 estados, más el Distrito de Columbia, que ya tienen ciertos estándares. Y, también, en desarrollarlos en aquellos estados que aún no los tienen.

Reglas para ayuda en el hogar

En julio, la inesperada anulación de una segunda norma provocó una fuerte conmoción. El Departamento de Trabajo anunció el regreso a una política que excluye a los trabajadores que brindan cuidados en el hogar de la Ley federal de Normas Justas de Trabajo (Fair Labor Standards Act, FLSA).

Un poco de contexto: en la época del New Deal, la FLSA estableció que los trabajadores debían recibir el salario mínimo federal (actualmente 7,25 dólares por hora) y cobrar por las horas extra. Pero la ley excluyó a la mayoría de los llamados “trabajadores de servicios domésticos”.  Recién en 1975 una norma del Departamento de Trabajo los incorporó, aunque dejó afuera a quienes se dedicaban al cuidado a domicilio.

“Hubo una mala interpretación del trabajo de cuidado en el hogar, como si fuera algo informal, no profesional, y sin calificación”, dijo Kezia Scales, vicepresidenta de PHI, una organización nacional de investigación y defensa. “Algo equivalente a una adolescente que cuida ocasionalmente niños. Alguien que pasa por la casa de tu mamá de vez en cuando y le hace compañía”.

Durante casi 40 años, los trabajadores y sus defensores lucharon por cambiar esa norma, ya que contribuía a los bajos salarios y escasos beneficios de una fuerza laboral en rápido crecimiento, compuesta en su mayoría por mujeres y personas de grupos minoritarios, con una gran presencia de inmigrantes.

En 2013, el Departamento de Trabajo respondió con una norma que incorporó a las trabajadoras de cuidado en el hogar a la ley laboral, dándoles derecho al salario mínimo, al pago de hora y media por las horas extra, y a que se les pagara el tiempo de traslado entre un cliente y otro.

Después de que las demandas de la industria no lograran revertir la medida en los tribunales, “todo se estabilizó y estuvo en vigor sin problemas durante una década”, explicó Scales.

Sin embargo, cada año trabajadoras de cuidado en el hogar presentaban cientos de denuncias por incumplimiento. En el 87% de los casos, el Departamento de Trabajo encontró violaciones a la ley laboral, según un informe de 2020 de la Oficina de Responsabilidad del Gobierno.

Desde 2013, las agencias que emplean personal de atención en el hogar debieron pagar unos $158 millones en salarios atrasados, según cálculos de PHI.

Repentinamente, en julio de 2025, el Departamento de Trabajo anunció que volvería a las regulaciones de 1975 y anularía la norma de 2013, argumentando que había tenido “efectos negativos en la práctica” y dificultado el acceso al cuidado para las personas.

Las agencias que emplean a la mayoría de las trabajadoras, financiadas principalmente a través de Medicaid, coincidieron en esa postura. “Muchas nunca obtuvieron ningún beneficio con esto”, señaló Damon Terzaghi, vicepresidente de la National Alliance for Care at Home.

“Los estados hicieron muchos cambios para, básicamente, desligarse de toda responsabilidad”, comentó. Un informe federal de 2020, por ejemplo, comprobó que 16 estados habían puesto un tope de 40 horas semanales a la atención en el hogar cubierta por Medicaid, para evitar así tener que pagar horas extra.

La alianza, que calcula que el número de agencias y empresas afectadas se redujo en un 30% desde 2013, respaldó la anulación de la norma.

Por el contrario, Scales, que espera que el Congreso actúe, calificó la medida como “un retroceso impactante”.

En lo que sí hay consenso es en que Estados Unidos nunca se ha comprometido realmente a financiar de manera adecuada el cuidado a largo plazo en el hogar. Con la legislación aprobada en julio —que abre la puerta a un recorte de $914.000 millones a Medicaid durante la próxima década—, resulta poco probable que esa situación cambie en el corto plazo.

El “arbitraje” de IA en Medicare

Además de eliminar políticas relacionadas con el cuidado de las personas mayores, la administración Trump ha establecido un programa piloto que introduce un elemento nuevo en Medicare tradicional: la autorización previa, utilizando inteligencia artificial.

Presentado como una medida a favor del contribuyente, Medicare lo llama WISeR, por sus siglas en inglés: Wasteful and Inappropriate Service Reduction (Reducción de Servicios Innecesarios e Inapropiados).

La autorización previa, mediante la cual las aseguradoras privadas revisan los tratamientos propuestos antes de aprobar su pago, es común en los planes de Medicare Advantage, a pesar de las objeciones de pacientes, médicos y organizaciones de salud. En cambio, casi no se ha aplicado en el Medicare tradicional.

Así y todo WISeR está comenzando a implementarse en seis estados (Arizona, New Jersey, Ohio, Oklahoma, Texas y Washington) como parte de un programa piloto de seis años, para evaluar si la revisión a cargo de empresas tecnológicas puede reducir costos y mejorar la eficiencia, sin afectar —y hasta tal vez mejorar— la calidad de la atención.

Inicialmente, WISeR se enfocará en 17 productos y servicios que, según los CMS, “históricamente han tenido mayor riesgo de desperdicio, fraude y abuso”. La lista incluye artroscopía de rodilla para artritis, dispositivos de estimulación nerviosa para varias afecciones y tratamientos para la disfunción eréctil.

El programa piloto excluye los servicios de emergencia, la atención hospitalaria o tratamientos cuyo retraso represente “un riesgo considerable”. Los rechazos basados en algoritmos deberán ser revisados por “un profesional clínico humano con la licencia correspondiente”.

Las empresas tecnológicas recibirán “una parte de los gastos que se eviten”. “Esto introduce lo peor de Medicare Advantage en Medicare tradicional”, dijo David Lipschutz, codirector del Center for Medicare Advocacy.

Las seis empresas que aprueban o rechazan tratamientos “tienen un interés financiero en los resultados”, dijo, y por lo tanto “un incentivo para negar los cuidados”.

Además, el Centro de Innovación de CMS, que supervisa el programa piloto, podría, en teoría, eludir el Congreso y extender la autorización previa a más servicios médicos en más estados.

La agencia no respondió preguntas sobre qué tipo de profesionales humanos revisarían las respuestas negativas, salvo que tendrían “experiencia relevante” y que las empresas tecnológicas serían “sancionadas financieramente por rechazos inapropiados, altas tasas de apelación o bajo desempeño”.

El programa prevé una “evaluación independiente, financiada con fondos federales” y la publicación de informes públicos anuales.

Legisladores demócratas presentaron proyectos de ley en ambas cámaras del Congreso para revocar WISeR. “Deberíamos reducir la burocracia en Medicare, no crear nuevos obstáculos que pongan en duda el criterio de los profesionales de la salud”, dijo la representante Suzan DelBene, del estado de Washington, una de las impulsoras de la iniciativa.

Por ahora, sin embargo, WISeR ya está en marcha y recibe solicitudes de autorización previa a través de sus portales electrónicos.

“The New Old Age” es una producción realizada en colaboración con The New York Times.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The most important reason for older adults to be vaccinated against the respiratory infection RSV is that their risk of being hospitalized with it declines by almost 70% in the year they get the shot, and by nearly 60% over two years.

And the main reason to roll up a sleeve for an annual flu shot is that when people do get infected, it also reliably reduces the severity of illness, though its effectiveness varies by how well scientists have predicted which strain of influenza shows up.

But other reasons for older people to be vaccinated are emerging. They are known, in doctor-speak, as off-target benefits, meaning that the shots do good things beyond preventing the diseases they were designed to avert.

The list of off-target benefits is lengthening as “the research has accumulated and accelerated over the last 10 years,” said William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center in Nashville, Tennessee.

Some of these protections have been established by years of data; others are the subjects of more recent research, and the payoff is not yet as clear. The first RSV vaccines, for example, became available only in 2023.

Still, the findings “are really very consistent,” said Stefania Maggi, a geriatrician and senior fellow at the Institute of Neuroscience at the National Research Council in Padua, Italy.

She is the lead author of a recent meta-analysis, published in the British journal Age and Ageing, that found reduced risks of dementia after vaccination for an array of diseases. Given those “downstream effects,” she said, vaccines “are key tools to promote healthy aging and prevent physical and cognitive decline.”

Yet too many older adults, whose weakening immune systems and high rates of chronic illness put them at higher risk of infectious diseases, have not taken advantage of vaccination.

The Centers for Disease Control and Prevention reported last week that about 31% of older adults had not yet received a flu shot. Only about 41% of adults 75 and older had ever been vaccinated against RSV, or respiratory syncytial virus, and about a third of seniors had received the most recent covid-19 vaccine.

The CDC recommends the one-and-done pneumococcal vaccine for adults 50 and older. An analysis in the American Journal of Preventive Medicine, however, estimated that from 2022, when new guidelines were issued, through 2024, only about 12% of those 67 to 74 received it, and about 8% of those 75 and older.

The strongest evidence for off-target benefits, dating back 25 years, shows reduced cardiovascular risk following flu shots.

Healthy older adults vaccinated against flu have substantially lower risks of hospitalization for heart failure, as well as for pneumonia and other respiratory infections. Vaccination against influenza has also been associated with lower risks of heart attack and stroke.

Moreover, many of these studies predate the more potent flu vaccines now recommended for older adults.

Could the RSV vaccine, protective against another respiratory illness, have similar cardiovascular effects? A recent large Danish study of older adults found a nearly 10% decline in cardiorespiratory hospitalizations — involving the heart and lungs — among the vaccinated versus a control group, a significant decrease.

Lowered rates of cardiovascular hospitalizations and stroke did not reach statistical significance, however. That may reflect a short follow-up period or inadequate diagnostic testing, cautioned Helen Chu, an infectious disease specialist at the University of Washington and co-author of an accompanying editorial in JAMA.

“I don’t think RSV behaves differently from flu,” Chu said. “It’s just too early to have the information for RSV, but I think it will show the same effect, maybe even more so.”

Vaccination against still another dangerous respiratory disease, covid, has been linked to a lower risk of developing long covid, with its damaging effects on physical and mental health.

Probably the most provocative findings concern vaccination against shingles, aka herpes zoster. Researchers made headlines last year when they documented an association between shingles vaccination and lower rates of dementia — even with the less effective vaccine that has since been replaced by Shingrix, approved in 2017.

Nearly all studies of off-target benefits are observational, because scientists cannot ethically withhold a safe, effective vaccine from a control group whose members could then become infected with the disease.

That means such studies are subject to “healthy volunteer bias,” because vaccinated patients may also practice other healthy habits, differentiating them from those not vaccinated.

Although researchers try to control for a variety of potentially confounding differences, from age and sex to health and education, “we can only say there’s a strong association, not a cause and effect,” Maggi said.

But Stanford researchers seized on a natural experiment in Wales in 2013, when the first shingles vaccine, Zostavax, became available to older people who had not yet turned 80. Anyone who had was ineligible.

Over seven years, dementia rates in participants who had been eligible for vaccination declined by 20% — even though only half had actually received the vaccine — compared with those who narrowly missed the cutoff.

“There are no reasons people born one week before were different from those born a few days later,” Maggi said. Studies in Australia and the United States have also found reductions in the odds of dementia following shingles shots.

In fact, in the meta-analysis Maggi and her team published, several other childhood and adult vaccinations appeared to have such effects. “We now know that many infections are associated with the onset of dementia, both Alzheimer’s and vascular,” she said.

In 21 studies involving more than 104 million participants in Europe, Asia, and North America, vaccination against shingles was associated with a 24% reduction in the risk of developing dementia. Flu vaccination was linked to a 13% reduction. Those vaccinated against pneumococcal disease had a 36% reduction in Alzheimer’s risk.

The Tdap vaccine against tetanus, diphtheria, and pertussis (whooping cough) is recommended for adults every 10 years, with vaccination among older adults often prompted by the birth of a grandchild, who cannot be fully vaccinated for months. It was associated with a one-third decline in dementia.

Other researchers are investigating the effects of shingles vaccination on heart attacks and stroke and of covid vaccination on cancer survival.

What causes such vaccine bonuses? Most hypotheses focus on the inflammation that arises when the immune system mobilizes to fight off an infection. “You have damage to the surrounding environment” in the body, “and that takes time to calm down,” Chu said.

The effects of inflammation can far outlast the initial illness. It may allow other infections to take hold, or cause heart attacks and strokes when clots form in narrowed blood vessels. “If you prevent the infection, you prevent this other damage,” Chu said.

Hospitalization itself, during which older patients can become deconditioned or develop delirium, is a risk factor for dementia, among other health problems. Vaccines that reduce hospitalization might therefore delay or ward off cognitive decline.

Health officials in the Trump administration have assailed childhood vaccines more than adult ones, but their vocal opposition may be contributing to inadequate vaccination among older Americans, too.

Many will not only miss out on the emerging off-target benefits but will remain vulnerable to the diseases the vaccines prevent or diminish.

“The current national policy on vaccination is at best uncertain, and in instances appears anti-vaccine,” said Schaffner, a former member of the CDC’s Advisory Committee on Immunization Practices. “All of us in public health are very, very distressed.”

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Or, you’ve completed a couple of weeks in rehab. Can you handle your complicated medication regimen, along with shopping and cooking?

Perhaps you fell in the shower, and now your family wants you to arrange help with bathing and getting dressed.

There are facilities that provide such help, of course, but most older people don’t want to go there. They want to stay at home; that’s the problem.

When older people struggle with daily activities because they have grown frail, because their chronic illnesses have mounted, or because they have lost a spouse or companion, most don’t want to move. For decades, surveys have shown that they prefer to remain in their homes for as long as possible.

That means they need home care, either from family and friends, paid caregivers, or both. But paid home care represents an especially strained sector of the long-term care system, which is experiencing an intensifying labor shortage even as an aging population creates surging demand.

“It’s a crisis,” said Madeline Sterling, a primary care doctor at Weill Cornell Medicine and the director of Cornell University’s Initiative on Home Care Work. “It’s not really working for the people involved,” whether they are patients (who can also be younger people with disabilities), family members, or home care workers.

“This is not about what’s going to happen a decade from now,” said Steven Landers, chief executive of the National Alliance for Care at Home, an industry organization. “Do an Indeed.com search in Anytown, USA, for home care aides, and you’ll see so many listings for aides that your eyes will pop out.”

Against this grim backdrop, however, some alternatives show promise in upgrading home care jobs and in improving patient care. And they’re growing.

Some background: Researchers and elder care administrators have warned about this approaching calamity for years. Home care is already among the nation’s fastest-growing occupations, with 3.2 million home health aides and personal care aides on the job in 2024, up from 1.4 million a decade earlier, according to PHI, a research and advocacy group.

But the nation will need about 740,000 additional home care workers over the next decade, according to the Bureau of Labor Statistics, and recruiting them won’t be easy. Costs to consumers are high — the median hourly rate for a home health aide in 2024 was $34, the annual Genworth/CareScout survey shows, with big geographic variations. But an aide’s median hourly wage was less than $17.

These remain unstable, low-paying jobs. Of the largely female workforce, about a third of whom are immigrants, 40% live in low-income households and most receive some sort of public assistance.

Even if the agencies that employ them offer health insurance and they work enough hours to qualify, many cannot afford their premium payments.

Unsurprisingly, the turnover rate approaches 80% annually, according to a survey by the ICA Group, a nonprofit organization that promotes co-ops.

But not everywhere. One innovation, still small but expanding: home care cooperatives owned by the workers themselves. The first and largest, Cooperative Home Care Associates in the Bronx borough of New York City, began in 1985 and now employs about 1,600 home care aides. The ICA Group now counts 26 such worker-owned home care businesses nationwide.

“These co-ops are getting exceptional results,” said Geoffrey Gusoff, a family medicine doctor and health services researcher at UCLA. “They have half the turnover of traditional agencies, they hold onto clients twice as long, and they’re paying $2 more an hour” to their owner-employees.

When Gusoff and his co-authors interviewed co-op members for a qualitative study in JAMA Network Open, “we were expecting to hear more about compensation,” he said. “But the biggest single response was, ‘I have more say’” over working conditions, patient care, and the administration of the co-op itself.

“Workers say they feel more respected,” Gusoff said.

Through an initiative to provide financing, business coaching, and technical assistance, the ICA Group intends to boost the national total to 50 co-ops within five years and to 100 by 2040.

Another approach gaining ground: registries that allow home care workers and clients who need care to connect directly, often without involving agencies that provide supervision and background checks but also absorb roughly half the fee consumers pay.

One of the largest registries, Carina, serves workers and clients in Oregon and Washington. Established through agreements with the Service Employees International Union, the nation’s largest health care union, it serves 40,000 providers and 25,000 clients. (About 10% of home care workers are unionized, according to PHI’s analysis.)

Carina functions as a free, “digital hiring hall,” said Nidhi Mirani, its chief executive. Except in the Seattle area, it serves only clients who receive care through Medicaid, the largest funder of care at home. State agencies handle the paperwork and oversee background checks.

Hourly rates paid to independent providers found on Carina, which are set by union contracts, are usually lower than what agencies charge, while workers’ wages start at $20, and they receive health insurance, paid time off, and, in some cases, retirement benefits.

Other registries may be operated by states, as in Massachusetts and Wisconsin, or by platforms like Direct Care Careers, available in four states. “People are seeking a fit in who’s coming into their homes,” Mirani said. “And individual providers can choose their clients. It’s a two-way street.”

Finally, recent studies indicate ways that additional training for home care workers can pay off.

“These patients have complex conditions,” Sterling said of the aides. Home care workers, who take blood pressure readings, prepare meals, and help clients stay mobile, can spot troubling symptoms as they emerge.

Her team’s recent clinical trial of home health aides caring for patients with heart failure — “the No. 1 cause of hospitalization among Medicare beneficiaries,” Sterling pointed out — measured the effects of a 90-minute virtual training module about its symptoms and management.

“Leg swelling. Shortness of breath. They’re the first signs that the disease is not being controlled,” Sterling said.

In the study, involving 102 aides working for VNS Health, a large nonprofit agency in New York, the training was shown to enhance their knowledge and confidence in caring for clients with heart failure.

Moreover, when aides were given a mobile health app that allowed them to message their supervisors, they made fewer 911 calls and their patients made fewer emergency room visits.

Small-scale efforts like registries, co-ops, and training programs do not directly address home care’s most central problem: cost.

Medicaid underwrites home care for low-income older adults who have few assets, though the Trump administration’s new budget will slash Medicaid by more than $900 billion over the next decade. The well-off theoretically can pay out-of-pocket.

But “middle-class retired families either spend all their resources and essentially bankrupt themselves to become eligible for Medicaid, or they go without,” Landers said. Options like assisted living and nursing homes are even more expensive.

The United States has never committed to paying for long-term care for the middle class, and it seems unlikely to do so under this administration. Still, savings from innovations like these can reduce costs and might help expand home care through federal or state programs. Several tests and pilots are underway.

Home care workers “have a lot of insight into patients’ conditions,” Sterling said. “Training them and giving them technological tools shows that if we’re trying to keep patients at home, here’s a way to do that with the workforce that’s already there.”

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But 5 pounds would come off and then invariably reappear, said Bucklew, 75, a public transit retiree in Ocean View, Delaware. Nothing seemed to make much difference — until 2023, when her body mass index slightly exceeded 40, the threshold for severe obesity.

“There’s this new drug I’d like you to try, if your insurance will pay for it,” the nurse practitioner advised. She was talking about Ozempic.

Medicare covered it for treating Type 2 diabetes but not for weight loss, and it cost more than $1,000 a month out-of-pocket. But to Bucklew’s surprise, her Medicare Advantage plan covered it even though she wasn’t diabetic, charging just a $25 monthly copay.

Pizza, pasta, and red wine suddenly became unappealing. The drug “changed what I wanted to eat,” she said. As 25 pounds slid away over six months, she felt less tired and found herself walking and biking more.

Then her Medicare plan notified her that it would no longer cover the drug. Calls and letters from her health care team, arguing that Ozempic was necessary for her health, had no effect.

With coverage denied, Bucklew became part of an unsettlingly large group: older adults who begin taking GLP-1s and related drugs — highly effective for diabetes, obesity, and several other serious health problems — and then stop taking them within months.

That usually means regaining weight and losing the associated health benefits, including lower blood pressure, cholesterol, and A1c, a measure of blood sugar levels over time.

Widely portrayed as wonder drugs, semaglutide (Ozempic, Wegovy, Rybelsus), tirzepatide (Zepbound, Mounjaro), and related medications have transformed the treatment of diabetes and obesity.

The FDA has approved several GLP-1s for additional uses, too — including to treat kidney disease and sleep apnea, and prevent heart attacks and strokes.

“They’re being studied for every purpose you can conceive of,” said Timothy Anderson, a health services researcher at the University of Pittsburgh and author of a recent JAMA Internal Medicine editorial about anti-obesity medications.

(Drug trials have found no impact on dementia, however.)

People 65 and older represent prime targets for such medications. “The prevalence of obesity hovers around 40%” in older adults, as measured by body mass index, said John Batsis, a geriatrician and obesity specialist at the University of North Carolina School of Medicine.

The proportion of people with Type 2 diabetes rises with age, too, to nearly 30% at age 65 and older. Yet a recent JAMA Cardiology study found that among Americans 65 and up with diabetes, about 60% discontinued semaglutide within a year.

Another study of 125,474 people with obesity or who are overweight found that almost 47% of those with Type 2 diabetes and nearly 65% of those without diabetes stopped taking GLP-1s within a year — a high rate, said Ezekiel Emanuel, a health services researcher at the University of Pennsylvania and senior author of the study.

Patients 65 and older were 20% to 30% more likely than younger ones to discontinue the drugs and less likely to return to them.

What explains this pattern? As many as 20% of patients may experience gastrointestinal problems. “Nausea, sometimes vomiting, bloating, diarrhea,” Anderson said, ticking off the most common side effects.

Linda Burghardt, a researcher in Great Neck, New York, started taking Wegovy because her doctor thought it might reduce arthritis pain in her knees and hips. “It was an experiment,” said Burghardt, 79, who couldn’t walk far and had stopped playing pickleball.

Within a month, she suffered several bouts of stomach upset that “went on for hours,” she said. “I was crying on the bathroom floor.” She stopped the drug.

Some patients find that medication-induced weight loss lessens rather than improves fitness, because another side effect is muscle loss. Several trials have reported that 35% to 45% of GLP-1 weight loss is not fat, but “lean mass” including muscle and bone.

Bill Colbert’s cherished hobby for 50 years, reenacting medieval combat, involves “putting on 90 pounds of steel-plate armor and fighting with broadswords.” A retired computer systems analyst in Churchill, Pennsylvania, he started on Mounjaro, successfully lowered his blood glucose, and lost 18 pounds in two months.

But “you could almost see the muscles melting away,” he recalled. Feeling too weak to fight well at age 78, he also discontinued the drug and now relies on other diabetes medications.

“During the aging process, we begin to lose muscle,” typically half a percent to 1% of muscle weight per year, said Zhenqi Liu, an endocrinologist at the University of Virginia who studies the effects of weight loss drugs. “For people on these medications, the process is much more accelerated.”

Losing muscle can lead to frailty, falls, and fractures, so doctors advise GLP-1 users to exercise, including strength training, and to eat enough protein.

The high rate of GLP-1 discontinuation may also reflect shortages; from 2022 to 2024, these drugs temporarily became hard to find. Further, patients may not grasp that they will most likely need the medications indefinitely, even after they meet their blood glucose or weight goals.

Re-initiating treatment involves its own hazards, Batsis cautioned. “If weight goes up and down, up and down, metabolically it sets people up for functional decline down the road.”

Of course, in considering why patients discontinue, “a large part of it is money,” Emanuel said. “Expensive drugs, not necessarily covered” by insurers. Indeed, in a Cleveland Clinic study of patients who discontinued semaglutide or tirzepatide, nearly half cited cost or insurance issues as the reason.

Some moderation in price has already occurred. The Biden administration capped out-of-pocket payments for all prescriptions that a Medicare beneficiary receives ($2,100 is the 2026 limit), and authorized annual price negotiations with manufacturers.

The reductions include Ozempic, Wegovy, and Rybelsus, though not until 2027. Medicare Part D drug plans will then pay $274, and since most beneficiaries pay 25% in coinsurance, their out-of-pocket monthly cost will sink to $68.50.

Perhaps even lower, if agreements announced in November between the Trump administration and drugmakers Eli Lilly and Novo Nordisk pan out.

The bigger question is whether Medicare will amend its original 2003 regulations, which prohibit Part D coverage for weight loss drugs. “An archaic policy,” said Stacie Dusetzina, a health policy researcher at the Vanderbilt University School of Medicine.

The Trump administration’s November announcement would expand Medicare eligibility for GLP-1s and related medications to include obesity, perhaps as early as spring. But key details remain unclear, Dusetzina said.

Medicare should cover anti-obesity drugs, many doctors argue. Americans still tend to think that “diabetes is a disease and obesity is a personal problem,” Emanuel said. “Wrong. Obesity is a disease, and it reduces life span and compromises health.”

But given the expense to insurers, Dusetzina warned, “if you expand the indications and extent of coverage, you’ll see premiums go up.”

For older patients, often underrepresented in clinical trials, questions about GLP-1s remain. Might a lower maintenance dose stabilize their weight? Can doses be spaced out? Could nutritional counseling and physical therapy offset muscle loss?

Bucklew, whose coverage was denied, would still like to resume Ozempic. But because of a recent sleep apnea diagnosis, she now qualifies for Zepbound with a $50 monthly copay.

She has seen no weight loss after three months. But as the dose increases, she said, “I’ll stay the course and give it a shot.”

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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.

The survey looked at nearly 3,000 Americans aged 50 and older and found that only a minority — fewer than 18% 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%.

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 1 in 5 — 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, 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.”

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%.

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, 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, California.

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.

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, California, 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.”

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Both patients, a man and a woman, had agreed to donate their brains after they died for further research. “An amazing gift,” said Edward Lee, the neuropathologist who directs the brain bank at the university’s Perelman School of Medicine. “They were both very dedicated to helping us understand Alzheimer’s disease.”

The man, who died at 83 with dementia, had lived in the Center City neighborhood of Philadelphia with hired caregivers. The autopsy showed large amounts of amyloid plaques and tau tangles, the proteins associated with Alzheimer’s disease, spreading through his brain.

Researchers also found infarcts, small spots of damaged tissue, indicating that he had suffered several strokes.

By contrast, the woman, who was 84 when she died of brain cancer, “had barely any Alzheimer’s pathology,” Lee said. “We had tested her year after year, and she had no cognitive issues at all.”

The man had lived a few blocks from Interstate 676, which slices through downtown Philadelphia. The woman had lived a few miles away in the suburb of Gladwyne, Pennsylvania, surrounded by woods and a country club.

The amount of air pollution she was exposed to — specifically, the level of fine particulate matter called PM2.5 — was less than half that of his exposure. Was it a coincidence that he had developed severe Alzheimer’s while she had remained cognitively normal?

With increasing evidence that chronic exposure to PM2.5, a neurotoxin, not only damages lungs and hearts but is also associated with dementia, probably not.

“The quality of the air you live in affects your cognition,” said Lee, the senior author of a recent article in JAMA Neurology, one of several large studies in the past few months to demonstrate an association between PM2.5 and dementia.

Scientists have been tracking the connection for at least a decade. In 2020, the influential Lancet Commission added air pollution to its list of modifiable risk factors for dementia, along with common problems like hearing loss, diabetes, smoking, and high blood pressure.

Yet such findings are emerging when the federal government is dismantling efforts by previous administrations to continue reducing air pollution by shifting from fossil fuels to renewable energy sources.

“‘Drill, baby, drill’ is totally the wrong approach,” said John Balmes, a spokesperson for the American Lung Association who researches the effects of air pollution on health at the University of California-San Francisco.

“All these actions are going to decrease air quality and lead to increasing mortality and illness, dementia being one of those outcomes,” Balmes said, referring to recent environmental moves by the White House.

Many factors contribute to dementia, of course. But the role of particulates — microscopic solids or droplets in the air — is drawing closer scrutiny.

Particulates arise from many sources: emissions from power plants and home heating, factory fumes, motor vehicle exhaust, and, increasingly, wildfire smoke.

Of the several particulate sizes, PM2.5 “seems to be the most damaging to human health,” Lee said, because it is among the smallest. Easily inhaled, the particles enter the bloodstream and circulate through the body; they can also travel directly from the nose to the brain.

The research at the University of Pennsylvania, the largest autopsy study to date of people with dementia, included more than 600 brains donated over two decades.

Previous research on pollution and dementia mostly relied on epidemiological studies to establish an association. Now, “we’re linking what we actually see in the brain with exposure to pollutants,” Lee said, adding, “We’re able to do a deeper dive.”

The study participants had undergone years of cognitive testing at Penn Memory. With an environmental database, the researchers were able to calculate their PM2.5 exposure based on their home addresses.

The scientists also devised a matrix to measure how severely Alzheimer’s and other dementias had damaged donors’ brains.

Lee’s team concluded that “the higher the exposure to PM2.5, the greater the extent of Alzheimer’s disease,” he said. The odds of more severe Alzheimer’s pathology at autopsy were almost 20% greater among donors who had lived where PM2.5 levels were high.

Another research team recently reported a connection between PM2.5 exposure and Lewy body dementia, which includes dementia related to Parkinson’s disease. Generally considered the second most common type after Alzheimer’s, Lewy body accounts for an estimated 5% to 15% of dementia cases.

In what the researchers believe is the largest epidemiological study to date of pollution and dementia, they analyzed records from more than 56 million beneficiaries with traditional Medicare from 2000 to 2014, comparing their initial hospitalizations for neurodegenerative diseases with their exposure to PM2.5 by ZIP codes.

“Chronic PM2.5 exposure was linked to hospitalization for Lewy body dementia,” said Xiao Wu, an author of the study and a biostatistician at the Mailman School of Public Health at Columbia University.

After controlling for socioeconomic and other differences, the researchers found that the rate of Lewy body hospitalizations was 12% higher in U.S. counties with the worst concentrations of PM2.5 than in those with the lowest.

To help verify their findings, the researchers nasally administered PM2.5 to laboratory mice, which after 10 months showed “clear dementia-like deficits,” senior author Xiaobo Mao, a neuroscientist at the Johns Hopkins School of Medicine, wrote in an email.

The mice got lost in mazes that they had previously dashed through. They had earlier built nests quickly and compactly; now their efforts were sloppy, disorganized. At autopsy, Mao said, their brains had atrophied and contained accumulations of the protein associated with Lewy bodies in human brains, called alpha-synuclein.

A third analysis, published this summer in The Lancet, included 32 studies conducted in Europe, North America, Asia, and Australia. It also found “a dementia diagnosis to be significantly associated with long-term exposure to PM2.5” and to certain other pollutants.

Whether so-called ambient air pollution — the outdoor kind — increases dementia because of inflammation or other physiological causes awaits the next round of research.

Although air pollution has declined in the United States over two decades, scientists are calling for still stronger policies to promote cleaner air. “People argue that air quality is expensive,” Lee said. “So is dementia care.”

President Donald Trump, however, reentered office vowing to increase the extraction and use of fossil fuels and to block the transition to renewable energy. His administration has rescinded tax incentives for solar installations and electric vehicles, Balmes noted, adding, “They’re encouraging continuing to burn coal for power generation.”

The administration has halted new offshore wind farms, announced oil and gas drilling in the Arctic National Wildlife Refuge in Alaska, and moved to stop California’s plan to transition to electric cars by 2035. (The state has challenged that action in court.)

“If policy goes in the opposite direction, with more air pollution, that’s a big health risk for older adults,” Wu said.

Last year, under the Biden administration, the Environmental Protection Agency set tougher annual standards for PM2.5, noting that “the available scientific evidence and technical information indicate that the current standards may not be adequate to protect public health and welfare, as required by the Clean Air Act.”

In March, the EPA’s new chairman announced that the agency would be “revisiting” those stricter standards.

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“I was avoiding going out in groups. I stopped playing cards, stopped going to Bible study, even going to church.”

Her audiologist was unable to offer Grutzmacher, a retired nurse in Elgin, Illinois, a solution. But she found her way to the cochlear implant program at Northwestern University.

There, Krystine Mullins, an audiologist who assesses patients’ hearing and counsels them about their options, explained that surgically implanting this electronic device usually substantially improved a patient’s ability to understand speech.

“I had never even thought about it,” Grutzmacher said.

That she was 84 was, in itself, immaterial. “As long as you’re healthy enough to undergo surgery, age is not a concern,” Mullins said. One recent Northwestern implant patient had been 99.

Some patients need to ponder this decision, given that after the operation, clearer hearing still requires months of practice and adaptation, and the degree of improvement is hard to predict. “You can’t try it out in advance,” Mullins said.

But Grutzmacher didn’t hesitate. “I couldn’t go on the way I was,” she said in a postimplant phone interview — one that involved frustrating repetition, but would have been impossible a few weeks earlier. “I was completely isolated.”

Hearing loss among older adults remains vastly undertreated. Federal epidemiologists have estimated that it affects about 1 in 5 people ages 65 to 74 and more than half of those over 75.

“The inner ear mechanisms weren’t built for longevity,” said Cameron Wick, an ear, nose, and throat specialist at University Hospitals in Cleveland.

Although hearing loss can contribute to depression, social disconnection, and cognitive decline, fewer than a third of people over 70 who could benefit from hearing aids have worn them.

For those who do, “if your hearing aids no longer give you clarity, you should ask for a cochlear implant assessment,” Wick said.

Twenty-five years ago, “it was a novelty to implant people over 80,” said Charles Della Santina, director of the Johns Hopkins Cochlear Implant Center. “Now, it’s pretty routine practice.”

In fact, a study published in 2023 in the journal Otology & Neurotology reported that cochlear implantation was increasing at a higher rate in patients over 80 than in any other age group.

Until recently, Medicare covered the procedure for only those with extremely limited hearing who could correctly repeat less than 40% of the words on a word recognition test. Without insurance — cochlear implantation can cost $100,000 or more for the device, surgery, counseling, and follow-up — many older people don’t have the option.

“It was incredibly frustrating, because patients on Medicare were being excluded,” Della Santina said. (Similarly, traditional Medicare doesn’t cover hearing aids, and Medicare Advantage plans with hearing benefits still leave patients paying most of the tab.)

Then, in 2022, Medicare expanded cochlear implant coverage to include older adults who could identify up to 60% of words on a speech recognition test, increasing the pool of eligible patients.

Still, while the American Cochlear Implant Alliance estimates that implants are increasing by about 10% annually, public awareness and referrals from audiologists remain low. Less than 10% of eligible adults with “moderate to profound” hearing loss receive them, the alliance says.

Cochlear implantation requires commitment. After the patient receives testing and counseling, the surgery, which is an outpatient procedure, typically takes two to three hours. Many adults undergo surgery on one ear and continue using a hearing aid in the other; some later go on to get a second implant.

The surgeon implants an internal receiver beneath the patient’s scalp and inserts electrodes, which stimulate the auditory nerve, into the inner ear; patients also wear an external processor behind the ear. (Clinical trials of an entirely internal device are underway.)

Two or three weeks later, after the swelling recedes and the patient’s stitches have been removed, an audiologist activates the device.

“When we first turn it on, you won’t like what you hear,” Wick cautioned. Voices initially sound robotic, mechanical. It takes several weeks for the brain to adjust and for patients to reliably decipher words and sentences.

“A cochlear implant is not something you just turn on and it works,” Mullins said. “It takes time and some training to get used to the new sound quality.” She assigns homework, like reading aloud for 20 minutes a day and watching television while reading the captions.

Within one to three months, “boom, the brain starts getting it, and speech clarity takes off,” Wick said. By six months, older adults will have reached most of their enhanced clarity, though some improvement continues for a year or longer.

How much improvement? That’s measured by two hearing tests: The CNC (consonant-nucleus-consonant) test, in which patients are asked to repeat individual words, and the AzBio Sentence Test, in which the words to be repeated are part of full sentences.

At Northwestern, Mullins tells older prospective patients that one year after activation, a 60% to 70% AzBio score — correctly repeating 60 to 70 words out of 100 — is typical.

A Johns Hopkins study of about 1,100 adults, published in 2023, found that after implantation, patients 65 and older could correctly identify about 50 additional words (out of 100) on the AzBio test, an increase comparable to the younger cohort’s results.

Participants over 80 showed roughly as much improvement as those in their late 60s and 70s.

“They transition from having a hard time following a conversation to being able to participate,” said Della Santina, an author of the study. “Decade by decade, cochlear implant results have gotten better and better.”

Moreover, an analysis of 70 older patients’ experiences at 13 implantation centers, for which Wick was the lead author, found not only “clinically important” hearing improvements but also higher quality-of-life ratings.

Scores on a standard cognitive test climbed, too: After six months of using a cochlear implant, 54% of participants had a passing score, compared with 36% presurgery. Studies that focus on people in their 80s and 90s have shown that those with mild cognitive impairment also benefit from implants.

Nevertheless, “we’re cautious not to overpromise,” Wick said. Usually, the longer that older patients have had significant hearing loss, the harder they must work to regain their hearing and the less improvement they may see.

A minority of patients feel dizzy or nauseated after surgery, though most recover quickly. Some struggle with the technology, including phone apps that adjust the sound. Implants are less effective in noisy settings like crowded restaurants, and since they are designed to clarify speech, music may not sound great.

For those at the upper end of Medicare eligibility who already understand roughly half of the speech they hear, implantation may not seem worth the effort. “Just because someone is eligible doesn’t mean it’s in their best interests,” Wick said.

For Grutzmacher, though, the choice seemed clear. Her initial testing found that even with hearing aids, she understood only 4% of words on the AzBio. Two weeks after Mullins turned on the cochlear implant, Grutzmacher could understand 46% using a hearing aid in her other ear.

She reported that after a few rough days, her ability to talk by phone had improved, and instead of turning the television volume up to 80, “I can hear it at 20,” she said.

So she was making plans. “This week, I’m going out to lunch with a friend,” she said. “I’m going to play cards with a small group of women. I have a luncheon at church on Saturday.”

The New Old Age is produced through a partnership with The New York Times.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Green burials are gaining popularity as an affordable, eco-friendly alternative to traditional funerals. They avoid toxic embalming chemicals, steel caskets, and concrete vaults, letting a body naturally decompose. Methods range from the elaborate — like “human composting” and water cremation — to a simple pine box.

“The New Old Age” columnist Paula Span appeared on WAMU’s Oct. 8 “Health Hub” to talk about the environmental and economic motivations behind these alternatives to conventional burials.

Jackson Sinnenberg contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).