Tag: Aging

Britain’s Hard Lessons From Handing Elder Care Over to Private Equity

LONDON — A little over a decade ago, Four Seasons Health Care was among the largest long-term care home companies in Britain, operating 500 sites with 20,000 residents and more than 60 specialist centers. Domestic and global private equity investors had supercharged the company’s growth, betting that the rising needs of aging Britons would yield big returns.

Within weeks, the Four Seasons brand may be finished.

Christie & Co., a commercial real estate broker, splashed a summer sale across its website that signaled the demise: The last 111 Four Seasons facilities in England, Scotland, and Jersey were on the market. Already sold were its 29 homes in Northern Ireland.

Four Seasons collapsed after years of private equity investors rolling in one after another to buy its business, sell its real estate, and at times wrest multimillion-dollar profits through complex debt schemes — until the last big equity fund, Terra Firma, which in 2012 paid about $1.3 billion for the company, was caught short.

In a country where government health care is a right, the Four Seasons story exemplifies the high-stakes rise — and, ultimately, fall — of private equity investment in health and social services. Hanging over society’s most vulnerable patients, these heavily leveraged deals failed to account for the cost of their care. Private equity firms are known for making a profit on quick-turnaround investments.

“People often say, ‘Why have American investors, as well as professional investors here and in other countries, poured so much into this sector?’ I think they were dazzled by the potential of the demographics,” said Nick Hood, an analyst at Opus Restructuring & Insolvency in London, which advises care homes — the British equivalent of U.S. nursing homes or assisted living facilities. They “saw the baby boomers aging and thought there would be infinite demands.”

What they missed, Hood said, “was that about half of all the residents in U.K. homes are funded by the government in one way or another. They aren’t private-pay — and they’ve got no money.”

Residents as ‘Revenue Streams’

As in the United States, long-term care homes in Britain serve a mixed market of public- and private-pay residents, and those whose balance sheets rest heavily on government payments are stressed even in better economic times. Andrew Dobbie, a community officer for Unison, a union that represents care home workers, said private equity investors often see homes like Four Seasons as having “two revenue streams, the properties themselves and the residents,” with efficiencies to exploit.

But investors don’t always understand what caregivers do, he said, or that older residents require more time than spreadsheets have calculated. “That’s a problem when you are looking at operating care homes,” Dobbie said. “Care workers need to have soft skills to work with a vulnerable group of people. It’s not the same skills as stocking shelves in a supermarket.”

A recent study, funded in part by Unison and conducted by University of Surrey researchers, found big changes in the quality of care after private equity investments. More than a dozen staff members, who weren’t identified by name or facility, said companies were “cutting corners” to curb costs because their priority was profit. Staffers said “these changes meant residents sometimes went without the appropriate care, timely medication or sufficient sanitary supplies.”

In August, the House of Commons received a sobering account: The number of adults 65 and older who will need care is speedily rising, estimated to go from 3.5 million in 2018 to 5.2 million in 2038. Yet workers at care homes are among the lowest paid in health care.

“The covid-19 pandemic shone a light on the adult social care sector,” according to the parliamentary report, which noted that “many frustrated and burnt out care workers left” for better-paying jobs. The report’s advice in a year of soaring inflation and energy costs? The government should add “at least £7 billion a year” — more than $8 billion — or risk deterioration of care.

Britain’s care homes are separate from the much-lauded National Health Service, funded by the government. Care homes rely on support from local authorities, akin to counties in the United States. But they have seen a sharp drop in funding from the British government, which cut a third of its payments in the past decade. When the pandemic hit, the differences were apparent: Care home workers were not afforded masks, gloves, or gowns to shield them from the deadly virus.

Years ago, care homes were largely run by families or local entities. In the 1990s, the government promoted privatization, triggering investments and consolidations. Today, private equity firms own three of the country’s five biggest care home providers.

Chris Thomas, a research fellow at the Institute for Public Policy Research, said investors benefited from scant financial oversight. “The accounting practices are horrendously complicated and meant to be complicated,” he said. Local authorities try “to regulate more, but they don’t have the expertise.”

The Financial Shuffle

At Four Seasons, the speed of change was dizzying. From 2004 to 2017, big money came and went, with revenue at times threaded through multiple offshore vehicles. Among the groups that owned Four Seasons, in part or in its entirety: British private equity firm Alchemy Partners; Allianz Capital Partners, a German private equity firm; Three Delta LLP, an investment fund backed by Qatar; the American hedge fund Monarch Alternative Capital; and Terra Firma, the British private equity group that wallowed in debt demands. H/2 Capital Partners, a hedge fund in Connecticut, was Four Seasons’ main creditor and took over. By 2019, Four Seasons was managed by insolvency experts.

Pressed on whether Four Seasons would exist in any form after the current sale of its property and businesses, MHP Communications, representing the company, said in an email: “It is too early in the process to speculate about the future of the brand.”

Vivek Kotecha, an accountant who has examined the Four Seasons financial shuffle and co-authored the Unison report, said private equity investment — in homes for older residents and, increasingly, in facilities for troubled children — is now part of the financial mainstream. The consulting firm McKinsey this year estimated that private markets manage nearly $10 trillion in assets, making them a dominant force in global markets.

“What you find in America with private equity is much the same here,” said Kotecha, the founder of Trinava Consulting in London. “They are often the same firms, doing the same things.” What was remarkable about Four Seasons was the enormous liability from high-yield bonds that underpinned the deal — one equaling $514 million at 8.75% interest and another for $277 million at 12.75% interest.

Guy Hands, the high-flying British founder of Terra Firma, bought Four Seasons in 2012, soon after losing an epic court battle with Citigroup over the purchase price of the music company EMI Group. Terra Firma acquired the care homes and then a gardening business with more than 100 stores. Neither proved easy, or good, bets. Hands, a Londoner who moved offshore to Guernsey, declined through a representative to discuss Four Seasons.

Kotecha, however, helped the BBC try to make sense of Four Seasons’ holdings by tracking financial filings. It was “the most complicated spreadsheet I’ve ever seen,” Kotecha said. “I think there were more subsidiaries involved in Four Seasons’ care homes than there were with General Motors in Europe.”

As Britain’s small homes were swept up in consolidations, some financial practices were dubious. At times, businesses sold the buildings as lease-back deals — not a problem at first — that, after multiple purchases, left operators paying rent with heavy interest that sapped operating budgets. By 2020, some care homes were estimated to be spending as much as 16% of their bed fees on debt payments, according to parliamentary testimony this year.

How could that happen? In part, for-profit providers — backed by private equity groups and other corporations — had subsidiaries of their parent companies act as lender, setting the rates.

Britain’s elder care was unrecognizable within a generation. By 2022, private equity companies alone accounted for 55,000 beds, or about 12.6% of the total for-profit care beds for older people in the United Kingdom, according to LaingBuisson, a health care consultancy. LaingBuisson calculated that the average residential care home fee as of February 2022 was about $44,700 a year; the average nursing home fee was $62,275 a year.

From 1980 to 2018, the number of residential care beds provided by local authorities fell 88% — from 141,719 to 17,100, according to the nonprofit Centre for Health and the Public Interest. Independent operators — nonprofits and for-profits — moved in, it said, controlling 243,000 beds by 2018. Nursing homes saw a similar shift: Private providers accounted for 194,100 beds in 2018, compared with 25,500 decades earlier.

Beyond Government Control

British lawmakers last winter tried — and failed — to bolster financial reporting rules for care homes, including banning the use of government funds to pay off debt.

“I don’t have a problem with offshore companies that make profits if they offer good services. I don’t have a problem with private equity and hedge funds who deliver good returns to their shareholders,” Ros Altmann, a Conservative Party member in the House of Lords and a pension expert, said in a February debate. “I do have a problem if those companies are taking advantage of some of the most vulnerable people in our society without oversight, without controls.”

She cited Four Seasons as an example of how regulators “have no control over the financial models that are used.” Altmann warned that economic headwinds could worsen matters: “We now have very heavily debt-laden [homes] in an environment where interest rates are heading upward.”

In August, the Bank of England raised borrowing rates. It now forecasts double-digit inflation — as much as 11% — through 2023.

And that leaves care home owner Robert Kilgour pensive about whether government grasps the risks and possibilities that the sector is facing. “It’s a struggle, and it’s becoming more of a struggle,” he said. A global energy crisis is the latest unexpected emergency. Kilgour said he recently signed electricity contracts, for April 2023, at rates that will rise by 200%. That means an extra $2,400 a day in utility costs for his homes.

Kilgour founded Four Seasons, opening its first home, in Fife, Scotland, in 1989. His ambition for its growth was modest: “Ten by 2000.” That changed in 1999 when Alchemy swooped in to expand nationally. Kilgour had left Four Seasons by 2004, turning to other ventures.

Still, he saw opportunity in elder care and opened Renaissance Care, which now operates 16 homes with 750 beds in Scotland. “I missed it,” he said in an interview in London. “It’s people and it’s property, and I like that.”

“People asked me if I had any regrets about selling to private equity. Well, no, the people I dealt with were very fair, very straight. There were no shenanigans,” Kilgour said, noting that Alchemy made money but invested as well.

Kilgour said the pandemic motivated him to improve his business. He is spending millions on new LED lighting and boilers, as well as training staffers on digital record-keeping, all to winnow costs. He increased hourly wages by 5%, but employees have suggested other ways to retain staff: shorter shifts and workdays that fit school schedules or allow them to care for their own older relatives.

Debates over whether the government should move back into elder care make little sense to Kilgour. Britain has had private care for decades, and he doesn’t see that changing. Instead, operators need help balancing private and publicly funded beds “so you have a blended rate for care and some certainty in the business.”

Consolidations are slowing, he said, which might be part of a long-overdue reckoning. “The idea of 200, 300, 400 care homes — that big is good and big is best — those days are gone,” Kilgour said.

Death Is Anything but a Dying Business as Private Equity Cashes In

Private equity firms are investing in health care from cradle to grave, and in that latter category quite literally. A small but growing percentage of the funeral home industry — and the broader death care market — is being gobbled up by private equity-backed firms attracted by high profit margins, predictable income, and the eventual deaths of tens of millions of baby boomers.

The funeral home industry is in many ways a prime target for private equity, which looks for markets that are highly fragmented and could benefit from consolidation. By cobbling together chains of funeral homes, these firms can leverage economies of scale in purchasing, improve marketing strategies, and share administrative functions.

According to industry officials, about 19,000 funeral homes make up the $23 billion industry in the U.S., at least 80% of which remain privately owned and operated — mostly mom and pop businesses, with a few regional chains thrown in. The remaining 20%, or about 3,800 homes, are owned by funeral home chains, and private equity-backed firms own about 1,000 of those.

Consumer advocates worry that private equity firms will follow the lead of publicly traded companies that have built large chains of funeral homes and raised prices for consumers. “The real master that’s being served is not the grieving family who’s paying the bill — it’s the shareholder,” said Joshua Slocum, executive director of the Funeral Consumers Alliance, a nonprofit that seeks to educate consumers about funeral costs and services.

Although funeral price data is not readily available to the public, surveys by the local affiliates of the alliance have found that when publicly traded or private equity-backed chains acquire individual funeral homes, price hikes tend to follow.

In Tucson, Arizona, for example, when a local owner sold Angel Valley Funeral Home in 2019 to private equity-backed Foundation Partners Group, prices increased from $425 to $760 for a cremation, from $1,840 to $2,485 for a burial with no viewing or visitation, and from $3,405 to $4,480 for a full, economical funeral.

In the Arizona city of Mesa, the sale of Lakeshore Mortuary to the publicly traded funeral home chain Service Corporation International led to price increases for a cremation from $1,565 in 2018 to $1,770 in 2021, for a burial from $2,795 to $3,680, and for an economical funeral from $4,385 to $5,090.

“We believe our pricing is competitive and reasonable in the markets in which we operate,” a Service Corporation International official said in an email.

Details of those price increases were provided by Martha Lundgren, a member of the Funeral Consumers Alliance of Arizona’s board. She said funeral home acquisitions have led to the cancellation of pricing agreements negotiated on behalf of consumers who are members of the alliance. In 2020, a cremation at Adair Dodge Chapel in Tucson cost members $395, nearly two-thirds off the $1,100 standard price. But after Foundation Partners Group acquired the funeral home, the member pricing agreement was canceled, and the price of a direct cremation rose to $1,370.

Foundation Partners Group officials said the price increases partly reflect the higher price of supplies, such as caskets, as well as increasing labor costs. But most of the increases, they said, represent a move to a more transparent pricing system that includes administrative and transportation fees that other funeral homes add on later.

“We don’t take advantage of people in there when they’re not thinking clearly,” said Kent Robertson, the company’s president and CEO. “That’s just not who we are.”

A big surge of consolidation happened in the U.S. funeral home industry in the late 1980s and early 1990s, and again around 2010, said Chris Cruger, a Phoenix-based consultant to the industry. And acquisitions have reached a feverish pace in the past two to three years. Many investors are banking on a significant uptick in demand for death care services in the coming years as 73 million baby boomers, the oldest of whom will be in their late 70s, continue to age.

“Sheer demographics are obviously in everybody’s favor here,” Cruger said. Funeral homes have attractive margins already, and combining them into chains to share administrative costs could boost profits even more.

Meanwhile, many funeral home owner-operators are reaching retirement age and have no one in the family willing to take over. A 2021 survey by the National Funeral Directors Association found that 27% of owners planned to sell their business or retire within five years.

The desire to sell, combined with the investment money pouring into the field, has driven prices for funeral homes to new heights. Before private equity turned its eye to funeral homes, they were selling for three to five times their annual revenue. “Now I’m hearing seven to nine,” said Barbara Kemmis, executive director of the Cremation Association of North America, a trade group for the cremation industry.

The value in funeral homes lies in more than their brick-and-mortar assets. Funeral home directors are often integral parts of their communities and have established significant goodwill with their neighbors. So when corporate chains acquire these homes, they rarely change the name and often keep the former owners around to smooth the transition.

Tony Kumming, president of the NewBridge Group in Tampa, Florida, helps broker funeral home sales. Many of his clients remain skeptical of the large firms and often will take less money to sell to someone they believe won’t stain their hard-earned reputations. Most former owners plan to live in the community and don’t want their friends and neighbors to be mistreated. “I’m not saying someone is going to take half of what another company is offering,” Kumming said. “But there’s two big pieces to a sale now: That’s money and the right fit.”

Five years ago, when Robert Olthof decided to sell his family’s funeral home in Elmira, New York, he contacted some of the large publicly traded funeral home chains. But as representatives from multiple companies visited him to make their offers, Olthof realized that none of the big chains had sent someone versed in the service side of the business. “They sent their accountants, and they sent their lawyers,” he recalled. “Everything was about the numbers, the numbers, the numbers. And I didn’t like that.”

Instead, Olthof sold to Greg Rollins, a former funeral director who had amassed a privately owned, 90-site chain of funeral homes throughout the Northeast. Rollins had offered less money than the big chains had, but he knew what it was like to be awoken at 2:30 a.m. and put on a suit to go help a grieving family. He knew what it was like to bury a child.

Robert Olthof stands next to a portrait of his father in this undated photo. Olthof sold his family’s funeral home in Elmira, New York, to a private owner after finding that the big chains interested in buying him out were more focused on the finances than the service side of the business. (Robert Olthof)

“I can’t put a dollar-amount value on how much it’s really worth selling to a person who is a funeral director themselves,” Olthof said. “Because moving forward, your name is still going to be on the front of that building.”

Victoria Haneman, a Creighton University School of Law professor who studies the funeral home industry, worries that new corporate ownership might be devastating for grieving families. “They are not behaving like normal, rational consumers,” she said. “They’re not bargain-shopping because death is viewed as an inappropriate time to bargain-shop.”

For most families, a funeral will be one of the largest expenses they ever incur. But they often enter the shopping process cognitively impaired by grief and unsure of what is customary or appropriate.

Only 1 in 5 consumers visit more than one funeral home to obtain a price list, according to a 2022 survey commissioned by the Consumer Federation of America. And online comparisons are virtually impossible — a study by the federation and the Funeral Consumers Alliance found that just 18% of the funeral homes they sampled listed their prices on their websites. As a result, families generally lean heavily on the expertise of a single funeral director, who has a motive to sell them the most expensive options. So consumers can be pushed into buying packages for open-casket funerals that include embalming and other services that drive up the cost and may be unnecessary.

“Is that sort of pickled, shellacked, cosmetized, preserved corpse where the future will be? I don’t know that the answer is ‘yes,’” Haneman said. “And I think there are investors who are betting that it’s not.”

Foundation Partners Group is a prime example. Backed by the private equity firm Access Holdings, the funeral home chain shifted five years ago to acquiring funeral homes with high cremation rates. Cremation rates nationally have been steadily climbing over the past two decades, with nearly 58% of families now choosing cremation over casket burials. Foundation Partners expects that rate to hit 70% by 2030.

The company has acquired more than 75 businesses in high-cremation states, including Arizona, California, Colorado, and Florida. Most of those funeral homes average a bit over 150 funerals per year.

Individual funeral homes “don’t have access to marketing budgets, they don’t have access to safety and health plans and benefits and these different things,” said Robertson, the Foundation Partners CEO. “And because we have the ability to drive marketing and do other things, we also take that 150-call firm to maybe 200 calls.”

Robertson said the funeral home industry is different from other sectors that private equity firms might consider investing in, describing it as a calling comparable to working in hospice care. Foundation Partners is fortunate their backers understand the service part of the industry, as well as the financials, he said. “Private equity firms aren’t necessarily known for having deep compassion for people. They’re more known for their financial returns,” he said. “To get both is really important.”

Foundation Partners owns Tulip Cremation, an online service that allows people to order a cremation with just a few clicks — and without having to set foot in a funeral home. Tulip currently operates in nine states where Foundation Partners has funeral homes. The company expects the service to eventually operate nationally.

Haneman said innovative approaches like Tulip’s are sorely needed in the funeral home industry, which has barely changed in 100 years. “It’s absurd to me that the average cost of a funeral is running $7,000 to $10,000,” she said. “People need less expensive options, and innovation is going to get us there.” Tulip charges less than $1,000 for a cremation; ashes are mailed back to the families.

Other online cremation services are Solace Cremation, Smart Cremation, and Lumen Cremation.

“Private equity investment has the potential to go one of two directions: It’s either going to entrench status quo and drive price, or the purpose of the investment is going to be disruption,” Haneman said. “And disruption promises the possibility of bringing more affordable processes to market.”

Genetic Tests Create Treatment Opportunities and Confusion for Breast Cancer Patients

The past decade has witnessed a rapid expansion of genetic tests, including new instruments to inform patients who have been diagnosed with breast cancer about the risk of recurrence and to guide their treatment.

But the clinical significance of many of the inherited mutations that can now be identified remains unclear, and experts are torn on when and how to deploy all the new tests available. Patients are sometimes left paying out-of-pocket for exams that are not yet the standard of care, and even the most up-to-date oncologists may be uncertain how to incorporate the flood of new information into what used to be standard treatment protocols.

A quarter-century ago, Myriad Genetics introduced the first breast cancer genetic test for BRCA mutations, two genes associated with a substantially elevated risk of getting breast cancer, opening the door to a new era in genetic testing. BRCA1 and BRCA2 mutations account for as many as half of all hereditary breast cancers, and people with a problematic mutation on one of those genes have a 45% to 72% chance of developing breast cancer during their lifetimes. They may also be at higher risk for ovarian and other cancers than people without harmful BRCA mutations.

But the clinical significance is murkier for many other genetic tests.

Testing for BRCA1 and BRCA2 genes used to cost thousands of dollars. Now, for a fraction of that, doctors can order multi-gene test panels from commercial labs that look for mutations in dozens of genes. Some direct-to-consumer companies offer screening panels for a few hundred dollars, though their reliability varies.

When Jen Carbary was diagnosed with breast cancer in 2017 at age 44, genetic testing identified a mutation in a gene called PALB2 that significantly increases the risk of developing breast cancer. Guidelines suggest that breast cancer patients with a PALB2 mutation, much like those with BRCA1 and BRCA2 mutations, consider having a mastectomy to reduce the chance of a breast cancer recurrence.

“I wish genetic testing was the standard of care,” said Carbary, who owed nothing for the test because her insurer covered the cost.

Carbary, who lives in Sterling Heights, Michigan, said the test results affirmed the decision she had already made to have a double mastectomy and provided important information for family members, including her 21-year-old daughter and 18-year-old son, who will likely be tested in their mid-20s or early 30s.

But some breast cancer experts are concerned that widespread testing may also identify genetic mutations whose impact is unclear, creating anxiety and leading to further testing and to treatment of questionable value that could raise costs for the health care system.

It can also confuse patients.

“It happens a lot, that patients find their way to us after getting confusing results elsewhere,” said Dr. Mark Robson, chief of the breast medicine service at Memorial Sloan Kettering Cancer Center in New York City. Robson said the cancer center has a clinical genetics service, staffed by doctors and genetic counselors, that helps people make decisions about how to manage genetic testing results.

For people diagnosed with breast cancer, many professional groups, including the influential National Comprehensive Cancer Network, or NCCN, recommend limiting testing to certain people, including those with high-risk factors, such as a family history of breast cancer; those who are 45 or younger when they’re diagnosed; and those with Ashkenazi Jewish ancestry.

But in 2019, the American Society of Breast Surgeons recommended a different approach: Offer genetic testing to all patients who are diagnosed with or have a personal history of breast cancer. The recommendation was controversial.

“The NCCN guidelines [cover] most of the women who needed testing, but we wanted to get them all,” said Dr. Eric Manahan, a general surgeon in Dalton, Georgia, and a member of the surgeons group’s board of directors.

Mutations on other genes that are associated with breast cancer are much less common than BRCA1 and BRCA2 mutations and generally don’t increase the risk of developing breast cancer as much. The cancer-causing impact of these genes may be less clear than that of the BRCA genes, which have been tested for since the mid-1990s.

And the appropriate response to the less common mutations — whether to consider a risk-reducing mastectomy or stepped-up screening — is often unclear.

“Things get sloppier and sloppier when you look at other genes,” said Dr. Steven Katz, a professor of medicine and health management and policy at the University of Michigan. “The risks tend to be lower for different cancers, and less certain and more variable. You might walk away wondering, ‘Why’d I have to know that?’”

After people are diagnosed with breast cancer, genetic testing can help inform their decisions about the types of surgery to pursue — for example, a high risk of recurrence or a new breast cancer might persuade some to opt for more extensive surgery, such as a double mastectomy. Testing can also provide important information to family members about their potential cancer risk.

(This type of “germline” genetic testing, as it’s called, looks at mutations in the genes that people inherit from their parents. It is different from genomic tumor tests that look at specific genes or proteins in the cancer cells and can help doctors understand the rate at which the cancer cells are dividing, for example, and the likelihood of a cancer recurrence.)

Increasingly, germline genetic testing can also help guide other treatment decisions. Some patients with metastatic breast cancer who have BRCA1 or BRCA2 mutations may be good candidates for PARP inhibitors, cancer drugs that target tumors with mutations in those genes.

But genetic testing that uncovers inherited mutations in many other genes yields less clearly actionable information, even though positive results may alarm people.

At Memorial Sloan Kettering, cancer specialists focus on “therapeutic actionability,” said Robson. Will testing help someone decide whether she should get a double mastectomy or provide other important guidance? “A policy of testing everyone will identify very few additional BRCA breast mutations but will cost a lot,” he said.

As a result, doctors are debating how best to deploy and incorporate new genetic knowledge. Insurers are trying to figure out which to pay for.

There is both underuse of tests that science says are relevant and overuse of tests that experts say provide information that can’t be interpreted with any scientific certainty.

The result may be confusion for patients newly diagnosed with breast cancer as they confront the expense of genetic tests and sometimes little guidance on the proper treatment.

Some doctors say the first step is to make sure that the small group of people who would clearly benefit are getting the genetic tests whose meaning is clearly understood. Only 15% of breast cancer patients who met select NCCN testing guidelines for inherited cancer received genetic testing, according to a 2017 study that examined data from a national household health survey between 2005 and 2015.

“I would argue that our focus needs to be on the people who are at high risk for breast cancer that aren’t even identified yet,” said Dr. Tuya Pal, associate director for cancer health disparities at Vanderbilt-Ingram Cancer Center and vice chair of the NCCN guidelines panel for genetic/familial high-risk assessment of breast, ovarian, and pancreatic cancers.

Patients may fall through the cracks because no one tells them they should be tested. In one analysis, 56% of high-risk breast cancer patients who didn’t get genetic testing said their doctors didn’t recommend it.

Even if doctors recommend genetic testing, they may lack the expertise to determine which tests people need and how to interpret the results. That’s the role of genetic counselors, but their ranks are stretched thin.

The consequences can be serious. In a study of 666 breast cancer patients who received genetic testing, half of those at average risk for inherited cancer got double mastectomies based on test results that found “variants of uncertain significance,” which aren’t clinically actionable. As many as half of surgeons reported managing such patients the same way as those with cancer-causing mutations.

“The bulk of our research would say that there is still room for improvement in terms of clinicians getting the understanding they need,” said Dr. Allison Kurian, director of the women’s clinical cancer genetics program at Stanford University and a co-author of the study.

Covid Still Kills, but the Demographics of Its Victims Are Shifting

As California settles into a third year of pandemic, covid-19 continues to pose a serious threat of death. But the number of people dying — and the demographics of those falling victim — has shifted notably from the first two years.

Given the collective immunity people have garnered through a combination of mass vaccination and protections built from earlier infections, Californians overall were far less likely to die from covid in 2022, when the omicron variant dominated, than during the first two years of the pandemic, when other variants were largely at play, amplifying a national trend.

Still, each week, the virus is killing hundreds of Californians, hitting hardest among the unvaccinated. The virus remained among the state’s leading causes of death in July, trailing heart disease, cancer, stroke, and Alzheimer’s disease but outpacing diabetes, accidental death, and a host of other debilitating diseases. In the first seven months of the year, about 13,500 California residents died of covid, according to preliminary death certificate data from the state Department of Public Health. By comparison, the virus killed about 31,400 people in 2020 and almost 44,000 in 2021.

From April 2020 through December 2021, covid killed an average of 3,600 people a month, making it the third-leading cause of death in the state cumulatively for that time period, behind heart disease and cancer. From December 2020 through February 2021, it briefly overtook heart disease as the leading cause of death, taking the lives of more than 38,300 Californians in just three months. During its most recent peak, in January 2022, covid took about 5,900 lives.

Covid fell out of the top 10 causes of death for a brief period in the spring only to reenter this summer as the omicron variant continued to mutate. In July, even with more than 70% of Californians fully vaccinated, covid was the fifth-leading cause of death, cutting short more than 1,000 lives, state data show.

Clearly vaccinations made a difference. Covid death rates fell in recent months as covid shots and prior infections afforded much of the population significant protection against severe illness, said Dr. Timothy Brewer, a professor of medicine and epidemiology at UCLA. Brewer said the omicron variant, while more transmissible than earlier strains, appears to be a milder version of the virus. Research into that question is ongoing, but preliminary data suggests omicron is less likely to cause serious disease and death, according to the Centers for Disease Control and Prevention, which also notes that the severity of symptoms can be affected by vaccination status, age, and other health conditions.

The decline in deaths was particularly striking among California’s Latino population.

In 2020 and 2021, Latino residents accounted for 47% of covid deaths in California — about 35,400 deaths — although they make up 40% of the state’s population. By comparison, Latinos accounted for 34% of covid deaths from January through July 2022, according to state data. That translates to about 4,600 deaths.

Conversely, the proportion of covid deaths involving white residents increased from 32% in the first two years of the pandemic to 44% in the first seven months of 2022. That equates to 24,400 deaths involving white residents in 2020-21 and about 6,000 deaths in the first seven months of 2022. White people make up about 35% of the state’s population.

Researchers point to several factors in the shift. During the first two years of the pandemic, large numbers of the workers deemed essential, who continued to report to job sites in person, were Latino, while white residents were more likely to be employed in occupations that allowed them to work from home, U.S. Census Bureau surveys show.

“They just got exposed more,” said Dr. George Rutherford, a professor of epidemiology and biostatistics at the University of California-San Francisco. “They’re doing essential jobs and had to leave the house and go to work.”

An imbalance in remote work remains, census data shows, but today the large majority of both Latino and white workers in California are reporting to work in person.

Seciah Aquino, deputy director of the Latino Coalition for a Healthy California, said efforts to make sure that testing, treatment, and vaccinations were available to underserved communities of color also had an impact. And because Latino communities were hit so hard during the pandemic, she said, many California Latinos are still wearing masks. “They are still making sure that they’re staying home if they’re sick,” she said. “They’re still abiding by those policies even if the greater narrative is changing.”

Age is also a key factor in the demographic shifts, Brewer said.

Californians age 75 and older made up 53% of covid deaths through July in 2022, up from 46% in 2020 and 2021. Only about 6% of the state’s residents are 75 and older. And white Californians 75 and older outnumber Latinos in that age group about 3 to 1.

In the initial vaccination rollout, California prioritized seniors, first responders, and other essential workers, and for several months in 2021 older residents were much more likely to be vaccinated than younger Californians.

“Now, the vaccination rates have caught up pretty much with everybody except for kids, people under 18,” Brewer said. “You’re seeing it go back to what we saw before, which is that age remains the most important risk factor for death.”

More than 86% of Californians age 65 and older have completed their primary covid shot series. But the protection afforded by vaccines wanes over time, and since many seniors got their shots early, enough time passed between their second shot and the omicron wave of early 2022 to leave them vulnerable. About one-third of Californians 65 and older had not received a booster by early 2022, when the omicron wave peaked, and about one-quarter still haven’t received a booster.

Geographic shifts in covid prevalence have occurred throughout the pandemic: Outbreaks hit one area while another is spared, and then another community serves as the epicenter a few months later.

Residents of the San Francisco-Oakland metro area accounted for 7.8% of the state’s deaths in 2022, through early September, up from 5.4% in 2020-21. The area is home to about 12% of the state’s residents. The Sacramento metro area has also accounted for a higher share of covid deaths this year: 6% in 2022 versus 4.5% in 2020-21.

At the same time, Los Angeles-Long Beach-Anaheim metro residents made up 42% of covid deaths in 2022, down slightly from 43% in 2020-21. The area is home to about 33% of the state’s residents. A similar dip happened in the nearby Riverside-San Bernardino metro area.

Again, age could be a factor in the geographic shifts. A higher proportion of residents in San Francisco and Sacramento are 75 and older than in Los Angeles and Riverside, census data show.

It’s unclear whether this shift will last. As the Los Angeles Times reported, covid deaths grew at a faster pace in July in L.A. County than they did in the Bay Area.

The data also shows that vaccination remains one of the strongest deterrents to death from covid. From January through July, unvaccinated Californians died at roughly five times the rate as vaccinated Californians. But the gap has narrowed. From April through December 2021, California’s unvaccinated residents died, on average, at around 10 times the rate of vaccinated Californians.

Brewer said the gap lessened because the omicron variant was more likely than earlier variants to “break through” and cause infection in vaccinated Californians. The omicron variant, while less deadly, also infected many more people than earlier variants.

This trend, too, may prove short-lived: The next generation of covid booster shots are rolling out across the state.

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Clearing Pollution Helps Clear the Fog of Aging — And May Cut the Risk of Dementia

During the past decade, a growing body of research has shown that air pollution harms older adults’ brains, contributing to cognitive decline and dementia. What hasn’t been clear is whether improving air quality would benefit brain health.

Two studies published this year by researchers at six universities and the National Institute on Aging provide the first evidence of such benefits in an older population.

One report, published in the Proceedings of the National Academy of Sciences, found that the risk of dementia declined significantly in women 74 and older following a decadelong reduction in two types of air pollution: nitrogen dioxide, a gaseous byproduct of emissions from motor vehicles, industrial sources, and natural events such as wildfires; and fine particulate matter, a mix of extremely small solids and liquids arising from similar sources.

A second report in PLOS Medicine, relying on the same sample of more than 2,200 older women, found that lower levels of these pollutants were associated with a slower rate of cognitive decline. In areas where air quality improvement was most notable, the rate of cognitive decline was delayed by up to 1.6 years, depending on the test.

Both studies are national in scope and account for other factors that could affect results, such as participants’ socioeconomic status, neighborhood characteristics, preexisting medical conditions, and lifestyle choices such as smoking.

What might explain their results? “We think that when air pollution levels are reduced, the brain is better able to recover” from previous environmental insults, said Xinhui Wang, an assistant professor of research neurology at the University of Southern California’s medical school. This hypothesis needs to be examined further in animal studies and through brain imaging, she suggested.

There are several theories about how air pollution affects the brain. Extremely tiny particles — a human hair is at least 30 times as large as the largest particle — may travel from the nasal cavities to the brain via the olfactory (smell) system, putting the brain’s immune system on high alert. Or, pollutants may lodge in the lungs, causing an inflammatory response that spreads and leads to the brain.

Also, pollutants can damage the cardiovascular system, which is essential to brain health. (Links between air pollution, stroke, and heart disease are well established.) Or tiny particles can cross the blood-brain barrier, wreaking direct damage. And oxidative stress may occur, releasing free radicals that damage cells and tissue.

Older adults are especially vulnerable to air pollution’s harmful effects because of reduced lung capacity and pollutants’ potential to exacerbate conditions such as respiratory illnesses and heart disease. Also, air pollution’s effects accumulate over time, and the longer people live the more risks they may encounter.

Yet recognition of the potential cognitive consequences of air pollution is relatively recent. Following several small studies, the first national study demonstrating a link between air pollution and cognition in a diverse sample of older men and women was published in 2014. It found that seniors living in areas with high levels of fine particulate matter were more likely to experience cognitive problems than people living in less polluted areas.

Another study, published a couple of years later, extended those findings by reporting that air pollution’s cognitive effects are magnified in older adults living in disadvantaged neighborhoods where pollution levels tend to be highest. The chronic stress that residents of these neighborhoods experience may “increase the rate at which neurons are damaged by toxic challenges,” the authors wrote.

Air pollution is only one of many factors that influence cognitive decline and dementia, researchers agree, and results of this kind establish associations, not causation.

Newer research suggests that older adults’ cognition is affected even when exposures are below standards set by the Environmental Protection Agency. “With older adults, there really is no level at which air pollution is safe,” said Jennifer Ailshire, an associate professor of gerontology and sociology at the University of Southern California.

“It’s important to keep on reducing the standards for these pollutants,” said Antonella Zanobetti, principal research scientist for environmental health at Harvard’s T.H. Chan School of Public Health. With colleagues, she has a National Institute on Aging grant to study how air pollution affects the risk of Alzheimer’s disease and related dementias among Medicare beneficiaries. In 2019, her work showed that higher levels of fine particulate matter are linked to more hospitalizations among older adults with dementia — a marker of disease progression.

Last year, in one of the largest U.S. studies to date, a different set of researchers examined the link between long-term exposure to fine particulate matter and nitrogen dioxide among 12 million Medicare beneficiaries with diagnoses of Alzheimer’s disease and other forms of dementia. Exposure to high levels of these pollutants appeared to accelerate cognitive decline that was already relatively advanced, leading to an increase in diagnoses, researchers concluded.

In addition to population-wide studies, nearly 20 scientific laboratories across the world are studying how air pollution contributes to dementia in animals. At USC, Caleb Finch, a professor who studies the neurobiology of aging, is co-principal investigator for a five-year, $11.5 million grant from the National Institute on Aging to study how air pollution in urban areas informs the risk of dementia and accelerated brain aging.

Among the questions that Finch said need to be addressed are: Which areas of the brain appear most vulnerable to air pollutants? When are people most at risk? How long does the damage last? Is recovery possible? And do lifestyle interventions such as diet and exercise help?

“The main point is we now realize that Alzheimer’s disease is very sensitive to environmental effects, including air pollution,” Finch said.

Recognizing this, the Lancet’s Commission on Dementia Prevention, Intervention, and Care in 2020 added air pollution to a list of modifiable risk factors for dementia and estimated that up to 40% of dementia cases worldwide might be prevented or delayed if these risk factors were addressed.

For her part, Ailshire is optimistic that public policies can make a difference. From 2000 to 2019, she noted, average annual fine particulate matter pollution decreased 43% nationally due to efforts to improve air quality. “I’m very hopeful that these efforts will continue,” she told me.

What can older adults concerned about air pollution do on their own?

On very hot days, go for a walk in the morning instead of the afternoon, when ozone levels are higher, said Dr. Anthony Gerber, a pulmonologist at National Jewish Health, a medical center in Denver specializing in respiratory diseases. Ozone, a toxic gas, is formed when various chemicals interact with sunlight and heat.

If you live in the western U.S., where wildfires disseminating fine particulate matter have become more common, “wear a KN95 mask” on days when fires are affecting air quality in your area, Gerber said. Also, if you can afford it, consider buying air purifiers for your home, he advised, noting that fine particulates can get into homes that aren’t well sealed.

To check air quality levels in your area, go to AirNow.gov, Ailshire recommended. “If it’s a high-risk day, that might not be the day to go out and do heavy yardwork,” she said.

But don’t stay inside all the time and become overly self-protective. “It’s really important for older adults to be outside and exercise,” Gerber said. “We don’t want seniors to end up sick because they’re breathing lots of particulates, but we don’t want them to become inactive and stuck at home either.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Dementia Patients Hold On to Love Through Shared Stories

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Credit Paul Rogers

Can you keep the love light shining after your partner’s brain has begun to dim? Just ask Denise Tompkins of Naperville, Ill., married 36 years to John, now 69, who has Alzheimer’s disease.

The Tompkinses participated in an unusual eight-week storytelling workshop at Northwestern University that is helping to keep the spark of love alive in couples coping with the challenges of encroaching dementia.

Every week participants are given a specific assignment to write a brief story about events in their lives that they then share with others in the group. The program culminates with a moving, often funny, 20-minute written story read alternately by the partners in each couple in front of an audience.

Each couple’s story serves as a reminder of both the good and challenging times they have shared, experiences both poignant and humorous that reveal inner strength, resilience and love and appreciation for one another that can be easily forgotten when confronted by a frightening, progressive neurological disease like Alzheimer’s.

“It’s been an amazing experience for us,” Mrs. Tompkins said of the program. “Creating our story revealed such a richness in our life together and is helping us keep that front and center going forward.”

She added that the program provides “an opportunity to process what you’re going through and your relationship to each other. It helped me digest all the wonderful things about John and how well we relate as a couple, things that don’t go away with Alzheimer’s disease. John is so much more than his disease.”

Ditto for Robyn and Ben Ferguson of Chicago, married 42 years in 2012 when they learned that Ben, a psychologist, had Alzheimer’s disease. “The diagnosis was crushing,” said his wife, who is also a psychologist. “Telling people in the program about it helped us recognize the impact on our lives and relationship and really face that. It made things feel not quite so bad.”

The Fergusons have publicly presented their 20-minute story together 19 times so far, helping to enlighten medical students and those training in social work and pastoral care, as well as researchers and members of the general public. “It reinforces our relationship as a couple, rather than caregiver and patient, even though he is 85 percent dependent on me for the activities of daily living.”

Dr. Ben Ferguson, now 69, said, “I feel we’re giving people information that could be very valuable in their future. It’s helpful to them to see us smile, have a good time and give a good report – as well as a bad report – about what goes on with this disease. It’s helpful for people to hear it from someone who has it, and it’s helped us avoid getting so morose.”

As for their presentations, which they now give almost monthly, his wife said, “They help us stay positive and give us a sense of purpose. We both feel a real need to do advocacy work, and this is the best thing we can do right now. We know there’s a sell-by date on this – we won’t be able to do it forever. But we don’t think about that now. Now we’re focused on helping people understand that your life doesn’t stop with the diagnosis. We want people to hear that you go on with your life, even though you may need a lot of help.”

Another workshop participant, Sheila Nicholes, 76, of Chicago, said of her husband, Luther, who has vascular dementia, that the storytelling “brings him back to being funny again. Writing our story together gave us a way to talk about these things, to think about where we were then and where we are now.”

Noting that dementia is “a very hush-hush illness in our black community,” Ms. Nicholes said she hoped that telling their story would help others speak more openly about it and learn to “just roll with the flow.”

The storytelling workshop, which started in January of 2014, was the brainchild of Lauren Dowden, then an intern in social work at Northwestern’s Cognitive, Neurological and Alzheimer’s Disease Center. She quickly learned from family members in a support group that “their concerns were not being addressed about dealing with loss, not just of memory, jobs and independence, but also what they shared as a couple.”

During the group sessions, Ms. Dowden said, “there’s so much laughter in the room, so much joy and love of life as well as poignancy and tears. As they move forward, as the disease progresses, they can be reminded of who they are, their strength and resilience, what has made their relationship strong, what they loved about the person, as opposed to just being patient and caregiver.”

As the program moves week to week, Ms. Dowden said, “there’s more touching, affection, looking at one another and laughing. There are delightful moments of connection when one member of a couple reveals something the other didn’t know.”

The weekly story assignments require that the couple collaborates, “and they learn how to work together in new ways, how to make adjustments, because they’ll have to make thousands and thousands of adjustments throughout the course of the disease.”

In executing the workshop assignments, Dr. Ferguson said she would ask her husband questions, he would answer and she would write down what he said. “The workshop was really transformative,” she said. “It gave us hope for our future together in dealing with this disease.”

Ms. Dowden said the feedback from those in the audience for the 20-minute joint stories has been heartening. She explained, “Students learn about the biology of neurodegenerative conditions. These stories enable them to see the human side of the disease, what it’s like to live with it, and may help them develop programs that help these families live better. In addition to the stigma, there’s a tendency to write off people with dementia.”

Ms. Dowden said she is currently refining the workshop curriculum so that it can be used as a model for other institutions to replicate. She is also expanding it to include mother-daughter and sibling pairs.

She realizes, of course, that a storytelling workshop may not be suitable for every couple. “It’s not good if there’s a lot of behavioral issues, a lot of conflict, and no insight,” she said. “But for those it does fit, it’s an opportunity to tap into the core of relationships, to still grow and learn and be delighted by one another.”

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Breast-Fed Babies May Have Longer Telomeres, Tied to Longevity

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Credit Roberto Schmidt/Agence France-Presse — Getty Images

Breast-fed babies have healthier immune systems, score higher on I.Q. tests and may be less prone to obesity than other babies.

Now new research reveals another possible difference in breast-fed babies: They may have longer telomeres.

Telomeres are stretches of DNA that cap the ends of chromosomes and protect the genes from damage. They’re often compared to the plastic tips at the end of shoelaces that prevent laces from unraveling. Telomeres shorten as cells divide and as people age, and shorter telomeres in adulthood are associated with chronic diseases like diabetes. Some studies have linked longer telomeres to longevity.

The new study, published in The American Journal of Clinical Nutrition, is a hopeful one, its authors say, because it suggests telomere length in early life may be malleable. The researchers, who have been following a group of children since birth, measured the telomeres of 4- and 5-year-olds, and discovered that children who consumed only breast milk for the first four to six weeks of life had significantly longer telomeres than those who were given formula, juices, teas or sugar water.

Drinking fruit juice every day during the toddler years and a lot of soda at age 4 was also associated with short telomeres.

Socioeconomic differences among mothers can muddy findings about breast-feeding because the practice is more common among more educated mothers. However, this group of children was fairly homogeneous. All of them were born in San Francisco to low-income Latina mothers, most of whom qualified for a government food program.

“This adds to the burgeoning evidence that when we make it easier for mothers to breast-feed, we make mothers and babies healthier,” said Dr. Alison M. Stuebe, an expert on breast-feeding who is the medical director of lactation services at UNC Health Care in Chapel Hill, N.C., and was not involved in the study. “The more we learn about breast milk, the more it’s clear it is pretty awesome and does a lot of cool stuff.”

The study did not establish whether or not breast-feeding enhanced telomere length. It may be that babies born with longer telomeres are more likely to succeed at breast-feeding. A major drawback of the research was that telomere length was only measured at one point in time, when the children were 4 or 5 years old. There was no data on telomere length at birth or during the first few months of life.

“We don’t have a baseline to see if these kids were different when they came out,” Dr. Stuebe said. “It could be that really healthy babies can latch on and feed well, and they already had longer telomeres. It could be successful breast-feeding is a sign of a more robust kid.”

The researchers were following children who were part of the Hispanic Eating and Nutrition study, a group of 201 babies born in San Francisco to Latina mothers recruited in 2006 and 2007 while they were still pregnant. The goal of the research was to see how early life experiences, eating habits and environment influence growth and the development of cardiac and metabolic diseases as children grow.

Researchers measured the babies’ weight and height when the children were born. At four to six weeks of age, they gathered detailed information about feeding practices, including whether the baby had breast milk and for how long, and whether other milk substitutes were used, such as formula, sugar-sweetened beverages, juices, flavored milks and waters. Information was also gathered about the mothers.

Children were considered to have been exclusively breast-fed at 4 to 6 weeks of age if they received nothing but breast milk, as well as medicine or vitamins.

When the children were 4 and 5 years old, researchers took blood spot samples that could be used to measure the telomeres in leukocytes, which are white blood cells, from 121 children. They found that children who were being exclusively breast-fed at 4 to 6 weeks of age had telomeres that were about 5 percent longer, or approximately 350 base pairs longer, than children who were not.

The new findings may help explain the trove of benefits that accrue from breast-feeding, said Janet M. Wojcicki, an associate professor of pediatrics and epidemiology at the University of California, San Francisco, and the paper’s lead author.

“What’s remarkable about breast-feeding is its ability to improve health across organ systems,” Dr. Wojcicki said. “Telomere biology is so central to the processes of aging, human health and disease, and may be the link to how breast-feeding impacts human health on so many levels.”

There are several possible explanations for the correlation between breast-feeding and longer telomeres. Breast milk contains anti-inflammatory compounds, which may confer a protective effect on telomeres. It’s also possible that parents who exclusively breast-feed their babies are more scrupulous about a healthy diet generally.

Yet another possibility is that breast-feeding is a proxy for the quality of mother-child attachment and bonding, said Dr. Pathik D. Wadhwa, who was not involved in the research but studies early-life determinants of health at the University of California, Irvine School of Medicine. “We know from studies looking at telomere length changes in babies who came from orphanages that the quality of the attachment and interaction, and more generally the quality of care that babies receive, plays a role in the rate of change in telomere length,” he said.

When children are exposed to adversity, neglect or violence at an early age, “psychological stress creates a biochemical environment of elevated free radicals, inflammation and stress hormones that can be harmful to telomeres,” said Elissa Epel, one of the authors of the study who is a professor at the University of California, San Francisco, and director of the Aging, Metabolism and Emotions Lab.

“The idea that breast-feeding may be protective for telomeres is heartening because we don’t know much about what’s going to help protect them in children, besides avoiding toxic stress. And boy, do we want to know,” Dr. Epel said.

Although genes can’t be changed, Dr. Epel said, “This is part of the genome that appears to be at least partly under personal control.”

Meet the Super Flasher: Some Menopausal Women Suffer Years of Hot Flashes

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Credit Kim Murton

What kind of hot flasher are you?

The hot flash — that sudden feeling of warmth that can leave a woman flushed and drenched in sweat — has long been considered the defining symptom of menopause. But new research shows that the timing and duration of hot flashes can vary significantly from woman to woman, and that women appear to fall evenly into four hot-flash categories.

Some women, called “early onset” hot flashers, begin to experience hot flashes long before menopause. Symptoms can begin five to 10 years before a woman’s last period, but the symptoms stop with the end of the menstrual cycle.

Then there are women who don’t experience their first hot flash until after menopause, the “late onset” hot flasher. And some women fall into a group the researchers called the “lucky few.” Some of these women never experience a single hot flash, whereas others briefly suffer only a few flashes when they stop menstruating.

And then there are the “super flashers.” This unlucky group includes one in four midlife women. The super flasher begins to experience hot flashes relatively early in life, similar to the early onset group. But her unpleasant symptoms continue well past menopause, like those in the late onset group. Her symptoms can last 20 years or more.

The findings come from the Study of Women’s Health Across the Nation, or SWAN, a 22-year-old study that has been tracking the physical, biological and psychological health of 3,302 women from a variety of racial and ethnic backgrounds. The study is being conducted at seven research centers around the country and is paid for by the National Institutes of Health.

“It explodes our typical myth around hot flashes, that they just last for a few years and everyone follows the same pattern,” said Rebecca Thurston, the senior author and a professor of psychiatry and epidemiologist at the University of Pittsburgh. “We may be able to better help women once we know in what category they are more likely to fall.”

That includes women like Lynn Moran, a 70-year-old retired financial planning assistant who lives near Pittsburgh and falls into the “super flasher” category. She remembers having her first hot flash around the age of 47. While the symptoms were subtle at first, soon the hot flashes became more bothersome. “It was enough to wake me up out of a sound sleep,” she said. “I wasn’t sleeping well because they were coming all night long and during the day. I was just miserable.”

Ms. Moran began hormone therapy, which helped but did not eliminate the symptoms. But when medical studies began to show health risks associated with the treatment, her doctor advised her to stop using hormones. She waited another 18 months until she retired, then stopped taking hormones in 2005.

The hot flashes “came back with a vengeance” and haven’t stopped since.

“I still have them. I still laugh about them,” she said, noting that she may experience several hot flashes a day. “I’ll be trying to get ready to go somewhere, curling my hair and have to redo everything and dry my hair again because I’ll be drenched. My makeup will literally run down my face. Here I am, 70 years old, complaining of hot flashes.”

Dr. Thurston notes that understanding variations on hot flashes is important to understanding women’s health in midlife. A 2012 study, published in the journal Obstetrics and Gynecology, suggested that the timing and duration of hot flashes may be an indicator of a woman’s cardiovascular health. The study found that frequent hot flashes were associated with higher cholesterol markers, particularly in thin women.

The latest findings from the SWAN study identified some patterns around the four subsets of women who experienced varying degrees of hot flashes. Women were distributed about equally among the groups, meaning 75 percent of women experienced some degree of hot flashes, while only 25 percent escaped the symptom.

Women in the early onset group were more likely to be white and obese. Women in the late onset group tended to be smokers. The lucky few women who had no hot flashes or only a few were more often Asian women and women in better health. The super flashers were more likely to be African-American, to be in poorer health and to consume alcohol. But the researchers cautioned that while they identified some statistical trends in each group, it’s important to note that each subset of hot flashers included a variety of women representing all races, ethnicities, body weights and health categories. No one factor appeared to determine a woman’s risk for any hot flash category.

For instance, while African-American women were three times as likely to be in the super flashers group, they represented only 40 percent of that group. The remaining 60 percent were white women, some Asian women and other groups.

Dr. Thurston said it is important that doctors understand that 75 percent of women have hot flashes in midlife and that they persist in at least one in four..

“It flies in the face of the traditional wisdom that women have these symptoms for three to five years around the final menstrual period,” she said. “We now know that is patently wrong.”

Talking to Younger Men About Growing Old

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For Robert Goldfarb, 85, resisting the decline of old age goes beyond the treadmill.

For Robert Goldfarb, 85, resisting the decline of old age goes beyond the treadmill.Credit

An electronic display on the treadmill in my local gym reminds me I’m not only running on the machine, but out of time. Its graph comparing changes in the runner’s heart rate to that of peers goes no further than age 70. I’m 85, and find it ominous that the machine presumes that anyone that old shouldn’t be on the thing.

Reminders that I’m now officially one of the old-old appear with greater frequency. Some are subtle, like the treadmill display; others are more jarring, like my daughter’s approaching 60th birthday. Most reminders are well-meaning: a young woman offering her seat on a bus, an airport employee hurrying over with a wheelchair, happily telling me I won’t have to walk to the gate or stand in line. I graciously decline their kindness, struggling not to protest, “But, I’m a competitive runner!” That I feel robust doesn’t matter; the man I see and the man they see are two very different people.

I recently read something the philosopher Montaigne wrote over 400 years ago: “The shorter my possession of life, the deeper and fuller I must make it.” His words inspired me to seek a path through old age without surrendering to it or ignoring its reality.

I began by fighting memory lapses. Rather than substituting “whatever” for an elusive word, I now strain to recall that word, even if means asking others to bear with me for a bit. I avoid phrases that suggest the end of things, like “downsizing” or “I no longer do that.” I subscribe to internet memory games. To recapture the excitement I felt in long-ago classrooms, I began rereading books I read in college.

I also decided to reach out to men my age to learn how they navigate through growing old. Like most of the men I began speaking with, I’m a product of the 1950s and its pressure to conform, to avoid risk, to shun anything that marked one as “different.” Many young people then were warned by parents that signing petitions bearing words like “protest” or “progressive” would get them rejected for a job or fired when they grew up. Men in my platoon didn’t embrace when we parted after serving in the Korean War. Closer than brothers, we settled for a handshake, knowing that’s what men did.

Almost immediately, I found conversations with men my age awkward. Attempts I made to discuss aging were met with jokes about the alternative. With few exceptions, those I spoke with regarded feelings as something to be endured, not discussed. It quickly became clear I was free to contemplate growing old, but not with them.

My wife suggested I meet with younger acquaintances to learn if they would talk with me about aging. I did, and found that men just 10 years younger spoke openly about changes in their minds and bodies. No one joked or changed the subject when one of them confided, “My father had Alzheimer’s, and I’m beginning to forget the same things he did,” or, “My firm’s managing partner said I was slowing younger associates and had to retire.”

It puzzled me that they felt so much freer to discuss feelings than men born just a decade earlier. Could it be because they were shaped by the ’60s, rather than the ’50s? Growing up, they protested what we accepted, challenged authority we obeyed, celebrated their individuality while we hoped to be one of the men in a gray flannel suit. They were the “me” generation, defined by Woodstock and rock ‘n’ roll, while my generation found comfort in Eisenhower’s paternal leadership and listening to soothing ballads like George Shearing’s “I’ll Remember April” and Margaret Whiting’s “Moonlight in Vermont.” Separated by a sliver of time, the two decades seem an eternity apart.

As I seek to reinvent myself, questioning what I do out of habit and what I’m not doing that could be liberating, it’s the voices of these younger men that I hear as I run on the treadmill today. That and the voice of Frank Sinatra from the ’50s, crooning a line from “September Song” that captures what I’ve been feeling: “But the days grow short when you reach September.” It’s realizing that I’ve reached November that presses me forward, ignoring the treadmill’s display, hoping I can lead a deeper and fuller life before I run out of time.

Robert W. Goldfarb is a management consultant and author of “What’s Stopping Me From Getting Ahead?”