Tagged Elderly

A Colonoscopy Alternative Comes Home

A Colonoscopy Alternative Comes Home

An at-home test for colon cancer is as reliable as the traditional screening, health experts say, and more agreeable.

Credit…Karlotta Freier

  • Jan. 11, 2021, 1:40 p.m. ET

Most Americans who are due for a colon cancer screening will receive a postcard or a call — or prompting during a doctor’s visit — to remind them that it’s time to schedule a colonoscopy.

But at big health care systems like Kaiser Permanente or the federal Veterans Health Administration, the process has changed. Patients who should be screened regularly (age 50 to 75) and who are of average risk, get a letter telling them about a home test kit arriving by mail.

It’s a FIT, which stands for fecal immunochemical test. The small cardboard mailer contains equipment and instructions for taking a stool sample and returning the test to a lab, to detect microscopic amounts of blood. A week or so later, the results show up on an online patient portal.

Five to 6 percent of patients will have a positive test and need to schedule a follow-up colonoscopy. But the great majority are finished with colon cancer screening for the year — no uncomfortable prep, no need to skip work or find someone to drive them home after anesthesia, no colonoscopy.

Last spring, when the coronavirus pandemic closed many medical facilities and postponed nonemergency procedures, this approach suddenly looked even more desirable.

“We know that from March to May, colon cancer screenings fell by about 90 percent,” said Dr. Rachel Issaka, a gastroenterologist at the University of Washington and the Fred Hutchinson Cancer Research Center. Although testing has resumed, she said, “we’re still not back to where we were.”

Yet colon cancer represents the third-highest cause of cancer deaths, after lung cancer and, tied for second place, breast and prostate cancer. Unlike those, colon cancer can be prevented with early detection.

With many older adults trying to avoid hospitals and surgical centers, even as their risk of colon cancer rises with age, an at-home test provides an alternative to colonoscopy — one that is both safer, with a lower risk of complications and Covid-19 exposure, and does as good a job.

“If your doctor tells you a colonoscopy is better, that’s not accurate,” said Dr. Alex Krist, chairman of the U.S. Preventive Services Task Force, an independent expert panel that reviews evidence and issues recommendations. “The data show the tests are equally effective at saving lives.”

The Task Force is updating its guidelines for colon cancer screening and this year will likely recommend lowering the age at which it should begin, to 45. But the recommendations on the upper end will remain unchanged: Based on strong evidence, adults up to age 75 should be screened regularly.

Beyond that age, the disadvantages begin to mount. The Task Force says the benefit of screening 76- to 85-year-olds is small, and that the decision should be an individual one, reached in consultation with a doctor.

Colon cancer develops slowly, explained Dr. James Goodwin, a geriatrician and researcher at the University of Texas Medical Branch in Galveston. Patients at older ages, who typically contend with several other diseases, may not live long enough to benefit. “You cause more harm than good,” Dr. Goodwin said.

The advice to stop screening isn’t always popular with patients. “People don’t like to hear about not living very long,” he said. But with colonoscopy, he noted, “you go through an unpleasant experience — or an unpleasant experience followed by an unpleasant diagnosis and unpleasant treatment — for something that, if you’d never known about it, wouldn’t cause you harm.”

Even if a test eventually finds colon cancer, surgery plus chemotherapy, the standard treatment, could itself endanger a frail older person. “I would be heavily biased against anyone getting a screening, of any sort, over age 80,” Dr. Goodwin said.

Although Americans still rely mostly on colonoscopy, his research has shown that for many older people, that test is overused, either because of the patients’ ages or because they are tested too frequently.

Yet screening is simultaneously underused. In 2018, according to the Centers for Disease Control and Prevention, only about 70 percent of adults were up-to-date on colorectal cancer testing. About one-fifth of those 65 to 75 had not been screened as recommended. Among those 50 to 65, where lack of Medicare or other insurance probably contributed, only about 63 percent were appropriately screened.

The Task Force has found several kinds of screening tests effective, but the ones used most for people at average risk are colonoscopy, at a recommended 10-year interval, or FIT annually.

A newer entry, an at-home test sold under the brand name Cologuard that detects blood and cancer biomarkers in stool, may be used every three years, but a study found it to be less effective than most other methods and far more expensive than FIT.

When screening is recommended, how does FIT stack up against colonoscopy?

Higher-risk patients — including those who have had colon cancer or parents or siblings with colon cancer, those with inflammatory bowel disorders like Crohn’s disease, and those who have had abnormal previous tests, including multiple or large polyps — should seek out a colonoscopy, often on an accelerated schedule. The procedure involves inserting a viewing instrument through the anus to directly visualize an anesthetized patient’s colon.

A colonoscopy offers one distinct advantage: if the gastroenterologist spots polyps, growths that over time could become cancerous (although most don’t), these can be removed immediately. “You’re preventing cancer, snipping out the things that could lead to cancer,” Dr. Goodwin said. After a negative colonoscopy, patients don’t need another for a decade.

But the procedure’s complications increase with age, although they remain low; the most serious, a perforated colon, requires hospitalization. Cleaning out the bowel on the day before the procedure, in preparation, is disruptive and disagreeable, and Dr. Goodwin notes that older patients sometimes experience cycles of diarrhea and constipation for weeks afterward.

Rural residents may find traveling to a facility difficult. The use of anesthesia means that every patient needs someone to drive or escort them home afterward. The prospect of spending two to four hours in a facility, even one using rigorous safety measures, will cause some older adults to postpone testing because of Covid-19 fears.

The FIT, which is far more widely used in other countries, avoids many of those difficulties. A marked improvement over earlier at-home stool tests, it requires a sample from one day instead of samples from three, and imposes no food or drug restrictions. A positive result still calls for a colonoscopy, but the great majority of patients avoid that outcome.

Why do so many Americans still undergo colonoscopies, then? “There’s a large financial incentive for people who do colonoscopies to do colonoscopies,” Dr. Goodwin said, so patients may not hear much about the alternatives.

“Many of my own patients are surprised to learn that there’s another way,” said Dr. Krist, also a family physician at Virginia Commonwealth University. “As they age, they want less invasive methods” and may be happy to switch.

Wider adoption of FIT could also save patients and insurers, notably Medicare, a boatload. The home test, which is available through several manufacturers, generally costs less than $20; a colonoscopy can easily exceed $1,000.

Moreover, with personalized messages to patients and follow-up reminders to return the kit, FIT use can result in more people being screened. That could prove important when the Preventive Services Task Force lowers the recommended age to 45, which would add 22 million Americans to the list of people advised to undergo colon cancer screening. Their needs, plus a backlog of patients who postponed tests during the pandemic, could swamp gastroenterology practices.

“If a provider doesn’t bring up” the possibility of an at-home test, Dr. Issaka said, “patients should feel empowered to ask about it.” Colon cancer screenings, of any type, “are considered non-urgent,” she said. “But they’re not optional.”

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Pressure Grows for States to Open Vaccines to More Groups of People

Pressure Grows for States to Open Vaccines to More Groups of People

Some states are already expanding eligibility to people 65 and over, even though millions of people the C.D.C. recommends go first — health care workers and nursing home residents — have yet to get shots.

Gov. Ron DeSantis of Florida, right, during vaccinations at the John Knox Village nursing home in Pompano Beach, Fla., last month.
Gov. Ron DeSantis of Florida, right, during vaccinations at the John Knox Village nursing home in Pompano Beach, Fla., last month.Credit…Marta Lavandier/Associated Press
Abby Goodnough

  • Jan. 9, 2021, 12:00 p.m. ET

Just weeks into the country’s coronavirus vaccination effort, states have begun broadening access to the shots faster than planned, amid tremendous public demand and intense criticism about the pace of the rollout.

Some public health officials worry that doing so could bring even more chaos to the complex operation and increase the likelihood that some of the highest-risk Americans will be skipped over. But the debate over how soon to expand eligibility is intensifying as deaths from the virus continue to surge, hospitals are overwhelmed with critically ill patients and millions of vaccine doses delivered last month remain in freezers.

Governors are under enormous pressure from their constituents — especially older people, who vote in great numbers and face the highest risk of dying from the virus — to get the doses they receive into arms swiftly. President-elect Joseph R. Biden Jr.’s decision, announced Friday, to release nearly all available doses to the states when he takes office on Jan. 20, rather than holding half to guarantee each recipient gets a booster shot a few weeks after the first, is likely to add to that pressure.

Some states, including Florida, Louisiana and Texas, have already expanded who is eligible to get a vaccine now, even though many people in the first priority group recommended by the Centers for Disease Control and Prevention — the nation’s 21 million health care workers and three million residents of nursing homes and other long-term care facilities — have not yet received a shot.

On Friday afternoon, New York became the latest state to do so, announcing that it would allow people 75 and over and certain essential workers to start receiving a vaccine on Monday.

But reaching a wider swath of the population requires much more money than states have received for the task, many health officials say, and more time to fine-tune systems for moving surplus vaccine around quickly, to increase the number of vaccination sites and people who give the shots, and to establish reliable appointment systems to prevent endless lines and waits.

Some states’ expansions have led to frantic and often futile efforts by older people to get vaccinated. After Florida opened up vaccinations to anyone 65 and older late last month, the demand was so great that new online registration portals quickly overloaded and crashed, people spent hours on the phone trying to secure appointments and others waited overnight at scattered pop-up sites offering shots on a first-come first-served basis.

Similar scenes have played out in parts of Texas, Tennessee and a handful of other states.

Still, with C.D.C. data suggesting that only about a third of the doses distributed so far have been used, Alex M. Azar II, the health and human services secretary, told reporters this past week: “It would be much better to move quickly and end up vaccinating some lower-priority people than to let vaccines sit around while states try to micromanage this process. Faster administration would save lives right now, which means we cannot let the perfect be the enemy of the good.”

Boxes of Moderna’s vaccine were prepared for shipment at a distribution center in Olive Branch, Miss., last month.
Boxes of Moderna’s vaccine were prepared for shipment at a distribution center in Olive Branch, Miss., last month.Credit…Pool photo by Paul Sancya

The C.D.C. guidelines were drawn up by an independent committee of medical and public health experts that advises the agency on immunization practices; it deliberated for months about who should get vaccinated initially, while supplies were still very limited. The committee weighed scientific evidence about who is most at risk of getting very sick or dying from Covid-19, as well as ethical questions, such as how best to ensure equal access among different races and socioeconomic groups.

Although the committee’s recommendations are nonbinding, states usually follow them; in this case, the committee suggests that states might consider expanding to additional priority groups “when demand in the current phase appears to have been met,” “when supply of authorized vaccine increases substantially” or “when vaccine supply within a certain location is in danger of going unused.”

Dr. Kevin Ault, an obstetrician at the University of Kansas Medical Center who serves on the advisory committee that came up with the C.D.C. guidelines, said that it was reasonable for states to start vaccinating new groups before finishing others, but that they should be careful about exacerbating inequities and biting off more than they can chew.

“Obviously if you’re going to vaccinate that group you need to have a well-thought-out plan in hand,” he said, referring to the over-65 population. “Having people camping out for vaccine is less than ideal, I would say.”

He added, “We put a lot of thought and effort into our guidelines, and I think they are good.”

After the first vaccines were given in mid-December, a dichotomy emerged between governors who were adhering precisely to the guidelines and others who moved quickly to populations beyond health care workers and nursing home residents.

Until Friday, Gov. Andrew M. Cuomo of New York, a Democrat, had threatened to penalize hospitals that provided shots to people who are not health care workers. By contrast, Gov. Ron DeSantis of Florida, a Republican, traveled to retirement communities around his state to emphasize the importance of getting people 65 and older, who number more than five million there, immunized fast.

“In Florida we’ve got to put our parents and grandparents first,” Mr. DeSantis said at The Villages, the nation’s largest retirement community, just before Christmas.

Gov. Andrew Cuomo of New YorkCredit…Andrew Kelly/Reuters
Gov. Mike DeWine of OhioCredit…Tony Dejak/Associated Press
Gov. Greg Abbott of TexasCredit…Eric Gay/Associated Press
Gov. Larry Hogan of MarylandCredit…Jonathan Ernst/Reuters

Decisions on how soon to expand eligibility for the shots have not fallen neatly along partisan lines.


Covid-19 Vaccines ›


Answers to Your Vaccine Questions

While the exact order of vaccine recipients may vary by state, most will likely put medical workers and residents of long-term care facilities first. If you want to understand how this decision is getting made, this article will help.

Life will return to normal only when society as a whole gains enough protection against the coronavirus. Once countries authorize a vaccine, they’ll only be able to vaccinate a few percent of their citizens at most in the first couple months. The unvaccinated majority will still remain vulnerable to getting infected. A growing number of coronavirus vaccines are showing robust protection against becoming sick. But it’s also possible for people to spread the virus without even knowing they’re infected because they experience only mild symptoms or none at all. Scientists don’t yet know if the vaccines also block the transmission of the coronavirus. So for the time being, even vaccinated people will need to wear masks, avoid indoor crowds, and so on. Once enough people get vaccinated, it will become very difficult for the coronavirus to find vulnerable people to infect. Depending on how quickly we as a society achieve that goal, life might start approaching something like normal by the fall 2021.

Yes, but not forever. The two vaccines that will potentially get authorized this month clearly protect people from getting sick with Covid-19. But the clinical trials that delivered these results were not designed to determine whether vaccinated people could still spread the coronavirus without developing symptoms. That remains a possibility. We know that people who are naturally infected by the coronavirus can spread it while they’re not experiencing any cough or other symptoms. Researchers will be intensely studying this question as the vaccines roll out. In the meantime, even vaccinated people will need to think of themselves as possible spreaders.

The Pfizer and BioNTech vaccine is delivered as a shot in the arm, like other typical vaccines. The injection won’t be any different from ones you’ve gotten before. Tens of thousands of people have already received the vaccines, and none of them have reported any serious health problems. But some of them have felt short-lived discomfort, including aches and flu-like symptoms that typically last a day. It’s possible that people may need to plan to take a day off work or school after the second shot. While these experiences aren’t pleasant, they are a good sign: they are the result of your own immune system encountering the vaccine and mounting a potent response that will provide long-lasting immunity.

No. The vaccines from Moderna and Pfizer use a genetic molecule to prime the immune system. That molecule, known as mRNA, is eventually destroyed by the body. The mRNA is packaged in an oily bubble that can fuse to a cell, allowing the molecule to slip in. The cell uses the mRNA to make proteins from the coronavirus, which can stimulate the immune system. At any moment, each of our cells may contain hundreds of thousands of mRNA molecules, which they produce in order to make proteins of their own. Once those proteins are made, our cells then shred the mRNA with special enzymes. The mRNA molecules our cells make can only survive a matter of minutes. The mRNA in vaccines is engineered to withstand the cell’s enzymes a bit longer, so that the cells can make extra virus proteins and prompt a stronger immune response. But the mRNA can only last for a few days at most before they are destroyed.

Gov. Larry Hogan of Maryland, a Republican, announced Tuesday that he would immediately switch to what he called the “Southwest Airlines model” for vaccine allocation, referring to the airline’s open seating policy. “We’re no longer going to be waiting for all the members of a particular priority group to be completed,” he said, “before we move on to begin the next group in line.”

Gov. Mike DeWine of Ohio, a Republican, urged patience in a news briefing Tuesday as he declined to estimate when the state would start vaccinating people beyond the first priority group, known as “1a.”

“We’re asking every health department, ‘Don’t go outside 1a, stay within your lane,’” he said, adding about the vaccines, “This is a scarce commodity.”

By Thursday Mr. DeWine had set a date for people 80 and older to start getting the vaccine — Jan. 19 — and said he would phase in everyone 65 and older, as well as teachers, by Feb. 8.

The reasons so many doses received by states have not yet been administered to the first priority group are manifold. The fact that vaccination began around Christmas, when many hospital employees were taking vacation, slowed things. More health care workers are refusing to get the vaccine than many of their employers expected, and some hospitals and clinics received more doses than they needed but felt constrained by state rules from giving them to people outside the first priority groups. Some initially worried they could not even offer leftover doses in open vials to people in lower priority groups and let them go to waste.

Frontline health care workers and people age 65 and older waited to be vaccinated at a sports complex in Fort Myers, Fla., last month.Credit…Octavio Jones for The New York Times

And federal funding for vaccination efforts has been slow to reach states and localities: They got only $350 million through the end of last year, a little more than $1 per resident of the country. The economic rescue package that Congress passed in December included $8 billion for vaccine distribution that state health officials had long sought, but the first tranche of it, about $3 billion, is only now starting to be sent out.

“There was great funding in the development of these products, great funding in the infrastructure to ship them and get them out,” said Dr. Steven Stack, commissioner of the Kentucky Department for Public Health. “But then there was no funding provided of meaning for administering the vaccine, which is the last mile of this journey.”

The C.D.C. has recommended that a “1b” group consisting of people 75 and older and certain essential workers, including teachers, corrections officers and grocery store employees, be vaccinated next. The second group is much larger, about 50 million people. And the third recommended priority group — people 65 to 74, anyone 16 and older with high-risk medical conditions, and essential workers not already reached — numbers almost 130 million.

Pfizer and Moderna have pledged to deliver enough vaccine doses for 100 million people to each get the two necessary shots by the end of March, and many more in the second quarter. Several other vaccine candidates are far along in the pipeline, and if approved for emergency use here could help ramp up distribution more quickly.

The C.D.C. committee initially considered recommending that a wide range of essential workers get vaccinated before older Americans. Its rationale was that many essential workers are low-wage people of color, who have been hit disproportionately hard by the virus and had limited access to good health care. That sparked a backlash, and several governors, including Mr. DeSantis, quickly made clear they would cater to older people first.

Alex M. Azar, the health and human services secretary, left, and Surgeon General Jerome Adams, right, during a vaccination at George Washington University Hospital on Dec. 14.Credit…Pool photo by Jacquelyn Martin-Pool

Dr. Mark McClellan, who formerly headed the F.D.A. and now runs Duke University’s health policy center, said that while pushing ahead to vaccinate older people and other particularly vulnerable groups would accelerate the overall effort, “we’re going to be missing a lot of higher-risk individuals along the way.”

“I do worry about that becoming uneven in terms of access,” he said during a press briefing, “with lower-income groups, minority groups maybe in a tougher position if we don’t make it very easy for people in these high-risk groups to get vaccinated.”

Dr. Marcus Plescia, the chief medical officer for the Association of State and Territorial Health Officials, said he was surprised to hear federal officials like Mr. Azar and Dr. Jerome Adams, the surgeon general, advocate expanding vaccine access so broadly so soon.

“We didn’t come up with priority populations to slow things down, but because we knew there would be limited numbers of doses,” Dr. Plescia said. “If we try to do this in an equitable, fair way, it’s not going to be as fast as if our only goal is to get vaccine into as many arms as possible.”

Whether or not they are widening access now, governors are ramping up pressure on hospitals to use their allocated doses more quickly. Mr. Cuomo threatened to fine those that did not use their initial allocations by the end of this past week and not send them any more.

Mr. Hogan warned hospitals this past week, “Either use the doses that have been allocated to you or they will be directed to another facility or provider.”

Don’t Let the Pandemic Stop Your Shots

the new old age

Don’t Let the Pandemic Stop Your Shots

Even as older adults await the coronavirus vaccine, many are skipping the standard ones. That’s not wise, health experts say.

Credit…Chris Lyons

  • Dec. 28, 2020, 12:12 p.m. ET

Peggy Stein, 68, a retired teacher in Berkeley, Calif., skipped a flu shot this year. Her reasoning: “How could I get the flu if I’m being so incredibly careful because of Covid?”

Karen Freeman, 74, keeps meaning to be vaccinated against shingles, but hasn’t done so. A retired college administrator in St. Louis, she quipped that “denial has worked well for me these many years.”

Sheila Blais, who lives on a farm in West Hebron, N.Y., has never received any adult vaccine. She also has never contracted the flu. “I’m such an introvert I barely leave the farm, so where’s my exposure?” said Ms. Blais, 66, a fiber artist. “If it’s not broke, don’t fix it.”

While older adults await vaccination against Covid-19, public health officials also worry about their forgoing, forgetting, fearing or simply not knowing about those other vaccines — the ones recommended for adults as we age and our immune systems weaken.

“There’s a lot of room for improvement,” said Dr. Ram Koppaka, associate director for adult immunization at the Centers for Disease Control and Prevention.

Every year, campaigns urge older adults to protect themselves against preventable infectious diseases. After all, influenza alone has killed 12,000 to 61,000 Americans annually over the past decade, most of them 65 or older, and has sent 140,000 to 810,000 people a year to hospitals.

The coronavirus pandemic has introduced another imperative. Those hospitals are filling fast with Covid-19 patients; in many places they are already swamped, their staffs overworked and exhausted.

“Knowing how stressed the health care system is, prevention is key,” said Dr. Nadine Rouphael, a vaccine researcher and infectious disease specialist at Emory University. “When we have record numbers of deaths, why would you go to a hospital for a vaccine-preventable illness?”

Yet the nation has long done a better job of vaccinating its children than its elders. The most recent statistics, from 2017, show that about one-third of adults over 65 had not received a flu shot within the past year. About 30 percent had not received the pneumococcus vaccine.

The proportion receiving the shingles vaccine, a fairly recent addition to the list, has inched up, but by 2018 only 34.5 percent of people over 60 had been vaccinated.

Moreover, Dr. Koppaka pointed out: “When you look deeper, there are longstanding, deep, significant differences in the proportion of Black and Hispanic adults getting vaccines compared to their white counterparts. It’s really unacceptable.”

Close to 40 percent of non-Hispanic whites had been vaccinated against shingles, for instance, compared with fewer than 20 percent of Blacks and Hispanics.

One might expect a group who can recall polio fears and outbreaks of whooping cough to be less hesitant to get vaccinated than younger cohorts. “You’ll probably have a different concept of vaccination from someone who never experienced what a serious viral illness can do,” Dr. Koppaka said.

When it comes to the Covid-19 vaccine, for instance, only 15 percent of those over 65 say they would definitely or probably not get it, compared with 36 percent of those 30 to 49, a Kaiser Family Foundation tracking poll showed earlier this month. (Ms. Stein, Ms. Blais and Ms. Freeman all said they would happily accept the Covid vaccine.)

But for other diseases, vaccination rates lag. Given that older people are more vulnerable to severe illness from them, why the gaps in coverage?

Internists and other doctors for adults don’t promote vaccines nearly as effectively as pediatricians do, said Dr. William Schaffner, an infectious disease specialist at Vanderbilt University. Older patients, who often see a variety of doctors, may also have trouble keeping track of when they got which shot.

Experts fear that vaccination rates may have fallen further during the pandemic, as they have among children, if older people wary of going to doctors’ offices or pharmacies skipped shots.

Financial and bureaucratic obstacles also thwart vaccination efforts. Medicare Part B covers three vaccines completely: influenza, pneumococcus and, when indicated, hepatitis B.

The Tdap and shingles vaccines, however, are covered under Part D, which can complicate reimbursement for doctors; the vaccines are easier to obtain in pharmacies. Not all Medicare recipients buy Part D, and for those who do, coverage varies by plan and can include deductibles and co-pays.

Still, older adults can gain access to most recommended vaccines for no or low cost, through doctors’ offices, pharmacies, supermarkets and local health departments. For everyone’s benefit, they should.

Here’s what the C.D.C. recommends:

Influenza An annual shot in the fall — and it’s still not too late, because flu season peaks from late January into February. Depending on which strain is circulating, the vaccine (ask for the stronger versions for seniors) prevents 40 to 50 percent of cases; it also reduces illness severity for those infected.

Thus far this year, flu activity has remained extraordinarily low, perhaps because of social distancing and masks or because closed schools kept children from spreading it. Manufacturers shipped a record number of doses, so maybe more people got vaccinated. In any case, fears of a flu/Covid “twindemic” have not yet been realized.

Nevertheless, infectious disease experts urge older adults (and everyone over six months old) to get flu shots now. “Flu is fickle,” Dr. Schaffner said. “It could take off like a rocket in January.”

Tetanus, diphtheria, pertussis. A booster of TD vaccine every 10 years, to prevent tetanus and diphtheria. If you’ve never had the Tdap vaccine — which adds prevention against pertussis — that’s the one you want. Although pertussis, better known as whooping cough, occasionally shows up in adults, newborns are particularly at risk. Pregnant women will ask expectant grandparents to get a Tdap shot. Because it is covered under Part D, a pharmacy is the best bet.

Pneumococcus. “It’s a pneumonia vaccine, but it also prevents the most serious consequences of pneumonia, including meningitis and bloodstream infections,” Dr. Koppaka said.

People over 65 should get the polysaccharide formula — brand name Pneumovax — but there are certain circumstances, such as immune-compromising conditions, to discuss with a health care provider.

Those over 65 may choose, again in consultation with a provider, to also get the conjugate pneumococcal vaccine (brand name Prevnar), which provides some additional protection. If so, C.D.C. guidelines specify which vaccine to take when.

Shingles. Social distancing won’t ward off this disease; anyone who had chickenpox, which is just about every senior, still carries the virus.

“If you live to be 80, you stand a 35 to 50 percent chance of having an episode,” Dr. Schaffner said. “And the older you are when you get it, the more apt you are to get the most serious complication” — lingering nerve pain called post-herpetic neuralgia.

The C.D.C. recommends Shingrix, the highly effective shingles vaccine the F.D.A. approved in 2017, for everyone over 50. The previous shingles vaccine has been discontinued. Get Shingrix even if you had the earlier vaccine, Zostavax, and even if you’ve had shingles — it can recur.

The two required shots, given two to six months apart, can total $300 out of pocket. But Medicare Part D beneficiaries will pay an average of $50 for the pair, said a spokesman for the manufacturer GlaxoSmithKline, and people with private insurance even less.

Hepatitis A and hepatitis B. These aren’t age-related; the vaccines are recommended for people with certain health conditions, including chronic liver disease and H.I.V. infection, or for travelers to countries where the diseases are widespread.

The hepatitis B vaccine is also recommended, at a provider’s discretion, for diabetics over 60 who haven’t been previously vaccinated. Talk to a health care professional about your risks.

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Now That Grandma Has Been Vaccinated, May I Visit Her?

Now That Grandma Has Been Vaccinated, May I Visit Her?

The start of a mass coronavirus vaccination campaign at U.S. nursing homes has brought hope to many families. But it may be a while before restrictions loosen. Here are answers to common questions.

Vera Leip, 88, of Pompano Beach, Fla., received the Pfizer-BioNtech vaccine at the John Knox Village retirement community last week.
Vera Leip, 88, of Pompano Beach, Fla., received the Pfizer-BioNtech vaccine at the John Knox Village retirement community last week.Credit…Joe Raedle/Getty Images

  • Dec. 21, 2020, 4:48 p.m. ET

A watershed moment has arrived for many families: This week health care workers from CVS and Walgreens, under contract from the federal government, will fan out to nursing homes across the country to begin vaccinating residents against the coronavirus. The shots not only will help protect the nation’s elderly and infirm — and the staff who care for them — but they raise the prospect of ending the devastating isolation many residents have felt for months.

Family members are hopeful that before too long, they will return to visiting parents and grandparents, aunts, uncles and other loved ones regularly again. We checked with experts on some common questions.

Will restrictions on visiting be lifted soon?

Probably not in a big way. Restrictions vary by state, and the federal government’s guidance on what it considers safe stands for now. They already allow visits under certain conditions. The Centers for Medicare & Medicaid Services, or C.M.S., recommended in September that outdoor visits with residents be allowed and indoor visits, too, if the facility has been free of cases for 14 days.

Some medical experts have said that those guidelines are too lax and that visits should be severely restricted, even banned. However, some of these experts are now saying that the vaccine changes the equation, somewhat.

“Once all residents are vaccinated, it opens the door for loosening of restrictions,” said Dr. Michael Wasserman, the immediate past president of the California Association of Long Term Care Medicine, a geriatrician and former executive at nursing home chains.

To allow visits, Dr. Wasserman recommends all residents of a nursing home should be vaccinated (unless they have some condition or allergy that would discourage vaccination on medical grounds); all staff members should be vaccinated; the nursing home should have the ability to ensure that visitors test negative for the coronavirus and have been disciplined about wearing a mask in public settings.

Is the vaccine safe and effective for old and frail residents of nursing homes?

The clinical trials of the Pfizer and Moderna vaccine included people over 65, and results showed it to be safe and to work as well in older people as in younger ones.

“This vaccine has gone through testing and clinical trials to ensure it meets the highest safety standards. It also is safe to get if you already had the virus,” says a campaign to encourage people to get the shots by the American Health Care Association and National Center for Assisted Living, a combined trade group representing nursing homes and assisted-living communities.

The lead administrator for C.M.S., Seema Verma, reinforced the confidence in the shot for older patients, including those with health conditions, in a statement last week: “I urge states to prioritize nursing homes and vulnerable seniors in their distribution of the vaccine.”

The point is echoed by Dr. Sabine von Preyss-Friedman, chief medical officer of Avalon Health Care Group, which operates nursing homes, who said the new vaccines appear “safe and effective.”

If restrictions are eased, should I visit right away?

The Pfizer and Moderna vaccines both require two injections — the initial shot and a booster three or four weeks later. Dr. von Preyss-Friedman recommends waiting at least two weeks after the second shot to have a visit.

“You hope these vaccines work, but these are elderly patients,” she said. “You want to err on the side of protection.”

She said that, ideally, the visitor would also be vaccinated as well. Since shots won’t be widely available for a few months, it may be best to wait until you get your vaccine. Until then, she believes nursing homes should consider visits on a case-by-case basis.

Would visitors still need to wear a mask?

Absolutely, medical experts said. This is particularly true if they are not vaccinated, but even after they are vaccinated “until rates in the community go down,” said Dr. Joshua Uy, a geriatrician and associate professor at the University of Pennsylvania Medical School and the medical director of Renaissance Healthcare & Rehabilitation Center, a nursing home in Philadelphia.

Dr. Uy said that he hopes that the federal government would supply enough personal protective equipment so that all visitors and residents could be properly gowned for such visits.

What is being done to encourage nursing home residents to get vaccinated?

The combined nursing-home and assisted-living trade group has started a program aimed at helping nursing homes and other care facilities to explain to residents the essential need to get the vaccine. The campaign, #getvaccinated, notes: “The elderly population has a much higher risk for getting very sick, being hospitalized, or dying from Covid-19. The vaccine has been shown to provide a great deal of protection against serious illness due to Covid-19.”

But the people they love most may have more effective persuasive powers. Families can help, Dr. Uy said, by encouraging their parents and grandparents in nursing homes to get vaccinated.

“The vaccine,” he said, “is going to be our way out.”

Frontline Workers and People Over 74 Should Get Shots Next, CDC Panel Says

Frontline Workers and People Over 74 Should Get Shots Next, CDC Panel Says

The recommendation was a compromise aimed at getting the coronavirus vaccine to the most vulnerable of two high-risk groups.

Director of nursing education Loraine Hopkins Pepe, left, administers the Pfizer BioNTech COVID-19 vaccine to Dr. Richard Fine, head of anesthesiology, at Einstein Medical Center in Philadelphia, PA.
Director of nursing education Loraine Hopkins Pepe, left, administers the Pfizer BioNTech COVID-19 vaccine to Dr. Richard Fine, head of anesthesiology, at Einstein Medical Center in Philadelphia, PA.Credit…Hannah Yoon for The New York Times
  • Dec. 20, 2020, 3:40 p.m. ET

Striking a compromise between two high-risk population groups, a panel advising the Centers for Disease Control and Prevention voted Sunday to recommend that people 75 and older be next in line to receive the coronavirus vaccine in the United States, along with about 30 million “frontline essential workers,” including emergency responders, teachers and grocery store employees.

The debate about who should receive the vaccine in these early months has grown increasingly urgent as the daily tally of cases has swelled to numbers unimaginable even a month ago. The country has already begun vaccinating health care workers, and on Monday, CVS and Walgreens were to begin a mass vaccination campaign at the nation’s nursing homes and long-term care facilities. This week roughly six million doses of the newly authorized Moderna vaccine are to start arriving at more than 3,700 locations around the country, including many smaller and rural hospitals.

The panel of doctors and public health experts had previously indicated it would recommend a much broader group of Americans defined as essential workers — about 87 million people with jobs designated by a division of the Department of Homeland Security as critical to keeping society functioning — as the next priority population and that elderly people who live independently should come later.

But in hours of discussion on Sunday, the committee members concluded that given the limited initial supply of vaccine and the higher Covid-19 death rate among elderly Americans, it made more sense to allow the oldest among them to go next along with workers at the highest risk of exposure to the virus.

Groups of essential workers, such as construction and food service workers, the committee said, would be eligible for the next wave. Members did clarify that local organizations had great flexibility to make those determinations.

“I feel very strongly we do need to have that balance of saving lives and keeping our infrastructure in place,” said Dr. Helen Talbot, a member of the panel and infectious-disease specialist at Vanderbilt University.

Together, the two groups the committee voted to prioritize on Sunday number about 51 million people; federal health officials have estimated that there should be enough vaccine supply to inoculate all of them before the end of February.

Still, as the first week of vaccinations in the U.S. came to a close, frustrations were flaring about the pace of distribution. Some 128,000 shots had been given in the as of Friday, according to a New York Times database tracking vaccinations — a total that was just slightly more than half the number of new cases reported across the country that same day.

This weekend Gen. Gustave F. Perna, who heads the Trump administration’s distribution effort, apologized for more than a dozen states learning at the last minute that they would receive fewer doses next week of the vaccine manufactured by Pfizer than they had expected. Tensions were also broiling in some states over local decisions regarding which health care workers should get their shots immediately and which should wait.

The director of the C.D.C., Dr. Robert Redfield, will review the panel’s recommendation and decide, likely by Monday, whether to embrace it as the agency’s official guidance to states. The panel, the Advisory Committee on Immunization Practices, emphasized that its recommendations were nonbinding and that every state would be able to fine-tune or adjust them to serve the unique needs of its population.

The 13-to-1 vote came as frustrations flared about the pace of vaccine distribution. Some 128,000 shots have been given in the first five days of the vaccine United States, according to a New York Times database tracking vaccinations — just slightly more than half the number of new cases reported across the country on Friday alone. This weekend, Gen. Gustave F. Perna, who heads the Trump administration’s distribution effort, apologized for at least 14 states learning at the last minute that they would receive fewer doses of the vaccine manufactured by Pfizer next week than they had expected. Tensions were also flaring in some states over local decisions regarding which health care workers should get their shots immediately, and which should wait.

In addition to teachers, firefighters and police, a subgroup of the committee suggested that “frontline essential workers” should include school support staff; day care, corrections personnel, public transit, grocery store and postal workers; and those in working in food production and manufacturing. But the group’s official recommendation is not that specific.

Originally, the committee had signaled last month that they had been inclined to let 87 million essential workers receive vaccines ahead of adults 65 and older. Many had expressed their alarm that essential workers, who are often low-wage people of color, were being hit disproportionately hard by the virus and additionally were disadvantaged because of their lesser access to good health care.

general population.”

Falls Are Tied to Social Isolation

Social Isolation May Increase Your Risk of Falls

People who lived alone or who had few social contacts were up to 24 percent more likely to have falls than their socially connected peers.

Nicholas Bakalar

  • Dec. 14, 2020, 2:50 p.m. ET

Living alone or being socially isolated may increase the risk for falls in older people, British researchers report.

Their study, in Scientific Reports, included data on 4,013 men and women, most older than 60, who reported they had fallen, and on 9,285 who were hospitalized after a fall. The scientists used well-validated questionnaires to assign each participant a score on a scale of social isolation ranging from zero to six, with six indicating the fewest social contacts. They were also graded on a similar scale to measure how lonely they felt.

After adjusting for socioeconomic, health and lifestyle factors, they found that people who lived alone were 18 percent more likely to have reported a fall than those who lived with others, and those who scored six on the social isolation scale were 24 percent more likely to fall than those with a score of zero. Scores on the test of loneliness were not associated with falls after adjusting for social isolation and other variables.

The risk of falls resulting in hospitalization was 23 percent higher in people living alone and 36 percent higher among those with the least social contact compared with those with the most.

“The key message is that the elderly socially isolated are at greater risk for falls,” said the lead author, Feifei Bu, a senior research fellow at University College London. “We are encouraging people to look after them more closely, help with daily activities, keep in touch, and so on.”

Hearing Aids Could Use Some Help

the new old age

Hearing Aids Could Use Some Help

The vital medical devices could be inexpensive and available over the counter. But efforts have stalled under the F.D.A.

Credit…
Isabel Seliger

  • Dec. 14, 2020, 11:56 a.m. ET

By now, we were supposed to be swiftly approaching the day when we could walk into a CVS or Walgreens, a Best Buy or Walmart, and walk out with a pair of quality, affordable hearing aids approved by the Food and Drug Administration.

Hearing aids, a widely needed but dauntingly expensive investment, cost on average $4,700 a pair. (Most people need two.) So in 2017, Congress passed legislation allowing the devices to be sold directly to consumers, without a prescription from an audiologist. The next step was for the F.D.A. to issue draft regulations to establish safety and effectiveness benchmarks for these over-the-counter devices.

Its deadline: August 2020. A public comment period would follow, and then — right about now — the agency would be preparing its final rule, to take effect in May 2021. So by next summer, people with what is known as “perceived mild to moderate hearing loss” might need to spend only one-quarter of today’s price or less, maybe far less. And then we could have turned down the TV volume and stopped making dinner reservations for 5:30 p.m., when restaurants are mostly empty and conversations are still audible.

“These regulations are going to help a lot of people,” said Dr. Vinay Rathi, an otolaryngologist at Massachusetts Eye and Ear. “There could be great potential for innovation.”

So, where are the new rules? This long-sought alternative to the current state of hearing aid services has been delayed, perhaps one more victim of the pandemic.

Of course, the agency has other crucial matters to address just now. Although the office charged with hearing aid regulations is not the one assessing Covid-19 vaccines, an F.D.A. spokesman said via email that it was dealing with “an unprecedented volume of emergency use authorizations” for diagnostics, ventilators and personal protective equipment.

Nevertheless, “issuing the proposed rule remains a priority and we are working expeditiously to do so,” the spokesman added, providing no timetable for when that might happen.

It’s a major undertaking. The F.D.A. has never established such requirements for hearing aids, because ever since it last issued regulations, in 1977, only state-licensed providers have been allowed to prescribe and sell them — and have been presumed able to safeguard wearers. Providers and manufacturers have also kept prices high by combining testing, fitting and sales into one costly package, a practice the new law was designed to disrupt.

No other country has regulated over-the-counter hearing aids, according to Dr. Frank Lin, an otolaryngologist and director of the Cochlear Center for Hearing and Public Health at Johns Hopkins University. “We’ll be the first,” he said. “There are no performance requirements. There’s no precedent.”

But, Dr. Rathi said, “it’s not like the F.D.A. put everything else on hold.” He pointed to an array of regulations issued last month by the agency, including guidance on cross-labeling oncology medications and rules on impurities in animal drugs. “They’re still going about a lot of their regular business.”

Recently he and a colleague wrote an editorial in The New England Journal of Medicine that questioned the delay, under a pointed title, “Deafening Silence from the F.D.A.”

Senator Elizabeth Warren, Democrat of Massachusetts and Senator Chuck Grassley, Republican of Iowa, who were among the sponsors of the bipartisan 2017 law, wrote to the F.D.A. commissioner last month urging action. They noted that “despite the pandemic, hearing loss continues to be a problem for millions of Americans.” In fact, masks and distancing create greater hearing difficulties.

One-quarter of Americans in their 60s and nearly two-thirds of those over 70 have hearing loss. Its damaging consequences can include social isolation, an increased risk of falls and much higher rates of dementia.

Yet a recent analysis of federal data shows that despite modest increases, in 2018 only about 18.5 percent of Medicare beneficiaries over 70 owned and used hearing aids.

Usage was lower among women than men and far lower among Black beneficiaries than white ones; the proportion of low-income seniors using hearing aids actually declined to 10.8 percent in 2018 from 12.4 percent in 2011.

Stigma explains some of that aversion. Hearing aids can feel like “constant reminders of aging,” said Kevin Franck, director of audiology at Massachusetts Eye and Ear and an author of the New England Journal editorial. “We have people who come in who want to hide them.”

The inconvenience of multiple visits to an audiologist or technician for testing, fitting and adjustment probably also plays a role.

But expense constitutes a formidable barrier. Traditional Medicare covers testing but not hardware or other services. (It does cover cochlear implants, for those whose hearing loss grows too severe for hearing aids.) Many Medicare Advantage plans provide some hearing coverage, but beneficiaries still wind up paying 79 percent of the cost out of pocket.

“It’s the No. 1 question we get,” said Barbara Kelley, executive director of the Hearing Loss Association of America. “‘I can’t afford hearing aids and Medicare doesn’t cover them. What do I do?’”

Advocates plan to keep lobbying Congress for Medicare coverage for hearing services and aids, included in the expansive bill H.R.3 that passed the House of Representatives last year but never came to a Senate vote.

In the meantime, over-the-counter devices retailing for several hundred dollars could make hearing aids broadly more affordable, for people or — one day, perhaps — for Medicare.

They could also solve another consumer problem, Dr. Lin added. Manufacturers can legally sell PSAPs — personal sound-amplification products that resemble hearing aids — as long as they don’t advertise them as a remedy for hearing loss. Their quality varies drastically.

The Hopkins team has been testing whether trained community health workers could help low-income seniors improve their hearing. (A pilot study indicates they can.) Their research protocol uses an effective PSAP from Sound World Solutions that retails for about $700 a pair.

But, Dr. Lin said, “most of what you see out there — ‘$50 miracle device!’ — is complete garbage. People can’t tell which to trust.”

Once federal requirements are set for over-the-counter hearing aids, however, manufacturers of quality PSAPs can apply for approval. “All the other PSAPs will go by the wayside,” Dr. Lin said. If their labels say they’re not approved by the F.D.A., “nobody will buy them, and they shouldn’t.”

Eyeing a vast and underserved market, consumer electronics companies (said to include Apple and Samsung) are standing by, along with start-ups. “There’s a lot of venture capital funding for hearing technology, once the barriers come down,” Dr. Rathi said.

Bose acted early, receiving F.D.A. clearance in 2018 for its Hearphone, which the buyer could tune with a smartphone app. But without the new rule, state restrictions would have prevented national sales, so Bose didn’t market it.

The company is working on a new over-the-counter product, however. “We’re cautiously optimistic that 2021 will be the year,” said Brian Maguire, director of the Bose Hear group.

Once the F.D.A. acts and companies and retailers ramp up, expect new products and advertisements to pop up in stores and online. “We’ll have a bit of a Wild West period,” Ms. Kelley said. “People are going to be confused. They’re going to need a lot of information.”

At that point, audiologists will no longer serve as exclusive gatekeepers to hearing aids. But they can still render important services: testing, education and counseling, adjusting devices — even if clients bought them elsewhere.

“Wearing something comfortably in your ear all day, day after day, is a challenge,” Dr. Franck said. “You want it customized. If you hear echoes or feedback, audiologists know a lot about those issues.”

But the country has only about 18,000 audiologists, Ms. Kelley pointed out. Particularly in rural areas, people with hearing loss might need to drive hours to find one.

But a supermarket? A big box store? A pharmacy? A website? Almost everyone can get to one of those.

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The Elderly vs. Essential Workers: Who Should Get the Coronavirus Vaccine First?

The Elderly vs. Essential Workers: Who Should Get the Coronavirus Vaccine First?

The C.D.C. will soon decide which group to recommend next, and the debate over the trade-offs is growing heated. Ultimately, states will decide whom to include.

The Department of Homeland Security’s list of essential workers is long and varied, including jobs such as tugboat operators and these grocery store clerks in Brooklyn.
The Department of Homeland Security’s list of essential workers is long and varied, including jobs such as tugboat operators and these grocery store clerks in Brooklyn.Credit…Juan Arredondo for The New York Times
  • Dec. 5, 2020, 10:41 a.m. ET

With the coronavirus pandemic surging and initial vaccine supplies limited, the United States faces a hard choice: Should the country’s immunization program focus in the early months on the elderly and people with serious medical conditions, who are dying of the virus at the highest rates, or on essential workers, an expansive category encompassing Americans who have borne the greatest risk of infection?

Health care workers and the frailest of the elderly — residents of long-term-care facilities — will almost certainly get the first shots, under guidelines the Centers for Disease Control and Prevention issued on Thursday. But with vaccination expected to start this month, the debate among federal and state health officials about who goes next, and lobbying from outside groups to be included, is growing more urgent.

It’s a question increasingly guided by concerns over the inequities laid bare by the pandemic, from disproportionately high rates of infection and death among poor people and people of color to disparate access to testing, child care and technology for online schooling.

“It’s damnable that we are even being placed in this position that we have to make these choices,” said the Rev. William J. Barber II, a co-chairman of the Poor People’s Campaign, a national coalition that calls attention to the challenges of the working poor. “But if we have to make the choice, we cannot once again leave poor and low-wealth essential workers to be last.”

Ultimately, the choice comes down to whether preventing death or curbing the spread of the virus and returning to some semblance of normalcy is the highest priority. “If your goal is to maximize the preservation of human life, then you would bias the vaccine toward older Americans,” Dr. Scott Gottlieb, the former Food and Drug Administration commissioner, said recently. “If your goal is to reduce the rate of infection, then you would prioritize essential workers. So it depends what impact you’re trying to achieve.”

The trade-off between the two is muddied by the fact that the definition of “essential workers” used by the C.D.C. comprises nearly 70 percent of the American work force, sweeping in not just grocery store clerks and emergency responders, but tugboat operators, exterminators and nuclear energy workers. Some labor economists and public health officials consider the category overbroad and say it should be narrowed to only those who interact in person with the public.

Essential and Frontline Occupations

About 70 percent of workers in the U.S. have jobs that are considered essential. A subset are considered “frontline” workers, meaning their jobs cannot be performed from home. Hover or tap to see each job.

Essential

Frontline

By Matthew Conlen·Note: States may have differing definitions of essential workers. | Sources: Labor Market Information Institute, Council for Community and Economic Research, National Bureau of Economic Research, U.S. Bureau of Labor Statistics, Cybersecurity and Infrastructure Security Agency

An independent committee of medical experts that advises the C.D.C. on immunization practices will soon vote on whom to recommend for the second phase of vaccination — “Phase 1b.” In a meeting last month, all voting members of the committee indicated support for putting essential workers ahead of people 65 and older and those with high-risk health conditions.

Historically, the committee relied on scientific evidence to inform its decisions. But now the members are weighing social justice concerns as well, noted Lisa A. Prosser, a professor of health policy and decision sciences at the University of Michigan.

“To me the issue of ethics is very significant, very important for this country,” Dr. Peter Szilagyi, a committee member and a pediatrics professor at the University of California, Los Angeles, said at the time, “and clearly favors the essential worker group because of the high proportion of minority, low-income and low-education workers among essential workers.”

That position runs counter to frameworks proposed by the World Health Organization, the National Academies of Sciences, Engineering, and Medicine, and many countries, which say that reducing deaths should be the unequivocal priority and that older and sicker people should thus go before the workers, a view shared by many in public health and medicine.

Dr. Robert Redfield, the C.D.C. director and the nation’s top public health official, reminded the advisory committee of the importance of older people, saying in a statement on Thursday that he looked forward to “future recommendations that, based on vaccine availability, demonstrate that we as a nation also prioritize the elderly.”

Once the committee votes, Dr. Redfield will decide whether to accept its recommendations as the official guidance of the agency. Only rarely does a C.D.C. director reject a recommendation from the committee, whose 14 members are selected by the Health and Human Services secretary, serve four-and-a-half-year terms and have never confronted a task as high in profile as this one.

But ultimately, the decision will be up to governors and state and local health officials. They are not required to follow C.D.C. guidelines, though historically they have done so.

Defining ‘essential’

The drive-through window at a fast food restaurant in Albuquerque. Food service workers have high rates of infection from the coronavirus.
The drive-through window at a fast food restaurant in Albuquerque. Food service workers have high rates of infection from the coronavirus.Credit…Adria Malcolm for The New York Times

There are about 90 million essential workers nationwide, as defined by a division of the Department of Homeland Security that compiled a roster of jobs that help maintain critical infrastructure during a pandemic. That list is long, and because there won’t be enough doses to reach everyone at first, states are preparing to make tough decisions: Louisiana’s preliminary plan, for example, puts prison guards and food processing workers ahead of teachers and grocery employees. Nevada’s prioritizes education and public transit workers over those in retail and food processing.

Share of workers in essential and frontline jobs, by state

By Matthew Conlen·Note: States may have different definitions of essential workers. | Sources: Labor Market Information Institute, Council for Community and Economic Research, National Bureau of Economic Research, U.S. Bureau of Labor Statistics, Cybersecurity and Infrastructure Security Agency

At this early point, many state plans put at least some people who are older and live independently, or people who have medical conditions, ahead of most essential workers, though that could change after the C.D.C. committee makes a formal recommendation on the next phase.

One occupation whose priority is being hotly debated is teaching. The C.D.C. includes educators as essential workers. But not everyone agrees with that designation.

Marc Lipsitch, an infectious-disease epidemiologist at Harvard’s T.H. Chan School of Public Health, argued that teachers should not be included as essential workers, if a central goal of the committee is to reduce health inequities.

“Teachers have middle-class salaries, are very often white, and they have college degrees,” he said. “Of course they should be treated better, but they are not among the most mistreated of workers.”

Elise Gould, a senior economist at the Economic Policy Institute, disagreed. Teachers not only ensure that children don’t fall further behind in their education, she said, but are also critical to the work force at large.

An empty classroom in Ohio. Public health experts disagree on whether teachers should get a top priority for the vaccine.Credit…Kyle Grillot/Reuters

“When you talk about disproportionate impact and you’re concerned about people getting back into the labor force, many are mothers, and they will have a harder time if their children don’t have a reliable place to go,” she said. “And if you think generally about people who have jobs where they can’t telework, they are disproportionately Black and brown. They’ll have more of a challenge when child care is an issue.”

In September, academic researchers analyzed the Department of Homeland Security’s list of essential workers and found that it broadly mirrored the demographics of the American labor force. The researchers proposed a narrower, more vulnerable category — “frontline workers,” such as food deliverers, cashiers and emergency medical technicians, who must work face to face with others and are thus at greater risk of contracting the virus.

By this definition, said Francine D. Blau, a labor economist at Cornell University and an author of the study, teachers belong in the larger category of essential workers. However, when they work in classrooms rather than remotely, she said, would they fit into the “frontline” group. Individual states categorize teachers differently.

Dr. Blau said that if supplies are short, frontline workers should be emphasized. “These are a subset of essential workers who, given the nature of their jobs, must provide their labor in person. Prioritizing them makes sense given the heightened risk that they face.”

The analysis, a working paper for the National Bureau of Economic Research, is in line with other critics, who say that the list of essential workers is too wide-ranging.

“If groups are too large, then you’re not really focusing on priorities,” said Saad B. Omer, director of the Yale Institute for Global Health, who worked on the vaccination frameworks for the W.H.O. and the National Academies.

The essential workers on the federal list make up nearly 70 percent of the American labor force, the researchers said, compared with 42 percent for the frontline workers. Women made up 39 percent of frontline workers and, in certain occupations, far more. Frontline workers’ education levels are lower, as are their wages — on average, just under $22 an hour. The proportion of Black and Hispanic workers is higher than in the broader category of essential workers.

Death vs. transmission

A nursing home resident in Brooklyn being taken to a hospital last April. The C.D.C. recommends that residents of long-term care facilities, along with health care workers, get the very first vaccines.Credit…Lucas Jackson/Reuters

Some health policy experts said that to prioritize preventing deaths rather than reducing virus transmission was simply a pragmatic choice, because there won’t be enough vaccine initially available to make a meaningful dent in contagion. A more effective use of limited quantities, they say, is to save the lives of the most frail.

Moreover, vaccine trial results so far show only that the shots can protect the individuals who receive them. The trials have not yet demonstrated that a vaccinated person would not infect others. Though scientists believe that is likely to be the case, it has yet to be proved.

Harald Schmidt, an expert in ethics and health policy at the University of Pennsylvania, said that it is reasonable to put essential workers ahead of older adults, given their risks, and that they are disproportionately minorities. “Older populations are whiter, ” Dr. Schmidt said. “Society is structured in a way that enables them to live longer. Instead of giving additional health benefits to those who already had more of them, we can start to level the playing field a bit.”

But to protect older people more at risk, he called on the C.D.C. committee to also integrate the agency’s own “social vulnerability index.”

The index includes 15 measures derived from the census, such as overcrowded housing, lack of vehicle access and poverty, to determine how urgently a community needs health support, with the goal of reducing inequities.

In a new analysis of the states’ preliminary vaccine plans, Dr. Schmidt found that at least 18 states intended to apply the index. Tennessee, for one, has indicated that it will reserve some of its early allotments for disadvantaged communities.

Still, some people believe it is wrong to give racial and socioeconomic equity more weight than who is most likely to die.

“They need to have bombproof, fact-based, public-health-based reasons for why one group goes ahead of another,” said Chuck Ludlam, a former Senate aide and biotech industry lobbyist who protested putting essential workers ahead of older people in comments to the committee. “They have provided no explanation here that will withstand public scrutiny.”

Blurred lines, many unknowns

Employees of the Four Seasons Rehabilitation and Nursing in Westland, Mich., demonstrated for better pay and protections during an outbreak of Covid-19 in October.Credit…Emily Elconin/Reuters

Further complicating matters, the different priority groups discussed by the C.D.C. committee are overlapping — many essential workers have high-risk conditions, and some are older than 65. Some states have suggested that they will prioritize only essential workers who come face to face with the public, while others have not prioritized them at all.

Even some people whose allegiance lies with one group have made the case that others should have an earlier claim on the vaccine. Marc Perrone, president of the United Food and Commercial Workers Union, which represents 1.3 million grocery and food processing workers, said that despite the high rate of infection among his members, he thought that older adults should go first.

“Here’s the thing: Everybody’s got a grandmother or grandfather,” Mr. Perrone said. “And I do believe almost everybody in this country would want to protect them, or their aging parents.”

But Dr. Nirav Shah, Maine’s top public health official, said he respectfully disagreed, repeating the explanation he had given his in-laws — who are older but in good health and able to socially distance.

He said: “I’ve told them: ‘You know what? I’m sorry, but there are others that I need to get this vaccine to first, so that when you guys get vaccinated, the world you come back into is ready to receive you.’”

All these plans are, of course, unfurling with essential information still unknown.Many state officials said that as on-the-ground realities emerge, they fully expect their plans to evolve.

One uncertainty: given the high rates of apprehension swirling around this vaccine, how many people in the early groups will actually line up for it?

“If a high proportion of essential workers decline to get the vaccine, states will have to quickly move onto the next group anyway,” said Dr. Prosser, the University of Michigan health analyst. “Because once the vaccines arrive, they will have to be used in a certain amount of time before they degrade.”

Additional work by Jugal K. Patel.

Who Will Get the Coronavirus Vaccine First?

After months of deliberation and debate, a panel of independent experts advising the Centers for Disease Control and Prevention is set to decide on Tuesday which Americans it will recommend to get the coronavirus vaccine first, while supply is still short.

The panel, the Advisory Committee on Immunization Practices, will vote in a public meeting on Tuesday afternoon, and it is expected to advise that health care workers be first in line, along with residents of nursing homes and other long-term care facilities. If the C.D.C. director, Dr. Robert R. Redfield, approves the recommendations, they will be shared with states, which are preparing to receive their first vaccine shipments as soon as mid-December, if the Food and Drug Administration approves an application for emergency use of a vaccine developed by Pfizer.

States don’t have to follow the C.D.C.’s recommendations, but most probably will, said Dr. Marcus Plescia, the chief medical officer for the Association of State and Territorial Health Officials, which represents state health agencies. The committee will meet again soon to vote on which groups should be next to receive priority.

Here are answers to some common questions about the vaccine and its distribution.

Who will get the vaccine first?

Based on its recent discussions, the C.D.C. committee will almost certainly recommend that the nation’s 21 million health care workers be eligible before anyone else, along with three million mostly elderly people living in nursing homes and other long-term care facilities.

A staggering 39 percent of deaths from the coronavirus have occurred in long-term care facilities, according to the committee. But there won’t be enough doses at first to vaccinate everyone in these groups; Pfizer and Moderna, the two companies closest to gaining approval for their vaccines, have estimated that they will have enough to vaccinate no more than 22.5 million Americans by January. So each state will have to decide which health care workers go first.

They may choose to prioritize critical care doctors and nurses, respiratory therapists and other hospital employees, including cleaning staff, who are most likely to be exposed to the coronavirus. Or they may offer the vaccine to older health care workers first, or those working in nursing homes, who are at higher risk of contracting the virus. Gov. Andy Beshear of Kentucky said on Monday that most of his state’s initial allocation would go to residents and employees of long-term care facilities, with a smaller amount going to hospital workers.

It’s important to remember that everyone who gets a vaccine made by Pfizer or Moderna will need a second shot — three weeks later for Pfizer’s, four weeks for Moderna’s.

Who gets it next?

The C.D.C. committee hinted last week that it would recommend essential workers be next in line. About 87 million Americans work in food and agriculture, manufacturing, law enforcement, education, transportation, corrections, emergency response and other sectors. They are at increased risk of exposure to the virus because their jobs preclude them from working from home. And these workers are disproportionately Black and Hispanic, populations that have been hit especially hard by the virus.

Individual states may decide to include in this group employees of industries that have been particularly affected by the virus. Arkansas, for example, has proposed including workers in its large poultry industry, while Colorado wants to include ski industry workers who live in congregate housing.

After essential workers, the priority groups likely to be recommended by the C.D.C. committee are adults with medical conditions that put them at high risk of coronavirus infection, and people over 65. But again, some states might diverge to an extent, choosing, for example, to vaccinate residents over 75 before some types of essential workers. All other adults would follow. The vaccine has not yet been thoroughly studied in children, so they would not be eligible yet.

If the C.D.C. director, Dr. Robert R. Redfield, approves the panel’s recommendations, they will be shared with states.
If the C.D.C. director, Dr. Robert R. Redfield, approves the panel’s recommendations, they will be shared with states.Credit…Stefani Reynolds for The New York Times

Who will make state-level decisions about priority groups?

Each state has a working group, composed largely of public health officials, that has been planning for months and making decisions about vaccination campaigns. Each state’s top health official and governor will probably sign off on final plans.

How long will states focus on one priority group before moving to the next in line?

States don’t need to reach everyone in one priority group before moving on to the next, according to the C.D.C. advisory committee. But more federal guidance is expected on the subject.

When will the first doses of a vaccine be shipped, and where will they go?

Federal officials have said they plan to ship the first 6.4 million doses within 24 hours after the F.D.A. authorizes a vaccine, and the number each state receives will be based on a formula that considers its adult population. Pfizer will ship special coolers, each containing at least 1,000 doses, directly to locations determined by each state’s governor. At first, almost all of those sites will probably be hospitals that have confirmed they can store shipments at minus 94 degrees Fahrenheit, as the Pfizer vaccine requires, or use them quickly.

When will a vaccine be available to the general public, and where will people receive it?

Federal officials have repeatedly suggested that people who are not in the priority groups — healthy adults under 65 who don’t work in health care or otherwise qualify as essential workers — should have access to the vaccine by May or June, because there will be enough supply by then. But a lot will have to go right for that to happen. One factor is whether, or when, other vaccines besides Pfizer’s and Moderna’s are approved.

Can employers like hospitals or grocery stores require their employees to be vaccinated?

Employers do have the right to compel their workers to be vaccinated. Many hospital systems, for example, require annual flu shots. But employees can seek exemptions based on medical reasons or religious beliefs. In such cases, employers are supposed to provide a “reasonable accommodation”; with a coronavirus vaccine, a worker might be allowed to wear a mask in the office instead, or to work from home.

Three companies have announced preliminary data indicating their vaccines are effective, and there are dozens of additional candidates in clinical trials. Can I choose which vaccine I get?

This depends on a number of factors, including the supply in your area at the time you’re vaccinated and whether certain vaccines are found to be more effective in certain populations, such as older adults. At first, the only choice is likely to be Pfizer’s vaccine, assuming it is approved. Moderna asked the F.D.A. for emergency authorization on Monday; if approved, it would most likely become available within weeks after Pfizer’s.

Are there any side effects from the shot?

Some participants in both Pfizer’s and Moderna’s trials have said they experienced symptoms including fever, muscle aches, bad headaches and fatigue after receiving the shots, but the side effects generally did not last more than a day. Still, preliminary data suggests that, compared with most flu vaccines, the coronavirus shots have a somewhat higher rate of such reactions, which are almost always normal signs that the body’s immune response is kicking in. At the meeting of the C.D.C. advisory committee last week, some members said it would be important for doctors to warn their patients about possible side effects and assure them of the vaccines’ safety.

How do I know it’s safe?

Each company’s application to the F.D.A. includes two months of follow-up safety data from Phase 3 of clinical trials conducted by universities and other independent bodies. In that phase, tens of thousands of volunteers get a vaccine and wait to see if they become infected, compared with others who receive a placebo. By September, Pfizer’s trial had 44,000 participants; no serious safety concerns have been reported.

The F.D.A. will also review the data for each vaccine seeking authorization and share it with its advisory committee, which will meet publicly — in the case of the Pfizer vaccine, on Dec. 10 — to ask questions and make a recommendation to the agency. The F.D.A. will then decide whether to approve the vaccine for emergency use.

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Finding Ways to Keep Patients at Home

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My patient was a proudly elegant woman in her 70s who lived alone. Her Parkinson’s disease had so severely restricted her ability to move that it would take her hours to get dressed in the morning. And leaving the house was virtually impossible, so she had to rely on neighbors and friends from her church community for help with shopping.

She was adamant that she wouldn’t want aggressive treatment to keep her alive. She’d been hospitalized many times, and she told me she wouldn’t want to take a hospital bed that would be better used for someone else. So she dutifully completed an advance directive that made her wishes clear. It said that she would not want to be kept alive on a breathing machine, and that she wouldn’t want cardiopulmonary resuscitation if her heart stopped. She also wouldn’t want to be fed through a tube if she was no longer able to eat. What was most important to her, though, was staying at home and avoiding a nursing home.

As a palliative care physician, I always urge my patients to complete advance directives. These are legal documents that tell doctors and family members what treatment they do and don’t want if they’re ever unable to make decisions for themselves. That’s important, because if I don’t know what my patients want, the default is to do everything to keep them alive, which typically results in unnecessary and costly treatment. Indeed, one of the most often-cited arguments for advance directives is the fact that 25 percent of Medicare spending is for people in the last year of life.

When my patient developed a cough and a fever, likely a result of pneumonia, she became too confused to make decisions for herself. Thanks to her advance directive, her family knew that she didn’t want aggressive treatment, and we knew that she wanted to stay home. So we arranged for short-term daily nursing visits and enough support so that, with additional help from her family, she was able to remain at home as she wanted.

I thought that she would get worse without aggressive treatment in the hospital, and that we would enroll her in hospice, so I was surprised when she began to improve. Soon she was able to make decisions for herself and even returned to the same level of independence that she’d had before she became sick. That’s when it became obvious to me that advance directives have their limits.

My patient lived, as many people with chronic, serious illnesses do, on a thin ledge of independence. The smallest nudge — a few missed medication doses, the loss of just a little support — left her entirely vulnerable. In my patient’s case, that nudge came two months later, when her neighbors ran into financial problems and their daughter, who had been doing the grocery shopping for my patient, had to take an after-school job. My patient valued her independence more than anything, so whenever her neighbors and her out-of-state family checked on her, or when we called her, she told us all that she was fine.

For three weeks, my patient subsisted on nothing but white rice, because that was all she had in the house. When her grand niece called us and asked us to check on her, we sent a social worker and a nurse to visit her. We found her housebound, surrounded by garbage, with no clean laundry and no toilet paper.

Despite our best efforts, we couldn’t do enough to keep her safe at home, so she went to live in a nursing home, where she spent the last two months of her life. An advance directive had helped her stay out of the hospital, as she had wanted. And perhaps it even made a bed available for someone who needed it more, as she’d hoped. But that piece of paper didn’t help her to live out her final months with the sort of comfort and dignity that she deserved.

When we talk about advance directives and reducing costly and unnecessary treatment at the end of life, we should also be talking about ways we can provide more support. We need to make sure that people like my patient have access to the kinds of care that can help them remain safely and comfortably at home.

Now when I help my patients complete an advance directive that defines the treatment they don’t want, we also discuss what support they’ll need in the future. I talk with my patients and their families about what’s going to be necessary to keep them safe and comfortable in their homes today, and next month and — if they’re lucky — for the next few years.

Those sorts of discussions are essential, but they’re not enough. We also need to revise the way we think about advance directives. Advance directives help reduce health care costs at the end of life by avoiding aggressive treatment, but that’s not the most compelling argument for them. It’s not enough to reduce what we spend on aggressive treatment at the end of life; we also need to spend those resources in better ways.

For someone around my patient’s age, the average cost of a hospitalization is about $13,000. So Medicare should have been willing to spend $13,000 to keep her safe and comfortable at home. That sum would have been more than enough to pay for a visiting nurse to continue to check on her after she recovered from pneumonia and a home health aide to help her with bathing and dressing. And it could have paid the girl next door to do her grocery shopping so a frail elderly woman didn’t need to subsist on white rice because it was the only food she had.

We should have been able to provide all of that help. My patient was adamant that she didn’t want to spend her last days of life in a hospital, taking up a bed that someone else could use. Let’s make sure that when people like her forgo costly treatment at the end of life, they get something in return.

Dr. David Casarett is a professor at the University of Pennsylvania Perelman School of Medicine and the author of “Stoned: A Doctor’s Case for Medical Marijuana.”

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A Mother’s Lesson: When Memory Fails, Delight in the Moment

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Credit Giselle Potter

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In 1988, the author’s mother wrote in The Times about her own mother’s dementia. <a href="http://timesmachine.nytimes.com/timesmachine/1988/01/31/399888.html?pageNumber=159">Read the full article in TimesMachine. </a>

In 1988, the author’s mother wrote in The Times about her own mother’s dementia. Read the full article in TimesMachine. Credit The New York Times

The first sign that the Alzheimer’s disease that ravaged my grandmother was back for her daughter was when Mom began having trouble saying “CNN.” She’d watched the cable news network for years with ferocious interest ever since returning from a life abroad in the Foreign Service to rural New Hampshire. There she nested in her mother’s house, saying she’d never move.

It was a distinctly peaceful life. I’d listen to her play the grand piano — the passion that had taken her to Juilliard decades earlier — and marvel at the lightness of her hands on the keys. On Sundays, she was the favorite lector at our church, reading the liturgy with an elegance instilled by her mother and grandmother, both trained elocutionists.

She also wrote and recorded essays on country living for NPR on subjects like “Mahler and Macaroni.” Words mattered a great deal to her. She mattered the world to me. I used to say I’d won the lottery when it came to mothers.

After Dad died, my mother continued to live alone in the big white house on the common. It was here in 1988 that she’d written a keenly observed Sunday commentary for this newspaper about her own mother’s battle with aging — and the dementia that “erased her life, line by line.”

She wanted me to promise that if her own light dimmed – or as she put it, “when I lose my mind too” – I wouldn’t upend my own life to care for her. But we never came up with a real plan.

About a year after CNN became “C…D…D…” and the home care team we’d improvised announced my mother’s decline was too much for them, my brothers and I barely convinced her to “visit” sunny California where my middle brother lived.

That visit became a new “post” in a fancy retirement community where, for $7,500 a month, she had her own studio and bathroom. She enjoyed music events and a stately dining room with a menu. There was even a church on the corner.

But like so many living with Alzheimer’s, Mom’s biorhythms were upside down. She’d often sleep during the day and be up all night doing what is known as “exit-seeking.”

Nights are the Achilles heel of most eldercare facilities staffed by the fewest caregivers — and the most inexperienced. Across the country, in many well-meaning Alzheimer’s units, memory care residents are treated with confinement.

So Mom “graduated” to the locked Memory Care unit for her “safety.” It broke my heart to watch her on tiptoes, peering through the locked door’s porthole across to the dining room she once enjoyed.

Alzheimer’s is not a mere matter of Swiss cheese memory and odd behaviors. It is a serious medical condition. It is terminal. It should be known for what it is: Brain Failure.

One morning, Mom emerged from her Memory Care room covered with bruises. The police came. The state came. There was even suggestion of a rape kit because my mother, clearly agitated, could say only, “the man, the man.”

We will never know what happened. But it stands to reason that if you lock up the most advanced Alzheimer’s residents with their attendant behavioral disorders, and apply nominal supervision, well, something is bound to happen. On the night in question, one newly hired caregiver attended 17 residents.

So we moved her again, this time to Seattle, close to my eldest brother and me, thereby violating the cardinal rule of Alzheimer’s care: thou shalt not move the patient. Change registers a full 10 on the Alzheimer’s Richter scale. The more Mom’s brain failed, the more I twirled to try to make things better.

Within a matter of weeks in the new place, she had fallen and broken her hip. Surgery followed, then three months in a rehab facility, and finally a move to a small adult family home with just six residents. She was exhausted and utterly disoriented. I was a wreck.

Still, I knew I was among the lucky ones. Despite the recent scan that showed her brain a mostly blank white slate, my mother somehow always managed to recognize me during our visits (although she’d begun calling me “Mom.”)

Where once I’d thought I’d lose my mind if she asked me the same question one more time, now I prayed to hear any full sentence just one more time. Ever the peripatetic family caregiver, I rarely stopped to inhabit my mother’s world: the one with no past, no future, just the present.

On our last Mother’s Day together, I took her to the big morning Mass at St. James Cathedral. As I attempted a Houdini maneuver getting her out of the car, up the curb and down the sidewalk to the church door, she somehow slithered from my grasp.

My mother sank to the ground in what seemed like slow motion. She never made a sound. She just lay there in the green grass in her rose-colored tweed suit, brilliant white hair glinting in the spring sun, blue eyes open wide, staring straight up into an unusually cloudless Seattle sky.

With church bells pealing through the cool morning air, my beautiful, brilliant mother stretched out her arms and made angels wings in the grass.

And all the doctors and all the medications and all the years of worry that couldn’t bring my mother back together again, also couldn’t defeat the magic of that moment.

I lay down next to her, threaded my fingers through hers, and for a brief wondrous moment, we held the present.

Mary Claude Foster is a journalist living in Seattle.

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Aging in Place

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Credit Paul Rogers

When I asked the other three members of my walking group, all of whom are in their mid to upper 70s, whether they had any concerns about future living arrangements, they each said they had none despite the fact that, like me, they live in multistory private homes without elevators and, in two cases, without bathrooms on every floor.

My Los Angeles son asked recently what I might do if I could no longer live in my house, and I flippantly replied, “I’m coming to live with you.” The advantages: I’d be surrounded by a loving and supportive family, and the warm weather is a benefit for someone like me who becomes increasingly intolerant of the cold with each passing year. The disadvantages: I’d lose a familiar community and a host of friends, and his house, unlike mine, is on a steep hill with no nearby stores; if I could no longer drive, I’d have to be chauffeured everywhere.

Probably my biggest deterrent would be relinquishing my independence and the incredible number of “treasures” I’ve amassed over the last half century. The junk would be easy, but parting with the works of art and mementos would be like cutting out my heart.

I suspect that most people are reluctant to think about changing where and how they live as long as they are managing well at the moment. Lisa Selin Davis reports in AARP magazine that “almost 90 percent of Americans 65 or older plan to stay in their homes as they age.” Yet for many, the design of their homes and communities does not suit older adults who lack the mobility, agility and swiftness of the young.

For those who wish to age in place, the authors of “70Candles: Women Thriving in Their 8th Decade,” Jane Giddan and Ellen Cole, list such often-needed home attributes as an absence of stairs, wide doorways to accommodate a walker or wheelchair, slip-resistant floors, lever-style door knobs, remotely controlled lighting, walk-in showers, railings, ramps and lifts. Add to these a 24-hour help system, mobile phone, surveillance cameras and GPS locaters that enable family members to monitor the well-being of their elders.

In many communities, volunteer organizations, like Good Neighbors of Park Slope in Brooklyn and Staying in Place in Woodstock, N.Y., help older residents remain in their homes and live easier and more fulfilling lives.

While many young adults chose to live and bring up children in the suburbs, a growing number of empty-nested retirees are now moving to city centers where they can access public transportation, shop on foot for food and household needs, and enjoy cultural offerings and friendly gatherings without depending unduly on others.

One reason my friends and I are unwilling to even consider leaving our Brooklyn community is our ability to walk to supermarkets, banks, food co-ops, hardware stores, worship and recreational facilities, and get virtually everywhere in the city with low-cost and usually highly efficient public transportation. No driving necessary.

We also wallow in the joys of near-daily walks in a big, beautiful urban park, remarking each time about some lovely vista — the moon, sunrise, visible planets, new plantings and resident wildlife.

Throughout the country, communities are being retrofitted to accommodate the tsunami of elders expected to live there as baby boomers age. Changes like altering traffic signals and street crossings to give pedestrians more time to cross enhance safety for people whose mobility is compromised. New York City, for example, has created Aging Improvement Districts, so far in East Harlem, the Upper West Side and Bedford-Stuyvesant, to help older people “live as independently and engaged in the city as possible,” Ms. Giddan and Ms. Cole wrote. In East Harlem, for example, merchants have made signs easier to read and provided folding chairs for seniors who wish to rest before and after shopping.

In Philadelphia, a nonprofit organization, Friends in the City, calls itself a “community without walls” designed to bring members closer to the city’s resources and to one another. It offers seniors a daily variety of programs to suit many cultural and recreational interests.

Also evolving is the concept of home sharing, in which several older people who did not necessarily know one another get together to buy a home in which to live and share responsibilities for shopping, cooking, cleaning and home repair. For example, in Oregon, Let’s Share Housing, and in Vermont, Home Share Now, have online services that connect people with similar needs, Ms. Giddan and Ms. Cole report. There’s also an online matching service — Roommates4Boomers.com — for women 50 and over looking for compatible living mates.

Of course, there are still many older adults, widows and widowers in particular, who for financial or personal reasons move in with a grown child’s family, sometimes in an attached apartment or separate floor. Host families may gain a built-in babysitter, and children can develop a more intimate relationship with grandma or grandpa.

For those with adequate finances, there is no shortage of for-profit retirement communities that help older people remain independent by providing supportive services and a host of amenities and activities. Some have extensive recreational and exercise facilities, as well as book and craft clubs, discussion groups and volunteer opportunities. Some take residents to theatrical productions and museums and on trips to nearby attractions.

I confess that retirement communities that house only older adults are not my style. I can’t imagine living in a place where I don’t see and interact with children on a daily basis. I find that nothing cheers me more than a smile or comment from a toddler. I guess I take after my father, who used to flirt with every child he noticed in a car near his. But I realize that, just as some people are averse to dogs, not everyone enjoys the companionship of a high-energy child.

For older people likely to require help with the activities of daily living, there are many assisted living facilities where residents can get more or less help, including aid with medications, feeding and ambulation, according to their changing needs.

And should I ever have to leave my home, Ms. Giddan and Ms. Cole point out that there is a new and growing cadre of professional organizers and moving managers to “help people sort through accumulated belongings, distribute and disperse what won’t be needed in the new setting, and assist with all stages of packing, moving and then unpacking, and staging the new home.”

This is the second of two columns about adjustments to aging. Read the first part: “Thriving at Age 70 and Beyond.”

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Seeing the Cycle of Life in My Baby Daughter’s Eyes

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Like many new fathers, I spend as much of my free time as I can get away with gazing into my baby daughter’s eyes as she stutters and scans. I remember a day not long ago when I rocked my daughter, Eva, in my arms, and her eyes stopped and steadied as they looked back into mine. Her arms and legs ceased to rock and her entire body just relaxed. A chill went down my spine.

I felt that for the first time, she had really seen me. She was about 3 months old at the time. Within moments, though, her eyes left mine and started whirring around in their sockets again. While this was the first time I had shared such a moment of joy coupled with disappointment with her, I had experienced this many times with patients at the end of life.

Many have alluded to the symmetry of the beginning and the end of life. Most people, however, become parents long before they become caregivers. For me the order was reversed. For while I only recently became a father, medical training has made me much better acquainted with those at the opposite end of the spectrum.

The agony of death is more than just physical – it is an existential wound that gnaws away until there is slow, and frequently unwilling, acceptance of the inevitability of one’s mortality. I sometimes see a similar pain in my baby girl’s eyes as she makes another arduous journey – learning how to be alive. Frequently, as she cries when she is hungry, or cries when she is overfed, or cries as she tries to have a bowel movement, or just cries, it seems as if she is yearning to go back to the simple comforts of her mother’s womb.

Changes in the medical system have brought the medicalization of the shallow slopes of our bell-curve-shaped lives. At the start of the century, most lives started and ended at home. However, while hospitals started to become the place where we took both our first breaths and our last in the 20th century, in recent years people have become eager to reverse both trends. Nutrition, too, has shifted from being completely natural, to being almost exclusively artificial formula for children and tube feeding and intravenous nutrition for the terminally ill, followed now by a realization that natural routes are best for both groups. What hasn’t changed, and what binds the pediatric and the geriatric, is the obsession with their bowel movements.

As medical science has progressed, while we have extended life, we have transformed death from a singular event, into dying, an entire phase of our lives that can last from days to years. This is mirrored by an extension of childhood as well, with children being more dependent for a longer period of time than ever before in human history. Parenting therefore has become more demanding – and more expensive.

Caregiving for those at the end of life, as those who live it will attest, is equally arduous yet is barely recognized at a similar scale. In some ways, caregiving is similar to parenting – women do most of the heavy lifting. In fact, two-thirds of all caregivers are female. Yet, caregiving for the dying is different from parenting because it does not yet have a formally recognized role within the care of the patient. While there is no chance Eva would ever see her pediatrician without her parents, elderly patients, some with levels of dependency equal to that of a 3-month-old, present to the hospital or clinic all by themselves, all the time. Furthermore, while there is much debate about paying workers through maternity or paternity leave, a similar discussion does not exist around whether leave granted to those caring for parents or loved ones at the end of life, particularly those getting home hospice services, should be paid.

Part of the problem is also how differently we view infancy and old age. A daily struggle my wife and I face is how to hold back from oversharing pictures and videos of Eva on social media. We document her life meticulously, afraid of letting any single gesture slip away. Yet, not only do we siphon off old people to live outside of our immediate circles, but images of what the end looks like are scant, uncelebrated and frequently morbid. There is a significant disparity of empathy toward children versus the elderly. Children’s shortcomings turn into viral YouTube videos, while those of the elderly are often derided and ridiculed by the very people charged with taking care of them.

In a more longitudinal sense, we care for our young the same way people have for thousands of years yet how we die has changed significantly over just the past few years and continues to be in flux. Advanced technology means that many people require much more assistance at home than before. Furthermore, while our lifespan has been extended dramatically, the years we spend with disability have also increased. Therefore, while we have had eons to define our roles as parents, the modern caregiver remains undefined and unrecognized, and thus, unsupported. Investing in children makes intuitive sense, but a similar case has not been built for taking care of the elderly.

As with raising a baby, the answer might come from the heart. What is really needed is for us to love the old as we do the new and celebrate the end as we do the beginning.

Haider Javed Warraich, M.D., a fellow in cardiology at Duke University Medical Center, is the author of the book “Modern Death – How Medicine Changed the End of Life,” coming in February 2017.

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Thriving at Age 70 and Beyond

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A recently published book, “70Candles! Women Thriving in Their 8th Decade,” inspired me to take a closer look at how I’m doing as I approach 75 and how I might make the most of the years to come. It would be a good idea for women in my age cohort to do likewise. With a quarter of American women age 65 expected to celebrate their 100th birthday, there could be quite a few years to think about.

It’s not the first time I’ve considered the implications of longevity. When one of my grandsons at age 8 asked, “Grandma, will you still be alive when I get married?” I replied, “I certainly hope so. I want to dance at your wedding.” But I followed up with a suggestion that he marry young!

Still, his innocent query reminded me to continue to pursue a healthy lifestyle of wholesome food, daily exercise and supportive social connections. While there are no guarantees, like many other women now in their 70s, I’ve already outlived both my parents, my mother having died at 49 and my father at 71.

If I have one fear as the years climb, it’s that I won’t be able to fit in all I want to see and do before my time is up, so I always plan activities while I can still do them.

I book cycling and hiking trips to parts of the world I want to visit and schedule visits to distant friends and family to be sure I make them happen. In a most pragmatic moment, I crocheted a gender-neutral blanket for my first great-grandchild, but attached a loving note in case I’m no longer around to give it in person.

Of course, advancing age has taken — and will continue to take — its incremental toll. I often wake up wobbly, my back hates rainy days, and I no longer walk, cycle or swim as fast as I used to. I wear sensible shoes and hold the handrail going up and down stairs.

I know too that, in contrast to the Energizer Bunny life I once led, I now have to husband my resources more carefully. While I’m happy to prepare a dish or two for someone else’s gathering, my energy for and interest in hosting dinner parties have greatly diminished. And though I love to go to the theater, concerts, movies and parties, I also relish spending quiet nights at home with my Havanese, Max, for company.

Jane Giddan and Ellen Cole, the authors of “70Candles!,” do not tout their work as definitive research. Rather, their effort involved scores of posts to an online blog, and eight gatherings in different cities with groups of women in or near their 70s, where participants were encouraged to share their stories and generate research questions that could be explored scientifically in more detail. Such studies are important: As baby boomers age, women in their 70s, already a large group, will represent an increasing proportion of the population, and how to best foster their well-being will be a growing challenge.

What are the most important issues facing these women as they age, and how might society help ease their way into the future? Leading topics the women chose to explore included work and retirement, ageism, coping with functional changes, caretaking, living arrangements, social connections, grandparenting and adjusting to loss and death.

As members of the first generation in which huge numbers of women had careers that defined who they were, deciding when to bow out can be a challenge. Some have no choice, others never want to, and still others like me continue to work part-time. However, sooner or later, most will need to find rewarding activities to fill their now-free time.

The authors reported that “the women seemed to fear retirement before the deed was done, and then to relish their newfound opportunities afterward.” Several warned against rushing into too many volunteer activities, suggesting instead that retirees take time to explore what might be most meaningful and interesting, from taking art classes or music lessons to mentoring students, becoming a docent or starting a new career.

As one woman said, “There are many places where you are needed and can make a difference.” Another said, “It’s more like putting new tires on a car… re-tiring!”

Still, many lamented society’s focus on youthfulness and its failure to value the wisdom and knowledge of elders like themselves. Ageism abounds, they agreed. As one woman wrote, “At my institution, there’s an unstated policy that anyone over 55 won’t get a job. We’re thought to be out of touch with the younger population and assumed to be lacking in the necessary technical skills.” A practicing attorney admitted, “People might not listen to me if they knew I was 71, so I keep it to myself.”

Adjusting to physical changes that accompany advancing years is often tough. Grandchildren, though a great joy to many, can be exhausting, necessitating a restorative nap. Adjustments are needed to reduce the risk of falls and fractures. Better lighting, hearing assists, a reliance on Post-it notes and lists as well as canes and walkers can become essential for safe and effective functioning.

As Ms. Giddan and Ms. Cole wrote, “Our bodies change as we age, even when we eat healthfully, exercise and try to take good care of ourselves. Sight, hearing, bones, joints, balance, mobility, memory, continence, strength and stamina — they will never be what they once were.”

There is also the matter of attending to or accommodating various aches and pains. As one physician reassured a woman of 70, “All my patients your age who are free of pains are dead.” I’m not one to run to the doctor the moment something hurts. Rather, I give it a few weeks — maybe a month — to see if it will go away on its own. Even if fully covered by Medicare, doctor visits cost time and effort, and tests that ensue may have side effects.

Also important as women age are social connections, especially with other women. Whether married, single, widowed or divorced, participants reported that women friends were their greatest source of support and comfort.

Perhaps most important, for men as well as women, is to think positively about aging. A 2002 study by epidemiologists at Yale found that “individuals with more positive self-perceptions of aging, measured up to 23 years earlier, lived 7.5 years longer than those with less positive perceptions.”

This is the first of two columns on adjustments to aging.

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Millions With Leg Pain Have Peripheral Artery Disease

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Credit Paul Rogers

More than eight million older Americans have a condition that can cause leg pain when they walk even short distances. Yet half of those who have the condition don’t know it and consequently don’t get treated for it, putting themselves at risk for a heart attack, stroke or worse.

The condition, called peripheral artery disease, or P.A.D., is marked by diseased or blocked arteries in the legs. More than half of those with such circulatory problems in the extremities also have coronary or cerebral artery disease, noted Dr. Iftikhar J. Kullo, a cardiovascular specialist at the Mayo Clinic, in The New England Journal of Medicine in March. Failure to diagnose and treat blocked arteries elsewhere in the body can result in more serious, or even fatal, problems if they affect the heart or brain.

It may seem odd that people who have serious difficulty walking normal distances would not know something is wrong and get checked out. Yet, as Dr. Kullo noted, P.A.D. is both underdiagnosed and undertreated. And the number of cases of P.A.D. is only likely to rise as the population ages, he said.

“A lot of people limit their activity for other reasons, like a hip problem, back pain or breathing difficulty, and may not push themselves hard enough to provoke symptoms of P.A.D.,” said Dr. Paul W. Wennberg, a cardiologist and specialist in vascular disease at the Mayo Clinic. Or they may think their limited ability to exercise is to be expected, given their advancing years. Still others, Dr. Wennberg said, “may have only minimal disease in their legs, or they adapt their lifestyle to where they don’t notice symptoms anymore.”

In other words, since walking brings on pain, people typically find myriad ways to avoid doing it.

But this very response — remaining sedentary — is counterproductive, Dr. Wennberg said, because the best treatment for P.A.D. is exercise: Walking up to the point of pain, then resting until the pain subsides, then walking again, repeating the sequence until you’ve walked for 20 to 30 minutes (not counting rests) every day.

With this approach, Dr. Wennberg explained, exercise tolerance gradually increases as collateral blood vessels form in the legs that can compensate for blockages in the main arteries.

Just as teachers often have star pupils, Dr. Wennberg talks fondly of a man who was his star patient. When first seen, the patient, a 76-year-old Minnesotan, was afflicted with such severe peripheral artery disease that he couldn’t walk much beyond his backyard. Although a nonsmoker, the man had chronic obstructive pulmonary disease, which also limited how far he could walk. Yet he desperately wanted to be able to hike the nature trail behind his house, which motivated him to follow the doctor’s prescription religiously: Walk until it hurts, rest, then walk some more. Repeat several times a day.

“He got a treadmill to use in his house, and he walked outside whenever he could,” Dr. Wennberg recalled. “In just three months, he had doubled his walking distance as measured on a treadmill in the lab, and before long he was able to walk the mile-long nature trail.” Not only did the exercise prescription reduce his leg pain, it also improved his breathing. Together, these benefits enabled him to walk the desired distance without pain or fatigue.

Another of Dr. Wennberg’s patients, Donovan Merseth, 76, of Zumbrota, Minn., said he walks his two dogs four or five times a day, accumulating daily walks of three to four miles. “The more active I am, the better I feel,” Mr. Merseth said in an interview. “I walk at a moderate pace,” he said, calling his exercise “a senior power walk.”

Variable symptoms present another stumbling block to getting a correct diagnosis of P.A.D. The discomfort P.A.D. causes “is more often atypical than typical,” Dr. Wennberg wrote in the journal Circulation. “Descriptions such as ‘tired,’ ‘giving way,’ ‘sore,’ and ‘hurts’ are offered more often than ‘cramp’,” which can challenge an examining physician’s ability to suspect P.A.D. as the cause of a patient’s discomfort.

He suggested that doctors ask, “What’s the most strenuous thing you do in a typical week? Do you do any routine exercise, like walking? Do you get pain when you walk?”

A simple noninvasive test that can be done in any doctor’s office, called the ankle-brachial index, or ABI, test, can reveal the likelihood of P.A.D. The test, which takes only a few minutes, compares blood pressure measured at the ankle with blood pressure measured in the arm. Lower pressure in the leg is an indication of P.A.D.

The index is calculated by dividing the systolic (top number) blood pressure in the arteries near the ankles by the systolic blood pressure in the arms. A low number strongly suggests a narrowing or blockage in the arteries that supply blood to the legs.

Follow-up tests, like an ultrasound exam of the arteries to the brain, may be done as well. “If there’s blockage in one area of the body, it’s likely also to be in another,” Dr. Wennberg noted.

Not surprisingly, the risk factors for P.A.D. closely match those for coronary heart disease: smoking (currently or formerly), diabetes, high blood pressure and high cholesterol. Consider asking your doctor to do the ABI test if you are 50 or older and have any of the above risk factors, even if you haven’t yet noticed a problem with walking (though insurance may not cover the cost if you lack symptoms).

However, Dr. Wennberg wrote, the ABI test done during rest may miss peripheral artery disease in nearly one-third of patients; they may require an ABI test following exercise on a treadmill to reveal the problem. The blood pressure measurements must be taken within a minute of stopping the exercise.

Given the same risk factors, African-Americans are more likely than Caucasians to develop P.A.D.

The average age at which people develop P.A.D. is 70, Dr. Wennberg said, adding that it occurs a decade earlier in people with diabetes and even earlier in people who both smoke and have diabetes.

Smoking increases the risk of developing P.A.D. fourfold, and more than 80 percent of people with the condition are current or former smokers.

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On Widower Watch

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Credit Stuart Bradford

He crossed the marbled lobby of his building, headed for the front door, leaning into his blue walker as if he were facing a gale-force wind. A golden starburst of drying urine ringed the front of his khaki pants. I thought we were meeting in his apartment, but one of us had the time wrong.

As a hospice volunteer for his late wife, I had traveled from my home in Brooklyn to the Upper West Side every Sunday for the last four years to spend time with them, adding more visits when they needed help with household tasks. When she died, I could hardly abandon him. We had, over the course of all our time together, become a kind of family.

Widowers are endangered beings, challenged by grief and its grim companions: loneliness, disorientation and a statistically high mortality rate. A 2012 study by a team at Rochester Institute of Technology showed that widowers are 30 percent more likely to die after the recent death of a spouse, compared to normal risks of mortality. The first six months after widowhood are the most challenging, but the effects of grief can last up to a decade.

At 90, the man I come to visit every week has a host of complicating ailments: He lives with a colostomy bag; his feet are permanently swollen and flaky with gout; he was given a diagnosis of prostate cancer more than a decade ago. It’s a slow growing cancer, and while he had treatment for it, he suspects that some of his current urination problems are a result. These health factors would be challenging enough on their own, but now they are compounded by profound grief.

It had been only eight weeks since he and I had watched his wife take her last breath on the sofa in their apartment upstairs. Her companionship — they had been married for 53 years — had long dictated his daily schedule; for years her illness required him to carry on with the duties of the household. With his wife gone, his routine gave way to a morass of unaccountability and unwelcome quiet.

It would be easy to be rebuffed by his stoical insistence that he’s fine, but his family and I have begun to track his emotional and physical wellness in a number of ways in the hope that we can forestall the typical effects of new widowhood. Which is why, as he and I stood in the lobby, I anxiously checked the time on my watch, vigilant for any indication that he was encountering psychological or physical difficulties.

He seemed a little confused about what day it was. Yet his thin white hair was neat; his sneakered steps deliberate and sure. His eyesight has been quickly fading over the past few years, but he continues to watch TV, and he is in charge of his hygiene and his schedule for all but four hours a day when his aide comes to cook his evening meal. Despite his soiled clothes, he seemed to be managing his activities of daily living (what gerontologists call A.D.L.s) successfully.

Social isolation is a risk many widowers face, compounded by solitary living. A Pew Research study reported in February showed that an increased number of men live alone: 18 percent, up from 15 percent in 1990. According to AARP, 90 percent of those over 65 wish to stay at home as long as possible.

Although his daughters call and visit frequently, they both live far away. Most of his friends are long dead and he is not a member of a synagogue or senior center, organizations that can often provide continuity and support to elder widowers. My weekly visits, and those of his niece and others, are important to ensure that he socializes.

Mobility can also be an inhibiting factor to maintaining social ties and physical health. Although he is still able to take the bus to doctors’ appointments across town, he tires easily. Some taxis can’t accommodate his walker, and his swollen feet and fading eyesight put him at risk for falling. The National Council on Aging notes that falls are the leading cause of fatal and nonfatal hospital admissions among the elderly. A misplaced step could lead to depression, feelings of helplessness and increased isolation during recovery. Still, it’s important to him that he remain independent as long as possible, which means he’s learning to balance mobility with safety.

Unlike many of his peers, my friend owns his home and has adequate finances to last until the end of his life, even if he increases the visiting hours of his home health aide. But in New York City alone, 20 percent of those over 65 live below the poverty line. Because the federal poverty rate is so low — $11,770 a year for a single person — many elderly people don’t qualify for the benefits they need, particularly in urban areas where housing and insurance rates can be higher.

According to a recent study by the University of California, Los Angeles’s Center for Health Policy Research, an increased number of senior citizens in California are experiencing “worse health, more depression and less access to care.” Because widowhood can decrease household income and other resources, those who have recently lost a spouse are particularly susceptible to this trend.

He will turn 91 this month. His older daughter is coming up from Virginia to host a party in his honor. I’ll pick up a cake, ordered by his younger daughter in Colorado, from his favorite bakery on the Upper East Side. We’ll drink champagne to toast his health, and we’ll miss his wife on this first birthday without her.

Marking family and personal occasions in this way has become increasingly important to all of us; these events intersect long, quiet weeks with laughter and company. And here’s the often unacknowledged benefit to keeping watch on a widower: With my grandparents dead and my friends all around my age, he diversifies my social life as much as I do his. He gives me a perspective on the city we live in that my peers simply don’t have. We spend our time together talking about our dissimilar lives and the things that matter to us, reminiscing about his many rich years, and looking up old poems in the vast library that lines the walls of his house. He is my friend and I miss him when I am away. As it turns out, nonagenarians are good company.

Ann Neumann is a visiting scholar at the Center for Religion and Media at New York University and the author of “The Good Death: An Exploration of Dying in America.”

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Walk, Jog or Dance: It’s All Good for the Aging Brain

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Credit Illustration by Sam Island

More people are living longer these days, but the good news comes shadowed by the possible increase in cases of age-related mental decline. By some estimates, the global incidence of dementia will more than triple in the next 35 years. That grim prospect is what makes a study published in March in The Journal of Alzheimer’s Disease so encouraging: It turns out that regular walking, cycling, swimming, dancing and even gardening may substantially reduce the risk of Alzheimer’s.

Exercise has long been linked to better mental capacity in older people. Little research, however, has tracked individuals over years, while also including actual brain scans. So for the new study, researchers at the University of California, Los Angeles, and other institutions analyzed data produced by the Cardiovascular Health Study, begun in 1989, which has evaluated almost 6,000 older men and women. The subjects complete medical and cognitive tests, fill out questionnaires about their lives and physical activities and receive M.R.I. scans of their brains. Looking at 10 years of data from nearly 900 participants who were at least 65 upon entering the study, the researchers first determined who was cognitively impaired, based on their cognitive assessments. Next they estimated the number of calories burned through weekly exercise, based on the participants’ questionnaires.

The scans showed that the top quartile of active individuals proved to have substantially more gray matter, compared with their peers, in those parts of the brain related to memory and higher-­level thinking. More gray matter, which consists mostly of neurons, is generally equated with greater brain health. At the same time, those whose physical activity increased over a five-year period — though these cases were few — showed notable increases in gray-matter volume in those same parts of their brains. And, perhaps most meaningful, people who had more gray matter correlated with physical activity also had 50 percent less risk five years laterof having experienced memory decline or of having developed Alzheimer’s.

“For the purposes of brain health, it looks like it’s a very good idea to stay as physically active as possible,” says Cyrus Raji, a senior radiology resident at U.C.L.A., who led the study. He points out that “physical activity” is an elastic term in this study: It includes walking, jogging and moderate cycling as well as gardening, ballroom dancing and other calorie-burning recreational pursuits. Dr. Raji said he hopes that further research might show whether this caloric expenditure is remodeling the brain, perhaps by reducing inflammation or vascular diseases.

The ideal amount and type of activity for staving off memory loss is unknown, he says, although even the most avid exercisers in this group were generally cycling or dancing only a few times a week. Still, the takeaway is that physical activity might change aging’s arc. “If we want to live a long time but also keep our memories, our basic selves, intact, keep moving,” Dr. Raji says.

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Reinventing Yourself: Stories From Our Readers

In a recent column, Jane E. Brody wrote about several people who had reinvented themselves. Some had changed their lives because they were no longer happy in their chosen careers, while others simply needed a change or were driven by a new-found passion.

We asked our readers to tell us how they had reinvented themselves. As usual their stories did not disappoint. Here are a few of our favorites, from a woman traveling the country as a volunteer to the late-in-life rabbi to the 70-year-old yoga instructor.

From Mailman to Teacher

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Frank spends some time with one of his students.

Frank spends some time with one of his students.Credit

“Upon retiring from a 30-year career as a humble mailman, I began volunteering in my granddaughters’ school. I quickly found that I really, really liked working with kids, and I spent a year training with Americorps as a reading tutor for struggling students. This training has given me an encore career as a substitute special-education assistant in the public schools. It’s joyful, very challenging and immensely satisfying, maybe even rejuvenating. Compared with my old days, as Bob Dylan says, ‘I was so much older then, I’m younger than that now.’”

Frank Robertson, Seattle

The Professional Volunteer

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Ms. Traynor rides a water buffalo while volunteering at Heifer Ranch in Arkansas.

Ms. Traynor rides a water buffalo while volunteering at Heifer Ranch in Arkansas.Credit

“After a 45-year career as an administrative assistant, most of that time as a single parent, I would have loved to retire, but without adequate financial resources, what could I do? It it was time to be creative.

I received a call from friends saying they had found a a small college in Sitka, Alaska, where the administration welcomed volunteers, offering free room and board. I began to rethink retirement. After all, all I needed do was get there!

It was a full calendar year before I was ready. In July, 2005, I retired. Feeling like Joan of Arc, I drove out of my driveway on my way to Alaska and never looked back.

I found that I was welcomed by any organization I approached to help, that college in Alaska, Heifer Ranch in Arkansas, Menaul School in New Mexico, a wildlife refuge in Florida, plus many others. I have traveled the entire country on a fixed income, getting out and giving back, always receiving more than I contribute, making many new friends in the process.”

Barbara M. Traynor
Slingerlands, N.Y.

The Later-In-Life Rabbi

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“After having a successful career as a screenwriter for 25 years, I decided to become a rabbi. I entered rabbinical school at age 54 and it took nine years for me to graduate. Today, at age 66 I am one of eight rabbis at Wilshire Boulevard Temple, the biggest and oldest synagogue in Los Angeles.”

Susan Nanus
Los Angeles

The Lawyer Who Became a Chaplain

“After 40 years working as an attorney, I retired from the law in 2014 to enter a six-month chaplaincy internship program at Brigham and Women’s Hospital. This led to volunteering as a chaplain at Boston Medical Center for six months and then a six-month chaplaincy internship at Boston Medical Center. I was later hired by Boston Medical Center as a per diem chaplain to help out on the weekends and one day a week.

The chaplaincy work is intense, typically comforting patients and families whose lives have changed dramatically and precipitously. As a 70-year-old, I feel incredibly fortunate to be able to engage the world in this way.”

Bill Crane
Boston

The Financially Savvy Actress

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“In 2008, I graduated college with a degree in drama and boarded a plane to the Philippines as a cast member on the international tour of ‘Cinderella,’ the musical. While performing in Asia, however, the American economy was in the midst of a meltdown. So, by the start of 2009, I was back in New York City, a young, recently unemployed actress at the height of the financial crisis.

I dove deep into personal finance, learning as much as I could. I sat at the back of the show’s tour bus every evening, plugging my daily expenses into spreadsheets. I studied investment principles while taking the subway home after late-night restaurant shifts.
As I began to share the tips and tricks I had uncovered with peers, I stumbled upon an eager audience: Regular people were struggling to get a grasp on their money, lost in the jargon and obscurity of traditional financial institutions and media.

I now use my love of theater and storytelling to teach young audiences how to leverage the powerful tools of personal finance and entrepreneurship to build a life on their own terms. The messages of change, progress and gratitude I receive in reply are more gratifying than any curtain call or on-stage bow I’ve ever taken.”

Stefanie O’Connell
New York

Back to School at 53

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“After 14 years doing a combination of engineering, teaching English in China and social justice work, I decided to take stock of my life. I’m now 53 years old and in my second year of graduate school studying for a master’s degree in clinical mental health counseling.

Reading articles, writing papers and engaging with my much-younger peers has invigorated my mind and energized my desire for my soon-to-be new vocation. While many of my peers are trekking to work, I’m in my jeans and sneakers making my way to classes with plenty of caffeine and snacks as I plow through my coursework. Frankly, it’s hardly work to me. Rather, it’s just part of a journey of not only reinvention but rediscovery of who I am and what I care about. It’s taken me nearly 30 years but I’m getting there!”

Elena Yee
Providence, R.I.

The 70-Year-Old Yoga Instructor

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I” retired from a job with the state of N.Y. about 15 years ago. At the time, I had been practicing yoga for about 20 years. I was offered an opportunity to teach at a senior center in the area and agreed to do it. I based my classes on what my teachers had been teaching me over the years. About seven years ago, I began training to be a yoga teacher at the age of 70. That was very challenging for someone who had taken her last college course many years earlier. I was the oldest person in my class to complete the training.

Today, I teach about five classes a week, some at my home where I have transformed my former dining room into a small studio. Most of my students are older and have some limitations physically and I try to accommodate my students’ needs. This ‘new’ career brings me great joy and satisfaction. I consider myself to be a very lucky woman!”

Claire Malone
Delmar, N.Y.

A New Career Working With Seniors

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“After 25 years of working in financial services, I am now the executive director of an assisted living community. When the job market for financial executives became more challenging during the recession, I looked around for a back-up plan.

I found assisted living after helping a friend’s mother who was sick. After helping her, I volunteered at a local assisted living. I loved working with seniors! I got my master’s degree in gerontology and started a position as business director of an assisted living community within a few months of each other. In 2013, I was promoted to executive director of our assisted living community. Every day is a good day. I love what I do and I think it shows.”

Betsy Connolly
Wayland, Mass.

Using the Arts to Promote Healthy Aging

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Credit Paul Rogers

Throughout the country, the arts are pumping new life into the bodies and minds of the elderly.

Two summers ago, a remarkable documentary called “Alive Inside” showed how much music can do for the most vulnerable older Americans, especially those whose memories and personalities are dimmed by dementia.

The film opens with a 90-year-old African-American woman living in a nursing home being asked about her life growing up in the South. All she could say in response to specific questions was, “I’m sorry, I don’t remember.”

But once she was fitted with an iPod that played the music she had enjoyed in her youth, her smile grew wide and her eyes sparkled as vivid memories flooded her consciousness. She was now able to describe in detail the music and dances she had relished with her young friends.

At another nursing home, a man named George with advanced dementia refused to speak or even raise his head when asked his name. He too was outfitted with an iPod, and suddenly George came back to life, talking freely, wiggling to the music in his wheelchair and singing along with the songs he once loved.

The Music and Memory project that provided the iPods was the inspiration of a volunteer music lover named Dan Cohen, and has since spread to many nursing homes and facilities for the aged around the country. Alas, not nearly enough of them. Medicaid, which fully covers the cost of potent drugs that can turn old people into virtual zombies, has no policy that would pay for far less expensive music players. So the vast majority of nursing home residents who might benefit are deprived of this joyous experience.

Nonetheless, across the country, the arts in their myriad forms are enhancing the lives and health of older people — and not just those with dementia— helping to keep many men and women out of nursing homes and living independently. With grants from organizations like the National Endowment for the Arts and the National Institute on Aging, incredibly dedicated individuals with backgrounds in the arts have established programs that utilize activities as diverse as music, dance, painting, quilting, singing, poetry writing and storytelling to add meaning, joy and a vibrant sense of well-being to the lives of older people.

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Walter Hurlburt, 90, decorates rooms at the Burbank Senior Artists Colony, a retirement facility where he lives.

Walter Hurlburt, 90, decorates rooms at the Burbank Senior Artists Colony, a retirement facility where he lives.Credit

Through a program called EngAGE in Southern California, 90-year-old Walter Hurlburt, who once made a living as a sign painter, now decorates rooms at the Burbank Senior Artists Colony, a retirement facility where he lives, with lovely oil paintings he creates from pictures he finds in magazines and books. Mr. Hurlburt regularly attends classes on various art forms at the residence where, he told me, “I’m always learning something new.”

His buddy at the residence, Sally Connors, an 82-year-old former schoolteacher, surprised herself by writing and directing a screenplay that was performed by fellow residents. Then, with Dolly Brittan, 79, a former early childhood educator, they both surprised themselves by writing their life stories in rap and performing their rap memoirs on a stage for at-risk teenagers they were mentoring.

Both she and Ms. Connors said their newfound involvement with the arts has made them feel decades younger.

Tim Carpenter, the executive director of EngAGE, is now working to expand this approach to senior living in other cities, including Minneapolis, Portland, Ore., and Raleigh, N.C. His goal is to create a nationwide network of programs for seniors that keep them healthy, happy and active through lifelong learning in every conceivable art form, enabling them to live independently as long as possible.

As in Burbank, Mr. Carpenter is promoting the development of arts colonies in senior residences where residents can study and create art in all its forms and where they can see their artistic creations come to life on a stage.

Dr. Gene D. Cohen, a gerontologist at George Washington University who died in 2009, was a staunch advocate for the mental and physical benefits of creativity for the elderly. He directed the Creativity and Aging Study, a controlled study sponsored by the National Endowment for the Arts at three sites, including Elders Share the Arts in Brooklyn, N.Y., that showed after only a year that the health of elders in the cultural groups stabilized or improved in contrast to a decline among those in the control groups.

In a film called “Do Not Go Gently,” Dr. Cohen, who founded the Creativity Discovery Corps, featured an architect who, at age 96, submitted a plan for redeveloping the World Trade Center site. Dr. Cohen pointed out that creativity challenges the mind and results in the formation of new dendrites, the brain’s communication channels.

At 26 different facilities in the Washington, D.C., area, 15 teaching artists work with seniors in centers where they live or visit regularly. Janine Tursini, director of Arts for the Aging in Rockville, Md., seeks to “get at what best jazzes up older adults.” Groups of about 20 older adults get involved in what she calls “art making” — music, dance, painting or storytelling.

Ms. Tursini said the N.E.A.-sponsored study showed that when older people become involved in culturally enriching programs, they experience a decline in depression, are less likely to fall and pay fewer visits to the doctor. In another study among people with Alzheimer’s disease, a sculpting program improved the participants’ mood and decreased their agitation even after the program ended.

“The arts open people up, giving them new vehicles for self-expression, a chance to tell their stories,” Ms. Tursini said. “The programs capitalize on assets that remain, not on what’s been lost.”

Naomi Goldberg Haas created the Dances for a Variable Population program to get older adults dancing. People who haven’t moved in years, even those who can no longer stand, can participate. Young professionals and older dancers go to various sites — libraries, churches, senior centers — where elders gather and encourage them to “move more.”

“Movement enriches the quality of their lives,” Ms. Haas said. “It’s absolutely healing. Balance, mobility, strength — everything improves.”

Social engagement, which nearly all these programs provide, has been repeatedly found in major population studies to prolong life and enhance healthy aging. Clinically, the programs have been linked to lowered blood pressure, reduced levels of stress hormones, and increased levels of the “happiness hormones” that are responsible for a runner’s high.

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Pursuing the Dream of Healthy Aging

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Credit Paul Rogers

Given their druthers, most people would opt for a long and healthy life. Few relish the idea of spending years, even decades, incapacitated by illness, dependent on caregivers and unable to enjoy the people, places and activities that make life worth living.

In 1980, Dr. James F. Fries, a Stanford University physician who studied chronic disease and aging, proposed that a “compression of morbidity” would enable most people to remain healthy until a certain age, perhaps 85, then die naturally or after only a brief illness.

Now, a prescient group of experts on aging envisions a route to realizing Dr. Fries’s proposal: one or more drugs that can slow the rate of aging and the development of the costly, debilitating chronic ailments that typically accompany it. If successful, not only would their approach make healthy longevity a reality for many more people, but it could also save money. They say that even a 20 percent cut in how fast people age could save more than $7 trillion over the next half-century in the United States alone.

“Aging is by far the best predictor of whether people will develop a chronic disease like atherosclerotic heart disease, stroke, cancer, dementia or osteoarthritis,” Dr. James L. Kirkland, director of the Kogod Center on Aging at the Mayo Clinic, said in an interview. “Aging way outstrips all other risk factors.”

He and fellow researchers, who call themselves “geroscientists,” are hardly hucksters hawking magic elixirs to extend life. Rather, they are university scientists joined together by the American Federation for Aging Research to promote a new approach to healthier aging, which may — or may not — be accompanied by a longer life. They plan to test one or more substances that have already been studied in animals, and which show initial promise in people, in hopes of finding one that will keep more of us healthier longer.

As Dr. Kirkland wrote in a new book, “Aging: The Longevity Dividend”: “By targeting fundamental aging processes, it may be possible to delay, prevent, alleviate or treat the major age-related chronic disorders as a group instead of one at a time.”

His colleague S. Jay Olshansky, a gerontology specialist in the School of Public Health at the University of Illinois in Chicago, said it is often counterproductive to treat one disease at a time. Preventing cardiac death, for example, can leave a person vulnerable to cancer or dementia, he explained.

A better approach, Dr. Kirkland said, would be to target the processes fundamental to aging that underlie all age-related chronic diseases: chronic low-grade inflammation unrelated to infection; cellular degradation; damage to major molecules like DNA, proteins and sugars; and failure of stem cells and other progenitor cells to function properly.

The team, which includes Dr. Nir Barzilai, director of the Institute for Aging Research at Albert Einstein College of Medicine in The Bronx, and Steven N. Austad, who heads the biology department at the University of Alabama at Birmingham, plans to study one promising compound, a generic drug called metformin already widely used in people with Type 2 diabetes. They will test the drug in a placebo-controlled trial involving 3,000 elderly people to see if it will delay the development or progression of a variety of age-related ailments, including heart disease, cancer and dementia. Their job now is to raise the $50 million or so needed to conduct the study for the five years they expect it will take to determine whether the concept has merit.

The project represents a radical departure from ordinary drug studies that test treatments for single diseases. However, the group, spearheaded by Dr. Barzilai, said the Food and Drug Administration has endorsed their idea to test a single substance for effectiveness against a range of ailments.

“If metformin turns out not to work, there are several other substances in the pipeline that could be tried,” Dr. Barzilai said. “Under the auspices of the National Institute on Aging, three research centers have tested 16 substances in different animal models and got incredible results with four of them.”

Green tea, one of those tested, bestowed no health or life span benefits, despite its popularity. But the drug rapamycin, an immune modulator used following organ transplants, was most effective among those tested, Dr. Barzilai said.

The team is starting with metformin because it is a cheap oral drug — costing about two cents a pill — with six decades of safe use in people throughout the world. Among those with Type 2 diabetes who have taken it for years, there is evidence suggesting that, in addition to diabetes, it protects against cardiovascular disease, cancer and possibly cognitive impairment, Dr. Kirkland said, adding that “it targets the fundamental processes of aging, which tend to be linked.”

Dr. Barzilai said, “Our goal is to establish the principle of using a drug, or two in combination, to extend health span. The best we can expect from metformin is two or three additional years of healthy aging. But the next generation of drugs will be much more potent.”

Dr. Barzilai is already conducting a complementary study of centenarians, the results of which could identify more drugs to delay age-related diseases. He and colleagues are isolating genes that appear to keep these long-lived men and women healthy for 20 to 30 years longer than other people and shorten the length of illness at life’s end. Several studies have already found that individuals with exceptional longevity experience a compression of morbidity and spend a smaller percentage of their life being ill, Dr. Barzilai and his colleague Dr. Sofiya Milman wrote in the “Aging” book.

By analyzing the action of genes that extend health span, “it should be possible to devise drugs that mimic the genes’ effects,” he said. Two such gene-based drugs that show early promise against age-related diseases are already being tested.

But until definitive studies are completed and substances are shown to be safe as well as effective in prolonging health, Dr. Olshansky cautioned against dosing oneself prematurely with widely touted substances like resveratrol, the antioxidant found in red grapes and wine, or growth hormone.

Consumers must exercise caution, he warned, because “there’s an entire industry out there trying to market the products we’re testing before they are adequately evaluated.”

He also emphasized that taking a drug found to ward off age-related ills is not a license to abandon a healthy lifestyle. Doing so “could completely negate the benefit of a compound that slows aging,” he said.

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