Mental Health

It’s Your Choice: You Can Change Your Views of Aging and Improve Your Life

People’s beliefs about aging have a profound impact on their health, influencing everything from their memory and sensory perceptions to how well they walk, how fully they recover from disabling illness, and how long they live.

When aging is seen as a negative experience (characterized by terms such as decrepit, incompetent, dependent, and senile), individuals tend to experience more stress in later life and engage less often in healthy behaviors such as exercise. When views are positive (signaled by words such as wise, alert, accomplished, and creative), people are more likely to be active and resilient and to have a stronger will to live.

These internalized beliefs about aging are mostly unconscious, formed from early childhood on as we absorb messages about growing old from TV, movies, books, advertisements, and other forms of popular culture. They vary by individual, and they’re distinct from prejudice and discrimination against older adults in the social sphere.

More than 400 scientific studies have demonstrated the impact of individuals’ beliefs about aging. Now, the question is whether people can alter these largely unrecognized assumptions about growing older and assume more control over them.

In her new book, “Breaking the Age Code: How Your Beliefs About Aging Determine How Long and Well You Live,” Becca Levy of Yale University, a leading expert on this topic, argues we can. “With the right mindset and tools, we can change our age beliefs,” she asserts in the book’s introduction.

Levy, a professor of psychology and epidemiology, has demonstrated in multiple studies that exposing people to positive descriptions of aging can improve their memory, gait, balance, and will to live. All of us have an “extraordinary opportunity to rethink what it means to grow old,” she writes.

Recently, I asked Levy to describe what people can do to modify beliefs about aging. Our conversation, below, has been edited for length and clarity.

Becca Levy poses for a portrait with her arms crossed.
Becca Levy, a professor at Yale University, studies the way our beliefs about aging affect physical and mental health.(Julia Gerace)

Q: How important are age beliefs, compared with other factors that affect aging?

In an early study, we found that people with positive age beliefs lived longer — a median of 7.5 additional years — compared with those with negative beliefs. Compared with other factors that contribute to longevity, age beliefs had a greater impact than high cholesterol, high blood pressure, obesity, and smoking.

Q: You suggest that age beliefs can be changed. How?

That’s one of the hopeful messages of my research. Even in a culture like ours, where age beliefs tend to be predominantly negative, there is a whole range of responses to aging. What we’ve shown is it’s possible to activate and strengthen positive age beliefs that people have assimilated in different types of ways.

Q: What strategies do you suggest?

The first thing we can do is promote awareness of what our own age beliefs are.

A simple way is to ask yourself, “When you think of an older person, what are the first five words or phrases that come to mind?” Noticing which beliefs are generated quickly can be an important first step in awareness.

Q: What else can people do to increase awareness?

Another powerful technique is something I call “age belief journaling.” That involves writing down any portrayal of aging that comes up over a week. It could be a conversation you overhear in a coffee shop or something on social media or on your favorite show on Netflix. If there is an absence of older people, write that down, too.

At the end of the week, tally up the number of positive and negative portrayals and the number of times that old people are absent from conversations. With the negative descriptions, take a moment and think, “Could there be a different way of portraying that person?”

Q: What comes next?

Becoming aware of how ageism and age beliefs are operating in society. Shift the blame to where it is due.

In the book, I suggest thinking about something that’s happened to an older person that’s blamed on aging — and then taking a step back and asking whether something else could be going on.

For example, when an older adult is forgetful, it’s often blamed on aging. But there are many reasons people might not remember something. They might have been stressed when they heard the information. Or they might have been distracted. Not remembering something can happen at any age.

Unfortunately, there’s a tendency to blame older people rather than looking at other potential causes for their behaviors or circumstances.

Q: You encourage people to challenge negative age beliefs in public.

Yes. In the book, I present 14 negative age beliefs and the science that dispels them. And I recommend becoming knowledgeable about that research.

For example, a common belief is that older people don’t contribute to society. But we know from research that older adults are most likely to recycle and make philanthropic gifts. Altruistic motivations become stronger with age. Older adults often work or volunteer in positions that make meaningful contributions. And they tend to engage in what’s called legacy thinking, wanting to create a better world for future generations.

In my own case, if I hear something concerning, I often need to take time to think about a good response. And that’s fine. You can go back to somebody and say, “I was thinking about what you said the other day. And I don’t know if you know this, but research shows that’s not actually the case.”

Q: Another thing you talk about is creating a portfolio of positive role models. What do you mean by that?

Focus on positive images of aging. These can be people you know, a character in a book, someone you’ve learned about in a documentary, a historical figure — they can come from many different sources.

I recommend starting out with, say, five positive images. With each one, think about qualities you admire and you might want to strengthen in yourself. One person might have a great sense of humor. Another might have a great perspective on how to solve conflicts and bring people together. Another might have a great work ethic or a great approach to social justice. There can be different strengths in different people that can inspire us.

Q: You also recommend cultivating intergenerational contacts.

We know from research that meaningful intergenerational contact can be a way to improve age beliefs. A starting point is to think about your five closest friends and what age they are. In my case, I realized that most of my friends were within a couple of years of my age. If that’s the case with you, think about ways to get to know people of other ages through a dance class, a book club, or a political group. Seeing older people in action often allows us to dispel negative age beliefs.

Source

Medicare Advantage Plans Send Pals to Seniors’ Homes for Companionship — And Profits

Widowed and usually living alone, Gloria Bailey walks with a cane after two knee replacement surgeries and needs help with housekeeping.

So she was thrilled last summer when her Medicare Advantage plan, SummaCare, began sending a worker to her house in Akron, Ohio, to mop floors, clean dishes, and help with computer problems. Some days, they would spend the two-hour weekly visit just chatting at her kitchen table. “I love it,” she said of the free benefit.

Bailey, 72, is one of thousands of seniors around the country being visited each week by employees of Papa Inc. Known as “Papa pals,” their primary aim is to provide companionship to seniors along with helping with errands and light housework duties. Since 2020, more than 65 Medicare Advantage plans nationwide have signed up with Papa, a Miami-based company, to address members’ loneliness — a problem exacerbated by the pandemic.

“It’s the best thing ever” to counteract social isolation, said Anne Armao, a vice president at SummaCare. More than 12% of the company’s 23,000 Ohio Medicare members used the Papa benefit last year.

But SummaCare and other health plans also stand to benefit by sending Papa pals into members’ homes. The workers can help the plans collect more money from Medicare by persuading members to get annual wellness exams, fill out personal health risk assessments, and undergo covered health screenings.

Accomplishing these steps helps plans in two ways:

  • By gleaning more information, plans may discover members have health issues that may earn higher reimbursement rates from Medicare.
  • Plans can boost their star ratings, which are based on more than 40 performance measures, including cancer, diabetes, and blood pressure screenings; outcome measures such as controlling hypertension; and overall satisfaction with the plan. Plans that score at least four stars on a five-star scale receive bonuses from Medicare.

Bonus payments from the star ratings make up an increasing share of federal payments to these private Medicare Advantage plans, which are an alternative to traditional Medicare. In 2021, Medicare paid plans $11.6 billion in bonus pay, double the amount in 2017.

The federal government’s base pay for the plans is a monthly fee for each member, but it increases that amount based on the members’ health risks. So plans also get billions of dollars a year in extra payments by pinpointing members’ health problems through a variety of measures, including the health risk assessments.

Yet federal investigators have found these diagnoses do not always result in additional treatment or follow-up care to beneficiaries. As a result, the federal government is probably overpaying the Medicare health plans and wasting billions in taxpayer dollars, according to the Medicare Payment Advisory Commission that advises Congress.

In a report last September, the Health and Human Services inspector general found 20 Medicare Advantage companies generated $5 billion in extra payments from the federal government for diagnoses identified through health risk assessments and chart reviews without documentation that the patients were treated for these issues.

Nearly half of Medicare enrollees get their coverage through Medicare Advantage.

David Lipschutz, associate director of the Center for Medicare Advocacy, said Papa pals provide an important benefit to seniors by helping them with chores, reducing their loneliness, and getting them to medical appointments. But the benefit can also help the insurers’ bottom lines.

“If there is one thing these plans are good at it’s maximizing their profit,” he said.

Medicare Advantage plans often give doctors financial incentives to get patients to undergo health assessments. Plan workers repeatedly call patients with offers to send nurses or doctors to their homes to complete them. Lipschutz said health risk assessments are useful only if the health plans act on the information by making sure patients are getting treatment for those issues.

Armao said the health risk assessment and annual wellness exam reminders are on the list of things Papa employees are told to ask about on visits.

“They are our eyes and ears who can learn so much from members in their homes,” she explained. Pals look in refrigerators to see if members have enough to eat, check on how members are feeling, and remind them to take prescriptions. SummaCare even directs pals to ask whether members have urinary incontinence or are up to date on cancer screenings.

Andrew Parker, who founded Papa in 2017 after finding a couple of college students to visit with his grandfather, take him to doctor appointments, and do other errands, said he estimates his company will provide more than a million hours of companionship in 2022. The Medicare plans pay Papa, a for-profit company, a per-member fee monthly.

“Papas [pals] are very proactive and will call you to see how you are feeling and, maybe not on the first day but over the course of the program, can ask, ‘Did you know your health plan would prefer if you had a wellness exam and it could help you with your health?’” he said. “A pal is a trusted adviser who can get them to think about benefits they do not know about.”

He said insurers often don’t know a member is facing a health issue until they see a medical claim. “We can identify things they don’t know about,” he said.

Until recently, Medicare rarely paid for non-health services. But Papa began working with Medicare Advantage plans in 2020, just one year after the program began allowing the private insurers to have more flexibility addressing members’ so-called social needs, such as transportation, housing, and food, which are not typically covered by Medicare but could influence health. Papa’s goal of addressing members’ loneliness took on even more significance during the pandemic when many seniors became socially isolated as they sought to reduce their risk of getting infected.

Papa has more than 25,000 pals whose average age is mid-30s. Before being hired, pals must undergo a criminal background check and a driving record review as part of the vetting process. After being hired, pals are trained on empathy, cultural competency, and humility.

Michael Walling, 22, who works as a Papa pal near his home in Port Huron, Michigan, said most seniors are receptive to getting help or a chance to talk to someone for a couple of hours.

One of his clients has trouble walking so Walling helps vacuum and mop her trailer and take her to the grocery store. On Christmas Eve, he even took her out to lunch. “It was to be my day off, but I didn’t want her to be alone on the holiday,” he said.

Tim Barrage, a former parole officer, who visits Bailey and about a dozen other seniors in the Akron area each week, turned to Papa because he was looking for a flexible part-time job to supplement income from his firearms safety training businesses.

“I’ve done work in the garden, hanging up and taking down Christmas decorations, cleaning ovens or stovetops,” he said.

Each time he arrives at a member’s home, Papa directs him to check to see how the member is feeling overall and then periodically ask about issues that can include the wellness exam and health risk assessment. At the end of the visit, he reports to Papa about what services he provided and how the member interacted with him. He alerts his supervisors at Papa to a member’s potential health issues, and Papa connects with the health plan to address them.

Jennifer Kivi, manager of Medicare product development for Priority Health, a Michigan health plan, said members who have used the Papa service said it makes them feel less lonely. “If we can reduce their loneliness, it helps members feel better and their physical health will improve,” she said.

The insurer doesn’t want its Papa pals to ask members a long list of health questions, but they can ask about cancer or diabetes screenings, which also can bolster a plan’s ratings. “What we have seen is you can have a doctor tell them and their insurance company tell them they need it, but a Papa pal can start to build that relationship with them, and it means a lot more coming from them,” she said.

Source

Alzheimer’s Drug Targets People With Mild Cognitive Impairment. What Does That Mean?

The approval of a controversial new drug for Alzheimer’s disease, Aduhelm, is shining a spotlight on mild cognitive impairment — problems with memory, attention, language or other cognitive tasks that exceed changes expected with normal aging.

After initially indicating that Aduhelm could be prescribed to anyone with dementia, the Food and Drug Administration now specifies that the prescription drug be given to individuals with mild cognitive impairment or early-stage Alzheimer’s, the groups in which the medication was studied.

Yet this narrower recommendation raises questions. What does a diagnosis of mild cognitive impairment mean? Is Aduhelm appropriate for all people with mild cognitive impairment, or only some? And who should decide which patients qualify for treatment: dementia specialists or primary care physicians?

Controversy surrounds Aduhelm because its effectiveness hasn’t been proved, its cost is high (an estimated $56,000 a year, not including expenses for imaging and monthly infusions), and its potential side effects are significant (41% of patients in the drug’s clinical trials experienced brain swelling and bleeding).

Furthermore, an FDA advisory committee strongly recommended against Aduhelm’s approval, and Congress is investigating the process leading to the FDA’s decision. Medicare is studying whether it should cover the medication, and the Department of Veterans Affairs has declined to do so under most circumstances.

Clinical trials for Aduhelm excluded people over age 85; those taking blood thinners; those who had experienced a stroke; and those with cardiovascular disease or impaired kidney or liver function, among other conditions. If those criteria were broadly applied, 85% of people with mild cognitive impairment would not qualify to take the medication, according to a new research letter in the Journal of the American Medical Association.

Given these considerations, carefully selecting patients with mild cognitive impairment who might respond to Aduhelm is “becoming a priority,” said Dr. Kenneth Langa, a professor of medicine, health management and policy at the University of Michigan.

Dr. Ronald Petersen, who directs the Mayo Clinic’s Alzheimer’s Disease Research Center, said, “One of the biggest issues we’re dealing with since Aduhelm’s approval is, ‘Are appropriate patients going to be given this drug?’”

Here’s what people should know about mild cognitive impairment based on a review of research studies and conversations with leading experts.

Basics. Mild cognitive impairment is often referred to as a borderline state between normal cognition and dementia. But this can be misleading. Although a significant number of people with mild cognitive impairment eventually develop dementia — usually Alzheimer’s disease — many do not.

Cognitive symptoms — for instance, difficulties with short-term memory or planning — are often subtle but they persist and represent a decline from previous functioning. Yet a person with the condition may still be working or driving and appear entirely normal. By definition, mild cognitive impairment leaves intact a person’s ability to perform daily activities independently.

According to an American Academy of Neurology review of dozens of studies, published in 2018, mild cognitive impairment affects nearly 7% of people ages 60 to 64, 10% of those 70 to 74 and 25% of 80- to 84-year-olds.

Causes. Mild cognitive impairment can be caused by biological processes (the accumulation of amyloid beta and tau proteins and changes in the brain’s structure) linked to Alzheimer’s disease. Between 40% and 60% of people with mild cognitive impairment have evidence of Alzheimer’s-related brain pathology, according to a 2019 review.

But cognitive symptoms can also be caused by other factors, including small strokes; poorly managed conditions such as diabetes, depression and sleep apnea; responses to medications; thyroid disease; and unrecognized hearing loss. When these issues are treated, normal cognition may be restored or further decline forestalled.

Subtypes. During the past decade, experts have identified four subtypes of mild cognitive impairment. Each subtype appears to carry a different risk of progressing to Alzheimer’s disease, but precise estimates haven’t been established.

People with memory problems and multiple medical issues who are found to have changes in their brain through imaging tests are thought to be at greatest risk. “If biomarker tests converge and show abnormalities in amyloid, tau and neurodegeneration, you can be pretty certain a person with MCI has the beginnings of Alzheimer’s in their brain and that disease will continue to evolve,” said Dr. Howard Chertkow, chairperson for cognitive neurology and innovation at Baycrest, an academic health sciences center in Toronto that specializes in care for older adults.

Diagnosis. Usually, this process begins when older adults tell their doctors that “something isn’t right with my memory or my thinking” — a so-called subjective cognitive complaint. Short cognitive tests can confirm whether objective evidence of impairment exists. Other tests can determine whether a person is still able to perform daily activities successfully.

More sophisticated neuropsychological tests can be helpful if there is uncertainty about findings or a need to better assess the extent of impairment. But “there is a shortage of physicians with expertise in dementia — neurologists, geriatricians, geriatric psychiatrists” — who can undertake comprehensive evaluations, said Kathryn Phillips, director of health services research and health economics at the University of California-San Francisco School of Pharmacy.

The most important step is taking a careful medical history that documents whether a decline in functioning from an individual’s baseline has occurred and investigating possible causes such as sleep patterns, mental health concerns and inadequate management of chronic conditions that need attention.

Mild cognitive impairment “isn’t necessarily straightforward to recognize, because people’s thinking and memory changes over time [with advancing age] and the question becomes ‘Is this something more than that?’” said Dr. Zoe Arvanitakis, a neurologist and director of Rush University’s Rush Memory Clinic in Chicago.

More than one set of tests is needed to rule out the possibility that someone performed poorly because they were nervous or sleep-deprived or had a bad day. “Administering tests to people over time can do a pretty good job of identifying who’s actually declining and who’s not,” Langa said.

Progression. Mild cognitive impairment doesn’t always progress to dementia, nor does it usually do so quickly. But this isn’t well understood. And estimates of progression vary, based on whether patients are seen in specialty dementia clinics or in community medical clinics and how long patients are followed.

A review of 41 studies found that 5% of patients treated in community settings each year went on to develop dementia. For those seen in dementia clinics — typically, patients with more serious symptoms — the rate was 10%. The American Academy of Neurology’s review found that after two years 15% of patients were observed to have dementia.

Progression to dementia isn’t the only path people follow. A sizable portion of patients with mild cognitive impairment — from 14% to 38% — are discovered to have normal cognition upon further testing. Another portion remains stable over time. (In both cases, this may be because underlying risk factors — poor sleep, for instance, or poorly controlled diabetes or thyroid disease — have been addressed.) Still another group of patients fluctuate, sometimes improving and sometimes declining, with periods of stability in between.

“You really need to follow people over time — for up to 10 years — to have an idea of what is going on with them,” said Dr. Oscar Lopez, director of the Alzheimer’s Disease Research Center at the University of Pittsburgh.

Specialists versus generalists. Only people with mild cognitive impairment associated with Alzheimer’s should be considered for treatment with Aduhelm, experts agreed. “The question you want to ask your doctor is, ‘Do I have MCI [mild cognitive impairment] due to Alzheimer’s disease?’” Chertkow said.

Because this medication targets amyloid, a sticky protein that is a hallmark of Alzheimer’s, confirmation of amyloid accumulation through a PET scan or spinal tap should be a prerequisite. But the presence of amyloid isn’t determinative: One-third of older adults with normal cognition have been found to have amyloid deposits in their brains.

Because of these complexities, “I think, for the early rollout of a complex drug like this, treatment should be overseen by specialists, at least initially,” said Petersen of the Mayo Clinic. Arvanitakis of Rush University agreed. “If someone is really and truly interested in trying this medication, at this point I would recommend it be done under the care of a psychiatrist or neurologist or someone who really specializes in cognition,” she said.

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

Source