What if aging isn't what we've been told

When my mother was referred to hospice, I braced for what I thought came next. As her court-appointed guardian, I'd already navigated enough systems to know that words like "hospice" carry a weight that shapes what everyone around you expects. The word itself seemed to close a door.

But here's what I've been sitting with: what if the door was never as shut as we were told?

A study published in March 2026 by researchers at Yale School of Public Health is challenging one of the most deeply held assumptions about aging. And the finding is worth sitting with, especially for those of us who care for older loved ones and make decisions on their behalf.

Forty-five percent of older adults improved in cognitive or physical function over a 12-year period. Not just held steady. Improved. That finding comes from Becca Levy and Martin Slade at Yale, drawing on data from more than 11,000 participants in the Health and Retirement Study, a nationally representative longitudinal survey of Americans over 50 (Levy & Slade, Geriatrics, 2026).

When the researchers looked at individual trajectories, the pattern was clear: roughly 32% improved cognitively, about 28% improved physically, and when you included those who remained stable alongside the improvers, more than half defied the stereotype of inevitable cognitive decline.

But here's the part that stopped me: when all those individual trajectories were averaged together using the standard approach in aging research, the familiar decline story reappeared. The improvement only became visible when someone thought to look at each person's path on its own.

Levy put it plainly: improvement in later life isn't rare, it's common, and it should be part of how we understand aging.

Scaled nationally, that 45% translates to more than 26 million older Americans currently improving in measurable ways. That's not a statistical footnote. That's a population the size of Texas.

This is where the study hits close to home for me. As a court-appointed guardian, conservator, and primary caregiver navigating health and legal systems, I've watched how assumptions about aging trajectories get baked into the decisions that shape someone's care. An algorithm denies a prior authorization. A care plan assumes a downward slope. A system designed around decline doesn't know what to do when someone stabilizes or improves.

The averaging problem in aging research is a metaphor for something bigger. When we design systems, policies, and care plans around the assumption that older people will only get worse, we stop looking for the 45% who are getting better. We stop designing for the possibility that things could go differently.

This connects to something I've been thinking about since writing about communities labeled "hard to reach": the problem often isn't the people. It's the lens.

And it makes me think of life course theory and its application in these scenarios.

Life Course Theory (LCT) offers a framework for understanding why aging trajectories vary so widely. Developed by sociologist Glen H. Elder, Jr. (University of North Carolina at Chapel Hill) and expanded by Richard Settersten (Oregon State University), the theory holds that how someone ages is shaped by their entire life story: where and when they grew up, what choices they had access to, who they were connected to, and what systems supported or failed them.

Elder's five core principles are life-span development (growth continues through old age), human agency (people actively construct their lives within constraints), historical time and place (when and where you live shapes how you age), timing of decisions (when something happens matters as much as what happens), and linked lives (our trajectories are shaped by the people and institutions around us). Settersten adds a critical equity lens: older people are the most heterogeneous age group, and social class, race, and gender create cumulative advantages and disadvantages that widen with age (Settersten, Innovation in Aging, 2017).

This isn't just academic; it means that when we see an older person's health decline, the question isn't only "what's happening biologically?" It's also "what systems, structures, and histories shaped this path?" And when we see improvement, we should ask the same thing.

Long before the 2026 Yale study, psychiatrist Gene D. Cohen was making a parallel argument from neuroscience. Cohen, the first chief of the Center on Aging at the National Institute of Mental Health and founder of the Center on Aging, Health & Humanities at George Washington University, spent three decades studying what the aging brain could do rather than cataloging what it couldn't.

In The Mature Mind: The Positive Power of the Aging Brain (Basic Books, 2005), Cohen proposed four developmental phases of later life: Midlife Reevaluation (a quest for meaning, not a crisis), Liberation (a growing sense of inner freedom), Summing Up (finding larger meaning in one's story), and Encore (reaffirming life themes even in the face of limitation). Each phase, Cohen argued, was powered by what he called "developmental intelligence," a maturing integration of cognition, emotional depth, judgment, and life experience.

The neuroscience Cohen described is worth acknowledging, too. As we age, our brains increasingly use both hemispheres for tasks that younger brains handle with only one. Cohen called this "moving to all-wheel drive." Research on dendrite growth found that these neural branches grew to their greatest length between the early fifties and late seventies. The brain doesn't just persist. It reorganizes.

In my role as primary caregiver for my Mom, I witness this kind of capacity more often than people might expect. One moment, in particular, early in my caregiving journey, will always sit with me. I was preparing food for my mother, who has dementia, and in my rush, I forgot a fork. On the table we use, we keep reading flash cards, a push-and-peel toy, and magazines. By the time I realized the fork was missing, no more than five or ten seconds, she'd picked up a flash card and started scooping food with it. A total MacGyver move. She'd solved the problem as quickly as I can tie my shoes.

That's developmental intelligence in action. Not in a research paper. At a kitchen table. On the fly.

In this house, these are the tools of the caregiving trade.

We tend to underestimate what people can do when they have dementia. Cohen's work gives us a framework for expecting more, not less. And the Yale study now gives us the population-level data to back it up.

Cohen died in 2009, but his intellectual legacy, as the founding figure of the creative aging movement, continues to shape how gerontologists, clinicians, and community programs understand what aging can be.

This is where my lived experience as a primary caregiver, court-appointed guardian, and conservator intersects most directly with the research. And I want to be careful here, because I'm not suggesting that positive thinking fixes everything. Aging is hard. Loss is real. The later stages of life carry weight that no study can wish away.

But the data on hospice outcomes tells a story that surprised me. Between 15% and 18.5% of all Medicare hospice patients are discharged alive each year, according to MedPAC's 2025 report (Chapter 9, Hospice services). That's roughly 250,000 people annually. Of those live discharges, more than a third were attributed to patients whose conditions stabilized or improved beyond the expected timeline.

Researchers have identified what some call the "hospice paradox": palliative care focused on comfort and quality of life sometimes produces the very improvement that makes patients ineligible for continued hospice services. One study found that hospice patients with certain conditions lived an average of 29 days longer than comparable patients not on hospice (Connor et al., Journal of Pain and Symptom Management, 2007).

The system, designed around the assumption that these patients are on a one-way path, has policies that often haven't caught up to what's actually happening. That gap between assumption and reality is something I think about a lot.

I'm not saying every hospice referral leads to improvement. It doesn't. But I am saying that when we hear "hospice," the door that word seems to close might have more room in it than we've been led to believe.

When we design from decline assumptions, we get systems that ration care based on age, spend billions more than necessary (Levy's research estimates ageism costs the U.S. $63 billion annually in excess healthcare spending), and build institutions that don't know what to do when someone gets better. The World Health Organization (WHO) has documented that in 85% of 149 studies reviewed, age determined who received medical procedures or treatments, regardless of individual capacity.

When we design from possibility, we get frameworks like the WHO's Age-Friendly Cities initiative (now spanning 1,300+ communities in 44 countries) and the Institute for Healthcare Improvement's (IHI) 4Ms Framework, which starts every clinical interaction with the question "What Matters?" rather than "What's wrong?" These are strengths-based approaches. They treat older people as the primary source of knowledge about their own lives.

The 4Ms Framework, developed by the Institute for Healthcare Improvement and The John A. Hartford Foundation, organizes care around four priorities:

• What matters Know and align care with each older adult's specific goals and preferences, including end-of-life care.

• Medication Use age-friendly medication that doesn't interfere with what matters to the person, their mobility, or their mentation.

• Mentation Prevent, identify, and manage dementia, depression, and delirium across care settings.

• Mobility Ensure older adults move safely every day to maintain function and do what matters to them.

This is the design question I keep coming back to: are we building care systems around what we assume about people or around what we've actually learned by listening to what people need?

That 45% figure from the Yale study is going to stay with me for a while. Not because it erases the hard parts of aging or caregiving. It doesn't. But because it names something I've witnessed as a guardian that I didn't have research language for: that the trajectory isn't always what you're told it will be. That sometimes, in the middle of what everyone expects to be an ending, something else happens.

Gene Cohen wrote that the ultimate expression of human potential is creativity. Becca Levy showed that what we believe about aging shapes how we actually age. And life course theory reminds us that none of this happens in isolation. Our paths are shaped by systems, structures, communities, and the beliefs those communities hold.

My mother picked up a flash card and solved a problem in five seconds. That moment didn't fit the story I'd been told. I'm glad I was paying attention.

Maybe the most useful thing I can do from this porch is to say it out loud: what if aging isn't what we've been told?