Probably no other federal program aside from Social Security has as much impact on older Americans and their families as Medicare, now front and center in the intensifying argument over the federal budget and deficit reduction.

Philip Scott Andrews/The New York Times Representative Paul D. Ryan, left, and Representative Eric Cantor, the House majority leader, responding to President Obama’s speech on deficit reduction on Wednesday.

Galloping Medicare costs have worried health care analysts and economists, as well as officeholders in both major political parties, but the remedies now on the table vary substantially.

Representative Paul D. Ryan, Republican of Wisconsin, who is chairman of the House Budget Committee, has proposed a profound shift in this 46-year-old program. For those now younger than 55, Medicare would provide vouchers enabling participants to buy private health insurance on their own instead of directly reimbursing doctors and hospitals. ”We have a moral obligation to the country to do this,” Mr. Ryan said of the strategies incorporated in the Republican plan.

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It has been a season for shedding, as my mom divests herself of that which she no longer uses: the golf clubs, a casualty of a shoulder incapable of even a putt; the car, a potential danger for a woman whose arthritis makes it almost impossible for her to look over her shoulder.

The author’s parents, Ira and Norma Stabiner; her mother wears a gray dress that has been lost.

When she and her husband of 22 years decided it was time to move out of their isolated, isolating house in Scottsdale, Ariz., and into a place with services, the pace of the giveaway picked up. It’s simple long division. The accumulated possessions of two people who were married to their original spouses for more than 40 years before widowhood brought them together, the stuff that fills a three-bedroom house and spills out into the garage, will not fit into their new one-bedroom-and-den apartment. Something — many more things — will have to go.

Adult children tend to focus on the housecleaning aspect of this transition, on the marvelous efficiency of move-managers or the exhilaration that accompanies the disappearance of useless belongings. We try to keep it upbeat. To paraphrase a Johnny Mercer/Harold Arlen song that came out just before my parents got married, you’ve got to accentuate the positive, eliminate the negative and don’t mess with Mr. In-Between.

It’s not that straightforward, though, and anyone who has ever cherished a loved one’s hand-me-down — or wondered about the statute of limitations on giving an unwanted item away — knows it.

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The more I talk to researchers about caring for older people, the more a couple of themes emerge. Namely:

a) Sometimes less really is more. Overtreatment can create big problems, as a recent post on prescribing antibiotics for common urinary tract infections reported, and it happens frequently.

b) Older bodies respond differently from younger ones, a reality health care providers don’t always take into consideration. A routine that includes a few late-day cocktails, to take one of many examples, can be a pleasure for a 40-year-old but a danger for an 80-year-old.

The latest conversation I’ve had along those lines, with Dr. Sei J. Lee, a geriatrician at San Francisco’s V.A. Medical Center, concerned diabetes, a huge health issue for seniors. More than a quarter of adults over 65 have diabetes, according to the American Diabetes Association.

Should the elderly respond to Type 2 diabetes in the same way as younger patients? Maybe not, Dr. Lee suggested in a recent commentary in The Journal of the American Medical Association.

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Estelle Gross, the author’s mother, in an undated family photo.

Maybe I sensed something was brewing. Maybe it was a coincidence. Maybe I’d simply had it with sleeping on my mother’s couch during visits to Deerfield Beach, Fla., where she kept the air-conditioning on full blast, the television on full volume and the mother-daughter sniping coming fast and furious.

I was grateful my mother lived in an assisted living community — far enough away that I wasn’t at her beck and call — and had for more than six years, making the move from the family home on Long Island of her own accord. She was spared the isolation of snowy winters, was mobile with a cane or a walker, played a mean game of bridge and told hysterical stories about the neighbor ladies on the prowl for new gentlemen friends before the last ones were cold in the ground. She was also relatively healthy and fiercely independent, exactly as I wanted her to stay, even if it meant keeping my eyes squeezed shut at early evidence to the contrary.

For example, for many years my mother’s most essential piece of furniture was one of those cheesy 1950s TV tables, the plastic kind, with a mottled finish designed to look like faux marble, used when a “Leave It to Beaver”-type family gathered in the den to eat dinner. This particular TV table first came to my adult notice after my mother was widowed and still living in my childhood home. Back then, her attachment to it, instead of buying a decent end table, was a matter of frugality. But by the time I was visiting her in Florida, the TV table was an early indicator of how disabled she had become.

Its top, a mere 12 inches square, held my mother’s address book, the TV Guide, the telephone, the remote control, her eyeglasses, an emery board, a deck of cards, whatever she was reading, a pad and a pencil. Each object was always in the identical place. My mother liked order. But this was something else. This was Survival. Because my mother’s shoulders were crippled by arthritis, she had figured out the exact spot for each object so it would cause the least pain when she swiveled and reached for it.

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“As people get more frail and old, physicians tend to do more, when often we should do less.”

This observation, by Dr. David Dosa, a geriatrician at Brown University, rings so true that elderly patients entering hospitals and nursing homes should probably write it across their foreheads with a Sharpie: Do Less.

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Case in point: the way some doctors respond to suspected urinary tract infections. It’s the most common infection among nursing home residents. A widely cited estimate is that one-third of residents who spend a year in a nursing home will develop one.

Guidelines published nearly 20 years ago, and adopted by organizations like the Infectious Diseases Society of America, specify when a patient with a positive urinalysis should receive antibiotics. Younger people who get a positive test result almost always need antibiotics; it’s not normal for them to have bacteria in their urine.

But many older people, Dr. Dosa points out, are “colonized” with bacteria. Often they live in environments with more germs, and they’re subject to procedures — like catheterization — that can lead to infection. Yet even though they may have a positive urinalysis, indicating the presence of bacteria, they’re not sick. “This is normal for them,” Dr. Dosa said. “Just because they’re colonized doesn’t mean they need to be treated.”

That’s why the so-called McGeer criteria (named for the infectious disease specialist who published them) call for antibiotics only if an older patient has three of these five symptoms: a fever; increased frequency or urgency of urination, or burning associated with it; pain behind or near the bladder; a change in the smell or appearance of urine; or deteriorating function or mental state.

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You can see the logic. Old people with dementia can become frightened and restless, angry or agitated. Reiki, a Japanese healing practice that supposedly channels a universal energy, is said to be soothing and deeply relaxing. So why not offer reiki to elderly dementia patients?

Home Care Partners, a nonprofit home care agency in Washington, won a two-year grant from the federal Administration on Aging to give it a try and has just finished training 36 aides in reiki. Next year, the agency will offer reiki training to family caregivers and to workers at adult day programs.

“It relieves stress, it reduces anxiety and it can help diminish pain,” said Marie Muller, the agency’s education manager and a trained reiki master. “We hope that our clients with dementia who become agitated and stressed will find reiki calming” — and thus will be less disturbed when aides help them bathe or dress or eat.

Even at this early point, Ms. Muller said, aides are beginning to see benefits. One reported that reiki, which involves gently placing hands on a patient’s clothed body (or just above it) in prescribed positions, was helping a client with painful arthritis. “She could feel the warmth, and her knees hurt her less,” Ms. Muller said. “The aide could observe her walking better.”

Scores of hospitals are also believers. At Portsmouth General Hospital in New Hampshire, for instance, two staff practitioners and a half dozen volunteers offer free reiki to all patients, family members and staff, last year providing more than 2,100 sessions.

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The Times reports this morning that two enormous studies have linked five genes to the development of Alzheimer’s disease. The associations are not strong — each gene confers an increase in risk of just 10 to 15 percent — but they should help point researchers to new mechanisms underlying this dementia.

For years, there have been unproven but persistent hints that cholesterol and inflammation are part of the disease process. People with high cholesterol are more likely to get the disease. Strokes and head injuries, which make Alzheimer’s more likely, also cause brain inflammation. Now, some of the newly discovered genes appear to bolster this line of thought, because some are involved with cholesterol and others are linked to inflammation or the transport of molecules inside cells.

Read the full article, “Vast Gene Study Yields Insights on Alzheimer’s,” and share your thoughts on the comments section. Have a question about Alzheimer’s disease or the new findings? Ask the reporter, Gina Kolata, at the Consults blog.

Noah Berger for The New York Times Dr. Manjula Kurella Tamura, at a clinic in Palo Alto, Calif., said “dialysis at the end of life is a different sort of treatment.”

The Times reports today on the frequent use of dialysis in elderly patients.

A law passed by Congress 39 years ago provides nearly free care to almost all patients whose kidneys have failed, regardless of their age or ability to pay.

But the law has had unintended consequences, kidney experts say. It was meant to keep young and middle-aged people alive and productive. Instead, many of the patients who take advantage of the law are old and have other medical problems, often suffering through dialysis as a replacement for their failed kidneys but not living long because the other chronic diseases kill them.

Read the full article, “When Ailments Pile Up, Asking Patients to Rethink Free Dialysis,” and share your thoughts in the comments section.

Celia Watson Seupel

We are driving in silence along the road near my house when I hear my mother counting. I am hunched over the wheel, gnawing the inside of my lip, plotting how I am going to pay this winter’s heating bill while Mom strains against her seat belt, craning her neck, whispering: Three! Four! Five!

The road near my house is edged with brambles, sedge, trees and ditches, with fields stretching up to the mountains and saggy sheds shadowing the tarmac, with a barn painted red and a barn weathered gray and another barn painted muted shades of mauve.

What the heck is she counting?

My mother is 92 years old and suffers from dementia. Rather, I suffer from her dementia, and she suffers from random pains, a slow left foot that needs scolding before it will leave the car, and not having quite as much pep as she used to. Though her mind has become a sieve that holds the mere shape of events — only the residue of something that occurs, without the substance of it — still she reaches out and embraces everything that falls upon her senses.

“Ma,” I blurt out, “what are you counting?”

She points to the side of the road. “You know, the things. The red things. The little men. Oochy-coochy, there’s another one. Six!”

“The hydrants?”

“Yes, that’s it. The hydrants. Aren’t they cute?”

They are cute. Sunk low in the earth, collared with grass, the bright diminutive cylinders topped with their red helmets are curiously out of place on the woodsy verge. They were installed only last year when a new village water system was created.

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So often, novels and movies with elderly protagonists take pains to depict them in a state of rebellion. They’re breaking out of an assisted living facility. They’re skydiving and climbing the pyramids, pursuing their bucket lists. They’re heading into space for one last, crucial mission.

They’re behaving, in other words, as if they weren’t old. The preferred word for this state, I believe, is “feisty.”

I cherish the newly published novel “Emily, Alone,” by Stewart O’Nan, because the main character doesn’t deny or resist her age.

We never learn precisely what that is, but she’s close to 80 and not thrilled about it. “Emily hates that she and her friends have come to be seen by others as fragile, even if she understands that in some ways, they are,” Mr. O’Nan told me in an interview. “She fights against being seen as helpless and vulnerable. She wants to see herself as capable, as we all do.”

Yet her aspirations are resolutely nonflamboyant. A quiet, dignified widow in Pittsburgh, she yearns for spring so that she can garden. She tries to swallow her frustration when her grown children remain noncommittal about coming home for holidays. She worries about her aged dog, Rufus. She enjoys the Eat ‘n Park’s two-for-one breakfast buffet with her sister-in-law, Arlene. She carries on.

The most dramatic event, in the months readers spend with her, is that she buys a new Subaru.

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Leila Arnett, 94, moved into a nursing home in Louisville, Ky., last summer. She’s having a hard time — congestive heart failure, aortic stenosis, trouble hearing and seeing, general frailty. She recognizes visiting family members and can make conversation, but her dementia is causing delusions.

Recently Mrs. Arnett reported being kidnapped by a relative’s “ruffian friends,” taken to the dining room and force-fed. As near as her family can figure out, she was referring to volunteers trying to help her eat. The week before, she informed her daughter Elaine, a friend of mine, that a Cuban man had slept with her in the bed.

More recently, her son Dr. John Arnett told me, “She said she’d had a red box and a gray suitcase on her bed, and that while she was in the bathroom, someone had come and stolen them.” This became a recurrent theme over the next few days, as Mrs. Arnett told friends and family about the supposed theft and asked a friend to escort her to the front desk so that she could report it to the police. Reassurance proved futile; the loss had become an obsession.

“I thought, we might as well take this off her mind,” said Dr. Arnett, who is an internist. He knew the red box she meant — it was empty but had once held jewelry, and was in a bureau at her house. When he drove over to retrieve it, he looked around for a darkish suitcase and, in a back closet, located a gray one so old that when he picked it up, the handle fell off. It held table linens and needlework.

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Ruth Fremson/The New York Times Rose Bosco, 95, and her friend Delores Brown, 73, left, read a magazine together at the Seaside Senior Center in Rockaway Beach, Queens.

The Times reports on Sunday on the plight of New York’s 256 senior centers, many of which have been threatened by budget cuts over the last two years. The centers feed about 28,000 elderly people at a cost of about $86 million a year. John Leland takes a close look at Seaside, a center situated on a windswept strip of land separated from the rest of Queens by the waters of Jamaica Bay.

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Suzanne DeChillo/The New York Times Ann Logan, with Henry, in her New York apartment.

Ann Logan and her three sisters grew up in Delaware; none of them have children. Their stepbrother and seven first cousins on both sides are childless, as well. “Each of us had different reasons,” she told me.

Ms. Logan, the eldest sister at 63, doesn’t regret her decision not to be a parent, but she does worry about the future as she and her relatives all age.

For now, divorced and living in Manhattan, she’s a busy lawyer with good friends, caring neighbors and an Abyssinian cat named Henry. When she needed a double knee replacement a couple of years ago, a friend flew in from Fort Worth to help her, followed by another friend from Washington, followed by one of her sisters. Then neighbors came by to be sure Ms. Logan was taking her medications and to encourage her to get up and walk.

Still, Ms. Logan said, “If I have to go to an emergency room in the middle of the night, I don’t have anyone to call.”

And as the years pass, she fears her problems will mount; after all, most seniors eventually develop both chronic diseases and disabilities. “You cannot impose on the kindness of strangers endlessly, despite what Blanche said,” Ms. Logan said. (You can tell she’s a theatergoer.)

Moreover, the “chosen family” of friends that she and so many other single people rely on for support and connection will age along with her. “When there’s no one to monitor whether we’re starting to act foolishly, what happens?” she wondered. “Our contemporaries might think we’re normal because they’re having the same problems.”

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The first reader to weigh in on a recent post about new fall-prevention guidelines was “h” from Chicago, who wrote: “I also wonder about bifocals causing falls. This is why I’m sticking to two pairs of glasses for now.”

That’s good advice, it turns out.

In a study published last year in the medical journal BMJ, Australian researchers found a decrease in the number of falls among people who switched to single-vision eyeglasses for outdoor activities and stairs.

The results, said the researchers, “demonstrated how multifocal glasses can impair visual abilities needed for detecting obstacles and judging depth.”

So I went back to the complete list of fall-prevention guidelines issued by the American Geriatrics Society and its British counterpart, the ones that focus primarily on incorporating tai chi and medication reduction. There, toward the end of a list of additional recommendations — No. 28 to be exact — was this: “An older person should be advised not to wear multifocal lenses while walking, particularly on stairs.”

Before you schedule an appointment at the ophthalmologist’s, though, or run to out buy an eyeglass lanyard for a parent, bear in mind one caveat from the Australian study: Some participants fell in the process of switching glasses.

Which brings us back to “h” from Chicago, or any other reader who figured this out without reading a study. Any other tips on how to handle eyeglasses without risking a fall?