Every cruiser has that one port. The stop you’d trade in a heartbeat for an extra sea day. The one where you looked at the excursion offerings, the crowds, and the logistics and decided it wasn’t worth it. We wanted to know which ports our readers felt that way about, so we asked. Some of the answers came as no surprise but others shocked us.
Of course, “overrated” is subjective. One cruiser’s tourist trap is another cruiser’s favorite beach day, and a port that disappoints on a packed five-ship day can be lovely when you have it to yourself. Still, clear patterns did emerge. Ports tended to land on the overrated list for one of three reasons: they’re too crowded or too commercialized, there’s too little to do or the port itself feels manufactured, or the real attractions are too far away from the actual cruise port.
Nassau, Bahamas
Nassau, Bahamas might be one of the most-visited cruise destinations in the world, but it’s also the one that topped our overrated list.
On a busy day, five or six ships can be docked at once, flooding a compact downtown with tens of thousands of people. Readers described the port area as an open-air shopping mall surrounded by aggressive vendors and taxi drivers. Some also cited recent safety concerns and underwhelming free beaches like the nearby Junkanoo Beach. Day passes to the popular Atlantis resort are also very overpriced. Not to mention, many frequent cruisers have the “been there, done that” sentiment about Nassau.
A few of you also lumped in Freeport, Bahamas, which has struggled to recover from previous storm damage.
How to make it worth it: Skip the downtown shopping area and Atlantis entirely. Head to a nicer beach, Cabbage Beach and Cable Beach are popular options, or plan a specific excursion — like swimming with the pigs or a Bahamian food tour. If you’re looking for authentic eats, you can also head to the Fish Fry about 1.5 miles from the cruise port.
Cruising the Bahamas? We’ve got you covered.
Nassau doesn’t have to disappoint. After dozens of Bahamas cruises, we’ve pulled together 30 tips on when to book, which ports are worth your day, and what we skip every time. See them all in our complete Bahamas cruise tips guide.
Cozumel, Mexico
Cozumel is another one of the busiest cruise ports in the world, and like Nassau, its popularity is a knock against it. The area right off the piers is wall-to-wall with the familiar lineup — tourist shops, tequila stands, Señor Frog’s, and relentless sales vendors. The cruise port is too commercialized, there are no walkable beaches, and it’s always crowded were the most popular complaints. Plus, famous sites like Chichén Itzá or Tulum require lots of travel to reach from the Cozumel cruise port, and the destination has become synonymous with drunk cruise passengers and pier runners.
Some of you pointed to Progreso as an even bigger letdown with its long pier, industrial setup, and lackluster beaches.
How to make it worth it: Cozumel is one of the top snorkeling destinations in the Caribbean given its location along the Mesoamerican Barrier Reef. Get off the pier and into the sea. You could also head to a beach club away from the port or visit the nearby San Gervasio Mayan site.
Jamaica (Ocho Rios and Falmouth)
Jamaica drew strong feelings too, with Ocho Rios and Falmouth both singled out. Falmouth in particular came up as a purpose-built port walled off from the actual town — you’re shopping in a manufactured complex rather than experiencing “real” Jamaica. But others would prefer not to experience Jamaica at all, citing persistent vendors as well as safety, drug, and crime concerns.
How to make it worth it: Jamaica’s best moments just require a little planning to ensure safety. Book a reputable shore excursion to Dunn’s River Falls, a bamboo raft ride on the Martha Brae, or a Chukka Eco-Adventure tour. These tours can be booked directly through your cruise line or with Shore Excursions Group, both of which vet the local providers they work with. If you’d rather relax, a well-reviewed beach club day pass gets you the Jamaica you pictured without being harassed by beach vendors.
Costa Maya, Mexico
Costa Maya is a port in Mexico that exists largely because of cruise ships. Readers described it as a “fake” cruise destination — with purpose-built shopping and a pool complex but lacking authenticity. It’s touristy, prices are high, and it can get crowded with multiple ships in port. Many also cite frequent cancellations due to winds and rough seas that prevent ships from docking.
How to make it worth it: Venture beyond the cruise port. The Mayan ruins at Chacchoben are a reasonable drive inland and are the real draw here. Those seeking some sand and sun will find beach clubs in the nearby fishing village of Mahahual as well— Maya Chan is one of the more popular options.
Headed to the Caribbean? Here’s how we do it.
One overrated port won’t make or break your trip. After more than 100 cruises, we’ve packed everything we know into 30 tips on booking smart, planning your days ashore, and getting the most out of every stop. Read them all in our top Caribbean cruise tips guide.
Ensenada, Mexico
Ensenada has a specific reason for landing on this list: it’s frequently a “we legally have to stop at a foreign port” stop. On many West Coast round-trip itineraries, Ensenada is there to satisfy the Passenger Vessel Services Act (PVSA) more than because it’s a go-to Mexican destination. Readers described it as a filler port with a rough-around-the-edges feel and limited activity options near the ship. Some of the top attractions are a considerable drive away which can be difficult to fit into a short port stop.
How to make it worth it: If you have enough time in port, La Bufadora, the giant marine geyser, is the signature excursion and worth the trip. The local wine country in Valle de Guadalupe is a pleasant surprise for foodies as well. Treat it as a low-key day rather than the highlight of the cruise and it delivers just fine.
Dominican Republic (Amber Cove specifically)
The Dominican Republic was another frequently mentioned overrated Caribbean cruise port, specifically Amber Cove. Amber Cove is a Carnival-developed port complex in DR just outside of Puerto Plata. And like Falmouth and Costa Maya, it drew the “manufactured port” critique — a nice-enough pool and shopping area that isn’t really the Dominican Republic.
While also purpose-built, Taino Bay tends to garner a more favorable opinion for its resort amenities and walkability to downtown Puerto Plata. Though, it too gets criticism for crowding, expensive food and drinks, and no natural beach.
How to make it worth it: Puerto Plata’s cable car up Mount Isabel de Torres, the 27 Waterfalls of Damajagua, or the downtown area — including San Felipe Fortress, the Malecon, Umbrella Street, and Pink Alley — are all worth your time.
All Cruise Line Private Islands
Here’s one that might raise some eyebrows, because private islands are often marketed as a highlight on Bahamas or Caribbean itineraries and many cruisers (including us) love them. But the word that came up again and again was authenticity. These islands are beautiful but readers felt they aren’t really destinations so much as curated experiences built and branded by the cruise lines. Further, Perfect Day at CocoCay, Great Stirrup Cay, and Celebration Key often get a bad reputation for their amusement park-like attractions and party vibes.
How to make it worth it: Go in seeing these destinations for what they are — a well-executed beach day, not a cultural port stop — and they’re hard to beat. Loungers and umbrellas with plenty of beachfront, food, drinks, and sometimes even lagoon pools await. There’s also upgraded amenities if you want them, from beach clubs or cabanas to full-fledged waterparks.
Icy Strait Point, Alaska (and Alaska in general, surprisingly)
This was the answer that shocked us most. When we asked about overrated ports, a lot of you named Alaska as a whole — which we did not see coming, because an Alaska cruise is a bucket-list trip for so many people, and a destination that continues to impress us over and over again. And when someone named a specific Alaska port, Icy Strait Point came up the most.
The Alaska-wide sentiment came down to expectations versus reality. Alaska is marketed as a once-in-a-lifetime spectacle, and for some cruisers the reality — gray skies, rain, cool weather, and glaciers that were farther away than social media suggested — didn’t match the hype. Many reported that their idea of a vacation is somewhere warm and tropical.
Icy Strait Point, specifically, is a converted cannery rather than a real town. Nearly everything worth doing is a pricey excursion, and if you don’t book one there’s not a lot to fill the day.
How to make it worth it: We’ll always argue that Alaska absolutely lives up to the hype — you just have to have the right expectations. It’s a completely different experience than a Caribbean cruise. Choose an itinerary with prime glacier viewing (Glacier Bay or Hubbard). Pack for rain and cool temperatures so weather doesn’t wreck the day. And lean into one-of-a-kind excursions like glacier walks or dog sledding. At Icy Strait Point specifically, the ZipRider and whale watching are great activities.
Want Alaska to live up to the hype? Learn from our mistakes.
The difference between a letdown and the trip of a lifetime is planning. After seven Alaska cruises, we put together 45+ tips on picking the right itinerary, packing for the weather, and choosing excursions that are actually worth it. Get them all in our expert Alaska cruise tips guide.
Victoria, British Columbia
Victoria, British Columbia is a lovely city, so why is it here? Blame the cruise schedule. On many Alaska round-trip sailings out of Seattle, Victoria is the required foreign port stop and it’s frequently slotted in for just a few hours in the evening. Readers’ complaints weren’t with the city itself; it was arriving at 7 PM for a short, dark visit that doesn’t leave time to see much of anything like the beautiful Butchart Gardens.
How to make it worth it: Find an itinerary that includes a longer visit or just accept that this is a quick taste and plan accordingly. If you’re only in port for a few hours, take a walk along the Inner Harbour and Fisherman’s Wharf, grab a drink or dinner near the water, and have a look at the illuminated Parliament Buildings. If you go in expecting a stroll, not a full port day, Victoria charms rather than disappoints.
Santorini, Greece
Santorini is one of the most photographed places on earth, which is precisely why some readers found it overrated. The complaint here isn’t “too little to do” — it’s overtourism (even with passenger caps in place). On a busy day, several ships tender thousands of passengers into a port with famously limited access. The cable car up from the old port bottlenecks badly and the picture-perfect villages of Fira and Oia get so swamped with crowds that the serene, blue-domed backdrops that you dreamed of are hard to find. Not to mention all the influencers and flying dress photo shoots!
How to make it worth it: Timing and logistics are everything in Santorini. If planning a DIY day, get on the earliest tender you can to beat the cable car rush. Better yet, book an excursion that includes alternate transportation so you skip the cable car ascent altogether. Many still require you to take the cable car back down at the end of the tour. Head to Oia early or late in the day if you can or consider seeing the island beyond the two famous towns, perhaps a winery or volcanic beach.
Civitavecchia, Italy
Civitavecchia earns its spot for the most straightforward reason on the list: it’s not really the destination. The port is sold as “Rome”, but Rome is roughly 1 to 1.5 hours away depending on traffic. Readers pointed out the frustration of spending a huge chunk of a precious port day in transit, leaving a compressed five or six hours maximum to take on the Colosseum, the Vatican, the historic city center, and everything else. The port town of Civitavecchia itself does have a few nearby attractions, but it’s nowhere near as alluring as Rome.
How to make it worth it: If Rome is the goal, book a ship-sponsored excursion or a reputable private tour so a missed train or traffic doesn’t cause you to miss the ship. Prioritize just one or two major sites with some time to stroll or enjoy lunch rather than trying to do all of Rome in an afternoon. Alternatively, skip the Rome sprint for a slower and far less stressful local day around Civitavecchia.
Planning a Mediterranean cruise? Here’s what to know.
Med port days are long, packed, and easy to get wrong when the big sights sit hours from the pier. These are the 35 tips we wish we’d known before our first sailing, from booking early to making every port count. Read them all in our Mediterranean cruise tips guide.
What to Do Instead: Consider a Ship Day
Here’s a piece of advice we give constantly, and it applies perfectly to a port you’re lukewarm about: you don’t have to get off the ship. One of our favorite cruise hacks is to deliberately pick a port day to stay onboard — and an overrated stop is the ideal candidate.
When most of the ship files down the gangway, the pools, hot tubs, and specialty venues empty out. You get a quiet ship, no lines at the buffet, a shot at good deck chairs, and often a spa or dining deal precisely because the cruise line knows most people are ashore. Instead of spending money and energy on a port that underwhelms, spend a relaxed day enjoying all the things you already love about cruising. Think of it as your own personal sea day.
It’s your vacation, and you can do whatever you want (well, within limits). Make a smart plan when going ashore in the ports you love, and give yourself full permission to stay on the ship at an overrated cruise port.
Comments
Did your most overrated port make this list? Which of these cruise ports do you think we got wrong? Drop us an anchor below to share which cruise destinations you tend to avoid.
This is the second in a series of posts explaining my Healthy Aging Checklist.
Remember, for the healthiest aging, we need to do the things that optimize health — and health care — so that the brain and body work at their best for now, and for the future.
In this post, we’ll cover proven ways to promote and maintain physical health as one ages.
6 Proven Ways to Promote Physical Health
Here are the six “healthy living” actions that I recommend, for promoting physical health in all older adults. They all have a solid track record (which cannot be said for everything I see recommended online). They are also good “bang-for-the-buck,” in part because they provide real benefits to just about everyone who adopts them. And they help whether or not an older person has already developed chronic illnesses.
Now, the truth is that many of these overlap with the recommended actions for brain health. But I’ve tried to provide more links and resources related to how these actions benefit aspects of physical health such as mobility, heart health, and immune function.
Get Your Free Physical Health Cheatsheet! The 6 actions to maintain physical health in a handy PDF checklist that you can print or save. Includes useful resources for each action item. Click here now.
1. Exercise regularly — and include strength training twice weekly.
Why: Exercise helps older adults maintain their strength and mobility, plus it improves just about every physical health outcome you can imagine, provided you don’t overdo it or get injured.
Walking daily is not enough! Research suggests that strength training (e.g. weight lifting or other exercises that strengthen muscles) is especially beneficial as we age. Without strength training, muscles weaken as we age, which can lead to anything from falls to difficulties with daily activities. I go into more detail about this topic in my Youtube video regarding exercising and aging:
A 2014 research study in JAMA found that a structured exercise program — involving sedentary adults aged 70-89 — reduced the risk of “major mobility disability.” Exercise also tends to improve mood, which has positive effects on the rest of the body.
Note: Research has shown that even less-than-recommended exercise brings health benefits so remember: it’s better to do a little bit every day than nothing at all. In fact, the most important thing is to find something that you can keep doing. Walking is relatively easy for many. Otherwise, classes or structured courses often help older adults stick with an exercise program; look for a class led by someone with experience coaching older adults.
If you are already walking regularly, that’s great, but it’s not enough to build up your muscles! So the next step is to try to incorporate all four different types of exercise that benefit older adults: strength, endurance, balance, and flexibility. Again, strength training is especially important in aging.
Why: Smoking tobacco is bad for just about every aspect of physical health. It’s especially damaging to the lungs, but also increases the risk of heart attacks, strokes, and various forms of cancer. Many tobacco-related diseases, such as chronic obstructive pulmonary disease, can cause difficult symptoms for years.
Fortunately, even after an older adult has developed smoking-related health problems, quitting smoking will reduce symptoms and one’s chance of a premature death: one study found that quitting smoking between ages 55-64 added four years to one’s life expectancy.
Note: Quitting smoking is hard, since nicotine is physically and psychologically addictive. Only 3-6% of people who try to quit on their own succeed. Medications and counseling have been proven to help quit smoking; combining these correctly usually increases the chance of successfully quitting to 30%. Many people need to try quitting a few times, so don’t let a past failure to quit stop you from trying again.
E-cigarettes do help some people quit smoking. Although we don’t yet know what are the long-term effects of vaping and using e-cigarettes, preliminary research suggests that it’s better to use e-cigarettes than it is to smoke.
Why: Studies have found that chronic sleep deprivation is linked to increased cardiovascular disease, increased levels of inflammatory blood markers, and decreased immune function. Being sleep-deprived also causes fatigue, which can make it hard to be physically active (and is bad for mood, too).
Note: Aging does cause sleep to become lighter and more fragmented, and may cause people to need a little less sleep than when they were younger. That said, chronic sleep difficulties or often waking up feeling tired is not normal in aging. Older adults often suffer from true sleep problems that can be treated once they are properly evaluated.
Why: Feeling chronically stressed has been linked to physical health problems such as cardiovascular disease, insulin resistance, and decreased immune function. Research suggests that this may be because stress can accelerate “cellular aging,” and also may promote inflammatory markers in the body.
Note: Common causes of stress in older adults include financial stress, relationship stress, work-related stress, and caregiving stress. To reduce chronic stress, it’s best to combine general approaches (such as improving sleep, exercising, meditation, relaxation strategies, etc) with approaches that can help you cope with your specific source of stress.
Why: The main reason is that obesity is a major risk factor for disability in late life. (Strange but true: as people get older, the link between obesity and premature death gets weaker, a phenomenon sometimes called the “obesity paradox in aging.”)
Obesity — usually defined as having a body mass index (BMI) of 30 or more — worsens arthritis. It’s also been linked to many health problems, such as cardiovascular disease, diabetes and glucose intolerance, certain types of cancer, and sleep-related breathing disorders.
Studies have found that when overweight or obese people lose even a modest amount of weight — such as 5-7% of one’s current weight — this can improve physical health and symptoms.
Do keep in mind that unintentional weight loss is a major red flag when it comes to the health of older adults, and should always be brought to the attention of health professionals.
Note: Historically, a low-fat diet has been recommended for weight loss and health reasons. However, I believe there’s a lot to be said for the theory that high-carbohydrate foods (which are often low-fat) increase insulin levels, promote hunger, and make it harder for people to lose weight. If you need to lose weight, you may want to do some research into various approaches before discussing with your doctor and coming to your own conclusions as to which weight-loss strategy to try. Older adults need to be especially careful about not losing too much lean body mass during intentional weight loss.
Why: Diet undoubtedly affects certain aspects of physical health. A healthy diet is one that doesn’t provoke negative health effects, such as being prone to take on extra weight, developing insulin resistance, developing atherosclerosis, or having uncomfortable symptoms in the belly or bowels.
Frail older people often need extra calories and protein, since malnutrition becomes more common as people age. Research also suggests that eating enough protein is important if you are working on strength training, as the muscles can’t grow stronger without enough protein. I talk on the importance of protein in my Youtube video here:
Note: Exactly what should or shouldn’t be eaten, as part of a healthy diet, is being constantly debated among experts and the general public. As the effect of diet on a person is very individual, it’s important to follow how one’s body seems to respond to a given diet. (Pay attention to how you feel, how your weight changes, and how your blood sugar and lipids change.)
In general, research suggests that a diet high in vegetables and fiber and low in ultra-processed foods and added sugars — such as the Mediterranean diet — is a good choice for many.
Why: Recent research suggests that a person’s health can be significantly influenced by the bacterial community (the microbiome) we all carry within our guts and in our body. The microbiome itself seems to be influenced by one’s diet as well as by other factors.
On the other hand, it’s not clear that taking extra vitamins and supplements — including popular anti-oxidants — promote health. The US Preventive Services task force report on this topic concluded the evidence of benefit is weak. Furthermore, commercially available supplements have often been found to be of poor quality, and “anti-aging” vitamins have no evidence behind them. To promote physical health, I believe that supporting the microbiome with good nutritious food will prove to be much more important than tinkering with supplements.
Note: It is not yet clear how we should advise people to optimize their microbiome, other than to eat a lot of fiber and minimize antibiotics. For some people, eliminating certain foods seems to improve well-being or certain symptoms. Research into the benefits of fermented foods and probiotics is ongoing. There is also fascinating research being done on how the microbiome changes with aging, and might influence certain aspects of the body’s aging.
What’s Your Plan for Promoting Physical Health While Aging?
So that’s my short list of activities that are most important to do, to promote physical health while aging.
Which of these are you already doing, and which of these will you try to work on in the next few months?
Also, if you think I’ve missed anything major in the list (it has to be something with good evidence and that works for virtually all older adults), please let me know.
Get Your Free Physical Health Cheatsheet! The 6 actions to maintain physical health in a handy PDF checklist that you can print or save. Includes useful resources for each action item. Click here now.
This is the second in a series of posts explaining my Healthy Aging Checklist.
Remember, for the healthiest aging, we need to do the things that optimize health — and health care — so that the brain and body work at their best for now, and for the future.
In this post, we’ll cover proven ways to promote and maintain physical health as one ages.
6 Proven Ways to Promote Physical Health
Here are the six “healthy living” actions that I recommend, for promoting physical health in all older adults. They all have a solid track record (which cannot be said for everything I see recommended online). They are also good “bang-for-the-buck,” in part because they provide real benefits to just about everyone who adopts them. And they help whether or not an older person has already developed chronic illnesses.
Now, the truth is that many of these overlap with the recommended actions for brain health. But I’ve tried to provide more links and resources related to how these actions benefit aspects of physical health such as mobility, heart health, and immune function.
Get Your Free Physical Health Cheatsheet! The 6 actions to maintain physical health in a handy PDF checklist that you can print or save. Includes useful resources for each action item. Click here now.
1. Exercise regularly — and include strength training twice weekly.
Why: Exercise helps older adults maintain their strength and mobility, plus it improves just about every physical health outcome you can imagine, provided you don’t overdo it or get injured.
Walking daily is not enough! Research suggests that strength training (e.g. weight lifting or other exercises that strengthen muscles) is especially beneficial as we age. Without strength training, muscles weaken as we age, which can lead to anything from falls to difficulties with daily activities. I go into more detail about this topic in my Youtube video regarding exercising and aging:
A 2014 research study in JAMA found that a structured exercise program — involving sedentary adults aged 70-89 — reduced the risk of “major mobility disability.” Exercise also tends to improve mood, which has positive effects on the rest of the body.
Note: Research has shown that even less-than-recommended exercise brings health benefits so remember: it’s better to do a little bit every day than nothing at all. In fact, the most important thing is to find something that you can keep doing. Walking is relatively easy for many. Otherwise, classes or structured courses often help older adults stick with an exercise program; look for a class led by someone with experience coaching older adults.
If you are already walking regularly, that’s great, but it’s not enough to build up your muscles! So the next step is to try to incorporate all four different types of exercise that benefit older adults: strength, endurance, balance, and flexibility. Again, strength training is especially important in aging.
Why: Smoking tobacco is bad for just about every aspect of physical health. It’s especially damaging to the lungs, but also increases the risk of heart attacks, strokes, and various forms of cancer. Many tobacco-related diseases, such as chronic obstructive pulmonary disease, can cause difficult symptoms for years.
Fortunately, even after an older adult has developed smoking-related health problems, quitting smoking will reduce symptoms and one’s chance of a premature death: one study found that quitting smoking between ages 55-64 added four years to one’s life expectancy.
Note: Quitting smoking is hard, since nicotine is physically and psychologically addictive. Only 3-6% of people who try to quit on their own succeed. Medications and counseling have been proven to help quit smoking; combining these correctly usually increases the chance of successfully quitting to 30%. Many people need to try quitting a few times, so don’t let a past failure to quit stop you from trying again.
E-cigarettes do help some people quit smoking. Although we don’t yet know what are the long-term effects of vaping and using e-cigarettes, preliminary research suggests that it’s better to use e-cigarettes than it is to smoke.
Why: Studies have found that chronic sleep deprivation is linked to increased cardiovascular disease, increased levels of inflammatory blood markers, and decreased immune function. Being sleep-deprived also causes fatigue, which can make it hard to be physically active (and is bad for mood, too).
Note: Aging does cause sleep to become lighter and more fragmented, and may cause people to need a little less sleep than when they were younger. That said, chronic sleep difficulties or often waking up feeling tired is not normal in aging. Older adults often suffer from true sleep problems that can be treated once they are properly evaluated.
Why: Feeling chronically stressed has been linked to physical health problems such as cardiovascular disease, insulin resistance, and decreased immune function. Research suggests that this may be because stress can accelerate “cellular aging,” and also may promote inflammatory markers in the body.
Note: Common causes of stress in older adults include financial stress, relationship stress, work-related stress, and caregiving stress. To reduce chronic stress, it’s best to combine general approaches (such as improving sleep, exercising, meditation, relaxation strategies, etc) with approaches that can help you cope with your specific source of stress.
Why: The main reason is that obesity is a major risk factor for disability in late life. (Strange but true: as people get older, the link between obesity and premature death gets weaker, a phenomenon sometimes called the “obesity paradox in aging.”)
Obesity — usually defined as having a body mass index (BMI) of 30 or more — worsens arthritis. It’s also been linked to many health problems, such as cardiovascular disease, diabetes and glucose intolerance, certain types of cancer, and sleep-related breathing disorders.
Studies have found that when overweight or obese people lose even a modest amount of weight — such as 5-7% of one’s current weight — this can improve physical health and symptoms.
Do keep in mind that unintentional weight loss is a major red flag when it comes to the health of older adults, and should always be brought to the attention of health professionals.
Note: Historically, a low-fat diet has been recommended for weight loss and health reasons. However, I believe there’s a lot to be said for the theory that high-carbohydrate foods (which are often low-fat) increase insulin levels, promote hunger, and make it harder for people to lose weight. If you need to lose weight, you may want to do some research into various approaches before discussing with your doctor and coming to your own conclusions as to which weight-loss strategy to try. Older adults need to be especially careful about not losing too much lean body mass during intentional weight loss.
Why: Diet undoubtedly affects certain aspects of physical health. A healthy diet is one that doesn’t provoke negative health effects, such as being prone to take on extra weight, developing insulin resistance, developing atherosclerosis, or having uncomfortable symptoms in the belly or bowels.
Frail older people often need extra calories and protein, since malnutrition becomes more common as people age. Research also suggests that eating enough protein is important if you are working on strength training, as the muscles can’t grow stronger without enough protein. I talk on the importance of protein in my Youtube video here:
Note: Exactly what should or shouldn’t be eaten, as part of a healthy diet, is being constantly debated among experts and the general public. As the effect of diet on a person is very individual, it’s important to follow how one’s body seems to respond to a given diet. (Pay attention to how you feel, how your weight changes, and how your blood sugar and lipids change.)
In general, research suggests that a diet high in vegetables and fiber and low in ultra-processed foods and added sugars — such as the Mediterranean diet — is a good choice for many.
Why: Recent research suggests that a person’s health can be significantly influenced by the bacterial community (the microbiome) we all carry within our guts and in our body. The microbiome itself seems to be influenced by one’s diet as well as by other factors.
On the other hand, it’s not clear that taking extra vitamins and supplements — including popular anti-oxidants — promote health. The US Preventive Services task force report on this topic concluded the evidence of benefit is weak. Furthermore, commercially available supplements have often been found to be of poor quality, and “anti-aging” vitamins have no evidence behind them. To promote physical health, I believe that supporting the microbiome with good nutritious food will prove to be much more important than tinkering with supplements.
Note: It is not yet clear how we should advise people to optimize their microbiome, other than to eat a lot of fiber and minimize antibiotics. For some people, eliminating certain foods seems to improve well-being or certain symptoms. Research into the benefits of fermented foods and probiotics is ongoing. There is also fascinating research being done on how the microbiome changes with aging, and might influence certain aspects of the body’s aging.
What’s Your Plan for Promoting Physical Health While Aging?
So that’s my short list of activities that are most important to do, to promote physical health while aging.
Which of these are you already doing, and which of these will you try to work on in the next few months?
Also, if you think I’ve missed anything major in the list (it has to be something with good evidence and that works for virtually all older adults), please let me know.
Get Your Free Physical Health Cheatsheet! The 6 actions to maintain physical health in a handy PDF checklist that you can print or save. Includes useful resources for each action item. Click here now.
This is the second in a series of posts explaining my Healthy Aging Checklist.
Remember, for the healthiest aging, we need to do the things that optimize health — and health care — so that the brain and body work at their best for now, and for the future.
In this post, we’ll cover proven ways to promote and maintain physical health as one ages.
6 Proven Ways to Promote Physical Health
Here are the six “healthy living” actions that I recommend, for promoting physical health in all older adults. They all have a solid track record (which cannot be said for everything I see recommended online). They are also good “bang-for-the-buck,” in part because they provide real benefits to just about everyone who adopts them. And they help whether or not an older person has already developed chronic illnesses.
Now, the truth is that many of these overlap with the recommended actions for brain health. But I’ve tried to provide more links and resources related to how these actions benefit aspects of physical health such as mobility, heart health, and immune function.
Get Your Free Physical Health Cheatsheet! The 6 actions to maintain physical health in a handy PDF checklist that you can print or save. Includes useful resources for each action item. Click here now.
1. Exercise regularly — and include strength training twice weekly.
Why: Exercise helps older adults maintain their strength and mobility, plus it improves just about every physical health outcome you can imagine, provided you don’t overdo it or get injured.
Walking daily is not enough! Research suggests that strength training (e.g. weight lifting or other exercises that strengthen muscles) is especially beneficial as we age. Without strength training, muscles weaken as we age, which can lead to anything from falls to difficulties with daily activities. I go into more detail about this topic in my Youtube video regarding exercising and aging:
A 2014 research study in JAMA found that a structured exercise program — involving sedentary adults aged 70-89 — reduced the risk of “major mobility disability.” Exercise also tends to improve mood, which has positive effects on the rest of the body.
Note: Research has shown that even less-than-recommended exercise brings health benefits so remember: it’s better to do a little bit every day than nothing at all. In fact, the most important thing is to find something that you can keep doing. Walking is relatively easy for many. Otherwise, classes or structured courses often help older adults stick with an exercise program; look for a class led by someone with experience coaching older adults.
If you are already walking regularly, that’s great, but it’s not enough to build up your muscles! So the next step is to try to incorporate all four different types of exercise that benefit older adults: strength, endurance, balance, and flexibility. Again, strength training is especially important in aging.
Why: Smoking tobacco is bad for just about every aspect of physical health. It’s especially damaging to the lungs, but also increases the risk of heart attacks, strokes, and various forms of cancer. Many tobacco-related diseases, such as chronic obstructive pulmonary disease, can cause difficult symptoms for years.
Fortunately, even after an older adult has developed smoking-related health problems, quitting smoking will reduce symptoms and one’s chance of a premature death: one study found that quitting smoking between ages 55-64 added four years to one’s life expectancy.
Note: Quitting smoking is hard, since nicotine is physically and psychologically addictive. Only 3-6% of people who try to quit on their own succeed. Medications and counseling have been proven to help quit smoking; combining these correctly usually increases the chance of successfully quitting to 30%. Many people need to try quitting a few times, so don’t let a past failure to quit stop you from trying again.
E-cigarettes do help some people quit smoking. Although we don’t yet know what are the long-term effects of vaping and using e-cigarettes, preliminary research suggests that it’s better to use e-cigarettes than it is to smoke.
Why: Studies have found that chronic sleep deprivation is linked to increased cardiovascular disease, increased levels of inflammatory blood markers, and decreased immune function. Being sleep-deprived also causes fatigue, which can make it hard to be physically active (and is bad for mood, too).
Note: Aging does cause sleep to become lighter and more fragmented, and may cause people to need a little less sleep than when they were younger. That said, chronic sleep difficulties or often waking up feeling tired is not normal in aging. Older adults often suffer from true sleep problems that can be treated once they are properly evaluated.
Why: Feeling chronically stressed has been linked to physical health problems such as cardiovascular disease, insulin resistance, and decreased immune function. Research suggests that this may be because stress can accelerate “cellular aging,” and also may promote inflammatory markers in the body.
Note: Common causes of stress in older adults include financial stress, relationship stress, work-related stress, and caregiving stress. To reduce chronic stress, it’s best to combine general approaches (such as improving sleep, exercising, meditation, relaxation strategies, etc) with approaches that can help you cope with your specific source of stress.
Why: The main reason is that obesity is a major risk factor for disability in late life. (Strange but true: as people get older, the link between obesity and premature death gets weaker, a phenomenon sometimes called the “obesity paradox in aging.”)
Obesity — usually defined as having a body mass index (BMI) of 30 or more — worsens arthritis. It’s also been linked to many health problems, such as cardiovascular disease, diabetes and glucose intolerance, certain types of cancer, and sleep-related breathing disorders.
Studies have found that when overweight or obese people lose even a modest amount of weight — such as 5-7% of one’s current weight — this can improve physical health and symptoms.
Do keep in mind that unintentional weight loss is a major red flag when it comes to the health of older adults, and should always be brought to the attention of health professionals.
Note: Historically, a low-fat diet has been recommended for weight loss and health reasons. However, I believe there’s a lot to be said for the theory that high-carbohydrate foods (which are often low-fat) increase insulin levels, promote hunger, and make it harder for people to lose weight. If you need to lose weight, you may want to do some research into various approaches before discussing with your doctor and coming to your own conclusions as to which weight-loss strategy to try. Older adults need to be especially careful about not losing too much lean body mass during intentional weight loss.
Why: Diet undoubtedly affects certain aspects of physical health. A healthy diet is one that doesn’t provoke negative health effects, such as being prone to take on extra weight, developing insulin resistance, developing atherosclerosis, or having uncomfortable symptoms in the belly or bowels.
Frail older people often need extra calories and protein, since malnutrition becomes more common as people age. Research also suggests that eating enough protein is important if you are working on strength training, as the muscles can’t grow stronger without enough protein. I talk on the importance of protein in my Youtube video here:
Note: Exactly what should or shouldn’t be eaten, as part of a healthy diet, is being constantly debated among experts and the general public. As the effect of diet on a person is very individual, it’s important to follow how one’s body seems to respond to a given diet. (Pay attention to how you feel, how your weight changes, and how your blood sugar and lipids change.)
In general, research suggests that a diet high in vegetables and fiber and low in ultra-processed foods and added sugars — such as the Mediterranean diet — is a good choice for many.
Why: Recent research suggests that a person’s health can be significantly influenced by the bacterial community (the microbiome) we all carry within our guts and in our body. The microbiome itself seems to be influenced by one’s diet as well as by other factors.
On the other hand, it’s not clear that taking extra vitamins and supplements — including popular anti-oxidants — promote health. The US Preventive Services task force report on this topic concluded the evidence of benefit is weak. Furthermore, commercially available supplements have often been found to be of poor quality, and “anti-aging” vitamins have no evidence behind them. To promote physical health, I believe that supporting the microbiome with good nutritious food will prove to be much more important than tinkering with supplements.
Note: It is not yet clear how we should advise people to optimize their microbiome, other than to eat a lot of fiber and minimize antibiotics. For some people, eliminating certain foods seems to improve well-being or certain symptoms. Research into the benefits of fermented foods and probiotics is ongoing. There is also fascinating research being done on how the microbiome changes with aging, and might influence certain aspects of the body’s aging.
What’s Your Plan for Promoting Physical Health While Aging?
So that’s my short list of activities that are most important to do, to promote physical health while aging.
Which of these are you already doing, and which of these will you try to work on in the next few months?
Also, if you think I’ve missed anything major in the list (it has to be something with good evidence and that works for virtually all older adults), please let me know.
Get Your Free Physical Health Cheatsheet! The 6 actions to maintain physical health in a handy PDF checklist that you can print or save. Includes useful resources for each action item. Click here now.
An HX Galapagos cruise is unlike anything we’ve experienced before. Heidi and I have sailed on over 100 cruises, many of them to the Caribbean and Bahamas. We’ve enjoyed the warm sun, the crystal clear water, and plenty of time on the ocean. We’ve also witnessed the impressive landscapes of Alaska and the Norwegian fjords.
The Galapagos has all of that too. But it also has so much more. Over nine days, we watched Nazca boobies build nests mere feet from us, swam alongside playful sea lions, and hiked across lava fields that looked like another planet.
The Galapagos is one of the most unique destinations in the world. And the cruise itself was anything but ordinary. It was truly an expedition. One we might not have been entirely prepared for.
More than 70 vessels operate in the Galapagos, and every single one is small. The National Park caps capacity at 100 passengers per ship, and many carry even less, some as few as 16 guests.
We knew expedition cruising was active, but even our Antarctica sailing didn’t prepare us for how packed these days were. Most days brought three or four outings, two before lunch and two after, with a mix of water-based activities and landings ashore.
Of course, we think cruising is the best way to see many destinations. But for the Galapagos, it’s almost essential. You cannot fly directly to the Galapagos from an international airport. Every visitor connects through Quito or Guayaquil, Ecuador and then takes a domestic flight to Baltra. HX includes these roundtrip flights from Quito to Baltra in the cruise fare.
When booking the Nine of the Best Isles itinerary with HX, the package includes two nights in Quito. You can also opt for a 5-night extension to Peru and Machu Picchu. Which we obviously did!
Every visitor also pays a $200 National Park entrance fee and a $20 Transit Control Card fee, both of which are required before you set foot on the islands. Again, HX took care of getting these documents for us, which was one less thing to sort out at 6 AM in an airport.
Before you fly to Baltra, your bags are also screened and sealed as a biosecurity precaution. All your luggage goes through biosecurity before the Baltra flight, and checked luggage comes out zip-tied shut until you land.
Our Ship — MS Santa Cruz II
Our first look at Santa Cruz II came from a zodiac, also known as a panga in South America. There was no gangway, no terminal, and no check-in desk.
We handed our checked bags to HX staff at the Baltra airport, boarded a bus with our carry-ons, and rode to a small pier. From there, we climbed into a panga, laptops and all, for a ten-minute ride out to the ship anchored offshore. Not the embarkation day that we expected!
HX charters the MS Santa Cruz II from Metropolitan Touring, an Ecuadorian company that has operated in the Galapagos for decades, and the ship underwent a full renovation in 2021.
Admittedly, the ship is smaller and older than the ones we usually sail, but the main focus of this trip is the Galapagos Islands after all. There are no balconies and no pool on Santa Cruz II, only two hot tubs.
There’s one bar and lounge. The Panorama Bar on deck 3 was open most of the day. It also had an aft outdoor lounge. This was a great place to relax between activities or spend a lazy afternoon outside admiring the scenery. It’s also where the evening port talks occurred.
In terms of other public venues, there’s a 24-hour fitness center, a singular restaurant, a small shop, and the Science Center. This is where we met for many activities; it also housed a small library, some furniture for lounging, and the coffee machine. Outdoors, you’ll find a couple observation decks as well. We liked the small area overlooking the bridge in front of the Science Center.
Given the cruise was so packed with expedition activities, we really didn’t miss any of the amusements you typically find on today’s mega ships.
As we already mentioned, the package includes round-trip airfare to the Galápagos from mainland Ecuador. The fare also includes two nights pre-cruise in Quito, a guided tour in Quito, and all necessary documentation and entry fees for the national park.
Once onboard, all beverages (alcoholic and non-alcoholic) are included, with only premium selections carrying a charge. There is also a self-serve coffee station in the Science Center that brews cappuccinos and espresso-based drinks. We visited this stand far more often than we care to admit.
All meals are included too, but we’ll get to the dining in a bit.
Starlink WiFi is included as well, one account per person, and it works across multiple devices. We checked social media, kept up with email, and even ran a few video conference calls without much trouble. But streaming video platforms like YouTube or Netflix are not acessible.
HX even includes self-service laundry, with an approved eco-friendly detergent. After two weeks of traveling and full days of hiking, snorkeling, and sweating, we were grateful for it.
HX also has a professional photographer/videographer onboard, and the photos and videos he captures during the week are shared with guests after the cruise. Of course, this did not stop us from taking too many photos and videos as well.
All activities are included, including ashore landings, kayaks, paddleboards, panga rides, glass bottom boat rides, and snorkeling. HX even provides the gear, including snorkel equipment, wetsuits, and walking sticks. In the stateroom, you’ll find an expedition backpack, an HX cap, and a water bottle, all of which are yours to keep.
Additionally, all service charges are included. At the end of the cruise, you can provide additional gratuities to the crew, bar staff, and expedition guides, or tip individual crew members directly at your discretion.
Besides the onboard boutique, which offers some souvenirs and gifts, there are essentially no additional costs once on the ship.
Dining on MS Santa Cruz II
There is one dining venue on Santa Cruz II, the Beagle Restaurant on Deck 0.
Meals ran on a fairly fixed schedule, with a buffet setup for breakfast and lunch and a table service meal at dinner time. Breakfast fell between 6:30 and 7:30 AM, depending on the day’s activities. Lunch landed around noon or 12:30 PM. Dinner was rather late by our standards, usually between 7:30 and 8 PM, following the evening’s expedition plan and announcements. It was open seating but most passengers gravitated toward the same table, especially since you had to pre-order dinner during lunch (which we thought was rather odd).
Overall, the food was passable but certainly not a highlight. We never went hungry, but it didn’t measure up to the other expedition cruises we’ve done in the past from brands like Atlas or Viking. That said, we suspect the destination bears more blame than the galley. Ecuador enforces strict limits on what can be imported into the islands, and the cruise line has to source a good deal of its supplies from local vendors.
Breakfast was nearly identical each morning, with scrambled eggs, breakfast meats, fruit, cereals, pastries, and continental items, plus a rotating option such as French toast or pancakes. You could also order custom eggs and omelets, which we did more than once.
Lunch typically offered one or two entrees, usually beef or fish, with rice and assorted sides. Chicken turned up now and then, which Heidi appreciated. There was a charcuterie spread with meats and cheeses, a salad bar, pasta of the day, and a couple of desserts.
On occasion, there was a carving station with items like roasted pork or grilled fish, which I was quite fond of. The Mexican-themed lunch with a taco bar and nachos was a highlight for us, which ironically showed up after Mexico beat Ecuador in the World Cup.
Each night for dinner there was roughly three choices each for starter, entree, and dessert. The menu changed nightly, but there was no real theme. There was also a comfort menu of Western classics that remained the same throughout the voyage. Some of the options included pizza, a burger, and grilled chicken with fries. You don’t want to overlook the kids chicken nuggets either.
Life Onboard MS Santa Cruz II
Every day followed a similar rhythm. The day started with breakfast, then one or two morning outings. Some mornings brought a guided walk, and other times we had a choice of activities. Everyone was back onboard by lunchtime. Then, there were one or two more activities in the afternoon, with the last one usually a hike with our assigned group.
By the time we got back onboard, we were exhausted from a long day. Some activities started as early as 6 AM and some finished as late as 6 PM, which meant we had to rush to shower and get ready for the evening.
On a few evenings, the crew met us with grilled snacks and drinks on the outdoor lounge. Other days, there were snacks in the bar at 6 PM, like cheese and crackers, sushi, or mini empanadas. Given the late dinners and active days, these snacks disappeared quickly.
Before dinner, there was usually a “tiny talk,” a short lecture given by a different member of the expedition team. Topics ranged from the mating rituals of blue-footed boobies and the difference between seals and sea lions to the islands’ colonization history, mangroves, and giant tortoises. Now, I will never forget that the Galapagos has no seals at all.
The expedition leader, Esteban, usually followed with the next day’s expedition plan and the activity options. A few nights brought something extra, like a captain’s toast, a slideshow from the photographer, or an HX charity auction.
With the long days, we often finished eating and went straight to bed. Although, the Panorama Bar is open until 11 PM. One night, I joined a bunch of the crew and a few fellow cruisers to watch the Ecuador World Cup Match. Another night, when we knew we had a later morning, we dragged ourselves to the bar around 9:30 PM and there was only one other couple there.
While we initially thought we might miss some of the usual cruise happenings like live music or trivia, it turned out we didn’t.
Beyond the evening “tiny talks” and expedition briefings in the Panorama Bar, there wasn’t much else going on. There were a few longer lectures on Galapagos Natural History and Darwin and the Galapagos. The Science Center also hosted a recurring hands-on series led by the expedition team on various topics. Guests could tour the bridge as well upon request at the reception desk.
The Discovery Room is the other onboard gathering space, stocked with games for families and a television with a DVD player.
One thing that surprised us was how many families were on board, but HX does run a Young Explorers program with dedicated activities for kids.
And then there’s another odd quirk. There are no televisions in the staterooms, not even to watch one of the talks you may have missed.
Our Oceanview Cabin
We stayed in cabin 120, an oceanview stateroom on Deck 1. The cabin was located on the starboard side near reception. At roughly 150 square feet, it was tiny, even by cruise ship standards. It consisted of one queen bed, two nightstands, a desk, and a bathroom. There was no seating area at all — no sofa, no chair, just the stool at the desk.
Entering the stateroom, the bathroom sits immediately on the right with the rest of the room opening up beyond it.
Storage was a real constraint. Drawer space was limited, with a few on the desk and one small one in each nightstand. The closet offered a short clothes bar and only a handful of hangers, which does not go far for overpackers like us with 2+ weeks’ worth of clothes.
Packing cubes saved us here, as did our magnetic hooks, which we used all week to hang bathing suits, raincoats, and laundry to dry.
The rest of the cabin worked fine, even if the shower was extremely small too. Outlets sat next to each nightstand, and we were glad we packed a cruise-approved power adapter along with a few extra plugs. Two people charging phones, a camera, a GoPro, and a laptop will use every outlet you can find.
As we mentioned earlier, one glaring omission from the stateroom was a television. While we didn’t have time to watch anything, it would be nice to have additional programming available for asynchronous viewing during the day or between sessions.
Another thing about the cabin that surprised us was the fact that we didn’t have a key card. While the room did lock from inside, we couldn’t lock the door when leaving the ship. Apparently, this “open door” policy is common on smaller expedition vessels in the Galapagos Islands.
Our Galapagos Itinerary
Excursions and Activities
Every day brought three or four outings, and most came with choices. There was always at least one daily hike, sometimes two. There was usually at least one snorkeling session as well. Alternative options like short walks in place of the hikes or panga rides and glass-bottom boat rides for those who didn’t want to snorkel were also available. Sometimes, there was free beach time which could be used to relax, snorkel, or kayak.
We were all assigned to a group named for Galapagos wildlife. We were the Cormorants, and our group included a few people we had met during the pre-cruise tour, along with several others we got to know over the course of the week.
While you never had to sign up for the hikes becasue these were always by assigned group, the other optional water-based activities did require daily sign-ups in the Science Center. For activities like glass-bottom boat rides or kayaking, you often had to sign up for a specific time. The glass-bottom boat, for example, might run at 9:40, 10:20, and 11:00 AM, while others are off on a deep-water snorkeling trip.
Wet and Dry Landings
Every excursion starts with a climb down into the panga from the back of the ship. But first, we needed to check out on the magnetic board (because there are no key cards to scan off) and grab any equipment like snorkel gear or walking sticks.
When heading ashore, it is either a wet landing or a dry landing, so it’s important to have the appropriate footwear. A dry landing means the panga pulls up to a small dock or a rock ledge and you step off without getting wet. A wet landing means you swing your legs over the side into ankle-deep water and wade to shore.
The expedition team tells you which one is coming at the briefing the night before and reminds you again in the morning. Dress accordingly. We wore hybrid water and hiking sandals for the wet landings, and for the most part, they worked perfectly.
Every Landing Requires a Guide
Every landing in the Galapagos happens with a licensed naturalist guide on a marked trail. Space on the beach is marked out, and you have to stay within designated snorkeling areas when in the water.
Carlos led most of our land treks and hikes, and he was the highlight of our trip. Like most of the crew, he is from the Galapagos. He was a wealth of knowledge and a passionate guide, and you could tell how much he cared about this place. He got excited every time he spotted wildlife, and he never ran out of things to explain.
On the optional outings, the guides rotate, so you get to meet several over the course of the week. We especially enjoyed Alexis, who guided us at Post Office Bay on Floreana, and Enny, who hosted a number of the panga rides.
How Physically Demanding Is a Galapagos Cruise?
The hikes are manageable for most people with an average fitness level. Guests on our sailing ranged across every age, from kids to an 87 year old who kept pace. Depending on the island, trails run over sand, rocks, and lava fields, so footing matters just as much as fitness. Most of the trails had little elevation. The steepest hike I did was the 372-step climb at Bartolomé, while Heidi opted to view Pinnacle Rock from the comforts of a panga.
Most days offered a short walking option that was less strenuous for those wanting to take it easy. The other thing to consider, though, is the heat and humidity in which you’ll be hiking. This definitely adds to the strain.
Deep-water snorkeling is where conditions vary the most. Some sites had noticeable current, but the guides adjusted for it by changing the entry point or the swim direction based on the group’s abilities.
That said, this trip is not accessible for everyone. There is no elevator on Santa Cruz II. Every landing requires you to climb in and out of a zodiac, often into ankle-deep water and onto uneven ground. And if you want to participate in the outings, you should have some degree of physical fitness and be able to climb stairs. Know your limitations before you book, and be honest with yourself about them so you’re not disappointed.
Pre-Cruise Extension (Machu Picchu & Quito)
Booking the pre-cruise extension through HX, we spent about a week in Peru and Ecuador before the cruise. The cruise line handled everything, including the hotels, flights, trains, guides, and most meals.
This pre-cruise tour was outstanding. We stayed in four- and five-star properties along the way, including the Tambo del Inka in the Sacred Valley, a luxury resort on the Urubamba River with an indoor-outdoor pool, gorgeous grounds, and an excellent restaurant.
Starting in Peru
The trip opened in Lima with a 2-night stay at the AC Marriott in Miraflores and a walking tour of the historic city center, a UNESCO World Heritage Site. The highlight was the Larco Museum, home to the finest private collection of Pre-Columbian art in the country.
From there, we flew to Cusco. We wasted no time, with a full day of exploration right after our morning flight. Highlights included a visit to a textile museum and some adorable llamas and alpacas. Later in the morning, we visited the Sacsayhuamán fortress, an Inca ceremonial compound with panoramic views over the city, before making the two-hour scenic drive out to the Sacred Valley. Here, we stayed at the luxurious Tambo del Inka for two nights.
It was in Cusco, at over 2 miles above sea level, that we began experiencing symptoms of altitude sickness. For us, it was mostly headaches and fatigue, but it definitely impacted our oxygen levels and our ability to sleep for a couple of nights.
Machu Picchu was the centerpiece of this extension. Again, HX managed all the logistics. We rode the Inca Rail from Ollantaytambo, which offered 360-degree views, stopped in Aguas Calientes, and took the short bus ride up to the site. We walked Circuit 2, the classic route, with our guide, and spent a couple of hours taking in a 600-year-old city that somehow still looks impossible.
After two nights in the Sacred Valley, we headed back to Cusco. Our first stop was the Misminay community, where Andean highlanders still practice ancestral farming techniques, textile weaving, and folkloric traditions passed down through generations. Lunch featured roasted guinea pig, a Peruvian specialty. In the afternoon, we had a walking tour in Cusco, from the Plaza de Armas and its post-conquest architecture to the Inca walls a few blocks away.
We then tucked ourselves in for one night at Palacio del Inka in the center of the city before an early depature to Quito the next morning.
Meeting Up with The Rest of the Expedition
After a long morning of travel from Cusco to Lima, then finally to Quito, we met up with the rest of the group heading to Santa Cruz II at the J.W. Marriott for a 2-night stay.
The next day, we toured Quito’s Old Town, one of the largest and best-preserved colonial quarters in South America, and had an Ecuadorian chocolate experience. Then, we headed north to the “Middle of the World” to stand with one foot in each hemisphere at the equator monument. It was a fitting way to end our land journey before heading to the Galapagos.
Santa Cruz (We Landed Here Three Times)
Because our 9-day (8 nights) route combined the Western and Northern itineraries, Santa Cruz turned up three separate times, on three different days, at three different landing sites. It is also the most densely populated island in the archipelago, making it the one place on the itinerary where you can see how people and wildlife coexist.
Day 1 — Cerro Dragón
Our first afternoon set the tone for the entire week. We flew from Quito to Baltra, transferred to the ship, completed lunch and mandatory briefings, and then were back off the ship to start exploring.
The ship sailed along the north shore of Santa Cruz to Cerro Dragón, which translates to Dragon Hill. The first stretch of the walk passes a brackish lagoon. From there, the trail climbs inland and opens onto views of the bay and the western islands beyond.
We saw both land iguanas and marine iguanas and some birds on this walk, which was a strong start. The terrain and elevation was rougher than we expected though, making us second-guess our fitness levels for this trip. Then again, we had been going since 5 AM! Dragon Hill turned out to be one of the more difficult walks of the whole trip.
As the sun set over the ship, we made our way back around 6 PM. It was a picturesque ending to our first real taste of what the Galapagos has to offer.
Day 3 — Puerto Ayora and the Charles Darwin Research Station
Day three was our only full day ashore, and it was the closest thing to a traditional port day we had all week.
We started at the Charles Darwin Research Station in Puerto Ayora, the center of conservation work in the Galapagos and home to the giant tortoise breeding program.
From there, we had the option for a bike ride into the highlands to a sugar mill, and I took it. It was hot and humid, but I did it anyway. Because when else am I going to bike through the Galapagos?
The second part of the day included a rather hearty lunch at a local farm called Manzanillo, and then the part everyone comes for: giant tortoises in the wild.
While it was a bit rainy, we could not get enough of the impressive giant tortoises with their massive shells protruding from the tall grass. These majestic creatures weren’t bothered by all of us taking videos and photos. They were just out doing what they have been doing for a hundred years.
Day 5 — Las Bachas
Day five was our turnaround day. The ship pulled into Baltra in the morning for a group of guests to disembark and a new group to board. Since we were staying on, we finally had a morning to sleep in.
The afternoon took us to Las Bachas, a soft sandy beach on the north shore. Heidi stayed on the beach while I did the beach snorkel, where I saw a lot of the same creatures, but I did get up close and personal with a turtle, which made my afternoon.
Afterward, we did the afternoon walk together, which follows the coast and delivered more wildlife sightings. Sally Lightfoot crabs everywhere, bright red against the black rock, and flamingos in the lagoon behind the beach.
A Morning in Isabela on Day 2
There was no ashore landing at Punta Vicente Roca. Everything here happened from a boat or in the water.
This was also the morning Heidi and I first divided and conquered. I did the first deep-water snorkel of the trip while she took the panga ride followed by a glass-bottom boat ride a couple hours later.
We were fitted for gear early that morning. I took a mask, snorkel, and fins but skipped the wetsuit. Water temperatures ran in the mid-70s Fahrenheit for the entire cruise, so it felt like bath water to me. They handed us a life jacket as well but told us it was optional. I wore mine for the first session, then ditched it so I could free dive and get better photos and videos.
The snorkeling session ran about 90 minutes, which turned out to be typical. We made several stops and got our first real look at what lives below the surface here. Schools of colorful fish, eagle rays, a giant sea turtle, and our first (of many) swimming sea lions.
An Afternoon in Fernandina on Day 2
Fernandina is the youngest island in the archipelago, and it looks the part. The landscape is raw lava, black and jagged, with almost nothing growing on it.
It also holds the largest marine iguana colony in the Galapagos. We walked right up on them. Not one or two, but big colonies piled on top of each other across the rock, close enough that you have to watch where you step. Sea lions were scattered along the beach as well, including a baby that stole the show.
Not to mention, we saw our first Galapagos penguin and some flightless cormorants that are exclusive to these western islands. Our guide also pointed out a Galapagos hawk in a tree, though even with the zoom on my camera, I couldn’t verify it was truly a hawk.
A Full Day in Floreana on Day 4
Floreana was our fullest day of the trip, and the one that gave us our single best wildlife moment.
Post Office Bay
We were off the ship by 7:30 AM for the Post Office, which is one of the odder traditions in travel. Whalers set up a wooden barrel here in the late 1700s so passing crews could leave letters for others to carry home. Two hundred and fifty years later, visitors still do it.
Plenty of people found cards from their state or country. We turned up exactly one from Massachusetts. Which reminds me, we still need to mail it to them!
Afterward, the beach offered snorkeling, kayaking, or paddleboarding. Heidi relaxed beachside, and I went kayaking. It was calm, and we did not see much wildlife, but paddling around that cove on a still morning was its own reward.
Punta Cormorant and Devil’s Crown
After lunch, we divided and conquered again. I did the deep water snorkel at Devil’s Crown while Heidi took the glass-bottom boat.
Devil’s Crown is a submerged volcanic crater that the guides said was some of the best snorkeling in the area. At first, it did not live up to it. Our first two stops turned up some fish and a hammerhead shark I could just barely make out.
Then, while we were moving between sites, a massive pod of dolphins came through. There had to be a hundred of them, maybe more. The pangas raced over, but they were gone as fast as they arrived. We got back in the water, figuring lightning would not strike twice. Within minutes, I heard someone yell “dolphin,” and a second pod came right through us.
They swam between forty or so snorkelers while I tried to hold it together long enough to get the video. It is the moment from this trip I will be talking about for years.
Back on board, I changed and reunited with Heidi for the afternoon hike with our group. The trail runs along sand dunes dotted with sea turtle nesting sites, and frigatebirds were circling overhead, looking for a chance at the eggs.
Further in, we came upon flamingos fishing for dinner in an interior lagoon. While it was one of our less scenic walks, Carlos still took the time to point out unique flora and share more personal backstory about how he became a naturalist and tour guide.
Seeing So Much of Santiago on Day 6
We spent the entire day six in Santiago, positioning at Buccaneer Cove in the morning followed by Puerto Egas in the afternoon. Both stops offered unique experiences.
A Morning at Buccaneer Cove
We did the morning panga ride together with our fellow Cormorants along the coast of Buccaneer Cove.
The rock formations here are impressive, including one that looked like a praying monk and Elephant Rock. Along the way, we spotted seabirds on the cliffs and a couple of fur seals lounging on the rocks. A few dolphins swam past, and we tried to follow, but a panga is no match for them.
The deep-water snorkel that followed more than made up for the rather uneventful panga ride. It was yet another exhilarating moment surrounded by wildlife.
Skies were slightly overcast, which sounds like bad news, but it was the opposite. Visibility was perfect without the glare of direct sun.
We saw colorful fish everywhere and Galapagos sharks cruising below us. A young sea lion even swam right into the group twisting, rolling, and showing off. The same could not be said for Heidi who took the glass-bottom boat one last time in hopes of seeing some marine life since she doesn’t snorkel.
An Afternoon in Puerto Egas
I skipped the beach snorkel after lunch because I had to get some work done. But the late afternoon nature walk more than made up for it.
A massive land iguana posed for us as if it had done so before. Manta rays leaped out of the water just off the beach. They were too fast for my camera, though! Fur seals posed on the dramatic lava formations. And we even saw a blue-footed booby.
An Early Morning at the Red Beach on Rabida Day 7
Day seven had the earliest start of the whole cruise. Snacks and some espresso-based drinks in the Science Center at 5:50 AM, and disembark at 6:10 for a sunrise walk along the beach.
Rábida is the red sand island. Iron in the volcanic rock gives the beach a deep rust color that looks almost artificial in photos.
Despite the early morning wake up, Carlos was in his element here. He walked us through the different species of flora found in the Galapagos as we passed the cacti lining our path. Wildlife gets all the attention on this trip, so it was a good reminder that the plants have their own story.
Santa Cruz II sat anchored off the coast, and the videos and photos from our elevated vantage point made the walk worth it. There were also several flamingos in the lagoon behind our landing spot.
Then, we headed back aboard for breakfast and more coffee.
I did the deep water snorkel later that morning, and it delivered yet again. Turtles, sea lions, and starfish, and another playful sea lion that spent over 15 minutes with our group — all of them closer to the coastline than at previous sites, which meant more up-close photos.
Heidi passed on the glass-bottom boat today and stayed onboard to start organizing our photos and videos.
Mastering the Bartolome Viewpoint
The afternoon took us to Bartolomé, and here we had some options.
I did the beach snorkel and the hike. Heidi skipped the beach and took the panga ride around Pinnacle Rock instead of climbing the nearly 400 steps to the viewpoint.
For the snorkel, our panga pulled up to the beach just in time to find a penguin sitting on a rock. He picked up a friend a little later. Several people spotted the penguins while snorkeling, but I was not one of them. Instead, there were giant sea lions, sea turtles, and sharks. Even an abbreviated snorkel here was eye-opening.
Back on the ship briefly to change clothes, I was off again for the climb to the summit viewpoint. It is a steep ascent, but the whole thing is a wooden staircase up a volcanic cone.
We stopped at several vantage points along the way to learn about how the island formed, how the lava fields took shape, and about the Galapagos on the silver screen. Master and Commander was filmed at this spot, which turned an already famous landmark into an even bigger one.
Cormorants Take Flight to Genovesa on Day 8
Genovesa is known as Bird Island, and it earns the name. This morning, we shared landing sites with another ship. So, throughout the day, we flip-flopped locations with their guests, both groups working around the same set of winged residents.
Prince Phillip’s Steps
The morning was a dry landing at the base of a steep rock staircase, which we climbed to reach a marked trail across the relatively flat top of the island.
The path was lined with birds. Different finch species. Nazca boobies building nests right at the edge of the trail. Red-footed boobies with their nests tucked neatly into the trees a few feet from our cameras. There were frigatebirds, storm petrels, and plenty of others that we didn’t see like the elusive short-eared owl.
The pace was quick because there was a lot of ground to cover and many reasons to stop. The birds are completely unfazed by people. They walk up to you. They wander onto the trail alongside the group and carry on with their day.
Darwin Bay
The afternoon walk was shorter and flatter, running along the beach at Darwin Bay.
We saw more frigatebirds, and this time we finally caught a male in full display, gular pouch inflated into a bright red balloon under his throat. More red-footed and Nazca boobies rounded out the walk.
Bird watching is not something we would say we are into. But you cannot help getting drawn in here. You are standing a few feet from birds that evolved in isolation for millions of years.
Plus, we also got to see more sea lions along the shore, including the cutest pup ever.
The Wildlife We Saw
Over nine days, we saw 12.5 of the Big 15 — which we thought was quite impressive.
Galapagos giant tortoises out in the wild in the Santa Cruz highlands. Marine iguanas by the hundreds on Fernandina. Land iguanas at Cerro Dragón and Puerto Egas. Galapagos sea lions on nearly every landing. Fur seals on the rocks at Buccaneer Cove, Isabella, and other stops. A Galapagos penguin waiting on the rocks for our panga at Fernandina and Bartolomé. Blue-footed boobies on Isabela and Fernandina, along with the flightless cormorants. Red-footed and Nazca boobies at Genovesa. Frigatebirds circling the turtle nests on Floreana, and a male in full display at Darwin Bay. American flamingos in the brackish lagoons of a few islands. Not to mention, sea turtles, sharks, stingrays, and more during our snorkeling adventures.
Technically, we had a couple sightings of Galapagos hawks, but both were at a distance (where the 0.5 comes in).
The two we missed outright were the waved albatross and Santa Fe iguana. Waved albatross nest almost exclusively on Española, and Española and Santa Fe both sit on the eastern Galapagos route.
One disappointment was that we saw fewer blue-footed boobies than we expected, and we never caught the courtship dance. Late June should be prime season for it. But as our guides pointed out, climate change and shifts in currents have impacted animal behavior.
How Much Does a Galapagos Cruise Cost?
Galapagos cruises are expensive. Depending on the cruise line, you can expect to pay around $800 to $1,500 per person per day. An HX Galapagos cruise is toward the middle end of that range. But keep in mind that the itinerary and length of the trip factor into the costs.
Most of the cruise options in the region are all-inclusive, including all onboard dining, WiFi, drinks, use of snorkeling equipment and walking sticks, as well as all outings and excursions.
HX also includes round-trip airfare from Quito to Baltra in their fares, two nights in a Quito hotel, airport transfers, a guided day in Quito, the $200 National Park entrance fee, and the $20 Transit Control Card.
Further, HX offers flexibility, with everything from seven-day sailings to eleven-day sailings, plus longer adventures that include Machu Picchu or other land extensions. That gives you anywhere from five to nine days in the islands, along with two nights in Quito on every itinerary.
Solo travelers also benefit from HX’s generous solo supplements. Most cruise lines charge a full 100 percent, which effectively doubles the fare. HX often runs 30 to 50 percent instead, and during promotions, it drops the supplement entirely. We were surprised by how many passengers on our expedition were traveling solo. In fact, for HX, the Galapagos is the second most popular destination for solo travelers, accounting for 13% of all solo travelers.
We were also surprised by how many families and multigenerational groups were onboard. HX is family-friendly, offering the most interconnecting cabins in the region and kid-friendly programming. So, it makes sense.
Whether you are cruising as a couple, with your family, or looking for an adventure on your own, a Galapagos cruise should certainly be on your bucket list.
Is an HX Galapagos Cruise Worth It?
Yes, absolutely. But, you need to understand exactly what a Galapagos expedition really entails.
If you’re a cruiser, then it’s likely that sometimes you sail for the ship and sometimes you sail for the destination. The Galapagos is definitely the latter, and Santa Cruz II is built accordingly. She is functional and comfortable but doesn’t compete with luxury vessels or modern ships you’ve sailed in other regions.
Honestly, we were initially hesitant about not having a balcony, the tiny cabin bathroom, and the lack of amenities onboard. But after a couple of days, we weren’t thinking about the ship at all. As long as there was an endless supply of caffeine, which there was, all we were thinking about is what we had just seen and what was coming next.
Would we do it again? Of course! We still have 2.5 animals to scratch off the Big 15. I guess that means an Eastern Galapagos route is in order for the future.
You Should Book an HX Galapagos Cruise If:
You want the wildlife to be the whole point, not a stop along the way
You are comfortable with early mornings, three or four outings a day, and very little downtime
You would rather have an expert guide than a balcony cabin
You value inclusive pricing and dislike being nickel-and-dimed
You snorkel, or you are willing to learn, because half this trip happens underwater
You want a small ship where you know the crew and guides by name
You are traveling with kids or grandkids
You have realistic expectations about the food and the cabins
You have some degree of physical fitness
You Should Skip a Galapagos Cruise If:
You cruise for the ship, the entertainment, the dining, and the nightlife
You want to sleep in or lounge by the pool with a drink in hand
You need a balcony, a spa, or a specialty restaurant to enjoy a sailing
You cannot climb in and out of a zodiac, or you require a wheelchair or an elevator
You are working with a tight budget
You want to explore independently (every landing requires a licensed guide)
You get motion sickness and rough seas are a dealbreaker
You prefer larger ships over itimate ones where you know everyone by name
Comments
Would you consider taking an HX Galapagos cruise? What is the most adventurous sailing you have been on? Drop us an anchor below to share your expedition experiences.
At Cohen Veterans Network, we’re committed to expanding access to high-quality, evidence based mental health care for veterans, service members, and military families. Our annual Day of Giving and Reflection extends that commitment to the communities where military families live and is especially meaningful during our 10th anniversary.
The network-wide tradition invites clinic teams and central office staff to step outside the walls of their clinics and offices and into their communities. It’s a chance to volunteer, learn, connect, and reflect on the values that unite us as an organization while embracing the diverse experiences of those around us.
Giving Back Through Community Service
On June 26, teams from across the country participated in more than two dozen community activities. Some spent the day volunteering. For example, the Steven A. Cohen Military Family Clinic at VVSD in San Diego visited Homefront Horsemanship Ranch, supporting daily ranch operations that benefit veterans and other visitors. The Cohen Clinic at Hope For The Warriors in Jacksonville, North Carolina transformed the windows of a YMCA youth center into a colorful mosaic, helping brighten the space for local children and families.
“A huge thank you to Cohen Veterans Network for spending your Day of Giving & Reflection volunteering at the New River YMCA Early Learning Center. Your willingness to invest your time and energy into creating a brighter environment for our youngest learners speaks volumes about your commitment to our community. Partnerships like this remind us that when we come together in service, we create lasting impact.”
Learning from Our Communities
Other teams focused on learning and building understanding. The Cohen Clinic at Centerstone in Hinesville, Georgia, visited the Mighty Eighth Air Force Museum to deepen their appreciation of military history. Meanwhile, the Cohen Clinic at VVSD in Torrance, California, gathered for a potluck where team members shared dishes that reflected their cultural backgrounds and the personal journeys that led them to careers in mental health.
A New Tradition: Day of Giving and Reflection Bingo
This year also introduced a new tradition. To encourage teams to explore their communities in unexpected ways and step outside their comfort zones, CVN created its first Day of Giving and Reflection Bingo Card. Filled with fun and meaningful prompts, the card inspired participants to seek out new experiences, spark conversations, and engage with their communities in creative ways. You can find the Bingo Card by clicking here.
Looking Ahead
As the network marks its tenth anniversary and Day of Giving and Reflection, our purpose and role in our communities continue to grow. While no two experiences looked the same, each reflected the same purpose: strengthening the connections that make our clinics, and the communities we serve, stronger.
Last Updated on July 28, 2026 by Sarah Wilson Aosta was my final stop before heading back home to Malta after a wonderful repeat house sit in Champex-Lac, Switzerland. I crossed into Italy by bus for two days of Roman history, mountain scenery and, of course, plenty of good food. Although it’s one of Italy’s […]
Discover the best New Zealand souvenirs to bring home, from iconic Kiwi snacks like Whittaker’s Chocolate and Pineapple Lumps to Manuka honey, wine, and locally made food gifts. Find out what treats are worth packing, where to buy them, and tips for getting your favourite New Zealand flavours home safely.
Agitation (getting “amped up” or “revved up”) and/or aggressive behavior
Restless pacing or wandering
Disinhibited behaviors, which means saying or doing socially inappropriate things
Sleep disturbances
These are technically called “neuropsychiatric” symptoms, but regular people might refer to them as “acting crazy” symptoms. Or even “crazy-making” symptoms, as they do tend to drive family caregivers a bit nuts.
And when these behaviors happen in the late afternoon or early evening, it’s usually called “sundowning“. (In most cases, sundowning is triggered by fatigue; anticholinergic medications may cause sundowning symptoms as well.)
Because these behaviors are difficult and stressful for caregivers — and often for the person with dementia — people often ask if any medications can help.
The short answer is “Maybe.”
A better answer is “Maybe, but there will be side-effects and other significant risks to consider, and we need to first attempt non-drug ways to manage these behaviors.”
In fact, until fairly recently, no medication was FDA-approved for the treatment of these types of behaviors in Alzheimer’s disease or other forms of dementia. (For more on the drugs that are FDA-approved to treat the cognitive symptoms of dementia, see here: 4 Medications to Treat Alzheimer’s & Other Dementias: How They Work & FAQs.)
But it has been VERY common for medications — especially antipsychotics — to be prescribed “off-label” for this purpose.
This is sometimes described as a “chemical restraint” (as opposed to tying people to a chair, which is a “physical restraint”). In many cases, antipsychotics and other tranquilizing medications can certainly calm the behaviors. But they can have significant side-effects and risks, which are often not explained to families.
Worst of all, they are often prescribed prematurely, or in excessive doses, without caregivers and doctors first putting in some time to figure out what is triggering the behavior, and what non-drug approaches might help.
For this reason, in 2013 the American Geriatrics Society made the following recommendation as part of its Choosing Wisely campaign: “Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.”
You may now be wondering what should be the first choice. This depends on the situation, but generally, the first choice to treat difficult behaviors or sundowning is NOT medication. (A possible exception: geriatricians do often consider medication to treat pain or constipation, as these are common triggers for difficult behavior.)
Of course, in certain situations, medication should be considered. If your family member has Alzheimer’s or another dementia, I want you to be equipped to work with the doctors on sensible, judicious use of medication to manage difficult behaviors.
In this post, I’ll review the most common types of medications used to treat sundowning and difficult behaviors in dementia. I’ll also explain the approach that I take with these medications.
5 Types of Medication For Sundowning or Difficult Behaviors in Dementia
Most medications used to treat difficult behaviors fall into one of the following categories:
1. Antipsychotics
These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms. (For more on psychosis, which is common in late-life, see 6 Causes of Paranoia in Aging & What to Do.)
Commonly used drugs: Antipsychotics often used in older adults include:
Risperidone (brand name Risperdal)
Quetiapine (brand name Seroquel)
Olanzapine (brand name Zyprexa)
Haloperidol (brand name Haldol)
For a longer list of antipsychotics drugs, see this NIH page.
Newer antipsychotics include:
Brexpiprazole (brand name Rexulti)
This antipsychotic was initially FDA approved for the treatment of schizophrenia and as an adjunct for major depression.
In May 2023, FDA approval was expanded to include the treatment of agitation associated with dementia due to Alzheimer’s disease.
Pimavanserin (brand name Nuplazid).
It was FDA-approved in 2016 for psychosis associated with Parkinson’s disease.
Usual effects: Most antipsychotics are sedating, and will calm agitation or aggression through these sedating effects. Antipsychotics may also reduce true psychosis symptoms, such as delusions, hallucinations, or paranoid beliefs, but it’s rare for them to completely correct these in people with dementia.
Risks of use: The risks of antipsychotics are related to how high the dose is, and include:
Decreased cognitive function, and possible acceleration of cognitive decline
Increased risk of falls
Increased risk of stroke and of death; this has been estimated as an increased absolute risk of 1-4%
A risk of side-effects known as “extrapyramidal symptoms,” which include stiffness and tremor similar to Parkinson’s disease, as well as a variety of other muscle coordination problems
People with Lewy-body dementia or a history of Parkinsonism may be especially sensitive to antipsychotic side-effects; in such people, quetiapine (brand name Seroquel) is considered the safest choice
Evidence of clinical efficacy: Clinical trials often find a small improvement in symptoms. However, this is offset by frequent side-effects. Studies have also repeatedly found that using antipsychotics in older people with dementia is associated with a higher risk of stroke and of death.
2. Benzodiazepines
This is a “sedative/tranquilizer” category of medication that relaxes people fairly quickly. So these drugs are used for anxiety, for panic attacks, for sedation, and to treat insomnia. They can easily become habit-forming.
Commonly used drugs: In older adults, these include:
Lorazepam (brand name Ativan)
Temazepam (brand name Restoril)
Diazepam (brand name Valium)
Alprazolam (brand name Xanax)
Clonazepam (brand name Klonopin)
Usual effects: In the brain, benzodiazepines act similarly to alcohol, and they usually cause relaxation and sedation. Benzodiazepines vary in how long they last in the body: alprazolam is considered short-acting whereas diazepam is very long-acting.
Risks of use: A major risk of these medications is that in people of all ages, they can easily cause both physical and psychological dependence. Additional risks that get worse in older adults include:
Increased risk of falls
Paradoxical agitation (some older adults become disinhibited or otherwise become more restless when given these drugs)
In older adults who take benzodiazepines regularly, there is also a risk of worsening dementia symptoms when the drug is reduced or tapered entirely off. This is because people can experience increased anxiety plus discomfort due to physical withdrawal, and this often worsens their thinking and behavior.
Stopping benzodiazepines suddenly can provoke life-threatening withdrawal symptoms, so medical supervision is mandatory when reducing this type of medication. (See How You Can Help Someone Stop Ativan for more information.)
Evidence of clinical efficacy: A recent review of clinical research concluded there is “limited evidence for clinical efficacy.” Although these drugs do have a noticeable effect when they are used, it’s not clear that they overall improve agitation and difficult behaviors in most people. It is also not clear that they work better than antipsychotics, for longer-term management of behavior problems.
3. Mood-stabilizers
These include medications otherwise used for seizures. They generally reduce the “excitability” of brain cells and other neurons.
Commonly used drugs: Valproic acid (brand name Depakote) is the most commonly used medication of this type, in older adults with dementia. It is available in short- and long-acting formulations.
Usual effects: The effect varies depending on the dose and the individual. It can be sedating.
Risks of use: Valproic acid requires periodic monitoring of blood levels. Even when the blood level is considered within an acceptable range, side-effects in older adults are common and include:
Confusion or worsened thinking
Dizziness
Difficulty walking or balancing
Tremor and development of other Parkinsonism symptoms
Gastrointestinal symptoms including nausea, vomiting, and/or diarrhea
Evidence of clinical efficacy: A review of randomized trials of valproate for agitation in dementia found no evidence of clinical efficacy, and described the rate of adverse effects as “unacceptable.” Despite this, some geriatric psychiatrists and other experts feel that valproate works well to improve behavior in certain people with dementia.
4. Anti-depressants
Many of these have anti-anxiety benefits. However, they take weeks or even months to reach their full effect on depression or anxiety symptoms.
Commonly used drugs: Antidepressants often used in older people with dementia include:
Citalopram, escitalopram, and sertraline (brand names Celexa, Lexapro, and Zoloft, respectively) are often used
Paroxetine (brand name Paxil) is another often-used SSRI, but as it is much more anticholinergic than the other SSRIs, geriatricians would avoid this medication in a person with dementia
Mirtazapine (brand name Remeron) is an antidepressant that can increase appetite and sometimes increases sleepiness when given at bedtime
Trazodone (brand name Desyrel) is a weak antidepressant that is sedating and is often used at bedtime to help improve sleep
Usual effects: The effects of these medications on sundowning and on agitation is variable. SSRIs may help some individuals, but it usually takes weeks or longer to see an effect. For some people, a sedating antidepressant at bedtime can improve sleep and this may reduce daytime irritability.
Risks of use:The anti-depressants listed above are generally “well-tolerated” by older adults, especially when started at low doses and with slow increases as needed. Risks and side-effects include:
Nausea and gastrointestinal distress, especially when first starting or increasing doses (SSRIs)
SSRIs may be activating in some people, which can worsen agitation or insomnia
Citalopram (in doses higher than 20mg/day) can increase the risk of sudden cardiac arrest due to arrhythmia
An increased risk of falls, especially with the more sedating antidepressants
Evidence of clinical efficacy: A 2014 randomized trial found that citalopram provided a modest improvement in neuropsychiatric symptoms; however the dose used was 30mg/day, which has since been discouraged by the FDA. Otherwise, clinical studies suggest that antidepressants are not very effective for reducing agitation. (In fact, randomized trials find that antidepressants do not seem to improve depressive symptoms in people with Alzheimer’s disease.)
5. Dementia drugs
These are the drugs FDA-approved to treat the memory and thinking problems associated with Alzheimer’s disease. In some patients, they seem to help with certain neuropsychiatric symptoms, and they might help with sundowning. For more on the names of these drugs and how they work, see 4 Medications to Treat Alzheimer’s & Other Dementias.
Note: I am not including medications to manage dementia-related sleep disturbances in this post. You can learn more about those here: How to Manage Sleep Problems in Dementia.
If you’re wondering which medication is best for sundowning and difficult behaviors in dementia
You may be now wondering just how doctors are supposed to manage medications for difficult dementia behaviors.
Here are the key points that I usually share with families:
Before resorting to medication: it’s essential to try to identify what is triggering/worsening the behavior, and it’s important to try non-drug approaches, including exercise.
Be sure to consider treating possible pain or constipation, as these are easily overlooked in people with dementia. Geriatricians often try scheduling acetaminophen 2-3 times daily, since people with dementia may not be able to articulate their pain. We also titrate laxatives to aim for a soft bowel movement every 1-2 days.
No type of medication has been clinically proven to improve sundowning for most people with dementia. If you try medication for this purpose, you should be prepared to do some trial-and-error, and it’s essential to carefully monitor how well the medication is working and what side-effects may be happening.
Antipsychotics and benzodiazepines work fairly quickly, but most of the time they are working through sedation and chemical restraint. They tend to cloud thinking further. It is important to use the lowest possible dose of these medications.
Benzodiazepines probably increase fall risk more than antipsychotics do, and are habit-forming. They are also less likely to help with hallucinations, delusions, and paranoias. For these reasons, if a faster-acting medication is needed, geriatricians usually prefer antipsychotics to benzodiazepines.
Antidepressants take a while to work but are generally well-tolerated. They may not improve depressive symptoms, but they seem to make some people with dementia less irritable or anxious. Geriatricians often try escitalopram or citalopram in people with dementia.
It is usually worth trying a dementia drug (such as a cholinesterase inhibitor or memantine) if the person is not already on these medications, as these drugs also tend to be well tolerated.
I admit that although studies find that non-drug methods are effective in improving dementia behaviors and to manage sundowning, it’s often challenging to implement them.
For people with dementia living at home, family caregivers or paid helpers often have limited time and energy to learn and practice behavior management techniques. Despite the risks of antipsychotics, family members are often anxious to get some relief as soon as possible.
As for residential facilities for people with Alzheimer’s and other dementias, they vary in how well their staff are trained in non-drug approaches.
What you can do about medications and sundowning
If your relative with dementia is not yet taking medications for sundowning and other difficult behaviors, consider these tips:
Start keeping a journal and learn to identify triggers of difficult behaviors. You will need to observe the person carefully. Your journaling will come in handy later if you start medications, as this will help you monitor for benefits and side-effects.
If the difficult behaviors really emerge or escalate in the late afternoon or evening, as is typical for sundowning, see if you can avoid fatigue or overstimulation by creating a routine that allows the person to rest quietly by mid-afternoon. You can find more tips to manage sundowning here.
Consider the possibility of depression. It’s reasonable to consider a trial of escitalopram or a related antidepressant. That said, clinical research suggests antidepressants don’t work well in people with dementia. Research does suggest that in dementia, depression treatments involving certain types of therapy plus positive lifestyle changes is probably more effective than medication.
If the person is often very agitated, aggressive, or paranoid, or if otherwise the behavioral symptoms are causing significant distress to the older person or to caregivers, it’s often reasonable to try an antipsychotic.
Be sure to discuss the increased risk of stroke and death with the doctor and among family members. This can be a reasonable risk to accept, but it’s essential to be informed before proceeding.
It’s best to start with the lowest dose possible.
If there have been visual hallucinations or other signs of possible Lewy Body dementia, quetiapine (brand name Seroquel) is usually the safest first choice to manage sundowning or other difficult behaviors.
For all medications for dementia behaviors:
Monitor carefully for evidence of improvement and for signs of side-effects.
Doses should be increased a little bit at a time.
Especially for antipsychotics, the goal is to find the minimum necessary dose to keep behavior manageable.
If your relative with dementia is currently taking medications for behaviors or for sundowning, then you will have to consider at least the following two issues.
One is whether the behavior issues currently seem manageable or not. If the behaviors are still often very difficult, then it’s important to look into triggers and other behavioral management approaches.
Ongoing agitation or difficult behaviors may also be a sign that the medication isn’t effective for your relative. So it may also be reasonable to consider a change in medication. The best is to work closely with a doctor AND a dementia behavior expert; some social workers and geriatric care managers are very good with dementia behaviors.
The other issue is to make sure you are aware of any risks or side-effects that the current medications may be causing.
The main side-effects I see people with dementia experience are excess drowsiness, excess confusion, and falls. These are usually due to high doses of antipsychotics and/or benzodiazepines. In such cases, it’s often possible to at least reduce the dosages somewhat. Addressing any other anticholinergic or brain-dampening medications can also help.
Now should you aim to get your relative completely off antipsychotics, in order to reduce mortality risk, improve alertness and thinking, and to reduce fall risk?
I have found that sometimes tapering people completely off antipsychotics is possible, but it can be a labor-intensive process. Furthermore, studies find that a certain number of people with dementia “relapse” after antipsychotics have been discontinued. Another very interesting 2016 study of antipsychotic review in nursing homes found that stopping antipsychotics tended to make behavior worse unless the nursing home also implemented “social interventions.”
In other words, attempting to completely stop antipsychotic medications involves effort, may be followed by worse behavior, and is less likely to succeed if you cannot concurrently provide an increase in beneficial social contact or exercise. It is certainly worth considering, but in people who are taking more than the starter dose of antipsychotic, it can be challenging.
No easy solutions but improvement IS usually possible
As many of you know, behavior problems are difficult in dementia in large part because there is usually no easy way to fix them.
Many — probably too many — older adults with Alzheimer’s and other dementias are being medicated for their sundowning or other behavior problems.
If your family is struggling with behavior problems, I know that reading this article will not quickly solve them.
But I hope this information will enable you to make more informed decisions. This way you’ll help ensure that any medications are used thoughtfully, in the lowest doses necessary, and in combination with non-drug dementia behavior management approaches.
And if you are looking for a memory care facility, try to find out how many of their residents are being medicated for behavior or for sundowning. For people with Alzheimer’s and other dementias, it’s best to be cared for by people who don’t turn first to chemical restraints such as antipsychotics and benzodiazepines.
This article was last updated by Dr. K in February 2025.
