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By Dr. Anthony Ellis, WCI Columnist
In my first year of practice as a psychiatrist in 1995, I saw a 69-year-old patient who was a successful real estate investor. She had accumulated several dozen properties, and she was renting them for income. She said she had built an empire and had become a millionaire. I asked her what she would be doing with all her money in retirement, and she said, “Well, my health is not so good, so I won’t be able to enjoy the money. I can’t walk very far due to my arthritis.” She went on to say that she had COPD from smoking, and she bad osteoarthritis in her knees and hips from being overweight for many years. She simply could not do many of the things she had planned for herself. Smoking, obesity, arthritis, and lack of mobility made her success bittersweet and supplied a cautionary tale that physicians have seen thousands of times.
My father was afflicted with Alzheimer’s Disease at about age 70, and it robbed him of the bulk of his “golden years” after his full retirement from nursing at age 65. He had become a nurse after serving six years in the British Army during World War II. The illness slowly destroyed his executive function, his memory, and his ability to care for himself. His quality of life was eroded further as he stopped driving, handed over his money management, and needed more care every year until he died at 79.
His intact retirement had lasted only five years.
He was a smoker for more than 40 years, and the artery-clogging effects had likely accelerated the onset and progression of dementia despite his other healthy habits and his daily outside walks. In his intact years, he was a nursing professor, a charge nurse, or a supervisor, and he had a singular intellect and amazing wit. The disease took everything away from him, and it was one of the worst times in my life as I was helpless to stop it. My father once told me, “Don’t end up like me.” He was referring to retiring on Social Security alone.
I followed this advice for financial reasons and for health reasons, and now that I've semi-retired at 58 and moved to the mountains of North Carolina from my Michigan McMansion, it's something I think about quite often.
Staying Physically and Mentally Healthy in Retirement
Seeing older patients who were financially well off but physically doing poorly and then watching my father’s short functional retirement spurred my move to Geriatric Psychiatry. I needed to learn things one might do to “not end up like that.” Seeing these types of outcomes focused my interest in living to an old age with our bodies, brains, and abilities intact. My wife and I became runners, and we ran road races for the next 20 years to stay in the best shape we could to improve our overall health and stamina. (In a prior post, I mentioned that I authored a book about running in 2005.)
I also took a position as the medical director of a geriatric psychiatry unit from 2001-2011. Having seen the effects of aging and dementia up close and personally, I wanted to be on the front in the battle against dementia. I learned as much as I could about the effects of aging on the body, brain, and functional longevity. I bore witness to the many ways that the brain “went bad” in the 60- to 95-year-old patients.
I helped them as much as I could with “too little, too late” dementia pharmaceuticals, antidepressants, exercise plans, and cognition-enhancing activities. I developed a hypothesis that brain amyloid management and removal were partly dependent on adequate vascular perfusion and oxygen delivery. A common denominator seemed to be the known vascular risk factors: smoking, HTN, diabetes, elevated cholesterol, obesity, inflammation, and a sedentary lifestyle. The more of these you had, the more “periventricular white matter hyperintensities” one would likely find on the brain MRI scans. You want your scan report to note “few or none” of these white spots and certainly not have it say “severe and confluent with associated cortical atrophy.”
Many patients with these risk factors tended to also have heart disease and strokes that markedly affected their quality of life and functional longevity in their later years. Their “decade of decline” was moved back from their 80s to their 70s or even their 60s. If they developed dementia, it was earlier and more aggressive.
I noticed that many of my older patients did not have enviable longevity. They were not hiking, biking, walking, swimming, traveling, and enjoying their hard-earned retirement income and Social Security. They tended to be saddled with about a dozen medications, notable arthritis, mobility issues, joint surgeries, obesity, and markedly decreased flexibility. The effect of all of this was a diminished or restricted ability to simply move and enjoy a modicum of quality. They were doing less of all the things I enjoyed. I took note of the relative absence of people over 70 on hiking trails and while traveling abroad. There seemed to be fewer people over age 65 in many of my favorite physical activities.
I started to lecture at the local medical graduate programs to psychiatry residents, social work students, and doctors and staff at the local community mental health centers on delaying the onset of dementia.
All doctors have seen “the list” that many patients over age 60 bring with them: two HTN meds, Synthroid, inhalers, diabetes meds, statins, arthritis medications, a “water pill,” and pain medication. This has become the identifying data for many patient histories. “This pleasant obese 60- to 85-year-old female (or male) with HTN, CHF, hypothyroidism, elevated lipids, GERD, type 2 diabetes, neuropathy, and chronic pain is seen for complaints of knee pain, back pain, decreased mobility, poor sleep, forgetfulness, and related depression.”
Below are the top 10 Medicare prescriptions administered by claim count (2014 data):
- Lisinopril (38.2 million claims)
- Levothyroxine Sodium (37.7 million claims)
- Amlodipine Besylate (36.3 million claims)
- Simvastatin (34.1 million claims)
- Hydrocodone-Acetaminophen (33.4 million claims)
- Omeprazole (33 million claims)
- Atorvastatin Calcium (32.6 million claims)
- Furosemide (27.1 million claims)
- Metformin HCL (23.5 million claims)
- Gabapentin (22.1 million claims)
How can you avoid having to make this list (and having to spend hundreds of thousands of dollars in healthcare) once you reach retirement age? Here's how I think about it and how I put these plans into action.
Steps for How to Thrive in Retirement
Here's what to do to stay healthy.
The high points:
- Do not smoke or, if you do, quit. Patches and gums improve the dismal 5% success rate to 50%.
- Maintain a healthy body weight to avoid diabetes, hypertension, and elevated lipids.
- Eat a healthy diet with plenty of vegetables, minimize red meat, and drink lots of water.
- Participate in aerobic exercise for an hour several times a week.
- Use body weight and functional exercises to maintain muscle mass.
- Stretch and do functional movement exercises or yoga to maintain flexibility.
- Develop an anti-stress regimen such as meditation or “forest bathing.”
- Maintain social connections.
- Optimize cognition through lifelong reading and learning.
- Get adequate sleep and practice good oral hygiene.
It is close to what many of us tell patients about wellness and reaping what they sow. So, if you know this and practice these points daily, you may stop reading here and send me a comment about another five wellness practices or how well you are doing so the rest of us can benefit. After all, we are lifelong readers and learners, and there are dozens of other things we tell our patients to do to avoid us.
Again, what is the use of seven-figure retirement savings if that money is mostly used for insurance copays, joint surgeries, long-term care, and the like? It’s nice to have the ability to pay for needed care, but it may be better to need far less care. All of us will lose muscle mass, gain weight, and become slower and less flexible, and these changes are clearly unavoidable. But why not mitigate or delay those with proven strategies?
Let’s look at the list in more detail.
Smoking is self-explanatory, and everyone knows it contributes to coronary heart disease, heart attacks, cancer, strokes, and premature aging. If you are smoking, you probably cannot do more for your health than to quit. When I see a wellness-oriented person smoking, it is frankly hard to take them seriously.
A healthy body weight has so many direct health correlates that one could surmise that we may have given up on ourselves as a species in some countries (especially wealthy countries like the US) based on the percentage of obese people. It must be very easy to gain weight and very hard to lose it. Food restriction is one of the few proven ways to expand longevity. The reduced risk of HTN; diabetes and its myriad effects; elevated lipids; dementia; increased cancer risk; higher risk of stroke and heart attack; negative effects on joint health and mobility; and the effects on mood, sleep, and sexual function are not enough for many of us. If one incorporates several of the other things on the list, it would likely influence weight.
By exercising several times per week, maintaining muscle mass with low-impact strength training, eating a healthy vegetable-laden diet, reducing stress, drinking lots of water, and getting adequate sleep, we would have a better chance at weight loss and maintaining a healthy weight.
Instead of training isolated muscle groups like biceps, triceps, calves, pectorals, back, or abdominals for aesthetics, utilizing compound body weight movements can help build a better body for daily activities, sports, or work. I don’t need 20-inch biceps in retirement. I need to be able to get on and off the ground, perhaps tend a garden, and bring in the groceries with fewer trips. I don’t need six-pack abs, but I do want to walk, drive, hike, swim, bike, get dressed without pulling a muscle, and travel without worrying about basic mobility and walking distances. These exercises typically use the whole body and multiple muscle groups and emphasize core strength and stability.
Functional weight training can be done without any equipment, and there is an entire industry built on body-weight exercises with six broad movement types: push, pull, bend, twist, squat, and lunge. Many of the exercises can also be done anywhere, including at home. Basic everyday activities like maintaining balance while putting shoes on or squatting to pick something up are crucial movements. Some of us reading this are old enough to know the odd feeling of barely being able to get a pair of shoes or shorts on without holding on to the wall for support. I can’t teach you these exercises here, but I invite you to peruse the internet for resources to start at the level that fits your ability and current fitness level.
Here are some other benefits of functional strength training:
- Reduced risk of injury due to better strength and balance.
- Improved form during everyday movements lowers the risk of injuries and falls.
- A stronger “you” can do things with more control and confidence.
- Improve your longevity and feel better in your body as you age.
Stretching and doing functional movement exercises or yoga also maintains flexibility.
Total body exercise activities like yoga are widely available at the beginner and more advanced levels at the YMCA, studios, online, and via home video or streaming services. Yoga improves muscle strength, balance, flexibility, and mobility. My wife and I practice yoga together because we noted decreased flexibility and balance as we age. She had to push me on this as I am frequently one of only three men in the classes. Yoga has been helpful in maintaining mobility and flexibility as well as core muscle strength as we have gotten older. We need this strength and balance for many of the activities we have planned in retirement. Yoga is also a low-impact activity that is easy on the joints, which is important in any exercise regimen for retirees.
You probably know or treat many people who have had knee, shoulder, hip surgery, or overuse injuries. I know people who have had joint surgeries due to running on pavement and other high-impact sports. These are fun when you are young. We ran for 20 years, but our days of running long distances on pavement are over, replaced with hiking, yoga, swimming, and walking in the woods.
Swimming is underutilized as a total body, low-impact exercise that can be maintained for one’s whole life after learning the basic skill. I have been a member of a gym with a pool or the local YMCA since 2007 to swim because I enjoy it. For me, it ticks all the boxes: low impact, aerobic, expands vital capacity, builds muscle, does not worsen flexibility, and feels like a meditation exercise. My own PCP recommended I try it, and I never looked back. I saw him last year, and he was still swimming laps at the local college pool at age 80, having completed his career in Internal Medicine.
After noticing the benefits of swimming, I trained for five months one summer in 2009 to complete the Bermuda “Round the Sound Swim.” At the end of my training, my resting heart rate was 49. This event had distances from 1,000 meters to 10,000 meters, and I completed the 4,000-meter event. It was spectacular. When I finished, I was feeling rather good about myself, and then a 10-year-old from India spoke with me about her finish in the 10,000-meter event.
In Michigan, there is a 5,000-meter event called “Swim to the Moon and Back” across five lakes near the town of Hell. I completed it at age 50 and again at 55. When my functional longevity fails, I can’t wait to tell the nursing home staff I swam through Hell . . . twice. Why? To stay functional.
What Is Forest Bathing?
It’s not sitting in an outdoor hot tub with a glass of wine, although I recommend that too if you have easy access and you might enjoy it. In 1982, the Japanese Ministry of Agriculture, Forestry, and Fisheries coined the term “shinrin-yoku” or “forest bathing.” I didn’t even know I was doing it until I read an article about the benefits. Most of us who have access to the outdoors or who can take a trip to get to a wilderness area or a calming outdoor vista that produces awe have tried it or specifically sought it out, not knowing the term. There is something very beneficial about being in the woods and walking trails or seeing these types of natural sights. In fact, people set up trips just to do this. We are going to visit five national parks in February to get even more of it. Not everyone will choose to move to a mountain and live in a forest to get a full-time dose, but if you can work this in, it may well be worth it.
Here's how Psychology Today writes about it:
“The idea is to immerse yourself in a natural environment and soak up the many health benefits of being in the green woods . . . Across the continents, you will find forest bathing clubs and guides and tutorials. Forest bathing, also referred to as forest or nature therapy, has become popular in all corners of the developed world. The restorative nature of sitting in nature has been called soft fascination, whereby we are enraptured and uplifted by our surroundings. Forest bathing is an antidote to pinging distractions, impending deadlines, and never-ending obligations. Also, in one study that included images of natural environments, people felt more positive about their body image, which is the opposite of the self-disdain we may feel when scrolling through social media.”
The rest of the above list is self-explanatory, and many of us try to get ourselves and our patients to develop and maintain social connections, optimize cognition through lifelong reading and learning, get adequate sleep, and practice good oral hygiene. Getting people to floss every day is about as hard as staying at their ideal body weight.
In summary, functional longevity is connected to brain health, which is connected to vascular health. Strength, balance, flexibility, and mobility can affect emotional well-being. You can manage and mitigate the known vascular risk factors. The inevitable loss of muscle mass and mobility with age can be counteracted to a degree with functional exercise and yoga. Look around on the trails when you are traveling for the active older folks. Ask them how they have done it. I’ll bet a lot of them are following a wellness plan, taking a yoga or fitness class, walking, eating well, not smoking, and having fewer copays and regrets.
Remember: what use is retirement if you can’t move? What use is a couple of million dollars, a pension, Roth money, and Social Security if you can’t take the trips you planned? You don’t want to be on 10 medications and have four different types of doctor’s appointments. While some decline and slowing down are inevitable, why not leverage a positive outcome?
If you're retired or close to it, how do you plan to maintain your functional longevity? Is that something you've thought about? Would any of these tips help? Would you give forest bathing a try? Comment below!