Episode 089: How to Retire Happy with Dr. Osorio
Sarah Sohyun Kim, Carolina Osorio, MD, David Puder, MD
There are no conflicts of interest for this episode.
On this episode of the psychiatry and psychotherapy...we continue our conversation with geriatric psychiatrist, Dr. Osorio, to talk about retirement—specifically, how to retire well and happy. She recently published a book for people in this transition: Stop Freaking Out About Retirement
Dr. Osorio noticed that some of her patients began to struggle with depression and anxiety when faced with retirement. These “golden years” are eagerly anticipated by all but when it came down to it, it was common for some people to feel lost, afraid, and anxious. This observation launched Dr. Osorio to examine what affects one’s ability to enjoy retirement and how to navigate one of the biggest transitions in life.
Many resources on retirement focus on financial planning, not the other aspects that make up one’s well-being. Financial means and medical care are essential, but preparing for a fulfilling retirement involves introspection and processing. Her focus is to help people through that process.
The Four Pillars
Dr. Osorio’s first pillar: Biology
Healthspan vs. lifespan
Dr. Osorio brings attention to “healthspan,” which is defined as “the period of life spent in good health, free from the chronic diseases and disabilities of aging” (Kaeberlein 2018). In the United States, lifespan between 1900 to 2017 increased from 47.3 to 78.6 (CDC/NCHS). But how desirable is it to have a longer lifespan if the last 20 years of life are spent in pain and sickness? The primary health goal for older adults is not simply to expand lifespan but to improve healthspan. Chronic diseases like lung cancer, stroke, heart disease, and diabetes threaten the older population’s healthspan, and are also the leading cause of death in the U.S. The onset of these diseases could be delayed or prevented with lifestyle modification.
Exercise vs. physical activity
After the age of 50, approximately 2% of muscle mass decreases every year and 15% in muscle strength every 10 years (Quittan 2016). Sarcopenia is a term for age-related loss of muscle strength and/or physical function. Studies have shown sarcopenia to be a significant predictor of in-hospital mortality in patients admitted to ICU as well as increased length of hospital stay (Toptas 2018, DeAndrade 2018). To attenuate the effect of sarcopenia, studies recommend resistance training 2-3 days per week (Vikberg 2019). Further benefits of strength training include fall prevention, improved activities of daily living (ADL) such as walking endurance, gait speed, and stair climbing (Papa 2017).
Diet
The Standard American Diet (SAD) includes excessive intake of processed foods, refined sugar, saturated fat, and sodium, with low intake of vegetables and fruits. Diets that are commonly associated with healthy lifestyles are vegan, vegetarian, and plant based. Here, Dr. Osorio points out that it is important to choose and adhere to a diet that is sustainable. If the above options are too difficult to maintain, consider Mediterranean diet or DASH (Dietary approaches to stop hypertension). Many studies link DASH to decreased risk of cardiovascular disease. These diets are characterized by high consumption of nuts, legumes, healthy lipids (e.g. olive oil), and lower intake of dairy and red meat products (Sanches 2018).
Sleep
Older adults generally experience age related changes in sleep architecture and circadian rhythm that can lead to sleep-maintenance insomnia and early awakening. Sleep deprivation is associated with numerous health risks including anxiety and mood disorders, heart disease, and increased build-up of beta-amyloid, a protein associated with impaired brain function and Alzheimer’s disease (Shokri 2018). To improve quality of sleep, Dr. Osorio recommends starting with small steps such as exercising and practicing sleep hygiene techniques. Eliminate in-bed activities other than sleep (phone, TV, etc.). If you are unable to fall asleep within 20 minutes, get out of bed and read a book until you feel sufficiently sleepy to return to bed and attempt falling asleep again. The goal is to break the association between the bed and wakefulness.
For insomnia patients, the first line of treatment is cognitive behavioral therapy for insomnia (CBTi) to identify and modify behaviors that perpetuate sleeping problems. Insomnia should be distinguished from other common sleep complaints and conditions as it commonly coexists with psychiatric or medical disorders, or use of certain medications or substances. If pharmacotherapy is considered for chronic insomnia, selection of medication should be individualized based on comorbidities, side-effect profiles, and patient age, especially in older adults who have a particularly high risk of adverse effects. One meta analysis study reported a significantly higher magnitude of adverse cognitive and psychomotor events than benefits associated with the use of hypnotics to treat older people with insomnia (Glass 2005), suggesting the necessity of additional caution when deciding whether pharmacotherapy is indicated for this patient population.
Over-the-counter (OTC) sleep meds
The use of anticholinergic medications such as Benadryl (diphenhydramine) is not recommended for treating insomnia in the elderly as it is linked to increased risk of delirium, cognitive decline, inattention, disorganized speech, and altered consciousness (Sateia 2017).
If behavioral modification and sleep-wake scheduling fail to show improvement, Dr. Osorio recommends a trial of melatonin prior to bed-time. It has been shown to be safe and effective for short-term use (3 months or less) to help with sleep disturbances such as delayed sleep-wake phase disorder, and in older patients with lower levels of melatonin (van Geijlswijk 2010). Melatonin is a hormone naturally secreted by the pineal gland but its level declines gradually over the life-span that may contribute to circadian rhythm dysfunction (Zhdanova 2001). It is sold as OTC with a recommended daily dose between 3 to 5mg taken early in the evening (Auger 2020). Higher doses may be indicated (up to 10mg) but can increase daytime sleepiness.
In our resource library, check out our excel sheet with data on which medications worsen cognitive function: here.
Dr. Osorio’s second pillar: Psyche
Dr. Osorio describes the concept of growth vs fixed mindset and how it affects one’s beliefs, expectations, and motivation. Stanford psychologist Carol Dweck introduced the concept that individuals with the growth mindset believe talent can be developed, and those with the fixed mindset believe their talents are innate. Dr. Osorio explains how the fixed mindset can perceive retirement as a confining experience that perpetuates self-imposed limitation and false belief about oneself. How would the growth mindset handle the challenges that come with retirement? Dr. Osorio helps examine why mindset is important and how it applies to setting and achieving new goals for those facing retirement.
Reticular activated system (RAS)
The RAS is a network of neurons that spans an extensive portion of the brainstem. It serves as a gatekeeper that filters and lets in information in a way that reinforces one’s belief. The neuroscience of the RAS confirms the importance of calibrating one’s self-belief that subsequently affects their thinking pattern and ability to change.
Limbic system & prefrontal cortex
The Limbic system deals with past traumatic experiences. Prefrontal cortex (PFC) is considered the rational brain that is activated when sustained attention or higher-level thinking process is required. It counterbalances the limbic system and allows for regulation of emotion and impulse. Healthy interaction between these systems is important in maintaining neural function and regulating negative emotion for carrying out goal-directed behavior.
Dr. Osorio discusses how a person can live in a state of high anxiety due to a hyper-stimulated limbic system from repeated exposure to negative experiences. This is supported through studies that show high-anxiety individuals exhibiting reduced activity of PFC and hyperactivity in the limbic system in response to fearful stimuli (Bishop 2004, Martin 2013).
Mindfulness meditation is a technique for calming the limbic system, bringing one’s attention to the present moment and helping engage with the world. The benefits of mindfulness meditation have been largely evidenced in research that showed reduced amygdala reactivity to negative stimuli and structural improvement in PFC (Kral 2018, Lazar 2005).
SMART goal setting
Set SMART (Specific, Measureable, Attainable, Realistic, Timely) goals that matter to you based on your values and life vision. What will be important to you in retirement? Then, turn these goals into actions. Dr. Osorio provides tools and exercises in her book to guide you through this process.
Dr. Osorio’s third pillar: Social
To some, retirement might mean getting out of a social circle at work that has made up a significant portion of one’s social life. A sudden change from interacting with people at work all the time to spending more time at home can feel isolating.
Loneliness has a constellation of health implications that encompass cellular to psychosocial domains. It is linked to increased susceptibility to infectious disease (Cole 2007, Pressman 2005), elevated blood pressure (Cacioppo 2014), cognitive decline (Béland 2005), smoking (Beutel 2017), and depression (Domènech-Abella 2017). Data also suggests the medical relevance of social relationships to improving patient care as shown by increased compliance with medication regimen and decreased length of hospitalization (DiMatteo 2004, Murphy 2008). The importance of social relationships goes beyond reducing mortality risk or maintaining physical function. Qualitative studies of older adult’s opinions on successful aging underscores the significance of doing something of value, acceptance of aging, and social connectedness (Lindsay-Smith 2018, Song 2015).
The shifting social identity is not trivial given how maintaining social connections is a critical part of healthy aging. Dr. Osorio discusses how to embrace the freedom that retirement brings and continue engaging oneself in the larger context of social and familial networks.
Dr. Osorio’s fourth pillar: Spiritual
Dr. Osorio shares different ways to see and feel the world that brings change and growth. One example Dr. Osorio discusses is the work of Viktor Frankl, psychiatrist and Holocaust survivor, and his acclaimed book called Man’s Search for Meaning. From his work she draws connections to retirement for contemplation. At this stage, what is the meaning of life, and how could it be realized?
“Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way” (Frankl 2006, p. 68)
Striving to find meaning in one’s life is the primary motivational force in man (Frankl 1992, p. 104). If you pursue meaning, you can always find it.
In Conclusion
As mental health professionals, all of our patients will eventually face this huge transition. Patient education and preparation are vital in developing the strategies for preventing a waning healthspan. Their physical health (proper exercise, sleep, and diet) should be honed alongside mental health (growth mindset, social/familial networks, finding meaning). These combine to contribute to a healthy transitory foundation. Our empathic, comprehensive clinical approach can help to ensure their retirement years are truly golden.
Order Dr. Osorio’s book here!
Works citation
Auger, R. Delayed sleep-wake phase disorder. In: UpToDate, Eichler, April (Ed.), UpToDate, Waltham, MA. Accessed on Aug 10, 2020.
Béland F, Zunzunegui MV, Alvarado B, Otero A, Del Ser T. Trajectories of cognitive decline and social relations. J Gerontol B Psychol Sci Soc Sci. 2005;60(6):P320-P330. doi:10.1093/geronb/60.6.p320
Bishop, S. , Duncan, J. , Brett, M. , & Lawrence, A. D. (2004). Prefrontal cortical function and anxiety: Controlling attention to threat-related stimuli. Nature Neuroscience, 7, 184
Cacioppo S, Capitanio JP, Cacioppo JT. Toward a neurology of loneliness. Psychol Bull. 2014;140(6):1464-1504. doi:10.1037/a0037618
CDC Centers for Disease Control and Prevention/National Center for Health Statistics [CDC/NCHS] https://data.cdc.gov/NCHS/NCHS-Death-rates-and-life-expectancy-at-birth/w9j2-ggv5
Cole SW, Hawkley LC, Arevalo JM, Sung CY, Rose RM, Cacioppo JT. Social regulation of gene expression in human leukocytes. Genome biology. 2007;8:R189. doi: 10.1186/gb-2007-8-9-r189.
DeAndrade J, Pedersen M, Garcia L, Nau P. Sarcopenia is a risk factor for complications and an independent predictor of hospital length of stay in trauma patients. J Surg Res. 2018;221:161-166. doi:10.1016/j.jss.2017.08.018
Frankl, Viktor E. (Viktor Emil), 1905-1997. Man's Search for Meaning; an Introduction to Logotherapy. Boston :Beacon Press, 1992, 2006.
Kaeberlein M. How healthy is the healthspan concept?. Geroscience. 2018;40(4):361-364. doi:10.1007/s11357-018-0036-9
Kral, Tammi R A et al. “Impact of short- and long-term mindfulness meditation training on amygdala reactivity to emotional stimuli.” NeuroImage vol. 181 (2018): 301-313. doi:10.1016/j.neuroimage.2018.07.013
Law TD, Clark LA, Clark BC. Resistance Exercise to Prevent and Manage Sarcopenia and Dynapenia. Annu Rev Gerontol Geriatr. 2016;36(1):205-228. doi:10.1891/0198-8794.36.205
Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893-1897. doi:10.1097/01.wnr.0000186598.66243.19
Lindsay-Smith G, O'Sullivan G, Eime R, Harvey J, van Uffelen JGZ. A mixed methods case study exploring the impact of membership of a multi-activity, multicentre community group on social wellbeing of older adults. BMC Geriatr. 2018;18(1):226. Published 2018 Sep 24. doi:10.1186/s12877-018-0913-1
Martin EI, Ressler KJ, Binder E, Nemeroff CB. The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology. Psychiatr Clin North Am. 2009;32(3):549-575. doi:10.1016/j.psc.2009.05.004
Papa EV, Dong X, Hassan M. Resistance training for activity limitations in older adults with skeletal muscle function deficits: a systematic review. Clin Interv Aging. 2017;12:955-961. Published 2017 Jun 13. doi:10.2147/CIA.S104674
Pressman SD, Cohen S, Miller GE, Barkin A, Rabin BS, Treanor JJ. Loneliness, social network size, and immune response to influenza vaccination in college freshmen [published correction appears in Health Psychol. 2005 Jul;24(4):348]. Health Psychol. 2005;24(3):297-306. doi:10.1037/0278-6133.24.3.297
Sanches Machado d'Almeida K, Ronchi Spillere S, Zuchinali P, Corrêa Souza G. Mediterranean Diet and Other Dietary Patterns in Primary Prevention of Heart Failure and Changes in Cardiac Function Markers: A Systematic Review. Nutrients. 2018;10(1):58. Published 2018 Jan 10. doi:10.3390/nu10010058
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307-349. Published 2017 Feb 15. doi:10.5664/jcsm.6470
Shokri-Kojori E, Wang GJ, Wiers CE, Demiral SB, Guo M, Kim SW, Lindgren E, Ramirez V, Zehra A, Freeman C, Miller G, Manza P, Srivastava T, De Santi S, Tomasi D, Benveniste H, Volkow ND. β-Amyloid accumulation in the human brain after one night of sleep deprivation. Proc Natl Acad Sci USA. 2018 Apr 9. pii: 201721694. doi: 10.1073/pnas.1721694115. [Epub ahead of print] PMID: 29632177.
The National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Food and Nutrition Board; Food Forum. Nutrition Across the Lifespan for Healthy Aging: Proceedings of a Workshop. Washington (DC): National Academies Press (US); 2017 May 18. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430985/ doi: 10.17226/24735
Toptas M, Yalcin M, Akkoc İ, et al. The Relation between Sarcopenia and Mortality in Patients at Intensive Care Unit. Biomed Res Int. 2018;2018:5263208. Published 2018 Feb 12. doi:10.1155/2018/5263208
Quittan M. Aspects of physical medicine and rehabilitation in the treatment of deconditioned patients in the acute care setting: the role of skeletal muscle. Wien Med Wochenschr. 2016;166(1–2):28–38.
van Geijlswijk IM, Korzilius HP, Smits MG. The use of exogenous melatonin in delayed sleep phase disorder: a meta-analysis. Sleep. 2010;33(12):1605-1614. doi:10.1093/sleep/33.12.1605
Vikberg S, Sörlén N, Brandén L, et al. Effects of Resistance Training on Functional Strength and Muscle Mass in 70-Year-Old Individuals With Pre-sarcopenia: A Randomized Controlled Trial. J Am Med Dir Assoc. 2019;20(1):28-34. doi:10.1016/j.jamda.2018.09.011
Zhdanova IV, Wurtman RJ, Regan MM, Taylor JA, Shi JP, Leclair OU. Melatonin treatment for age-related insomnia. J Clin Endocrinol Metab. 2001;86(10):4727-4730. doi:10.1210/jcem.86.10.7901