Episode 089: How to Retire Happy with Dr. Osorio

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Article Authors: 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!

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