Transcript

Ben:                 Welcome everyone. My name is Ben Smith. I'm joined by the Cosmo Kramer to my George Costanza, Curtis Worcester.

Curtis:              All right.

Ben:                 How are you doing today, Curtis?

Curtis:              I'm well, Ben. How are you?

Ben:                 I'm well. We're really happy to have a really special guest here today. One of the topics we want to be diving into in this show today is facing and fighting mental illness in retirement. And that's... When we start talking to our clients about not just goals, right? Is things that are happy and things that they're trying to attain in their life, but you also have to focus in on their fears. And fears is something that... It gets pretty uncomfortable that people don't want to talk about. And one of the things that you see as we're supporting clients through maybe 30 years of their retirement or 8000 days is that they may not even address it early in their retirement.

Ben:                 But at some stage inevitably, there's enough of our clients that are in a situation with they themselves are dealing with a mental illness or their spouses. And what we find is a lot of our clients, they don't know where to go, and they don't know who to talk to, they're scared, right? And they don't know what they don't know about it, they've never faced it before. And then they come in, and they're at a very vulnerable place. And sometimes if it's them, they may be talking to us about it, or it's, "I'm coming here, and I'm coming without my spouse who I think is afflicted, and I don't know where to go." And so it's a very vulnerable time.

Ben:                 And so what we wanted to do is really talk to somebody that, in Maine, is an expert about this, and having a really full-fledged conversation about that fear. And it may be addressing some things that may be this unfounded, in terms of, fears and things that maybe they could be thinking about to better prepare for dealing with Alzheimer's, dementia or other sorts of mental illnesses. So today, we brought in Dr. Cliff Singer. And so Cliff works at Acadia Hospital, and really specializes in geriatric mental illness. And that's why we wanted to have him here today. So welcome, Cliff. Happy to have you on the show.

Cliff:                 Thanks for having me.

Ben:                 Yeah. So we wanted to, in terms of, the format of our show, and again, the title of the show is Retirement Success in Maine. We always like to spend a little time just getting to know you, right? Is in terms of, why you're passionate about this field, but maybe we could just kind of start with growing up, growing up experience and getting into the medical field. How did that start for you?

Cliff:                 Well, I grew up in New York. I initially wanted to be a veterinarian actually.

Ben:                 Okay. Good.

Cliff:                 And I spent the summer working for a veterinarian and realized I don't want to do that at all. But I was interested more in talking to people and working with people and when I was in college I volunteered with Special Olympics and worked with kids with developmental disabilities. And I was a zoology major interested in brain development through the ages, through evolution. And working with the kids with developmental disability, I figured I want to... I thought I'd become a pediatric neurologist.

Ben:                 Okay, Good.

Cliff:                 I went to medical school in Florida. My parents moved to Florida when I was in college. So I went there for medical school, and we had the first geriatrics rotation in the country, in a medical school, spent six weeks at a retirement community as a medical student and was fascinated by it because this was in the late 1970s. And the older adults at that time had 19 century childhood. So I really... I loved the stories. I got to meet two Spanish American War veterans.

Curtis:              Wow.

Cliff:                 And so I started thinking about geriatrics as a career and then that didn't really gel until after medical school and residency. I went to Portland, Oregon to do residency at Oregon Health and Science University and I got to do a geriatrics rotation during my psychiatry rotation. I chose psychiatry because it was either that or neurology. And neurology in those days was a diagnostic specialty. It wasn't a lot you could do for people. We had a few things that we could do, a few drugs to treat seizure disorders, migraine and Parkinson's disease, but mostly it was, "Well, this is what you got."

Ben:                 In geriatric at that time too, right? And we see this from the financial lens is in terms of people living longer today is kind of been a newer experience, right? Is that median age have continued to rise over the last 30 years, right? So people may be living or living a lot shorter durations than maybe they are today.

Cliff:                 Well, there's always been old people.

Ben:                 Yes.

Cliff:                 Even going back to ancient times. It's always been super survivors. Lifespan hasn't changed much, healthspan has changed a little bit. But yeah, I mean, huge... It's a huge, huge increase in numbers of people making it to old age. And geriatrics, 40, 50 years ago, or 30 something years ago, when I was getting into it. I mean, they were... Still, it was focused... The geriatricians skill is really focused on old old age, not young old age. That's starting to change as we start thinking more about prevention. And prevention has to start much earlier, but the clinical skills of geriatrician really come into play when people are passing the 75 or 80-year landmark, that's when people actually really do start to get old.

Cliff:                 Psychiatry was of interest to me because even back then there was a lot more I thought you could do with people. We had more treatments available and it was also the personal relationship with people that counted so much. In geriatrics, psychiatry combined my interest in medicine, neurology, and psychiatry in one so I ended up doing a fellowship in geriatric medicine, which combined well with my psychiatry training.

Ben:                 So essentially, launched that passion for you then, right? In terms of, "This is something that I really can see myself making a difference in. I really want to do." So in Portland, Oregon, that was where that formed for you?

Cliff:                 That's right.

Ben:                 Yeah.

Cliff:                 That's right. I mean, I love the stories these people told about their childhoods and clinically, I was really fascinated by their experiences, aging and why some people were able to do it so gracefully and other people struggle so much.

Ben:                 So from there... Because I know one of the questions we always like to ask our guests are is why Maine? Right? Because it feels like Maine is a place where you have to choose. Winters can be hard and there's four seasons and some challenges with the rural demographics that we have here. So how did you go from Portland, Oregon, on the extreme side of the country over to the east coast? Over to Maine. How did that launch to you?

Cliff:                 Why indeed. I spent 25 years in Oregon after my residency and fellowship training, I stayed on the faculty. My daughter who grew up in Portland wanted to make documentary films and she wanted to move to New York to do that. My parents, aunts and uncles and cousins who were mostly on the East Coast, so I decided to come back east, after being away for 25 years. And was recruited for a job at the University of Vermont in Burlington. I was there for four years. Left Vermont, not happy with my job. And a resident of mine from the University of Vermont recruited me to start a geriatric program here at Acadia Hospital in Bangor.

Ben:                 Nice.

Cliff:                 So I came here nine years ago, started the program and I've never been happier.

Ben:                 Good for you, right?

Curtis:              It's awesome.

Ben:                 When I hear people is this whole purpose is finding a purpose in retirement but also finding purpose in life, right? Is if you're running from a career just defined then that purpose and that's pretty hard to get to that point too. So it's always great when you're finding in each stage of your life you're going, "All these experiences had to build up to this for me to get to this point and really find my purpose and get that happiness." And it all reverberates, which is what I really love.

Ben:                 So cliff, can you give us, in terms of, you're now in Maine and you're launching this program. Can you just get into a little bit more detail about what that program is that you helped launch at Acadia Hospital and what services you're providing as part of that, again, with your specialty in geriatric psychology?

Cliff:                 Yeah, sure. I named the clinic we started The Mood and Memory Clinic. And that refers to the two broad categories that geriatric psychiatrists would be concerned with. And one is mental and emotional disorders, problems, mood, anxiety, sleep disorders. And the memory refers to the cognitive disorders, cognitive impairment, and dementia caused by many, many different disorders. And that's part of our expertise, trying to figure out why a person is having cognitive problems.

Ben:                 Got you. And how has the program grown? So when you started, was it just you? How is it... Because obviously, you have funding things that happened with grants and things along those lines, but how does it change in the last nine years and developed?

Cliff:                 So in the beginning, I was partnered with one nurse and Acadia Hospital did not have a reputation in the community as an institution that was interested in helping older adults. The focus was really on children, adolescents, and young adults. So we were starting from scratch. Now, there were some older adults seeking services there, but it was a slow growth initially. But once word got out, things grew quickly. And so by 2012, we had three nurses and three providers, two psychiatrists and a nurse practitioner. That's our current model.

Cliff:                 Each nurse follows about 250 to 300 patients. And with the three nurses we have about generally, about 900 patients at any given time, we get two to four referrals a day, mostly from primary care providers, but families and patients themselves call as well, some neurologists refer to us, some agencies refer to us. In 2013, I thought that we had grown to the point where we can start a research program. So we started our Alzheimer's disease clinical trials program and that's been very successful in partnership with Eastern Maine Medical Centers, Clinical Research Center, which facilitates clinical research throughout Northern Light Health, what is now Northern Light Health.

Cliff:                 So that's been a great partnership. And we've had a very successful growth in our research program and now are branching out into grant funded research with collaborators at Jackson Lab in University of Maine and others around the state.

Ben:                 I was reading about that. It had some really great positive press that was I think, was last year the Bangor Daily was covering that and you're seeing it out there. One of the things I was reading about that study, which I really loved was a quote from one of the participants in the study. And this just resonated with me because we're hearing this quote almost with a lot of the conversations we have, and I'll read it for you, it was Bonnie Johnson saying, "You always have that in the back of your mind that is it you? Do you have it? Are you going to get it?" She says.

Ben:                 So I do want to just touch on that study because I think it's a really good question to ask is... It must have been tough to find people willing to say, "Hey, I want to embrace." And it was a clinical trial that you were working on and to embrace it, but also know that result because, in terms of, your studies, it's not like is... You're trying to develop or look at progression, right? Where people are, they may have markers.

Cliff:                 Either prevention or progression, or progression and people who do not yet have any symptoms but do have risk factors, like certain biomarkers, which we can talk about later.

Ben:                 Yeah.

Cliff:                 And to see whether they start to develop memory problems or other symptoms over time.

Ben:                 That's going to be pretty scary to raise your hand and say, "Hey, I'm willing to participate in this. I do think I have risk factors, maybe family history and which is why I'm coming to you and then finding those biomarkers to then participate in this study and see if I am progressing towards that or not." So it's a very mortal thing to face. It's very scary thing to admit to.

Cliff:                 It is.

Ben:                 And approach. So can you talk about that, in terms of, developing that study at Acadia hospital and finding those people and how they've faced that?

Cliff:                 Well, we have many studies, that was just one. But the idea, either of coming forward to volunteer for what's essentially, prevention study to identify particular risk factors that you might have and then to be followed over time to see if you develop symptoms and to be randomly assigned to a treatment that could potentially help or not, takes a lot of courage. I was concerned that we would not be able to develop a robust research program here and we really to... As far as population have been very, very pleased that we've been so successful.

Cliff:                 Turns out that people are highly motivated to contribute to research. Not everyone, of course, and some people do, as you say, don't want to know, many people do. And they not only want to know for themselves, they want to know for their kids and their grandkids and they want to be part of the solution. So it's not that hard to find people. Generally, they have family histories, or sometimes they're concerned because subjectively they feel like they're starting to have some memory problems, but they want to step forward and try to help.

Cliff:                 Once people have a diagnosis, say they've been part of our clinic or have been evaluated elsewhere and have a diagnosis, either a mild cognitive impairment, which is an early stage or early dementia, often from Alzheimer's disease, then they or their family members are often very motivated to get something. Just like oncology clinics, cancer centers rely on clinical trials to find new treatments. So do we, in Alzheimer's disease and cognitive disorders centers, we rely on clinical trials to try to identify new treatments and so people recognize that and are really highly motivated to participate. And we're currently the only center in Maine doing clinical trials. So we get people around from all over the state.

Ben:                 Great. In regards to the state of Maine, we're one of the older states in the nation. Second, I think is depending whatever study you look at there.

Cliff:                 Yeah, median age, we're the oldest but there's quite a few states clustered around there. We're old though.

Ben:                 Sure. So in what you just said, in terms of, the clinical trial piece, but also is I know... So we're in Bangor today. And you find that Northern Light Health in Bangor, especially as a service center to lots of eastern and northern Maine as well. Are you finding that... You just talked about some amazing statistics about people being referred in. In terms of, that referral process, so part of just reputation of people going, "That's where you go." Are you finding that this is speeding up because the demographics of the state of you're seeing more referrals coming in? Is there more need than you've thought there were or currently is? And what do you think then going forward about your services and attacking the need that you see in the state of Maine?

Cliff:                 So we have a real problem with access to services. Yes, there's increasing demand or request for our help. Is it because we're becoming better known, we have a reputation? Sure. I'm sure that's part of it. I can't say that's just because of the aging of the population there are more older adults, we can look at the demographic projections of the increase rapid rise of people with, say Alzheimer's disease, and the rapid increase in older adults who are at risk for mental illnesses, depression especially.

Cliff:                 So yeah, the numbers are increasing as the population increases. Sadly, we can't... Our service is limited in its size, mostly because of space limitations. So we have a 10 month wait list now, which is unacceptable. And we've started a philanthropy campaign to... So that we could build more space and scale our program up to the point where it can be community needed, it needs to be three times the current size.

Ben:                 And then going forward, right? It's not just meeting the current capacity need but also what you think projected going forward is going to have to be, right?

Cliff:                 That's true.

Ben:                 So you always have to continue to keep up with those trends as it goes.

Cliff:                 That's right. Fortunately, we're not alone. Other people are... We have a unique program in the state but others... There are other geriatric assessment clinic and dementia specialists in the state, particularly, in Central and Southern Maine. So there are others trying to do this work too. But we have a unique place, not only because of our location, but the integration with research is unique.

Ben:                 Yeah, great. I want to kind of switch over to, again, some of the questions that we've been having or conversations with our clients. And one of the things that really comes into for our conversations is, again, there's this concern about developing mental illnesses as they age. So if someone's right now, early retirement or maybe pre-retirement and they're thinking about or they have this worry or this fear about developing mental illness. How founded is that common concern that, in my life, I am going to develop a mental illness and I'm really very scared about that. How common? I guess would be the question.

Cliff:                 Let's think about mental and emotional disorders in one category and cognitive disorders in another because risk factors and overall risk is very different.

Ben:                 Okay.

Cliff:                 A person's risk for developing an emotional or mental disorder such as major depression or a variety of anxiety disorders is based primarily one on early childhood and early adult history. Did they have problems as a young adult? Or even as a middle-aged adult? If they had good psychological, healthy psychological development and good psychological health throughout childhood and adulthood, their risk of developing a problem later in life is much less.

Ben:                 Okay.

Cliff:                 However, there are things that happen later in life that overwhelm even the most well adjusted and adaptable people. Isolation, loss of mobility and independence, loss of loved ones take their toll chronic pain and medical problems that affect a person's ability to live independently and do the things they want to do are things that are very, very challenging to cope with. And some people do it extraordinarily well. But even the best among us, the most well-adjusted and adaptable among us are, are challenged by loss of functional independence and isolation. And perhaps most importantly, loss of sense of purpose, which is so essential for a person's feeling worth. Those are very, very difficult challenges.

Ben:                 And I know, we talked a little bit off air, Dion Walsh with Eastern Area Agency and Aging. That's one of the things that she was saying, right? Is the biggest thing that she was saying for an issue for that population that she works with, has been the isolation. They've lost a loved one and they're living by themselves, winters hard, were rural. People want to live in their lifelong homes that are not made to be lived in if you're dealing with certain physical or mental issues. And how do you keep that person there and they're not socializing it with anybody? Right? They lose their loved one, they get depressed, they go inward, and they just shut down.

Cliff:                 Right.

Ben:                 So I just echoing what you said there was that we heard that from her and it's something that I think is, it feels pervasive, it seems like it's a common thread that we're hearing. I don't know if it's just because we're in the northeast and the harshness of a winter and that help hurts but also how rural we are as a group and it's tough. We don't have really great transportation systems for people to get into a coffee group or meet me to do something for... If you're living an hour and a half to two hours away.

Cliff:                 Right.

Ben:                 Right? It's all those things are really hard challenges to overcome where people have this ingrained sense of, "I have to live in my house that I've lived in forever."

Cliff:                 Yeah. The ties that bind, or the systems that support a person in a rural environment can be so tenuous, and even in small towns, for example, recently at Tim Hortons in Old Town closed. And that was a senior center for people. How can they go to the Dunkin Donuts and McDonald's is two miles down the road? Yeah. But some people don't drive and they hate to ask for help. And it's hard to change patterns. But that's in Old Town. In many towns if there was just one place and it closed down, there's no other option unless you drive 10 or 15 miles, so the same thing with social supports. If a friend dies or a family member moves away, that's it.

Curtis:              Yeah.

Cliff:                 Yes. Just very few layers of support to keep people living alone.

Ben:                 I want to go back to one of the things you said and going to the emotional and mood disorders and depression, especially. If I'm in a situation of, it's me, and I'm alone, or it's me and a spouse, how would I know that I'm beginning to develop some emotional or mood disorder? What would I be seeing in myself? And maybe... And that also might be tough because people might not be aware enough of themselves to be able to sense it or objectively measure themselves. But what would they see? If they're starting to develop that. What factors would they have?

Cliff:                 It's often a family member or friend who sees it first. So might see the anxiety or the irritability or the social withdrawal. The person themselves may not feel sad or hopeless, the feelings that a person would classically identify as depression. They may just feel frustrated, worthless, alone, irritable, cranky, not wanting to go out but they may not understand or see the underlying emotional issue. Others would see it, might see it first. And then that's not always true. People do on themselves often seek help. Women are much more likely to voluntarily seek help than the men will.

Cliff:                 Anxiety is often a symptom that drives people to seek help because anxiety is really physically uncomfortable, or it manifests in physical symptoms like heart palpitations, shortness of breath, chest pain, gastrointestinal problems, so they may seek... They may go to their primary care provider and the Primary Care or emergency department even particularly if it's sudden chest pain that due to anxiety, which is quite common. And so that's where they may first get diagnosed with an anxiety disorder. And there may be a depression underlying that.

Ben:                 And if it's a loved one, right? That noticing that, so an external party noticing that about you?

Cliff:                 Yep.

Ben:                 What's the best way to actually directly communicate that? Right? Because here you have somebody that's really probably anxious about lots of things or depressed and then pointing that out to them in a way that is constructive and not destructive, it makes it worse.

Cliff:                 Yeah.

Ben:                 I'm sure that's a lot of the external parties' anxiety about that moment, right? Is how do I then carefully tell you that maybe we should be doing something to get you back on a better road or helping you address this or thinking about, again, getting you out of that?

Cliff:                 Yeah, right. It's challenging. The person themselves may be in denial that they have a problem. Maybe other family members are in denial, "Oh, dad's fine." Maybe the doctor is even in denial about it, "Oh, he's just getting old." You hear that a lot. And so it can take some persistence and gentle persuasion or if a person is not willing to consider psychological explanation for or psychiatric explanation for what symptoms they're having. In fact, there are physical problems that need to be evaluated and ruled out as an underlying cause of psychological symptoms or behavioral symptoms.

Cliff:                 So it's okay to use that justification. "Mom, I really think you need a medical checkup." Now, it can be touchy to communicate to the healthcare provider your concerns, you can do that in a private letter, a phone call, or it's always best to accompany your spouse or your parent to a doctor's visit. Now, most people who work with older adults will definitely take the families report, the spouses, the caregiver, the adult child, they want to hear from that person to know how they're functioning. Now, this is less true of people in the young old age group, people in their 60s and early 70s. Those people generally, are very independent, speak up for themselves. Now, a lot of older people in their 80s, 90s do too, but the families report really becomes more important.

Ben:                 Because do you feel like, in terms of, and this is just from a anecdotal from what we see with our client experience is this... It's really tough for people to admit vulnerabilities.

Cliff:                 Yeah.

Ben:                 So it's maybe somebody forced it. I'm like, "We're going to go see our primary care physician and I want to just talk generally. Here's a symptom, here or there. I want to just make sure they're aware of and see if we can just talk about more." But the whole... I don't know. The vulnerability part, I don't know if it's just a general this is, as people age, they're more... It's their own mortality they're addressing or it is their concern about addressing that because that's just another step to, "Well, I'm getting old and that's something I'm not." Right? "I'm not old. Even if, whatever age I am, I'm not old and I don't address me passing away." So all of those things that we see is there's a lack of maybe self-awareness of wanting to admit something or looking to address it. Even if there's nothing wrong is to have that conversation.

Cliff:                 That lack of or that reluctance to acknowledge aging is more common in younger adults, and as people transition to old age. You're not going to find many 70-year-olds or 80-year-olds who don't want to talk about aging or don't want to acknowledge aging and talk about it honestly. And many of them say, "You're only as old as you feel." They try to stay... They're very active. But none of them will deny that they're getting closer to death or that their body is changing. Most of them have come to terms with death anxiety. That peaks in adolescence, midlife and then slowly resolves.

Cliff:                 And most people as they age become more accepting of the inevitability of death. What people are afraid of is dependency, not death. They're afraid of not being able to live independently and do the things they want to do.

Ben:                 Okay. And really the conversations we have with our clients, they make this statement to us of, "Hey, I'm not going to go to a nursing home and I'm concerned about that if I go to nursing home, it's going to raid my financial resources and there's going to be nothing left for my spouse." And again, it's always easy to maybe say when you're far away from it, and you're not in that moment, but that seems to be a common phrase that we hear from either the population we work with or people that we talk to. Are you hearing that? And if you are hearing it, what's your response to that?

Cliff:                 Everyone shares that fear. I'm a boomer and I certainly don't want to spend the last few weeks even or months of years of my life in a nursing home, but it's very important to realize a few things. First of all, there are many other options besides nursing homes. And also nursing homes are getting better. But there are other options who's assisted living facilities in retirement homes of various sorts, but still, people don't want to leave their homes. And I think what we're going to see is that the demands of the baby boomer generation is going to change the culture so that more options will be available to keep people in their homes.

Cliff:                 Especially, technologies which will help people function. It's a very, very active area of research, nationally, internationally. And at the University of Maine that there will be different forms of technologies that are going to enable a person to stay safely in their home. Whether that be robotics that provide direct physical care or interactive technologies that remind people to take their medications or keep them safe in the environment that will enable them to be home. There's also different social movements that are underway for groups of people who are our friends or either new friends or old friends who will be living together and naturally occurring retirement communities who can take care of each other. Either in new homes that they share more or in networks within home communities that already exist.

Ben:                 I mentioned that I went to the AARP listening study session for the state of Maine. That was, I think three people brought that up about, they're hearing that happening in New York State and the West Coast, especially the common living communities, people with shared values and shared beliefs and getting together and looking out for each other and banding resources and putting those things together. And there was a complaint about, well, what is there like that here? And it seems like it's not here yet. But that demand or at least that voice was being heard, which I loved there.

Cliff:                 I just visited an intergenerational retirement community in Portland, Oregon, and people here in Bangor are interested in replicating this project. And it's very good. Both for the kids and the older adults to be in these intergenerational communities. It's a healthy thing. We're not supposed to be... Generations are not supposed to be isolated from one another. So it works great for all... The sandwich generation between generation too benefits from it. And so you're going to be seeing more and more of those communities and those options.

Ben:                 Awesome. Okay. And I guess that's another question I wanted to get into then. Because in terms of, dependency, it feels like if you were maybe living in a more dense population area, your independence might go up because you have more things available to you and more accessibility to... Whether it be services or food or entertainment or socialization. So I guess my question is due to being a rural state and the weather that we have, do you feel like there's certain behaviors or concerns that are more unique to living in the northeast then maybe if you're in Florida or other types of maybe warmer climates with different population patterns?

Cliff:                 I think there's several demographic patterns that affect aging in Maine. One is... They're two populations. One, people who have lived here for decades and decades, grew up here. And the other group people who retired here, they came here when they were still healthy in their 50s and 60s and now are aging in place and getting frailer. Their kids may live elsewhere, they usually, have developed friendships but a lot of people in that demographic spend their winters in Florida or elsewhere. So it's more... Their roots are not as deep.

Cliff:                 So that can be challenging for them as they get frailer because they just don't have the wide social network. I think in 20 years it may be. But again, their friends maybe snowbirds and or be getting frail themselves. So they're vulnerable. The people with deep social networks in Maine, who have lived here their whole life may still struggle for the same reasons their children may live elsewhere. Although I find... I don't know if this is necessarily true, I suspect it is that if their kids grew up here, then there's likely still one or two of them around. They may not live in the same town anymore, but there's commonly a resource more commonly than people who retire here for sure. It is more commonly that family members, siblings or adult children to be around to help.

Cliff:                 So those are two groups of people face different challenges. I think the people who have lived here all their lives tend to have deeper networks but people are spread out and it's still challenging with Lack of concentrated services and frail networks that are dependent either on one relative or one friend whose whereabouts and own health may be fragile.

Ben:                 AARP had a listening session the other day for the state of Maine. They said that aging plan that they're devising right now. And one of the... Basic... That was the theme that was just hit on for the entire two hours was caregiving support, right? We just don't have a lot of infrastructure, we haven't funded a lot of infrastructure into caregivers, especially with remote, right? Is how remote people are and trying to get people access to caregiving support or training, right? If you're caring for your spouse or your parent and you got a full-time job yourself, and maybe you have kids or grown kids, whatever the situation is. I've never done it before, right?

Ben:                 And at what stage can I not take care of them? And how do you progress from one level of care to the next? How does the system work? And I was just like pervasive across that, and which was... I'm glad that that was a lot of the conversation, across all income levels, right? The challenges are even more I think for the lower income levels and just even navigating the legal ease of it and communicating and talking to people about their specific challenges. But I thought that was a really kind of neat theme that was happening from that.

Ben:                 I do want to reverse. So we talked about mood and emotional disorders, and we've started getting into the cognitive side. I want to go back to almost the same question I asked you about developing an emotional disorder about if I'm maybe early retirement or early or I guess early in that stage. And again, I'm trying to think about those that are concerned about developing that condition of how do I know...

Cliff:                 Developing dementia.

Ben:                 Developing dementia. Yeah, how do I then look at this and say, "I am concerned of... If I'm seeing these. I don't know what the warning signs are, and how do I know that I am seeing warning signs? And is there something I could be doing about it, than not addressing it? And hopefully, it doesn't happen."

Cliff:                 Yeah, well, first of all, to answer that question, you have to know what's normal for normal aging.

Ben:                 Right.

Cliff:                 And so there are certain cognitive changes that are typical of aging and they start early in life, our memories peak at age 30.

Ben:                 Okay.

Cliff:                 It's all downhill from there. And by memory, I mean, episodic memory. I mean, encoding information about conversations or events in one's life, or learning new facts. And it doesn't necessarily become problematic until you really start noticing some forgetfulness. Generally, people notice in their 50s. Women especially notice in the perimenopausal years, because there's more of an abrupt change around that time. Now, women, in general, have better verbal memories than men do. Men can remember numbers, they can remember baseball.

Ben:                 Sure

Cliff:                 But they can't remember a conversation they had last night. We struggle that way. So generally, in one's 50s or 60s, people start to notice word finding difficulties. What's that call? Or they forget conversations, "Did I ask you this already? Did you tell me this already?" Those kind of things. Usually, you just have to ask that question once or twice. So word finding problems, remembering or forgetting conversations, forgetting what you were meant to do, forgetting what you came into the room to get, forgetting where you put something. These are common things that become more difficult with age and don't necessarily indicate you developing dementia. They're more interested of the fact that your memory doesn't encode new information as well as it used to.

Cliff:                 So if you want to remember something, you have to activate the frontal part of your brain, the frontal cortex. And you do that by thinking and attending. So most of the forgetfulness that we associate with getting older is really those two things. Being distracted by something and not really paying attention. And the fact that your encoding, your recording system is not as efficient. So as you get older, you can't multitask and hope to remember something, you really have to focus and concentrate in order to record new information and then retrieving that information is more challenging unless you practice and rehearse it more.

Cliff:                 That's what's normal and also retrieving nouns and names of people. And to some degree recognizing faces. That's a little bit more challenging too. Now, It's a gradual progression from there to when it becomes more worrisome. So getting lost in a familiar place, forgetting a familiar recipe or instructions forgetting to do something or forgetting how to do something that you're normally able to do, asking questions repetitively, more than twice in a short period of time. Those are markers that something more serious is happening. There are also behavioral personality changes that you see early in these diseases, meaning like Alzheimer's disease and the other conditions that lead to dementia, for example, people can become much more anxious than they used to be or more irritable than they used to be.

Cliff:                 People become more... The term we use is apathetic. They lose interest in going out, they lose interest in meeting new people, they lose interest in activities, hobbies, they lose interest in caring for themselves. So there's some overlap here with depression. Some of these changes and behaviors could be depression. But sometimes the depression can be one of the early signs of a condition that's going to get worse with time, such as Alzheimer's disease.

Ben:                 In terms of progression, right? So if you're outside of the normal aging, and you started developing some of those signs of dementia, what... And I hate the word normal because there's a lot of what isn't always an average. But what do you think about in terms of progression of when you start seeing signs to when you start really may becoming? Whether it be a dependency is what you talked about previously? That you're just now completely dependent on somebody or something for help. What do you see there?

Cliff:                 Well, it's important to pay attention to these frustrating quirks of memory that are normal, but then slowly get a little worse to the point where there becomes concern about daily functioning. This transition period is called mild cognitive impairment.

Ben:                 Okay.

Cliff:                 People can still live independently and drive and manage most of their affairs. But as it goes along the path to dementia, some vulnerabilities develop. So people may have more traffic accidents, they may get loss, not be able to navigate as well, they may not manage their finances as well, they may not manage their medications as well. And very importantly, they become more vulnerable to financial scamming, they start losing their judgment. And that's the sign that they're starting to transition to the next phase which is early dementia.

Ben:                 Got you.

Cliff:                 Now, once dementia... What separates that mild cognitive impairment from dementia is we have clinical criteria to determine that but that's really the transition from when a person can really live independently to when they need more oversight.

Ben:                 Is there, in terms of, what you see today, if someone's coming and seeking your help and your team's help, and you've assessed them as being maybe earlier dementia, is there anything that you see or you can do or anything in a apparatus of control that can slow progression over time and what's normal or average?

Cliff:                 Yes, the earlier the better is the rule that applies here.

Ben:                 Okay.

Cliff:                 But we do know that several things help people function better, longer and may even slow the progression of the disease. So those things are outlined in several reports. The most recent report is something from the World Health Organization, which reviews all the evidence of lifestyle factors that help preserve brain health as you progress into old age. And the Federal Center for Disease Control, the CDC is initiating a nationwide effort, healthy brain aging initiative and the Maine CDC is participating in this. And we have an initiative at Northern Life Health called MAINAH, the Maine Initiative for Neurologic Aging and Health or MAINAH.

Cliff:                 And this promotes healthy brain aging, lifestyle factors and also gives people opportunities to participate in research about healthy brain aging and dementia. but the things that are known to be helpful, first of all, dietary interventions. So we all know about the Mediterranean diet, which is low inflammation, lot of antioxidants, lots of fruits and vegetables, very reduced levels of animal fats, reliance mostly on vegetable oils and nuts as sources of fats. Does allow coffee and wine. So there's some joy in the Mediterranean diet. And so that that kind of diet that is more plant-based and vegetable oil based is... There's pretty strong evidence that it slows cognitive decline.

Cliff:                 We even recommend it to people who already have more advanced dementia because it may be never too late for something that's healthy. Especially, it's healthy, not just for the brain but, of course, for the heart and a healthy cardiovascular system promotes good brain health too. The next thing is physical activity. Now, it's commonplace to be aware that 150 minutes of vigorous physical activity a week is... It's sort of known to help the heart and the brain. But that's 30 minutes, five days a week. So that's, that's a reasonable target. But some of us don't manage that either. And we know that even a little bit is better than nothing. What I recommend to my patients, no matter whether they still have healthy brains or they're in more advanced dementia is that they should move at least every hour.

Cliff:                 Get up, stretch, move around. And if they're able to walk, get a 10-minute walk in, several times a day that meets that criteria, but just sitting for long periods of time, that's damaging. It also helps their pain levels if they move around. The next is getting adequate sleep. While you're sleeping, your brain doesn't produce beta amyloid, which is a pathologic protein, which gets deposited in the brain is the initiating step of Alzheimer's disease. So while you're awake, beta amyloid is produced, while you're sleeping, it's not produced. And there's a system in the brain that clears it during sleep, the glymphatic system. So we've known for a long time that sleep deprivation increases your risk for Alzheimer's disease and dementia, cognitive decline. We didn't know exactly why. This is one potential mechanism.

Ben:                 That's really interesting.

Cliff:                 Why sleep is helpful at preserving brain health. We also know that relaxation, meditation, relaxation is helpful, stress reduction techniques, helpful. People always ask about cognitive training. Should they do Sudoku, crossword puzzles and the like. And there's a lot of commercially available computer-based brain games, brain fitness games that are available. There's conflicting evidence. We know that these things tend to improve function in the things that they test.

Cliff:                 Like if you exercise memory, or exercise process, rapid processing and reaction time, you're going to improve on that game. But there isn't convincing evidence that it generalized to overall brain health. I still encourage those kind of brain active behaviors because it does help that function. And it's often enjoyable and it gives a person a sense of agency and empowerment to exercise the brain so to speak.

Ben:                 So I want to ask just another question here kind of related is like... Okay, day one, you find that you you haven't diagnosed or you have confirmation here about having dementia, whatever the stages, do you think that person should be communicating that to parties in their life? Again, part of this is that vulnerability and that dependence of, "Hey, by you knowing this about me, maybe you have a little bit more understanding." And maybe they don't want their sympathy but maybe there's this, "You're allowing me to function at my best level because you have an understanding of who I am and what I'm dealing with today." Are you seeing people communicate it or not? And do you think they should?

Cliff:                 It's a very personal question for a person to answer and they have to answer it for themselves. The Alzheimer's Association and I and a lot of clinical people think that open, honest communication about diagnosis is best. We sometimes get requests from families not to mention the word Alzheimer's disease. If that is the diagnosis, but we assume that people want honest, open information about their diagnoses and what they do with that information is certainly up to them. These diagnoses can be very stigmatizing.

Cliff:                 On the other hand, they do allow people to prepare, they need to prepare their financial future and their legal future and they need to prepare their families expectations. Doesn't have to happen right away because there's time usually. Unless the diagnosis has been delayed because of denial or avoidance or for whatever reason, and behaviors and symptoms are already far advanced then I think family education about a person's behavior is very important. I noticed president George H. W. Bush behavior had changed. He was pinching women. And I know it was embarrassing for Barbara Bush, probably embarrassing for everybody around.

Cliff:                 And it's so clearly related to cognitive changes that were occurring. No one acknowledged that or said that. It was left to some people to think ill of him. And this is completely out of character for him. It was so obviously related to the same disease that was affecting his mobility. It was affecting his motor system and it was affecting his ability to speak and to control impulses. It's a very common thing for people to have that impulse control problems. So that was a situation where I thought, a public conversation about the symptom would have been helpful to destigmatize what was obviously, a symptom of a brain disorder, of a brain disease.

Cliff:                 And that can be true of people in families. Although, usually, it's rare that a family doesn't want to talk about it openly or a patient doesn't want to talk about it openly. I mean, you have to be selective. This diagnosis, the diagnosis of a dementia, Alzheimer's disease or other dementias can be very isolating. People stop coming around if the person with dementia doesn't recognize you, for example, or doesn't speak, doesn't seem to remember that you just visited. There's not a lot of reinforcement for staying engaged. And so the spouse may notice that friends don't come around anymore. So it can be an isolating experience.

Cliff:                 I think open discussion about the symptoms of the dementia and the expectations, and what might be helpful, or what might be good ways to spend time with a person with dementia. For example, we know that people with advanced dementia respond very well to music. And we generally respond well to music that we listened to when we were in high school or young adults. There's a wonderful program called Music and Memory that's used in a lot of nursing homes in long-term care facilities. And you can use music... People with advanced dementia still can respond to music, can still respond to art, can still respond emotionally to things and even if they can't verbalize their feelings. And so, using time with a person with dementia to look at old photos or to listen to music can really be a way to connect with them emotionally.

Ben:                 It's a great way to trigger something, right? Again, if you're looking for feedback, there may or may not be a trigger that happens from music or photos that but you're more likely maybe to receive some feedback from their enjoyment of that?

Cliff:                 That's right.

Ben:                 Yeah.

Cliff:                 That's right. It makes the time with them pleasant for everyone.

Ben:                 I want to wrap up the conversation. First of all, in terms of, the Alzheimer's, dementia, what do you think, again, if you had your crystal ball or time machine if you're looking at the future, what do you think the next 30 years looks like for your field? Right? Is what you see in the geriatric side and how things develop or what you hopefully would like to see develop?

Cliff:                 Well, it's easy to feel a little discouraged because clinical trials, so many clinical trials have failed recently, and there's this sense of futility focused primarily on the amyloid hypothesis that led to creation of several methodologies to remove amyloid for the brain thinking that would halt the development all of Alzheimer's disease and typically it was done too late in people who already have symptoms. We still hope that reducing amyloid, brain amyloid levels can be helpful for people who are at risk for Alzheimer's disease but do not yet have symptoms. So if you do it early enough.

Cliff:                 But there are many other mechanisms that potentially would be helpful that are being investigated now. So we have to have hope. It's a very complicated problem. One thing that we've been working on in collaborations with people at Jackson Lab and the University of Maine is our research studies that look at the interaction of developing symptoms, developing early biomarkers in the brain and genetics. Investigators at Jackson Lab have added several new genes to the panel of genes that influence, not only risk but more importantly, perhaps resilience why some people who have some Alzheimer's disease in their brain don't develop symptoms, or at least can tolerate the disease for decades without developing cognitive memory or cognitive symptoms.

Cliff:                 This kind of complex modeling of genetics and developing symptoms of the disease is a new approach. There are also many new avenues of research. Some investigators just reported really strong evidence implicating a gingival bacteria. Bacteria is found in the mouth and the gums, in the brains of people with Alzheimer's disease. So there may be a subset of people not everybody by any means, a subset of people for whom that drives the disease. So we should add oral health as another potentially preventative measure. And there are many new molecules being tested to help neurons, brain cells become stronger and more resistant to disease effects. Many different mechanisms, genetic, molecular, that are being investigated. And we'll be looking at some of those.

Cliff:                 There are new also molecules that slow the progression of tau through the brain, tau tangles. Remember Alzheimer's disease is defined by both amyloid plaques in the brain and tau tangles due to pathologic proteins. And we've been focused on amyloid, which is the first step. But there are now ways that we might be able to intervene in the progression of tau tangles to the brain. And that correlates more closely with the development of symptoms.

Cliff:                 Although our initial clinical trials have been a little discouraging, there's reason to be hopeful. And as we think about the Healthy Brain Initiative of the World Health Organization and the Center for Disease Control, federal and state in Maine, we hope that we'll be able to make a difference at the population health level as people become better about changing diets and incorporating more physical and cognitive activities.

Ben:                 Excellent. I want to wrap up with a... So this is a personal question to you. We have this idea retirement success and find that people that have... If they're finding their purpose in retirement away from their career, that those are the ones that lead to really more fulfilled, happier lives in retirement. So for you personally, as you're forecasting your life and your retirement if you had your crystal ball, what would you say that would be for you? Would be that thing that you'd always wanted to do or are on that wish list to live that fulfilled retirement?

Cliff:                 I'm afraid my retirement list is dull.

Ben:                 I don't think there's anything dull. We've encountered it all at this stage.

Cliff:                 Well, first of all, I hope to be able to work into my early 70s. Another eight years, perhaps? And then after that, if I'm capable, I'd want to do more writing than I've been able to do. Well, and also doing research and seeing patients. I want to get to the gym more. And I want to do more travel, you know I mean? That's the things that I've either put off or haven't done enough of.

Ben:                 What's that top destination for you for travel? Where's the place you always wanted to go that you never got to go?

Cliff:                 I've never been to Australia or New Zealand and I want to go. I haven't done it. I've never been to Africa either. So I'd like to go there and haven't explored Eastern Europe as much as I would like. So those are some destinations that I hope to get to.

Curtis:              Nice. Perfect.

Ben:                 Well, thank you for joining the show today. We really appreciate your time and lending the expertise for the audience today. Just want to thank you for everything. This is just fascinating conversation to hear from your end. I appreciate it.

Cliff:                 Oh, thanks for having me. It's been fun.

Ben:                 Thanks. Really good episode today in terms of, the podcasts and I think from our perspective, they're just... This is such a deep topic that... We just run into this fear, this feeling, this dread about what does this mean about retirement and people are very fixated on that within the retirement of they're living with this thought. So again, while we really liked having Dr. Singer here today was to address it, right? Let's make it real, let's bring it to the room, let's really beat it up a little bit and around it. And one of the things, I think the biggest thing that he addressed for me that I loved, that I took away from it was this idea of... And when I'm sitting down with clients is this idea of... I'm usually talking about this idea of mortality, right?

Ben:                 You have death and maybe have an unacceptance of death and some of these fears about death. And I love that he just had a completely different permutation to this. This is all about this fear of dependency, they've accepted death. That's not what they're concerned with and that's not what they're facing. So all these emotional, cognitive disorders and diseases, what they represent to people is dependency and increased dependency in a world where I have less and less people that I can depend on. So what a hard world that is where I need somebody... Probably, maybe the highest dependency maybe I've ever had in my life on anything other than maybe when I'm first born. And I'm probably more aware of it at that point. And maybe I have kids that are away or my spouse is no longer here, all those things. Oh, man, that was fascinating.

Curtis:              Yeah. So I definitely echo everything you just said there, Ben, it was a really important conversation for us to have. So certainly, well-worth the time we spent with Cliff. One piece that really stuck out to me, and it's sort of a recency bias, he was talking about and I'm not going to bring up the medical terms or even attempt to because I know we're going to butcher that. But The process of the brain when we sleep and how essentially it was, while we are awake, the brain produces this element that essentially, can be linked to these diseases.

Curtis:              And while we sleep, the brain not only doesn't produce it, it also clears it out. And I was actually listening to a podcast about a week ago and there was... They had a guest on the podcast, his name was Dr. Michael Linux. And he was actually talking about that same phenomenon. And that was the first time I'd heard it. So to hear Dr. Singer bring it up today. It was really cool.

Ben:                 Yeah. So neat from obviously, knowing how it works. And obviously, we always hear, right? Eat better, have more exercise, get more sleep, but the why, right? Why is that important? And especially it's more important as we're aging as well and tying it to that fear that we have. And I think what I see and we see a lot is when people have enough manifested pain in their life, right? And fear is that something that you are motivated by as well is using that to then create change in your life. And I think he gave us a lot of that evidence too. Well, here's what it looks like, here's what it is, here's how we can address it.

Ben:                 But if you're doing these certain things he mentioned the Mediterranean diet and how that really has positive links to either slowing progression or minimizing some of the impact of that. That's a really great point. So I liked that. All of that was in there, in the show today. Because again, personally, I had my grandmother develop dementia and seeing the impact to my grandfather while he was trying to support her and he probably got help too late. He was in a house with her and trying to manage her as she's getting physical with him and trying to leave. And it's sometimes hard to admit when you need help and what resources are out there.

Ben:                 So I just thinking about this situation why is this conversation important? I think there's even if... Going back in time I wish I had had this information because that would have been really helpful. So yeah, again, I just really appreciate everyone's time today and spending a little bit more time on this topic because it's very important and as we talked about it, we brought a little bit of financial resources in. There's all these things impact everything in your life, including financial, which is why when we're talking to our clients is we have a financial lens to it and it always impacts everything.

Ben:                 So it's just better to address. So obviously, we want to wrap this episode up. So we are... If you want more resources, you can always go to our blog, blog.guidancepointllc.com/8. So the number eight. And you can find more resources from Dr. Singer. More links to resources in the state of Maine. The transcript of this podcast, if you want to read a certain part, just always appreciate your time and your attention and we'll see you next time.