In conversation with the geriatrician

0:00How to Live to 100, or Die Trying, is brought to you by Genical.

0:10I've spent the last few years chatting with geriatricians, 80-year-olds, centenarians, academics, caregivers, advocates, and grandchildren. The list goes on, all in pursuit of stories for the Toronto Star's Third Act project. The third act is a partnership with the National Institute on Aging and Toronto Metropolitan University, producing independent journalism with the added benefit of research and expertise from the NIA, namely Dr. Samir Sina. Dr. Sina is a geriatrician. He is the NIA's Director of Health Policy Research and was Director of Geriatrics at Sinai Health and the University Health Network until he took a sabbatical as a visiting fellow at the University of Oxford's All Souls College.

1:03Over the last few years, I've had a lot of chats with Dr. Sina. These conversations were always informative, engaging, and often mind-expanding. So with that in mind, I hope you enjoy this one.

1:30From the Toronto Star, this is How to Live to 100 or Die Trying. And I'm your host, Moira Welsh.

1:48So when you graduated from medical school not so long ago, you could have gone into any number of specialties. So why did a young Dr. Sina choose geriatrics?

2:00Dr. Samir Sinha:When we go into medical school, we go in because we want to help people. And I think, you know, a lot of your journey in medicine is trying to find that population that resonates with you and where you can actually make a big difference. And I had an interest in always working with vulnerable populations. And I realized that with our population aging as it was and a lack of geriatricians and what the New York Times calls a rare and endangered species of physician, I realized that that's where I could make an enormous difference. And I never regretted that decision for an absolute moment. Does it excite you, this career?

2:37Dr. Samir Sinha:Absolutely. I think someone said to me early in my career that you seem to preach geriatrics with evangelical zeal. And I did not take that as any form of an insult. I just said, absolutely. And your foresight from all those years ago obviously leads to a fortuitous moment in time right now because we are moving into a period in the early 2030s. It's actually quite a remarkable period when one in four Canadians will be age 65 and older, and a great many of us, including millennials and Gen Z, can expect a very long life, possibly decades longer than those born in 1900 when the life expectancy was 50.

3:21Are we ready for this?

3:23Dr. Samir Sinha:I don't think we're ready for this as a society. And I think one of the things that challenges me as a geriatrician is, you know, the great inequities that we have in our society. You know that if you live in certain postal codes in Toronto, you're going to live, you know, decades longer than a person who's been born and raised in another postal code. And so it reminds us about how many things really can impact whether someone has a lovely longevity dividend or not. And so I think that's part of the work that I do as a geriatrician. And how do I help people stay healthy and independent for as long as possible?

3:56Dr. Samir Sinha:How do I help them age well? But also, how do we start tearing down some of these inequities so that everybody can benefit from a longevity dividend as well? It's interesting because, you know, there is this moment that we're entering into and there is perhaps sort of a sense of abundance of years ahead of us. And yet you are right that those years only come or mostly come to those who are wealthy enough to have, you know, the health care and all the benefits that come with it. And so many people are shut out from that. And that's something we don't really talk about enough. Well, I don't think we like to talk about aging in the first place, right?

4:33Dr. Samir Sinha:You know, in a society that's inherently ageist, we don't value getting older. We almost think of it as a punishment and a period of decline that just inevitably leads to death. So I think, A, people don't want to think about their aging. And I think that's why we have such a fascination with this whole anti-aging movement, this longevity, if you will, movement, but in one that has gone to extremes. And I think we don't often think about the opportunities to really say, how do we support people to stay healthy and well? So I think we need to really start reframing how we think about these things so that we can say, how do we make sure that people can not only add more years to life, but more life to those remaining years?

5:15Dr. Samir Sinha:And I think there's a way we can do both. So one of the sort of slivers of demographic intrigue may be the centenarians. They're one of Canada's fastest growing cohorts and a number that is, according to Statistics Canada, expected to grow by tenfold by around 2050. And for young people today, there are increasing odds that they will actually reach their 100th birthday. So from your observations as a physician, what is it like now to live to 100. Can you tell us about your centenarian patients? Yeah, I have about half a dozen centenarian patients, and they're an absolute joy to care for. But they represent kind of the reality of making it to 100.

5:56Dr. Samir Sinha:Some of them, you know, are absolutely could swim circles around me cognitively. You know, they're just fascinating and they're just full of wisdom. And they're still living life, you know, to the fullest as they can. I have others who are living with dementia, and we know that to make it to 100, that's a gift in itself. But, you know, for a lot of people, there are people who are living with dementia by that point. There are people with significant physical disabilities, including vision loss and hearing loss. But I think what I've noted is that as we age, I think you can either take a real positive glass half full approach or a glass half empty approach.

6:35Dr. Samir Sinha:And I tend to find that the folks who make it to that magical age are people who have a lot of resilience in them. That despite, you know, kind of the vagaries of aging and what chance and luck, you know, genetics and good living might bring you, I think one thing that I've constantly seen is this desire to live, this desire to stay engaged as much as possible. And that's what really brings me a lot of satisfaction from having the privilege of caring for these remarkable individuals. Can you tell us what to expect physically and cognitively as we grow older? And can you describe the aging process, say starting at around 50, of what the average person could experience?

7:17Dr. Samir Sinha:Yeah, so I'll even go back further because, you know, we realize that aging is something that happens right from day one. And I think we have to appreciate that. And if you look at our natural life cycles, as you noted, back in 1900, our life expectancy was on 50 years of age. It's now just in our early 80s now. So when people say, what was the greatest thing we've accomplished over the last 100 years? Some people say we put a person on the moon. I think it's the fact that we almost doubled our life expectancy. But things start to matter, you know, right from a young age, including, you know, finishing high school.

7:50Dr. Samir Sinha:The fact that we're more educated means that our brains are much more robust and will protect us from getting dementia later on. We know that our bones on our muscles, they peak in their bone and muscle mass in our late 20s. After that, they start to kind of wither away unless we keep staying active, if you will, getting some exercise that keeps our bones and muscles strong. So there are key components and key markers that start happening early in our lives. But, you know, things come home to roost, if you will, you know, starting in your 50s and onwards. That's where the accumulation of effects might start giving people the risks of heart disease that can lead to heart attacks or strokes.

8:30Dr. Samir Sinha:That's where I like to think about our houses, for example, that they're built strong and they're working well, but with wear and tear, if you will, with mileage, as I like to say, and if you're thinking about a car, things start to break down. You know, you might start having knee problems, you might start having other things. And so this is that opportunity where it's important to work with a primary care provider to start being mindful about things that you can start attending to identify and address. Because then where this really starts to impact people is by their 60s, 70s, and 80s, where you can start seeing physical limitations due to arthritis.

9:08Dr. Samir Sinha:If people have developed osteoporosis and they're not treating that, that brittle bone disease, that bone loss that started in your late 20s now leading to a fracture. These are the things that can start limiting your mobility and your functional independence. But also as we age, those cumulative things that I've talked about, including hearing loss and vision loss and poor vascular health issues, can start really impacting your brain and start leading to an increased risk of dementia. And so as we get older, we start seeing rates of dementia go from less than 5 % in a person who's in their 60s to by the time you make it to 100, about 50 % of those individuals will be living with a cognitive impairment.

9:50Dr. Samir Sinha:But what I want to remind people is that up to 50 % of dementias now can be prevented or delayed by taking those proactive steps earlier in life. Let's return for a moment to your comments on finishing high school, getting an education, and continuing to learn throughout life. How specifically does that help our brains avoid dementia? Well, it's the idea of think of your brain as a muscle. And if you don't exercise it, if you don't build a strong foundation, then, you know, it's going to be hard for it to remain strong. So the idea that when we're learning things, as we stay active, when you're learning a new task, you have to, if you will, lay down new connections.

10:30Dr. Samir Sinha:Your brain has to kind of build that scaffolding to store that information to learn new tasks and have all that. That's what we call, you know, brain plasticity. It's all those neural networks that you're creating. And you can imagine, you know, people who end up not only just finishing high school, but we're talking university and that, you know, these are brains that have really been kind of exercised, if you will. And that's why we also say that there are key things that you can do to keep your brain active throughout your life. So this is why we talk about the importance of social engagement and staying socially connected to others.

11:03Dr. Samir Sinha:Because when you're just interacting with others, you're talking, you're learning about new things, that actually exercises your brain. We talk about the importance of maintaining your vision and your hearing, because if you're not actually getting good auditory inputs because of hearing loss, if you can't actually see what's around you, then it's really hard to, again, get information that gets into your brain, helps you process and think things through. That's why we're learning more about our brain and I guess think of it as that muscle, that if you don't keep it, if you don't build it up and, you know, keep it active, if you will, and engaged, then that's where we see that as one of those risk factors for why people's brains can, if you will, wither, if I can use that term, or atrophy and experience some level of dementia and cognitive impairment.

11:53We'll be right back.

12:02So for some, this new prospect of increased longevity presents a wonderful opportunity and more years to travel or study or spend time with family. But for others, it leads to years of struggle. From a societal perspective, what excites you about the opportunities created by these added decades? And what do you see as perilous? We sort of touched on this earlier, but I just want to sort of narrow, focus in on that. So what excites you about these opportunities created by these extra decades?

12:34Dr. Samir Sinha:Yeah, so what excites me about these extra decades is it's just so much opportunity that people can have. It's a term that we call the longevity dividend. So if you get that dividend, if you get those extra years, number one is, you know, let's make sure that those are good years. and part of that is making sure that people are healthy and well so they can really enjoy that time. But there's a lot of things that go into creating health and wellness. So not only is it kind of a healthy body, but also making sure that you can afford to exist. There are a lot of people who enter kind of that retirement period where they might be subsisting, if you will, off a government pension, but we know that that's just not enough to live, you know, kind of that life of travel and excitement and adventure that often people want to do.

13:22Dr. Samir Sinha:So we have to make sure that we help people think at an early age about you could live a long life. Are you ready? And do you have your finances in order? Are you thinking about your financial well-being? And are we supporting you to do that? But also, are there things that you can do from an early age to make sure that it's one thing to have finances and money, but if you're not healthy and you can't travel physically, then that's another problem. So I think the key is, is that those years can be really exciting if you feel that you've got the supports and that you've got the healthy body and mind to be able to pursue those adventures.

13:59Dr. Samir Sinha:But I think for a lot of people, those opportunities get cut short if we actually don't make sure that people are staying healthy and well. And that's why, you know, we've really tried to think about what are the illnesses that we can prevent? What are the illnesses that we can manage, for example? And how do we make sure that we have what we call a compression of morbidity so that right now we often say that the average person who makes it to 65 will have about 20 years of life expectancy ahead of them. And the majority of those years are going to be relatively good health. But again, the factors that I've talked about earlier that can impact your health and your financial and social well-being, that can really determine how much of those extra 20 years of life are going to be good and robust years or years of suffering and challenge.

14:49And that really makes up a conversation that people are increasingly having about health span versus lifespan, basically. Health span being the ability to enjoy those later years and lifespan being the amount of time, I guess, essentially that your heart is beating and you're actually alive. So what is the value of individuals focusing on their health span? And is there a potential of it going a little bit off the rails towards obsessiveness?

15:19Dr. Samir Sinha:Absolutely. I mean, I think while there's been this kind of wide-standing anti-aging movement, I think now we're seeing this huge trend, as you noted, in this idea of health span or that. You know, geriatricians like myself have been focusing on this kind of area for years. But I find it absolutely fascinating right now when on social media and the like, you know, you see people talking about coal plunges or take this turmeric every day and this will kind of do you wonders. And the sad truth is a lot of that is gimmicky. A lot of that might have a thread or a shard of kind of evidence that makes it interesting and potentially plausible.

15:57Dr. Samir Sinha:But there's no robust evidence around a lot of these gimmicks out there that actually say, yes, a cold plunge every day is going to allow you to live five extra years. I can tell you with a great deal of clarity what will allow an older person to live five years longer than other people. Wonderful study done a few years ago that showed that even people in their 70s who start doing these three things are going to live five years longer than people who don't. And that's staying socially connected, you know, maintaining meaningful social connections in your community. It means staying physically active.

16:30Dr. Samir Sinha:And we're not talking about running marathons or pumping weights. We're talking about going for a walk and doing that at least 150 minutes a week, for example. And number three, don't smoke. But, you know, beyond that, you know, there are other, again, a lot of motherhood and apple pie things. But I think what really troubles people is, well, yeah, we've heard that one and I'm not doing that. But maybe this cold plunge, that sounds kind of exciting. So if I do that, maybe that'll work. But I think we actually know a lot of the secrets that would actually help us live longer and healthier lives.

17:03Dr. Samir Sinha:I think the challenge is that how do we build it into our lifestyles? How do we self-motivate ourselves? But, you know, beyond that, how do our societies and how do the places where we live also motivate us to take the stairs more often, walk to things in our own neighborhoods? And so structurally, there are ways in which we can create environments that promote healthy aging, and we need to promote more of that as well. Yeah, I don't know how exciting a cold plunge sounds, actually. It's terrifying. Especially in Canada in February. It's terrible. Like, you know, okay, if it's your thing, go do it, right?

17:38Dr. Samir Sinha:But honestly, like, I'm so glad when I looked at the evidence around it, it's not there. So I was like, thank God I don't have to go do cold plunges now. We'll be right back.

17:58As a doctor, you have seen many, many vulnerable people with lives of great meaning. And I guess I'm curious if you sort of look around at society and see, in our desire to remain strong, is there a fear that we will lose our acceptance of fragility?

18:16Dr. Samir Sinha:This has been a long debated topic within the world of aging and you may have heard the term successful aging. And increasingly, you know, we're encouraging people not to use that term. Because when you again, you look at these Silicon Valley billionaires, for example, who are doing cold plunges and cryogenic whatever and eating turmeric all day long. There are also these kind of this bro culture that also does the second is the first loser. I think you've seen that on those workout T-shirts and this idea that the only thing that is acceptable is perfection and that anything less than that is a failure.

18:51Dr. Samir Sinha:And so even that term successful aging, it really kind of connotes that either you get it perfect, like you get to 100, you win the gold star. If you're not cognitive impaired, you have no diseases and you're still running marathons. Yeah, there's a few of those folks. Frankly, there's more of them these days, but they're unicorns in the grand scheme of aging right now. And so what I like to focus on is the idea of healthy aging and the idea that you don't know what the cards will hold in your world. There are things that you can do to put more of the odds in your favor. But I think if we start thinking of glaucoma as a failure, cognitive impairment as a failure, having arthritis and mobility issues as a failure, for example, well, then I think a whole bunch of us will be very depressed.

19:38Dr. Samir Sinha:And you can see that how then people start thinking that, well, I, you know, my body's falling apart. I can't get enjoyment anymore. I'm not going to go anywhere and I'm too frail and all these sorts of things. And I think when people get into that pessimistic mindset, I think that really holds people back because what I see on the opposite end, my patients who say, yeah, I've got arthritis, but I'm going to manage it as best I can and I'm going to stay as active as I can. I might have to walk with a cane or walk with a walker, but I'm walking and I'm living. And I find those folks who can accept and embrace that fragility, the idea that not everything is going to work out perfectly, they're the ones who end up being more satisfied with their lives and not feeling like failures.

20:25Yeah, it seems like it's very, unsurprisingly, data-focused and, you know, my VO2 max is better than your VO2 max and so on. There's a lot of numbers to compare.

20:37Dr. Samir Sinha:Yeah, but they're all like, and a lot of them are useless numbers as well. Like this is what, you know, my colleagues who look at the science of longevity say, people come into my office now and they show me reams of data that their Fitbit or their whatever can show them. Then I'm like, yeah, that's nice. You know, great that you obsess over those numbers. That doesn't mean anything to me, frankly. And so, yeah, like, yeah, there's a lot of data, but a lot of it's noise and it's meaningless. And then I kind of laugh because I'm like, if you're staring at your phone all day long, just looking at your data, what would have actually helped you live longer is actually going for a walk and staying socially connected or reading something interesting that stimulates your mind and helps you enjoy those moments better.

21:20Dr. Samir Sinha:It's this kind of weird, perverse thing that people think they're living better through science, but a lot of it's junk science. Why are most people afraid of old age? Well, because I think when you think about old age, you think about dying, right? You're one step closer to your end, whatever that might actually be. And I think people just look at old age as a period of decline, of being retired and therefore kind of out of the loop. I think as a society, we demonize old age. You know, we make fun of people being incontinent, slow, demented, and useless, frankly. And so why would you want to sign up to old age when society is giving you all of those messages?

22:02Dr. Samir Sinha:If people are well, they don't come and check in and say, I'm well. As physicians, people come to you when they have problems and they need you to help solve them. And so I think the challenge that as young medical students you would see is you're living in a hospital and you forget that you're only seeing maybe 10 % of older people because the majority of older people are living healthy, active, engaged lives. They're the backbone of our volunteer workforces. They're the backbone of our child care, you know, kind of aspects in our country and elder care. Like, I mean, they're doing so many things, yet we don't actually see the healthy aspects.