What mid-career physicians need to know about retirement’s effects on cognitive function (Part 1)

By Anne Meneghetti, MD

Neurologist Howard Tucker, MD, practiced for over three quarters of a century, landing in the Guinness Book of World Records as the oldest practicing doctor in 2021 at the age of 98. The centenarian then became a TikTok “grandfluencer,” educator of medical residents in Cleveland, and an expert witness on medical-legal cases. Did I mention that he passed the Ohio Bar exam at age 67? #overachiever. I’ll venture to say that most of us envision a different future for our golden years: treating every day like a weekend, pursuing hobbies, maximizing time with loved ones, tackling home improvements, and enjoying bucket-list-worthy travel all come to mind.

The allure of finally escaping the stress of practice is often tempered by concerns, including worries about financial security, feelings of obligation to patients, and fear of losing a sense of purpose that is tightly identified with being a physician. Perhaps you’ve witnessed what can happen to some highly career-driven individuals, from any profession, during retirement. A few years into retirement, they may seem less sharp, less intellectually vibrant. Is it due to some neurocognitive condition? Or it is possible that retirement could be bad for the brain? A growing body of research suggests this might be the case. It stands to reason that working keeps the brain actively engaged in a way that retirement typically doesn't. This use-it-or-lose-it concept may be especially relevant for knowledge-based professions like medicine, with its daily problem-solving challenges, social interactions, and perpetual learning. The potential for post-retirement cognitive decline is one more factor to consider when contemplating hanging up your white coat for the last time. Every brain, every career, and every retirement scenario is unique. And there’s every reason to expect that we can control at least a few of the factors that contribute to cognitive health as we age.

When do most physicians retire?

The largest percentage of physicians retire after 65, though nearly 30% retire between the ages of 60 to 65, and 12% retire before their 60th birthday, according to an AMA Insurance Agency survey done before the pandemic. Primary care physicians retire at a median age of 64.9 years, with females retiring a year earlier than males, according to a study published in 2016. Owing in part to our extended training, the physician workforce skews older than other professions. In 2021, nearly half of all active physicians were older than 55; however, age varied significantly by specialty: more than 90% of pulmonary specialists, but only 9% of sports medicine physicians, exceeded age 55. The average practicing physician is 53 years old, per 2021 data: cardiac surgeons and general practitioners are among the oldest, with an average age of 58; and hospitalists among the youngest, at 43 (Newitt, 2022). These stats raised alarms that two out of every five practicing physicians could reach retirement age within a decade.

Did the pandemic accelerate or decelerate physician retirement?

The pandemic understandably accelerated physicians’ interest in early retirement. In 2021, more than half of physicians surveyed reported that the pandemic had altered their future employment plans, with a fifth of that group seriously considering retiring early (Jackson, 2023). A quarter of primary care clinicians surveyed in 2022 reported that they planned to exit within 3 years. A generational differential in retirement planning was evident in a 2023 survey: Nearly 60% of GenX physicians are aiming for retirement by age 60; only 19% of them planned to work after age 65 (Jackson, 2023). Many Baby Boomers (born 1946-1964) are still working full time. Part-time work increases with increasing age, reported by 12% of physicians aged 51-60, 17% of those aged 61-65, and 29% of those aged 66-70. Though the pandemic certainly spurred interest in early retirement, it also brought economic concerns to the fore. The same survey reported that 38% of respondents—and 46% of those over age 60—are delaying their retirement timeline because of economic uncertainties.

What’s the typical trajectory of cognitive decline?

Most physicians I know have an outsized concern about cognitive decline. If they misplace their keys or struggle to recall name of a famous movie star, they instantly wonder, 'Is this an early sign of dementia?' This is perhaps even more so for those of us with family members who have dementia. Conversely, many of us know older individuals who are as sharp as a tack. I recently attended a celebration-of-life service for a nearly 108-year-old woman who had an amazing memory and a shining intellect. Interpreting retirement effects on cognition requires examining the backdrop of age-correlated cognitive decline.

Cognitive impairment is more common than I suspected. Comprehensive neuropsychological testing of participants in the 2016 Health and Retirement Study revealed that a third of individuals 65 years and older had dementia (10%) or mild cognitive impairment (22%). Every 5-year increment in age upped the risk. Although no male-female difference was detected, dementia prevalence was more common in non-Hispanic Black individuals and MCI was more common in Hispanic individuals, compared with non-Hispanic White individuals. Studies suggest that inductive reasoning, verbal memory, and other cognitive functions all decline with age, more steeply after age 65, though these changes vary from one person to another. While fluid reasoning and cognitive flexibility may decline with age, crystallized accumulated knowledge is generally preserved.

How does retirement affect cognition?

Against the landscape of cognitive decline in the population, what are the specific effects of retirement? It’s not easy to disentangle age-correlated changes from retirement effects. Confounders abound in retirement studies, given that retirement rationales, timing, and individual circumstances vary greatly—and there are varying methods to assess cognitive ability. One systematic review of international studies concluded that retirement had no clear adverse effect on global cognition, and only slightly diminished memory skills. However, a slew of studies suggest that retirement negatively affects cognitive function, especially memory, though rates vary substantially. A 2012 report from Science Direct on the Health and Retirement Study concluded that retirement had a significant negative impact on word learning and recall (Bonsang, 2012); a 2017 analysis confirmed the effect, and added that longer duration of retirement was linked to more rapid decline. A UK civil servant study found that verbal memory decline was 38% faster post-retirement, beyond what’s expected by age alone. Researchers didn’t detect retirement-related worsening of abstract reasoning and verbal fluency, though these also declined with advancing age. Complete retirement has also been associated with a 6-9% worsening of depression scores, realized around six years into retirement, according to a 2006 of the Health and Retirement Study (Dhaval, 2006).

Data on differential effects by gender are multifaceted and conflicting. A 2019 analysis of the Health and Retirement study found that post-retirement cognitive performance declined only in women (Oi, 2019). Another study noted a sex difference, concluding that retirement-related declines in episodic memory were steeper in females—specifically the women who were prone to disengage from highly challenging activities and pursuit of their goals. In contrast, in one Australian study, retirement modestly diminished cognitive performance for men more so than women (Atalay, 2019). In men, researchers found significant decrements in working memory and word reading. Working memory and information processing speeds were not significantly affected by retirement in women; though researchers noted that the retired women in this study were more likely to be involved in activities such reading, club memberships, as well as household and volunteer activities. These findings support the use-it-or-lose-it theory for retiree mental activity.

Does higher education protect against cognitive decline?

Higher educational attainment does seem to delay and reduce the duration of cognitive impairment in those aged 65 and older, according to the 2016 Health and Retirement Study. Every additional year of education was linked with a reduced risk of dementia and MCI. That’s good news for physicians! The concept of “cognitive reserve” hypothesizes that higher pre-retirement functioning hedges against losses. Education level was the most important predictive factor to cognitive functioning at age 54, followed by race, wealth and income, parental education, occupation, and depression, in an analysis of this study (Zheng, 2023).

For approaches to mitigating post-retirement cognitive decline, read part 2 of this article.

References

Newitt, Patsy. (2022, March 11). Beckers ASC Review. https://www.beckersasc.com/asc-news/physicians-average-age-by-specialty.html#:~:text=The%20average%20age%20of%20a,with%20a%20reported%20birth%20year

Jackson Physician Search. (2023, March 16). Preparing for the Waves of Physician Retirements Survey Results https://www.jacksonphysiciansearch.com/white-paper-preparing-for-the-wave-of-physician-retirements-survey-results/

Bonsang, Eric, et al. (2012, May). Does retirement affect cognitive functioning? Science Direct. https://www.sciencedirect.com/science/article/abs/pii/S0167629612000331?via%3Dihub

Dhaval, Dave, et al. (2006, March). The Effects of Retirement on Physical and Mental Health Outcomes. National Bureau of Economic Research Paper Series. https://www.nber.org/system/files/working_papers/w12123/w12123.pdf

Oi, Katsuya. (2019, February). Does Gender Differentiate the Effects of Retirement on Cognitive Health? Sage Journals. https://journals.sagepub.com/doi/10.1177/0164027519828062

Atalay, Kadir, et al. (2019, June). The effect of retirement on elderly cognitive functioning. https://www.sciencedirect.com/science/article/abs/pii/S0167629618307458?via%3Dihub

Zheng, Hui, et al. (2023, February 10). PLOS One. Predictors of cognitive functioning trajectories among older Americans: A new investigation covering 20 years of age-and non-age-related cognitive change. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0281139