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Assisted Living For Seniors -7 Big Questions To Know Why, When, And How

By 14th March 2021

1. What’s It Really Like To Live At An Assisted Living Facility?

Betty and Roy are amazing!

Married for over 60 years, and still living in their two-story ranch home where they raised their kids. Roy still drives the 2008 Subaru to their doctor’s appointments and monthly allergy injections. Betty had a hip replacement a few years ago and got around just fine. Or so she tells her kids.

The sad reality is that they do not use most of their house anymore. They use their master bedroom, bath, TV room, and kitchen… and that’s it.

Extra bedrooms like the formal dining room and front living room are rarely used. The clutter is piling up as is the dust, and taking care of all those surfaces is exhausting. Sometimes they will discuss the inevitable over coffee:

Should they be considering a move to a nearby senior living community?

2. They Perceive Themselves As Very Independent – Do They Need Assisted Living Services?

Let’s take a closer look. Betty does not wear her favorite necklace anymore because the clasp is too difficult to manage. Roy does not wear his beloved watch for the same reason. Both opt for slip-on shoes rather than a more stable type of athletic shoe because the laces are too difficult to reach and tie.

Shopping for groceries is a hassle and standing up in the kitchen to prepare a full meal is becoming more difficult. Opting for frozen dinners and ready-made snacks has become the norm.

There have been a few times now that the little pill boxes for the daily regiment have been jostled, and a few pills get bounced out so the daily dosages may have been affected. Nothing bad has happened. Yet.

Can An Assisted Living Solve All Of Those Problems?

Assisted Living includes help with grooming, as the jewelry issues. Dressing, tying shoes, medication management to prevent over or under-dose, as well as personal hygiene and mobility support.

When Is A Good Moment To Think About It?

Most likely now would be a good time if you are over 62 or have loved ones over the age of 62.

3. How Do You Know If Your Parents Need Help?

Pay Attention To The Mail, Fridge, And Kitchen

Do you notice that the unopened mail is piling up? This could be due to failing eyesight which also hampers writing abilities and causes legibility issues. Managing the checking account, opening, sorting, and paying bills is just too much.

Perhaps there is spoiled or uneaten food in the fridge or the pantry. This could be a sign that shopping, cooking, and cleaning are too much trouble.

Diminished eyesight or sense of taste or smell leads to loss of interest. Ant this may be worse if they have any difficulty with chewing or swallowing.

And let us face it! When we are living alone, sometimes it’s just not worth it to prepare a well-balanced meal. You can try to help them with this by moving pantry items or the microwave within reach.

Take a peek at their pots and pans the next time you visit. Are they scorched? This can be a sign of forgetfulness while cooking and over-all short-term memory loss.

Is Their Home Uncharacteristically Cluttered Or Messy?

This can be especially troubling when the parent has always been neat and tidy. Sometimes it could be an underlying condition like arthritis that is causing pain. It is too difficult to organize or put things away.

It can be hard to decide what to do with things. This too can be a symptom of depression or a more serious condition. Simplify as much as possible. Hire someone to help with cleaning and organizing.

Are They Living Under Any Dangerous Conditions? (Slippery Floors, Throw Rugs, Clutter On Stairs)

Perhaps you have noticed their hygiene has slipped. There could be fear of falling in the tub or shower that is quite real.

Sorting laundry, washing, drying, and folding, or hanging can become a challenge. Especially if the closet is not well lit and their poor eyesight is an issue.

The lack of interest in appearance can be due to less social interaction and companionship. Identify physical barriers, as these can be an easy fix. Consider velcro zipper-pullers and easy-fitting clothes. Could there be someone to help with laundry or with grooming?

Make sure to take these changes seriously as they could be symptoms of a more serious condition or illness.

Could They Be Suffering From Memory Loss Or Depression?

Forgetting to take medications is common and can be quite dangerous. This can be a warning sign for short-term memory loss, depression, or confusion. Depression is different than just feeling blue.

Can you identify the causes?

  • Is your loved one homebound and not interested in activities that used to bring them joy and life satisfaction?
  • Have they lost their friends, so the isolation has become even more real?

Consider a psychiatric evaluation. And take a look at the possibility of medication interactions or side effects.

Are Your Loved Ones Missing Appointments?

Have they missed multiple doctors’ appointments?

This can be a transportation issue, short-term memory loss, lack of organization, or just an overall lack of interest and depression.

Are you receiving calls from them at odd hours?

Perhaps because they are disoriented and not sure of the time of day or night. This can also be a cry for help as they battle isolation and depression.

Do You Have Any Suspicion They Have Had A Fall?

Seniors often neglect to mention that they have had a fall. Be sure to ask. Falls can be caused by medication side effects. Physical weakness or gait disturbance is also a factor. Look for the obvious too around the home.

Are there loose throw rugs?

Is the lighting sufficient or is it cozy, aka poorly lit? Be sure the floor surfaces are even and not slippery.

How can you help with frequent falls?

Schedule a complete physical and medication review with the primary physician. Be sure there are not multiple medical professionals providing prescriptions that may be interacting. Check the home for safety and make immediate changes. Speak with the appropriate medical professional about physical therapy.

4. Should I Consider Anything Else Before Deciding?

Pay attention to unusual appearance or behavior

  • Could they be confused about the season or the weather?
  • Do they not recognize friends and neighbors?
  • Is this a single occurrence or frequent behavior?
  • Is this a marked departure from typical behavior?
  • Consult with their physician and consider a psychiatric evaluation. Be sure prescribed medication is being taken correctly. Could they be suffering from a urinary tract Infection?

5. How To Talk To My Parents About Assisted Living?

The most important next step is to talk with your parents or loved ones. Discuss what tasks are hard or painful for them to do. How are they sleeping? What are their sleeping patterns? Are they experiencing fatigue? Are there any risky behaviors that need to be addressed? Has there been a loss of appetite? What are their concerns and fears? Finances? Dementia?

If the idea of having a frank, one-on-one discussion with a parent is too difficult, consider asking the physician or clergy to assist with the conversation. This brings us back to who pays for Assisted Living if it is indeed needed for a senior citizen.

What Assisted Living Can Do For Them?

Assisted Living is a term that is used by Residential Care Facilities, home care companies, and long-term insurance plans. In plain English: Assisted Living is recommended for people who need assistance with their activities of daily living.

The great majority of Residential Care Facilities for the Elderly accept private payment for the month-to-month rent and care plan fees.

This can be paid out of standard savings, from the proceeds of selling a home, through a long-term care insurance policy, or from the Veteran’s benefit of Air and Assistance.

6. What’s The Cost Of Assisted Living?

The average cost for Assisted Living is $2500-$7000 per month. This includes an apartment, utilities, three meals, and two snacks each day, laundry and housekeeping, activities, and scheduled transportation.

Assisted Living Facilities are continuing to be built. Depending on what level of care your loved one needs, assisted living can be much more affordable than long-term in-home care or nursing home care.

All Residential Care Facilities for the Elderly offer similar services. At least they look similar on paper. Research by visiting potential facilities. Ask about the rent cost and also the level of care plan costs that are charged separately, depending on the number of hands a person requires.

The costs will vary from facility to facility. Some use a point system, and some use a few levels of care. If a resident does not need any assistance with the activities of daily living, they would be considered Independent Living.

What Does The Process Look Like?

A Physician’s Report is used to start the process and then an in-person assessment would be scheduled. The facility representative would be looking at specific activities.

For example, when it comes to bathing, they would be asking if the person needed help to bathe or shower? How often does the person bathe? How often do they require help? Is it stand by or hands-on? Most seniors do not benefit from daily bathing as their skin tends to become thinner and drier. If a person likes to shower daily and requires assistance, it would be more expensive than a once-a-week preference.

The same principles apply to grooming needs, mobility issues, incontinence, medication management, laundry requirements, and eating. Time equals money.

7. How Do People Pay For Assisted Living?

Va Aid And Attendance Eligibility
You may be eligible for this benefit if you get a VA pension and you meet at least one of the requirements listed below. At least one of these must be true:

  • You need another person to help you perform daily activities, like bathing, feeding, and dressing, or
  • You have to stay in bed—or spend a large portion of the day in bed—because of illness, or
  • You are a patient in a nursing home due to the loss of mental or physical abilities related to a disability, or
  • Your eyesight is limited (even with glasses or contact lenses you have only 5/200 or less in both eyes, or concentric contraction of the visual field to 5 degrees or less)
  • Housebound benefits eligibility

You may be eligible for this benefit if you get a VA pension and you spend most of your time in your home because of a permanent disability (a disability that does not go away).

Note: You can’t get Aid and Attendance benefits and Housebound benefits at the same time.

Benefit Table

  • Status Monthly Benefit
  • Surviving Spouse $1,244 Monthly / $14,928 Annually
  • Single Veteran $1,936 Monthly / $23,232 Annually
  • Married Veteran $2,295 Monthly / $27,540 Annually
  • Two Vets Married $3,071 Monthly / $36,852 Annually
  • Tax-Free long-term

Under current law, the following wartime periods are considered to decide eligibility for VA pension benefits:

  • Mexican Border period (May 9, 1916, to April 5, 1917, for Veterans who served in Mexico, on its borders, or in adjacent waters)
  • World War I (April 6, 1917, to November 11, 1918)
  • World War II (December 7, 1941, to December 31, 1946)
  • Korean conflict (June 27, 1950, to January 31, 1955)
  • Vietnam War era (February 28, 1961, to May 7, 1975, for Veterans who served in the Republic of Vietnam during that period. August 5, 1964, to May 7, 1975, for Veterans who served outside the Republic of Vietnam.)
  • Gulf War (August 2, 1990, through a future date to be set by law or presidential proclamation)

Life Insurance Policy

Life Insurance is also used to pay for Assisted Living. Policies vary but some do offer a life insurance conversion program that allows seniors to convert their policy into long-term care payments.

A conversion such as this will pay less than a typical life insurance settlement. Of course, most folks are thinking of their beneficiaries when they take out a life insurance plan but there are other options such as selling the plan to a third-party company that in return provides the policyholder with a senior or life settlement which is 50%-75% of the original face value.

Working with a geriatric care manager may be helpful if the family is considering combining resources to help with the matriarch or patriarch of the family. They can help to navigate the options for siblings to divide up the hands-on care vs. the monetary care.

Are they one of the fortunate few that purchased long-term care insurance? Congratulations! The policy does vary, some were written so long ago the concept of Assisted Living as we enjoy it in modern times did not even exist. The language may refer to nursing home care, or have specific diagnoses listed to be covered or excluded. It is helpful to read over the policy in full and connect with the company before needing it.

There are annuities available and they can be quite complicated. Talk to a trusted financial advisor. Reverse mortgages fall under the same umbrella. Be sure you invest time to research the benefits and the pitfalls of a reverse mortgage.

Rent Their House Instead Of Selling It

Another option is to rent out the home rather than selling it or entering a reverse mortgage. A rental company can take the day-to-day burden off the family’s shoulders. The focus can then be on a better quality of life for everyone.

Conclusion

A better quality of life is the priority when researching assisted living options for your parents or loved ones. Keep that and the “Six R’s in mind: Do the right thing, for the right reason, with the right people, at the right time. and you will not have regrets for the rest of your life.

10 Senior Living Residences’ Questions you SHOULD Ask

By 22nd January 2021

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When you hear the phrase “Senior Living” what do you imagine?

A. A resort-like lifestyle for folks who are 60 and older
B. An elegant cruise ship on land
C. A solution for the weary family caregiver
D. A respite for the lonely widowed

Senior Living is all of that and so much more. Especially in the past year as the senior living industry has navigated new challenges. Senior Living has continued to offer a sense of community for residents. This includes but is not limited to peer-to-peer friendships, healthy meals, and multi-generational activities, and social engagement. For many seniors and their adult children, isolation has become an all-too-common problem. Can you imagine how comforting it is to just walk outside the front door of your apartment and safely visit with neighbors?

The culture of each senior living community is unique. Just like each one of the seniors who reside inside.

10 Questions You Should Ask When Looking For A Senior Living Residence

There are a considerable amount of senior living residences in Fresno to choose from. That’s why it’s important to know what type of questions we should ask when looking for the right one. And that goes for them and ourselves.

Let us share with you a list of the most important questions we think you should ask, before deciding on a senior living residence.

#1 What Do All These Levels Of Care Mean?

The Senior Living Industry has its alphabet soup of acronyms. And when you are starting to look around they may seem confusing. Here’s a little list of the most common.

● IL: Independent Living (The person can perform all activities of daily living on their own)
● AL: Assisted Living (Assistance with medication management, grooming, dressing, bathing, hygiene, or transferring is needed)
● MC: Memory Care (A Dementia diagnosis needs specific programs of support)
● SNF: Skilled Nursing Facility (Typically needed following a hospital stay)
● Rehab: Short term Rehabilitation, physical and occupational therapy
● RCFE: Residential Care Facility for the Elderly
● CCRC: Continuing Care Retirement Community

In the Fresno area, there are dozens of senior living options to choose from. Some are 100% Independent Living communities. Some are 100% Memory Care Facilities. Many others have a mix of two levels of care.

For instance, The Vineyards California Armenian Home offers the full continuum of care including Independent Living Villas and apartments, Assisted Living apartments, dedicated Memory Care, and an onsite skilled nursing facility with short term physical and occupational therapy. As with any housing decision you will want to consider your budget and your lifestyle. What senior community has the values, experience, and solutions for your circumstance?

#2 How Many Communities Should I Tour?

During most of the quarantine season, onsite tours were not available. As we move into 2021 tours are available thru Face time, Google Duo, Zoom, and in some cases back to in-person tours. Keeping residents safe is the priority.

You can learn a lot with a virtual visit! Remember, it is not just about the real estate part, it is about the programs inside.

There are 6-Bed homes that are often run by families with a more casual environment and simpler amenities. There are mid-size and larger communities that can offer an array of services and amenities as they have more residents, staff, and resources. Each senior living community will have its management style and culture.

Tour as many as you can until you find the one that feels like home. The final desired outcome is being comfortable, safe, and happy in a new home, with support, friends, and peace of mind.

#3 How Do We Know What Level Of Care Is Appropriate?

The Physicians Report 602A form is a reporting tool that a potential resident’s primary physician completes. It includes clinical information that helps to direct the senior living professionals as they perform their assessment. This form is available online and is accepted by all California Residential Care Facilities for the Elderly.

The information provides a snapshot of the individual’s physical health. This includes primary and secondary diagnoses. It also let us know if they have the ability to perform their activities of daily living, and what assistance they may need.

Once the 602A is reviewed by the facility’s director of care, an in-person assessment is performed. And of course, once a person moves into a senior living community the staff continues to become more familiar with the unique personality and ever-evolving needs of each resident. The goal is to keep residents as independent as possible for as long as possible. The plan of care is going to be tailored for each resident’s needs.

#4 What About Technology?

The Senior Living industry continues to adapt and change. Even though the technology is a positive disruptor, it cannot replace the community and person-to-person connection.

However, the tools that are being developed will enhance care and aging with dignity. Tech can help us preventing falls, and improving the quality of life. It can help both the resident and the staff.

The foundation and core of the industry are helping the senior accomplish security, certainty, and predictability.

There are many advances in technology that address cognitive needs. As we remove the fear of aging, we can all move forward together.

By continuing to have purpose and engagement, residents in senior living communities enjoy a higher level of daily satisfaction. This can include online courses, walkie-talkie Bingo, virtual concerts, and screen led exercise classes.

#5 What Kind Of People Choose To Work In Senior Living?

More professionals are choosing to work in the senior living industry, bringing with them dynamic ideas. This business requires empathy and strategic planning. The industry meets the needs of a growing population. We mentor staff to be leaders and the residents teach the younger generations.

When you consider the number of Senior Living communities that exist, you can only imagine the number of staff that are employed throughout the departments. When initially investigating senior living options you will meet with the community marketing team. Typically, these individuals will have had experience in some type of sales as they need to be fluent in storytelling. They truly enjoy being able to capture the magic of senior living and share it with you.

I never get tired of watching the same scenario: A senior moving in, who is scared and not too happy about the reality of getting older… And then seeing that same person bloom as they enjoy peer to peer friendships and thrive even more as each month passes. It is always amazing!

Figuring out what you do not know can be difficult. A Senior Living Advisor is trustworthy. Ask questions. Get answers.

There are staff members who work in the dining room and transition to caregivers and vice versa. The common denominator is that people who work in senior living understand that we are ladies and gentlemen taking care of ladies and gentlemen. With delicious food, fun activities, safe transportation, housekeeping, and kindness.

#6 Who Do I Talk To If There Is A Problem Once I Move In?

Most problems can be easily solved. This is the case in 99% of situations and industries. It is the same in senior living. Communication is key. From honey do’s for maintenance to care concerns, address your questions to the appropriate department manager or directly to the Administrator. If a satisfactory solution is not presented, there is also the Ombudsman program.

The website can be viewed on the Ombudsman page

Here is an overview of what they offer residents and their families.

#7 What If I Do Not Want To Drive Anymore?

You do not have to drive to continue enjoying your independence. Transportation is included in lifestyle options. Typically, the transportation is included in the monthly rent for doctor’s visits and personal appointments with weekly adventures and shopping included as well. All this is subject to the varying safety precautions of the county and state.

The great news is that you do not have to drive to do more of what you want to do! At The Vineyards California Armenian Home, our residents have so many choices each day. Get up early and have coffee with a neighbor at The Harvest Cafe? Sleep in and order room service? Enjoy a good book from the Grape Leaf book Nook library? Talk a walk around the gorgeous park? Throw a load of delicates in their very own washing machine?

Relax in the central courtyard under the palm trees. Stay cozy in the Fireside Room and watch a favorite soap opera. Plan a girl’s night out in the 3rd-floor bistro. Review the day’s event calendar and decide how busy or relaxed one wants to be.

#8 Who Pays For Senior Living?

Senior Living is primarily private pay. Senior Living communities may also work with Long Term Care Insurance for Assisted Living and Memory Care.

There is also an Air and Attendance program available for Veterans.

Am I eligible for VA Aid and Attendance or Housebound benefits as a Veteran or survivor?

Va Aid And Attendance Eligibility
Am I eligible for Veterans Pension benefits?
You may be eligible for the Veterans Pension program if you meet the requirements listed below.

Both of these must be true:

● You did not receive a dishonorable discharge, and
● Your yearly family income and net worth meet certain limits set by Congress. Your net worth includes all personal property you own (except your house, your car, and most home furnishings), minus any debt you owe. Your net worth includes the net worth of your spouse.

Find out about Veterans Pension rates. And at least one of these must be true about your service. You:

● Started on active duty before September 8, 1980, and you served at least 90 days on active duty with at least 1 day during wartime, or
● Started on active duty as an enlisted person after September 7, 1980, and served at least 24 months or the full period for which you were called or ordered to active duty (with some exceptions) with at least 1 day during wartime, or
● Were an officer and started on active duty after October 16, 1981, and you had not previously served on active duty for at least 24 months.

And at least one of these must be true. You:

● Are at least 65 years old, or
● Have a permanent and total disability, or
● Are a patient in a nursing home for long-term care because of a disability, or
● Are getting Social Security Disability Insurance or Supplemental Security Income

You may be eligible for this benefit if you get a VA pension and you meet at least one of the requirements listed below.

At least one of these must be true:

● You need another person to help you perform daily activities, like bathing, feeding, and dressing
● You must stay in bed—or spend a large portion of the day in bed—because of illness
● You are a patient in a nursing home due to the loss of mental or physical abilities related to a disability
● Your eyesight is limited (even with glasses or contact lenses you have only 5/200 or less in both eyes or concentric contraction of the visual field to 5 degrees or less

#9 Are They Going To Keep My Parents Safe?

Seniors are an especially vulnerable group when it comes to safety and health concerns. In recent surveys as noted on the seniorlifestyle.com blog, 91% of adult children with a parent in a retirement community were pleased with their parent’s safety and physical security.

● Elderly robbery victims are 53% more likely to be victimized in their own homes than younger victims. Among retirement community residents, 93% reported that they felt there was a safety net in place for them if something went wrong vs 60% of seniors living alone reported they were not prepared for an emergency.

● Seniors who engage in social programming are 26% less likely to develop dementia than those who live alone and seniors who live alone have a 59% higher risk of physical decline.

● In senior living community-dwelling adults, fall prevention programming led to a decrease in fall rates of 25%-40%. Whereas one in three seniors that live in private homes experience a serious fall each year.

● In a survey of seniors in senior living communities, 77% of participants say they eat healthier as a result of nutritional programming. Nearly one in six seniors struggle to feed themselves, drastically raising the risk of heart disease, asthma, and depression.

● In a study of 4000 seniors, 40% reported their sense of community as the most important contributor to their quality of life. Seniors living in isolation have up to a 90% increased risk of cardiovascular disease.

There are many safety variables to consider. Senior Living communities have notable advantages over living at home alone with a caregiver.

#10 When Do I Know I Am Ready?

We have a set of three questions that can help you decide:

● Are you (or your senior loved one) living a lifestyle that is healthy physically, emotionally, and socially?
● Do you and your spouse enjoy shopping and cooking delicious and nutritionally balanced meals?
● Do you enjoy doing laundry and changing your sheets? Do you enjoy cleaning your home and pulling weeds in the garden?

Are you answering no?

Perhaps it is time to start asking deeper questions.
● Is your house an asset or a burden?
● Do you only live in a couple of rooms in a large home?
● Have there been growing concerns about health issues?
● Are you lonely?
● Do you want to have more time to enjoy your interests and let go of some of the mundane household duties?
● Are there memory issues?
● Are you ready to relax and enjoy peace of mind?

Remember there are different chapters in life, and all of them bring new joys and learnings. Are you ready to begin a new one of personal freedom and support?

Conclusion

We hope you find the perfect place for you or your beloved one. Remember there are organizations and institutions ready to help. You are not alone.

Now it’s time for you to be proactive! This is about your health, your safety, and even your life. What other questions would you suggest to add to the list?

Let us know in the comments!

The Benefits of Exercise

By 16th June 2020

Over the years, it is easy to forget about exercise when it’s not routine. A recent study suggested that about 67 percent of older adults are sedentary for at least 8.5 hours each day. Making exercise fun as part of your routine can help in the long term, and there are numerous benefits you receive!

  1. Arthritis: Exercise is one of the most crucial options for arthritis management. Regular activity helps lubricate the joints and can help reduce overall pain and stiffness that is often present among individuals with arthritis. Moreover, obesity is a risk factor for the disease, and increasing physical activity levels can help better manage the debilitating symptoms of arthritis.
  2. Heart disease: Heart disease is one of the biggest causes of death in the United States. The Centers for Disease Control and Prevention state that about one in every four deaths is attributed to heart disease. More people exercising later in life can help reduce the number of individuals with heart disease through the management of blood pressure and blood glucose, and decreasing LDL cholesterol.
  3. Metabolic Dysfunction (type II diabetes and obesity): Type II diabetes and obesity are two closely related diseases in which the body is in metabolic dysfunction. Exercise can help maintain proper body weight and help regulate blood glucose and insulin levels to make the body more efficient.
  4. Cancer: Exercise has been shown to help improve overall cancer risk among a variety of different forms of cancer. Studies have shown a 30 to 40 percent reduction in breast cancer risk among women who perform moderate to regular exercise.
  5. Hypertension: Exercise can help lower systolic blood pressure significantly through moderate-intensity physical activity. Try breaking up exercise into three bouts throughout the day lasting for at least 10 minutes each to receive blood pressure–lowering effects.
  6. Depression: Exercise can have a beneficial effect on personal mood. Studies suggest that group exercise classes among older adults can help reduce symptoms of depression by 30 percent or more in exercising older adults. The modest improvement in depressive symptoms can help maintain an overall greater vitality later in life and help prevent negative feelings or thoughts that are common with aging.
  7. Dementia: Dementia is a disabling condition affecting many older adults. With a wide range of mental disorders categorized as dementia, there is a great need to understand how to prevent the condition. Exercise is one prevention strategy that can help slow the mental decline. A recent study showed a 37 percent reduced risk and a 66 percent reduction in risk of dementia when older adults performed moderate-intensity exercise, suggesting every adult ought to exercise to help lower the risk of mental decline and to help prevent mental disability later in life.
  8. Quality of life: Maintaining functional independence is something many older adults want. A regular exercise inclusive of strength and balance training can help accomplish this. Aim to be physically active for 30 minutes every day and to strength train at least two non-consecutive days per week.
  9. Insomnia: Certain medications and life events can prevent the body from proper sleep. Higher levels of physical activity can help exhaust the body enough to place it in a position for restful and lasting sleep. Avoid strenuous exercise two hours before bed to obtain these benefits, and aim to meet the daily activity recommendations.
  10. All-cause mortality: Exercise is known to reduce death from all causes. In fact, a recent study showed a 30 to 80 percent reduction in all-cause mortality when individuals exercised at an intensity level greater than 4 METS, suggesting that exercise can help delay premature death from various causes.