Aging …….

What exactly is inevitable?

Population shift…..

The fastest growing segment of the population- those over 85 years of age!– In this country and around the world

Unfortunately, about half of the 85+ year old folks are frail, unable to provide for themselves

Are these women aging well???

John Turner, age 67 John Turner, age 79

Aging does NOT have to be ugly

What IS frailty????

Currently, frailty is undefined It is probably a bit like indecency…..you

recognize it when you see it

For our purposes, frailty is inability to accomplish the basics….dressing, bathing, shopping, walking with an aide

Causes of frailty

Primary……loss of muscle

Secondary: lifestyle factors

Aging in muscle: Cross-sectional studies

Fiber loss- denervation, apoptosis

Fiber atrophy, particularly in type II– Ratio of II/I goes from ~1.25/1 to ~0.85/1

between the ages of 30 and 80 years

Lower extremities> upper extremities– Postural/locomotor > non-postural

Rate of loss in males > females

Concomitant age-related changes that may contribute to muscle loss

Decline in circulating sex hormones – Testosterone, estrogen

Reduced growth hormone– Decline in IGF-1

Increase in inflammation– TNF-α, IL-6

Other factors that influence massin later years………

Lifestyle of activity/inactivity Nutrition Diminished ability to recover from disuse,

injury– Failure to activate signaling pathways

“old millieu”

Clinical consequences…..

Diminished strength, power– Concentric, isometric > eccentric

Slowing of movement Loss of finesse

Sum total: diminished physical function(e.g., women live an average of 4 years in a frail and dependent condition)

Consequences of lost muscle mass

Sarcopenia

Sarcos= flesh penia= reduction in

Until 50 years ago this phenomenon rarely existed. Aging a new phenomenon of modern society

Baltimore Longitudinal study

MEN- torque @180o/s AGE 20-29 yrs Range 101-248 ft/lbs

AGE 80-96 yrs Range 16-239 ft/lbs

WOMEN- torque AGE 20-29 yrs Range 28-126 ft/lbs.

AGE 80-96 yrs Range 12-117 lbs

Grip strength for 874 men

Lifestyle factors that influence well-being in later years

EXERCISE– Evidence suggests routine physical activity can

delay by ~15 years the loss in muscle mass that typically occurs

Muscle function in master lifters

Pearson et al, MSSE, 2002

IIa fiber cross-sectional area in VL biopsies from Master weight-lifters

Lifestyle factors that influence well-being in later years………

Nutrition– Older adults cannot get enough nutrient

dense food without adding exercise to the daily routine

– 1500 kcal intake not adequate to maintain minimal RDA

– Need ~200-300 kcal of exercise daily to make up the difference

Fiatarone study

Exercise plus nutrition- effect on strength

Unknown if exercise enhances absorption from gut

Fiatarone et al, NEJM, 1994

Lifestyle factors that influence well-being in later years…….

STRESS– Loss of friends. spouse– Poverty– Health– Loss of independence

Depression

Clearly exercise is important but what is effective in later years?

Strength training advocated by ACSM, AARP– Not everyone can do it, equipment not

appropriate or available, need help to establish prescription, not everyone interested

– Questionable if women respond as well to this type of activity as men

Strength-training for frail elderly

WOMEN (84±4 yrs)

Bench Press

3342 lbs (27±9%)Biceps curl

1219 lbs (58±14%)Leg press

70114 lbs (63±14%)Knee extension

3245 lbs (41±15%)

MEN (81±3 yrs)

Bench Press

8067 lbs (-16±5%)Biceps curl

2543 lbs (72±6%)Leg Press

150175 lbs (20±6%)Knee extension

35100 lbs (186±24%)

Strength-training cont’d

WOMENKnee flexion

53-75 (42±7%)Seated row

51-70 lbs (37±9%)

Total % increase= 45%

Sum of gains= 114 lbs

MENKnee flexion

65-110 lbs (69±13%)Seated row

73-125 lbs (71±15%)

Total % increase= 67%

Sum of gains= 192 lbs

Exercise type?

Current findings suggest that all exercise approaches are useful for the enhancement of functional capacity– Strength-training (traditional or even Theraband)– Aerobic activity (walking, cycling)– Flexibility/balance (e.g., Tai Chi, Yoga, dance)

Only weight-training increases muscle mass

0

5

10

15

20

25

30

Flex/Bal Aerobic Strength

Pre

Post

Functional outcomes- PPT

Other contributors to frailty?

Is there an increase in osteoporosis?

My goodness, yes!

By age 50, more than 50% of women are already on their way toward osteoporosis.

Why????????

Poor dietary intake of calcium– Soda, not milk– Junk food

Inactivity Smoking Alcohol abuse Your mom

Much greater risk for fracture

Poorer bone stock Living longer Little physical demand

To summarize……

Frailty is a recent phenomenon in our society Much of the loss in function is due to a ~50%

reduction in quantity of muscle mass and bone mass

Nearly half of the loss in muscle and bone is preventable through an active lifestyle and good nutrition

What does it all mean?

Your mother was right

0

10

20

30

40

50

60

70

80

90

100

10 20 30 40 50 60 70 80 90 100

Sedentary

Active

Age in years

Goal: Compression of FrailtyP

erce

nt

A look back in time

Aging is a new phenomenon in our society Lifespan 100 years ago was 47 years Inactivity also a recent phenomenon

– ADLs were difficult Wash tubs Beat the rugs Scrubbed the walls, floors Food preparation- gardening, butchering, grinding

Historical overview

1900- everyone worked hard: on farms, in factories, doing the chores

1950- most jobs were industrial, lots of farms, chores were still hard

2000- almost everyone works in an office, few farms, chores are easy

Most of what we do is sedentary

And this is the consequence

Hypokinetic Disease Kraus & Raab, 1961 www.kff.org publication#7250, 2005

1950

2000

Children spend 4.5 more time in sedentary activities than 50 yrs earlier

4.5X

Hobbies,board games,

TV

Hypokinetic Disease Kraus & Raab, 1961 www.kff.org publication#7250, 2005

1950

2000

4.5XTV, music,computer,

video gamesreading,movies

10 40Number of hours per week

2044

020406080

100

1960 1980 2000 2020 2040 2060

Extending its increasing rate of rise, all children (6-11 yrs old) all children (6-11 yrs old) are predicted to be obese in 2044

Source: Simon Lees

Why are we concerned about this?

Obese children develop adult

chronic disease risk factors

Raised diastolic

High LDL cholesterol

Low HDL cholesterol

Raised systolic

High triglycerides

High fasting insulin

Raised diastolic

High LDL cholesterol

Low HDL cholesterol

Raised systolic

High triglycerides

High fasting insulin

2.4

3

3.4

4.5

7.1

21.1

Odds of a 5-17 yr old obese child having cardiovascular risk factors

0 5 10 15 20

Odds Ratios

Freedman Pediatrics 103:1175, 1999

There are other concerns about inactivity

Diminished strength Loss of coordination and flexibility Loss of bone mass Quality of life (higher incidence of

depression) Can’t think as well

Lifestyle factors that influence well-being in later years

EXERCISE– Evidence suggests routine physical activity can

delay by ~15 years the loss in muscle mass that typically occurs

Age 55 yrs Age 80 yrs

Inactivity affects your quality of life

Inactive people are 10x more likely to be depressed

Inactive people take more medications Inactive people have poorer sex lives Inactive people get colds and flu more often

than active individuals

Myths of aging: to be old is to be sick

Myths of aging: you can’t teach an old dog new tricks

Fiatarone et al: JAMA 1994– 8 weeks of resistance training resulted in a more

than 200% increase in leg extension strength– Better ability to walk

Subjects ranged in age from 86-94 yrs and lived in a nursing home

Myths of aging: the horse is out of the barn

Adopting recommended lifestyle behaviors is beneficial in later years– Keeping cholesterol in check– Blood pressure down– Prevent diabetes

It is NEVER too late to benefit from increased physical activity

Myth: choose your parents wisely

At most, genetic factors influence ~30% of age-related decline.

Social and behavioral factors play a MUCH bigger role in one’s overall health status and functioning

Myth: OLD= DISEASE

No question: the incidence of disease increases markedly with advancing age.

Most of the diseases affecting older adults are lifestyle-related

Myth: old adults ‘deserve’ to rest

The greatest contribution to premature frailty and disability is inactivity

Old nuns study, old Georgians……– Those that lived to 100 yrs were physically active– Engaged in their communities– Mentally challenged– Caring – Ate decently

Myth: PT has nothing to offer

We have more potential to influence the health and well-being of the older adult population than ANY other practitioner

We should be establishing wellness programs all over the place.

PT assessment

Many tools to choose from– Men and women who are really low level

Katz and Barthel indices- for nursing home population MDS OARS for a more comprehensive look at BADL, IADL

– Men and women transitioning to frailty Late life FDI CS-PFP Physical performance test

PT assessment continued

Evaluations for assisted living Evaluations for community dwelling Tools specific for

– Balance loss– Strength and power deficits– Speed of movement/coordination– Range of motion– Muscular and cardiovascular endurance

Functional assessments

Assessments cont’d

And, assessments for men and women who are fit and physically active (like Jack LaLanne)

– Strength machines– Treadmills for oxygen uptake– Other task specific equipment (e.g., work hardening)

We have a lot of options appropriate to the level of capability of all older adults

– The challenge: selecting the right tools

And now, onto the WHI study…

(not exactly a natural segue from assessments)

What was the WHI? Halted prematurely in 2002 N=161,000+ post-menopausal women

– Those with intact uterus given E2+ progesterone– Those without a uterus were given E2 only

E2 + progesterone

Increased risk of– Heart attack– Stroke (e.g., 34 vs. 42 in 10000 women)– Blood clots– Breast cancer

Decreased risk of– Hip fracture, low bone mass (osteoporosis)– Colorectal cancer

Estrogen only

Increased risk of:– Stroke– Blood clots

Decreased risk of: – Osteoporosis, hip fracture

No differences between E2 and placebo– Breast cancer– dementia

So, now what?

Pendulum swinging back Women started ~10 yrs post menopause Women not screened a priori for heart

disease So many women are pretty unhappy

How can something that was beneficial suddenly become detrimental??

What to conclude?

Need a lot more data Need to begin women on E2 at an earlier age Must screen women for heart disease and

other disorders before starting HRT E2 agonists necessary