Aging

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Aging .

• What exactly is inevitable?

2
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

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Are these women aging well???
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Aging does NOT have to be ugly
John Turner, age 67
John Turner, age 79
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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

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Causes of frailty

• Primaryloss of muscle
• Secondary lifestyle factors

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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 extremitiesgt upper extremities
• Postural/locomotor gt non-postural
• Rate of loss in males gt females

8
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-a, IL-6

9
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

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Clinical consequences..

• Diminished strength, power
• Concentric, isometric gt 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)

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Consequences of lost muscle mass
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Sarcopenia

• Sarcos flesh
• penia reduction in
• Until 50 years ago this phenomenon rarely
  existed. Aging a new phenomenon of modern society

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Baltimore Longitudinal study

• MEN- torque _at_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

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Grip strength for 874 men
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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

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Muscle function in master lifters
Pearson et al, MSSE, 2002
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IIa fiber cross-sectional area in VL biopsies
from Master weight-lifters
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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

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Fiatarone study

• Exercise plus nutrition- effect on strength
• Unknown if exercise enhances absorption from gut

Fiatarone et al, NEJM, 1994
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Lifestyle factors that influence well-being in
later years.

• STRESS
• Loss of friends. spouse
• Poverty
• Health
• Loss of independence
• Depression

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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

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Strength-training for frail elderly

• WOMEN (844 yrs)
• Bench Press
• 33?42 lbs (279)
• Biceps curl
• 12?19 lbs (5814)
• Leg press
• 70?114 lbs (6314)
• Knee extension
• 32?45 lbs (4115)

• MEN (813 yrs)
• Bench Press
• 80?67 lbs (-165)
• Biceps curl
• 25?43 lbs (726)
• Leg Press
• 150?175 lbs (206)
• Knee extension
• 35?100 lbs (18624)

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Strength-training contd

• WOMEN
• Knee flexion
• 53-75 (427)
• Seated row
• 51-70 lbs (379)
• Total increase 45
• Sum of gains 114 lbs

• MEN
• Knee flexion
• 65-110 lbs (6913)
• Seated row
• 73-125 lbs (7115)
• Total increase 67
• Sum of gains 192 lbs

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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

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Functional outcomes- PPT
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Other contributors to frailty?
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Is there an increase in osteoporosis?

• My goodness, yes!
• By age 50, more than 50 of women are already on
  their way toward osteoporosis.

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Why????????

• Poor dietary intake of calcium
• Soda, not milk
• Junk food
• Inactivity
• Smoking
• Alcohol abuse
• Your mom

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Much greater risk for fracture

• Poorer bone stock
• Living longer
• Little physical demand

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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

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What does it all mean?

• Your mother was right

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Goal Compression of Frailty
Percent
Age in years
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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

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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

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Most of what we do is sedentary
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And this is the consequence
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Children spend 4.5 more time in sedentary
activities than 50 yrs earlier
1950
Hobbies, board games, TV
1950
4.5X
4.5X
TV, music, computer, video games reading, movies
2000
2000
10
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Number of hours per week
Hypokinetic Disease Kraus Raab, 1961
www.kff.org publication7250, 2005
Hypokinetic Disease Kraus Raab, 1961
www.kff.org publication7250, 2005
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Extending its increasing rate of rise, all
children (6-11 yrs old) are predicted to be
obese in 2044
Source Simon Lees
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Why are we concerned about this?

• Obese children develop adult
• chronic disease risk factors

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Odds of a 5-17 yr old obese child having
cardiovascular risk factors
2.4
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
3
3.4
4.5
7.1
21.1
15
20
0
5
10
Odds Ratios
Freedman Pediatrics 1031175, 1999
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There are other concerns about inactivity

• Diminished strength
• Loss of coordination and flexibility
• Loss of bone mass
• Quality of life (higher incidence of depression)
• Cant think as well

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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
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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

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Myths of aging to be old is to be sick
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Myths of aging you cant 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

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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

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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 ones overall health status and
  functioning

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Myth OLD DISEASE

• No question the incidence of disease increases
  markedly with advancing age.
• Most of the diseases affecting older adults are
  lifestyle-related

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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

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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.

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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

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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

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Assessments contd

• 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

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And now, onto the WHI study

• (not exactly a natural segue from assessments)
• What was the WHI?
• Halted prematurely in 2002
• N161,000 post-menopausal women
• Those with intact uterus given E2 progesterone
• Those without a uterus were given E2 only

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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

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Estrogen only

• Increased risk of
• Stroke
• Blood clots
• Decreased risk of
• Osteoporosis, hip fracture
• No differences between E2 and placebo
• Breast cancer
• dementia

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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??

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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