aging ……. what exactly is inevitable?. population shift….. the fastest growing segment of the...
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Aging …….
What exactly is inevitable?
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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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John Turner, age 67 John Turner, age 79
Aging does NOT have to be ugly
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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
Primary……loss 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 extremities> upper extremities– Postural/locomotor > non-postural
Rate of loss in males > females
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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
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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 > 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 @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 (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%)
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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
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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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0
5
10
15
20
25
30
Flex/Bal Aerobic Strength
Pre
Post
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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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
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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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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
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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
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Why are we concerned about this?
Obese children develop adult
chronic disease risk factors
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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
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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) Can’t 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 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
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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 one’s 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 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
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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 N=161,000+ 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