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???
Aging does NOT have to be ugly
John Turner, age 67
John Turner, age 79
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
–

Lower extremities> upper extremities
–

Ratio of II/I goes from ~1.25/1 to ~0.85/1
between the ages of 30 and 80 years
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
–

Reduced growth hormone
–

Testosterone, estrogen
Decline in IGF-1
Increase in inflammation
–
TNF-α, IL-6
Other factors that influence mass
in 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 wellbeing 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 wellbeing 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
Fiatarone et al, NEJM, 1994

Unknown if exercise enhances absorption from gut
Lifestyle factors that influence wellbeing 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)
MEN
Bench Press
Bench Press
3342 lbs (27±9%)
Biceps curl
1219 lbs (58±14%)
Leg press
70114 lbs (63±14%)
Knee extension
3245 lbs (41±15%)
(81±3 yrs)
8067 lbs (-16±5%)
Biceps curl
2543 lbs (72±6%)
Leg Press
150175 lbs (20±6%)
Knee extension
35100 lbs (186±24%)
Strength-training cont’d
WOMEN
MEN
Knee flexion
Knee flexion
53-75 (42±7%)
Seated row
51-70 lbs (37±9%)
Total % increase= 45%
Sum of gains= 114 lbs
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
Functional outcomes- PPT
30
25
20
Pre
Post
15
10
5
0
Flex/Bal
Aerobic
Strength
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
–
–



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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
Goal: Compression of Frailty
100
90
80
Percent
70
60
Sedentary
Active
50
40
30
20
10
0
10
20
30
40
50
60
Age in years
70
80
90 100
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



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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
Children spend 4.5 more time in
sedentary activities than 50 yrs earlier
Hobbies,
board games,
TV
1950
2
2
4.5X
TV, music,
computer,
video games
reading,
movies
2000
1
1
0
0
10
10
10
20
20
30
30
40
40
40
Number of hours per week
Hypokinetic Disease Kraus & Raab, 1961 www.kff.org publication#7250, 2005
5
5
% of population
Extending its increasing rate of rise,
all children (6-11 yrs old)
Chart Title
are predicted to be obese in 2044
120
y = 3E-36e
R = 0.9594
100
100
80
80
60
60
40
40
20
20
0
0
1960
1980
0.0423x
2
2044
2000
2020
2040
2060
2060
Source: Simon Lees
Why are we concerned about this?
Obese children develop adult
chronic disease risk factors
Odds of a 5-17 yr old obese child having cardiovascular risk factors
Raised diastolic
2.4
6
High LDL cholesterol5
3
Low HDL cholesterol 4
3.4
Raised systolic
3
High triglycerides
2
4.5
7.1
21.1
High fasting insulin 1
0
0
55
10
10
15
15
20
20
Odds Ratios
Freedman Pediatrics 103:1175, 1999
25
There are other concerns about
inactivity

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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 wellbeing 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



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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

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Late life FDI
CS-PFP
Physical performance test
PT assessment continued

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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:
–
–

Decreased risk of:
–

Stroke
Blood clots
Osteoporosis, hip fracture
No differences between E2 and placebo
–
–
Breast cancer
dementia
So, now what?

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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