Exercise and Aging

1. Exercise and Aging Brian K. Unwin, M.D. Colonel, United States Army Department of Family Medicine Uniformed Services University

2. Who are you?

3. Why are you here?

4. Goals • Develop an understanding of normal aging physiology • Incorporate aerobic and resistance exercise into treatment and prevention plans of the elderly • Appropriate pre-exercise assessment

5. By attending this lecture you will…

8. Exercise and aging physiology

9. Physiologic changes with aging (Board Questions) • Decreased • Muscle mass • Muscle strength • Muscle power • Muscle endurance • Muscle contraction velocity • Muscle mitochondrial function • Muscle oxidative enzyme capacity

10. Decreased Maximal and submaximal aerobic capacity Cardiac contractility Maximal heart rate Stroke volume and cardiac output Nerve conduction velocity Balance Decreased Proprioception Gait velocity Gait stability Insulin sensitivity Glucose tolerance Immune function Bone mass/strength/density Collagen cross-linkage, thinning cartilage, tissue elasticity Physiologic changes with aging (Board Questions)

11. Physiologic Questions • Increased • Arterial stiffness • Myocardial stiffness • Systolic blood pressure • Diastolic blood pressure • Visceral fat mass • Total body fat • Intramuscular lipid accumulation

12. Age Related Decline:What is Normal?Hazzard, 4th Edition, p. 1390

13. Exercise and VO2 Max Hazzard, 4th edition

14. Use It or Lose It • Sedentary people lose large amounts of muscle mass (20-40%) • 6% per decade loss of Lean Body Mass (LBM) • Aerobic activity not sufficient to stop this loss • Only resistance training can overcome this loss of mass and strength • Balance and flexibility training contributes to exercise capacity

15. Use It and Lose Less of It • Resistance training improves strength by a range of 40-150% • Lean body mass increases 1-3 kg • Muscle fiber area 10-30%

16. What is exercise? • Lifestyle choices • Organized sports • Unstructured play • Household and Occupational tasks

17. Increased Muscle Mass • Endurance training emphasis • Walking isn’t enough • Progressive resistance training • DM prevention? • Dependency prevention? • Falls and fractures • Disuse • Sarcopenia • Frailty

18. Body composition • Genetic, lifestyle and disease factors • Metabolic, cardiovascular and musculoskeletal systems impacted • Lifestyle is under patient’s control

19. Burning Fat • Decreases in total body adipose tissue • Aerobic and resistive training • Energy restricted diets and/or high volume exercise (5-7 hours/week) • Visceral fat selectively mobilized

20. Metabolic syndrome Vascular disease Osteoarthritis Gallbladder disease Diabetes Hypertension Dyslipidemia Sleep apnea Breast cancer Colon cancer Endometrial cancer Impotence Osteoarthritis Depression Disability What’s fat got to do with it?

21. Geriatric Disease and Epidemiology: • Top 10 Chronic Conditions (1989) • Arthritis • Hypertension • Hearing Impairment • Heart Disease • Cataracts • Orthopedic Impairment • Chronic sinusitis • Diabetes • Visual Impairment • Varicose Veins Kane's Essentials of Geriatrics

23. Exercise and prevention

24. Common Chronic Diseases • Genetic • Environmental factors • Most chronic illness related to behavior and patterns of physical activity • Exceptions: Parkinson’s, degenerative neurologic diseases • Exercise may be protective with dementia

25. Diabetes and Osteoporosis • Insulin Resistance • Improves insulin sensitivity • Detraining may reduce exercise effect • Primary prevention demonstrated • Osteoporosis prevention and treatment • Stabilization or increase in bone density in pre- and postmenopausal women with resistive or weight bearing exercise • 1-2% per year difference from controls

26. Dyslipidemia • Not a lot of data in elderly • No clear primary and secondary prevention data • Exercise associated with less atherogenic profiles • Duration and frequency factors • Weight loss (or fat loss) associated with increased HDL • Gender differences with training • Less training effect on HDL in women

27. Hypertension • Most trials cross sectional and cohort • Lower pressures in active individuals • 5-10 mmHg • Type and intensity • Greater training effect in those with mild to moderate hypertension • 6-7 mmHg drop in systolic and diastolic pressure • Effect present in low-to-moderate exercise

28. ASCVD and ASPVD • Exercise training beneficial in ASPVD • Reduced claudication pain • Greater walking distance • Improved functional endpoints • Benefit in selected patients with coronary artery disease.

29. Arthritis • Improved functional status • Faster gait • Lower depression • Less pain • Less medication use • Strength and endurance training benefit

30. Cancer • Potential protective benefits with • Breast Cancer • Colon Cancer

31. Exercise treatment of chronic disease • May treat symptoms and disuse and not the underlying disease • Parkinson’s • COPD • Claudication • Chronic renal failure • May reduce recurrence of disease • ASCVD • Falls

32. Exercise and emotional health and well being

33. Emotional well being • Genetic, social, personality, and psychological constructs • Leading cause of death and disability in developed countries

34. Exercise and Mental Health • Positive psychologic attributes • Lower prevalence and incidence of depressive symptoms • Reversal of hippocampal volume loss? • Reversal of cognitive loss? • 14 randomized, controlled trials: • Aerobic and resistance training • Higher intensities • Meaningful improvements in depression • Response rates of 31-88% • Equipotent to standard treatment

35. Exercise and disability

36. Function relates to strength • Non-linear relationship between strength and function • Concept of Threshold • EPESE Study: • Physically active patients at baseline less likely to develop disability • Exercise improves functional limitations • Functional balance tasks • Gait speed • Arthritis

37. Fitness and Functional Status Hazzard, 4th Edition

38. Exercise relevant in geriatrics • Exercise appropriate in frail elderly • Exercise appropriate with comorbidities • Exercise appropriate in functional impairment and disability

39. Exercise and longevity

42. Exercise Evaluation

43. Relative Acute illness Undiagnosed chest pain Uncontrolled diabetes Uncontrolled hypertension Uncontrolled asthma Uncontrolled CHF Musculoskeletal problems Weight loss and falls Absolute Inoperable Aortic Aneurysm Cerebral aneurysm Malignant ventricular arrhythmia Critical aortic stenosis End-stage CHF Terminal illness Behavioral problems Contraindications

44. For everyone else • What does the patient want? • What does the patient need? • What are the patient’s cardiac risk factors? • What are the patient’s orthopedic risk factors?

45. Risk Factors • Hypertension • Beta Blockers • Hypercholesterolemia • Smoking • Diabetes • Hypoglycemics • Family History • Orthopedic Risk Factors • Susceptible to injury • High intensity resistance • High impact aerobics

46. Risk Assessment Categories • Apparently Healthy • Zero to one risk factors • Higher Risk • 2 or more risk factors or symptoms • Disease • Cardiac • Pulmonary • Metabolic

47. Exercise Stress Test • High Risk Individual • Generally no indication for individual planning mild to moderate exercise

48. Consider other impairments • Vision/hearing • Adaptive devices • Environmental issues

49. Modes General activities Aerobic Walking Sports Resistance Supervision/technique Benefit with one set Flexibility Static stretch Balance Risk assessment Dynamic and static balance Mode governed by: Duration 30 minutes Frequency Most days Intensity Borg Scale 12-14 55-75% of MHR Exercise Prescription

50. ACSM guidelines for healthy aerobic activity • Exercise 3-5 days each week • Warm up 5-10 minutes before aerobic activity • Maintain intensity for 30-45 minutes • Gradually decrease intensity of workout, then stretch to cool down during last 5-10 minutes • If weight loss is goal, 30 minutes five days a week