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Functional Decline and Aging: How can exercise influence these changes?

Functional Decline and Aging: How can exercise influence these changes?. Jonathan F. Bean MD, MS, MPH Associate Professor Dept. PM&R, Harvard Medical School. Disclosures. Federal Funding NIH NIA, NICHD No other disclosures. Outline. Outline Background/conceptual issues

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Functional Decline and Aging: How can exercise influence these changes?

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  1. Functional Decline and Aging: How can exercise influence these changes? Jonathan F. Bean MD, MS, MPH Associate Professor Dept. PM&R, Harvard Medical School

  2. Disclosures • Federal Funding • NIH • NIA, NICHD • No other disclosures

  3. Outline • Outline • Background/conceptual issues • Exercise and Functional Activities • Exercise and Participation in Life Roles • Medical conditions relevant to PM&R care and the maintenance of independence

  4. Older adults are the fastest growing segment of the population 30 Women  65 y Men  65 y 20 Percent 10 0 1940 1960 1990 2020 2040 Aging and Demographics U.S. Bureau of the Census, 2000

  5. Changes with Aging Both Strength and power decline after age 35 1995, Metter et al., Baltimore Longitudinal Study on Aging

  6. 60 50 40 30 20 10 0 Percent of Older Persons with Difficulty or Inability in ADLs by Age and Sex, United States, 1995 Difficulty Inability Percent W M W M W M W M W M 70 y 70-74 y 75-79 y 80-84 y 85 y Supplement on Aging II, NCHS

  7. In 1995, 79% of the 70+ age group had 1 or more of the following chronic disorders: Arthritis Hypertension Heart disease Diabetes mellitus Respiratory disease Cancer Stroke Functional disability is highly associated with chronic disorders OLDER PATIENTS HAVE HIGHRATES OF COMORBIDITY

  8. Does the disease model help us conceptually? • Geriatric impairments more strongly associated with incident disability than chronic diseases • Cardiovascular Health Study • Chaudhry et al. JAGS, 2010 MC Escher: http://www.wisdom.weizmann.ac.il/~glasner/courses/CV_2009_2/img/escher-relativity.jpg Let’s consider the disablement model

  9. Mobility is predictive of adverse outcomes Short Physical Performance Battery Performance of 3 tasks Each scored between 0-4 Standing Balance Gait Speed over 4 meters 5 repeated chair stands Best performance is 12 4-year disability rates according to SPPB From:   Guralnik: N Engl J Med, Volume 332(9).Mar 2, 1995.556-561

  10. JAMA April 2014 “Measuring gait speed is simple, quick, reproducible, inexpensive, and feasible in clinical settings.”

  11. Mobility within the disablement paradigm ICF Model Body System Impairment Impairment Mobility problems cause limitations that impact participation and disability Functional Limitation Activity Limitation Restricted Participation Nagi Model Disability

  12. Clinical Practice PRIMARY CARE OF OLDER ADULTS Chronic Disease Management Advocated Mobility Screening Arthritis CHD Stroke Diabetes Osteoporosis Etc. Observed Physical Performance Final Common Pathway Falls Disability Morbidity Mortality Rehabilitative Exercise

  13. Realties of independent living for older adults

  14. Exercise and Impairment ICF Model Body System Impairment Impairment IMPAIRMENT Nagi Model

  15. Loss of Strength with Aging: a theoretical model % MVC needed to perform ADLs

  16. Strength Training Changes in 1 RM with Progressive Resistance Training among older adults Frontera et al. , 1988

  17. Co-Impairments can have augmentative effectsStrength and Balance as predictors of walking ability Rantanen et al., JAGS, 2001 Incidence rates of severe walking disability based on baseline knee-extension strength and standing balance

  18. Changes in Power and CMD in FunctionBean et al. J Am Geriatr Soc 2010

  19. Trunk Muscle Integrity and Aging • Trunk muscle endurance is also linked to back pain • Trunk muscle integrity is critical for optimal peripheral power generation http://www.bandbhac.org.uk www.gc4health.com http://www.brandeis.edu/hbi

  20. Exercise and Mobility ICF Model Mobility Functional Limitation Activity Nagi Model

  21. What impairments should be prioritized? Impairments Balance Strength Power asymmetry Velocity of movement Reaction time Aerobic Capacity Range of Motion Core muscle integrity Kyphosis Obesity Pain Sensory Loss Cognitive Impairment Depression Visual Impairment Rehabilitative Impairments Medical Impairments

  22. The Boston RISE StudyBean et al., Arch Phys Med Rehab; 2013

  23. Multivariable models prediction LLFDI function Note: Standardized estimates presented as absolute values. Both models were adjusted for age, sex, overweight status, obese status, and the manifestation of sensory loss

  24. Issues that may impact design of Exercise • Specificity of training • New models to optimize compliance and adherence

  25. Exercise for Fall PreventionSherrington et al.Effective Exercise for the Prevention of Falls: A Systematic Review and Meta AnalysisJ Am Geriatr Soc, 2008

  26. 0.5 units = clinically meaningful difference Does one size fit all?... Implications of specificity of training • RCT comparing two 16-week exercise programs • N=138, mean age 75 years • 62% had ≥2 chronic musculoskeletal conditions • ~30% with h/o heart disease *Bean, JF et al. Increased Velocity Exercise Specific to Task (InVEST) training vs. the National Institute on Aging’s (NIA) strength training program: changes in limb power and mobility, Jnl Gerontol Med Sci, 2009

  27. Hip Rehab Trial

  28. Hip Rehab Results Main Findings • Improvements at 6 months • Performance-based Mobility • Patient reported Mobility • Patient reported Activities • Findings persisted till 9 months

  29. Exercise and Disablement ICF Model Participation Disability Nagi Model

  30. Department of PM&R, Harvard Medical School “Prehabilitation” 188 community dwelling older adults (75+ years) Gill, TM et al, NEJM Prehabilitation

  31. LIFE study, JAMA 2014

  32. LIFE study-sub groups

  33. Developing new care paradigms:The Live Long Walk Strong Program Focused on mobility and fall injury prevention Integration with Primary Care Medicare compatible Treats those with MCI

  34. The Live Long Walk Strong Program MACIPA PCP P M & R Rehabilitative Care Community PCP SCREEN + _ EDUCATION/ REFERRAL PM&R EVAL + PROGRAM MANAGER PT OT COMMUNITY EXERCISE/ACTIVITY PROGRAMS

  35. How should rehab be designed? http://spauldingrehab.org/conditions-and-treatments/live-long-walk-strong

  36. PCORI/NIA funded trial Implementation Trial • Multicenter RCT • Targeting the prevention of fall related injuries • Pepper Centers • Ancillary studies welcomed

  37. Cognitive Function and Mobility • Cognitive decline linked to mobility decline • Alzheimer’s • Mild Cognitive Impairment • Role of executive function • Dual task performance • Walking while talking • Predictive of falls and functional decline

  38. MCI and Mobility in Boston RISE

  39. Prevalence of Musculoskeletal Pain Leveille et al; JAMA, 2009

  40. Pain and the onset of mobility problems and disability Eggermont et al. , JAGS, 2014

  41. Mskl Pain and Mobility

  42. Summary Points • Exercise can help slow functional decline among older adults • We must be aware of conditions such as MCI and Pain that can impact participation • PM&R clinicians should embrace this challenge • Take advantage of available resources • Geriatrics at your finger tips

  43. Questions and Comments

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