1. 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

3. Are these women aging well???

4. Aging does NOT have to be ugly John Turner, age 67 John Turner, age 79

5. 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

6. Causes of frailty • Primary……loss of muscle • Secondary: lifestyle factors

7. 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

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-α, 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”

10. 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)

11. Consequences of lost muscle mass

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

13. 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 Baltimore Longitudinal study

14. Grip strength for 874 men

16. 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

18. Muscle function in master lifters Pearson et al, MSSE, 2002

19. IIa fiber cross-sectional area in VL biopsies from Master weight-lifters

20. 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

21. Fiatarone study • Exercise plus nutrition- effect on strength • Unknown if exercise enhances absorption from gut Fiatarone et al, NEJM, 1994

22. Lifestyle factors that influence well-being in later years……. • STRESS • Loss of friends. spouse • Poverty • Health • Loss of independence • Depression

23. 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

24. WOMEN (84±4 yrs) 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%) MEN (81±3 yrs) Bench Press 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 for frail elderly

25. WOMEN Knee flexion 53-75 (42±7%) Seated row 51-70 lbs (37±9%) Total % increase= 45% Sum of gains= 114 lbs MEN Knee flexion 65-110 lbs (69±13%) Seated row 73-125 lbs (71±15%) Total % increase= 67% Sum of gains= 192 lbs Strength-training cont’d

26. 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

27. Functional outcomes- PPT

28. Other contributors to frailty?

29. Is there an increase in osteoporosis? • My goodness, yes! • By age 50, more than 50% of women are already on their way toward osteoporosis.

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

31. Much greater risk for fracture • Poorer bone stock • Living longer • Little physical demand

32. 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

33. What does it all mean? Your mother was right

34. Goal: Compression of Frailty Percent Age in years

35. 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

36. 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

37. Most of what we do is sedentary

38. And this is the consequence

39. Children spend 4.5 more time in sedentary activities than 50 yrs earlier Hobbies, board games, TV 1950 1950 4.5X 4.5X TV, music, computer, video games reading, movies 2000 2000 10 40 Number of hours per week Hypokinetic Disease Kraus & Raab, 1961 www.kff.org publication#7250, 2005 Hypokinetic Disease Kraus & Raab, 1961 www.kff.org publication#7250, 2005

40. 100 80 60 40 2044 20 0 2060 2040 1960 1980 2020 2000 Extending its increasing rate of rise, all children (6-11 yrs old) are predicted to be obese in 2044 Source: Simon Lees

41. Why are we concerned about this? Obese children develop adult chronic disease risk factors

42. 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 103:1175, 1999

43. 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

44. 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

45. 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

46. Myths of aging: to be old is to be sick

47. 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

48. 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

49. 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

50. Myth: OLD= DISEASE • No question: the incidence of disease increases markedly with advancing age. • Most of the diseases affecting older adults are lifestyle-related