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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

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
Disclosures
  • Federal Funding
    • NIH
      • NIA, NICHD
  • No other disclosures
outline
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
aging and demographics
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

changes with aging
Changes with Aging

Both Strength and power decline after age 35

1995, Metter et al., Baltimore Longitudinal Study on Aging

percent of older persons with difficulty or inability in adls by age and sex united states 1995

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

older patients have high rates of comorbidity
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
does the disease model help us conceptually
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

mobility is predictive of adverse outcomes
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

jama april 2014
JAMA April 2014

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

mobility within the disablement paradigm
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

clinical practice
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

exercise and impairment
Exercise and Impairment

ICF Model

Body System Impairment

Impairment

IMPAIRMENT

Nagi Model

slide17
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

trunk muscle integrity and aging
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

exercise and mobility
Exercise and Mobility

ICF Model

Mobility

Functional Limitation

Activity

Nagi Model

what impairments should be prioritized
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

multivariable models prediction llfdi function
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

issues that may impact design of exercise
Issues that may impact design of Exercise
  • Specificity of training
  • New models to optimize compliance and adherence
slide26

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

does one size fit all implications of specificity of training

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

hip rehab results
Hip Rehab Results

Main Findings

  • Improvements at 6 months
    • Performance-based Mobility
    • Patient reported Mobility
    • Patient reported Activities
  • Findings persisted till 9 months
exercise and disablement
Exercise and Disablement

ICF Model

Participation

Disability

Nagi Model

prehabilitation
Department of PM&R, Harvard Medical School

“Prehabilitation”

188 community dwelling older adults (75+ years)

Gill, TM et al, NEJM

Prehabilitation
developing new care paradigms the live long walk strong program
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

macipa pcp p m r rehabilitative care community

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

how should rehab be designed
How should rehab be designed?

http://spauldingrehab.org/conditions-and-treatments/live-long-walk-strong

pcori nia funded trial
PCORI/NIA funded trial

Implementation Trial

  • Multicenter RCT
  • Targeting the prevention of fall related injuries
  • Pepper Centers
  • Ancillary studies welcomed
cognitive function and mobility
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
prevalence of musculoskeletal pain
Prevalence of Musculoskeletal Pain

Leveille et al; JAMA, 2009

summary points
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
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