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Exercise and Aging. Brian K. Unwin, M.D. Colonel, United States Army Department of Family Medicine Uniformed Services University. Who are you?. Why are you here?. Goals. Develop an understanding of normal aging physiology

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exercise and aging

Exercise and Aging

Brian K. Unwin, M.D.

Colonel, United States Army

Department of Family Medicine

Uniformed Services University

goals
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
physiologic changes with aging board questions
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
physiologic changes with aging board questions10
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)
physiologic questions
Physiologic Questions
  • Increased
    • Arterial stiffness
    • Myocardial stiffness
    • Systolic blood pressure
    • Diastolic blood pressure
    • Visceral fat mass
    • Total body fat
    • Intramuscular lipid accumulation
exercise and vo2 max
Exercise and VO2 Max

Hazzard, 4th edition

use it or lose it
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
use it and lose less of it
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%
what is exercise
What is exercise?
  • Lifestyle choices
  • Organized sports
  • Unstructured play
  • Household and Occupational tasks
increased muscle mass
Increased Muscle Mass
  • Endurance training emphasis
    • Walking isn’t enough
  • Progressive resistance training
    • DM prevention?
    • Dependency prevention?
    • Falls and fractures
    • Disuse
    • Sarcopenia
    • Frailty
body composition
Body composition
  • Genetic, lifestyle and disease factors
  • Metabolic, cardiovascular and musculoskeletal systems impacted
  • Lifestyle is under patient’s control
burning fat
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
what s fat got to do with it
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?
geriatric disease and epidemiology
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

common chronic diseases
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
diabetes and osteoporosis
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
dyslipidemia
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
hypertension
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
ascvd and aspvd
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.
arthritis
Arthritis
  • Improved functional status
  • Faster gait
  • Lower depression
  • Less pain
  • Less medication use
  • Strength and endurance training benefit
cancer
Cancer
  • Potential protective benefits with
    • Breast Cancer
    • Colon Cancer
exercise treatment of chronic disease
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
emotional well being
Emotional well being
  • Genetic, social, personality, and psychological constructs
  • Leading cause of death and disability in developed countries
exercise and mental health
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
function relates to strength
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
fitness and functional status
Fitness and Functional Status

Hazzard, 4th Edition

exercise relevant in geriatrics
Exercise relevant in geriatrics
  • Exercise appropriate in frail elderly
  • Exercise appropriate with comorbidities
  • Exercise appropriate in functional impairment and disability
contraindications
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
for everyone else
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?
risk factors
Risk Factors
  • Hypertension
    • Beta Blockers
  • Hypercholesterolemia
  • Smoking
  • Diabetes
    • Hypoglycemics
  • Family History
  • Orthopedic Risk Factors
    • Susceptible to injury
    • High intensity resistance
    • High impact aerobics
risk assessment categories
Risk Assessment Categories
  • Apparently Healthy
    • Zero to one risk factors
  • Higher Risk
    • 2 or more risk factors or symptoms
  • Disease
    • Cardiac
    • Pulmonary
    • Metabolic
exercise stress test
Exercise Stress Test
  • High Risk Individual
  • Generally no indication for individual planning mild to moderate exercise
consider other impairments
Consider other impairments
  • Vision/hearing
  • Adaptive devices
  • Environmental issues
exercise prescription
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
acsm guidelines for healthy aerobic activity
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
acsm active aging
ACSM Active Aging
  • 5 ways to eat better
  • 5 ways to increase eating pleasure
  • 5 ways to eat well
  • 5 easy steps to begin endurance exercise
  • Exercising safely
  • Three ways to test your fitness
  • Five causes of inactivity
  • Five easy steps to beginning strength exercises
summary
Summary
  • Exercise prescription is essential
  • Potential for significant improvements at mid-life
  • Role in prevention and treatment of common diseases
  • Few reasons not to provide exercise prescription
more physiology

More Physiology

Courtesy:

Col (R) George Fuller, M.D.

Reference:

Hazzard’s Practice and Principle of Geriatrics and Gerontology, 4thEdition

cv changes associated with aging
CV Changes Associated with Aging
  • LV wall thickness: mild increase
  • Cardiac mass: mild increase
  • LV capacity: minimal to no change
  • Functional reserve: decreased
  • LV systolic function: no change
  • LV diastolic function: decline
aging cv physiology
Aging CV Physiology
  • Preload: preserved due to atrial kick
  • Afterload: increased
  • Resting Heart Rate: no change
  • Maximum: attenuated
  • Cardiac Output: no change
aging heart response to exercise
Aging Heart: Response to Exercise
  • SV: increase
  • Diastolic LV filling: early deficit
  • LVEDV (preload): increases
  • LVESV: reduced
  • Cardiac Output: maintained
  • Net effect: increased volume ejected
ventilation changes with aging
Ventilation Changes with Aging
  • Gas exchange: less efficient
  • Rib cage: more rigid
  • Lung elastic tissue: diminishes
  • Fibrous tissue: increased
  • Compliance: diminished
  • Respiratory muscles: decline
  • Alveolar surface are: reduced
  • Oxygen transport: reduced
ventilation changes with aging58
Ventilation Changes with Aging
  • Resistance to airflow: increases
  • Vital capacity: reduced
  • Arterial O2 tension: falls
  • Mean arterial O2 saturation: falls
  • Arterial CO2 tension: no change
  • Diffusing capacity: reduced
  • Ventilation/Perfusion Imbalance
aging lungs response to exercise
Aging Lungs: Response to Exercise
  • Training attenuates decline in lung capacity
  • Overall, no limitation in pulmonary function with no lung disease
muscular changes with aging
Muscular Changes with Aging
  • Strength: decline
  • Muscle mass: decreased
  • Nervous system: decrease chain of activation from CNS to motor unit activation
  • Motor latencies increase
  • Alpha motor neurons: decrease in size and number
  • Neuromuscular junction: degeneration
  • Mitochondrial disruption
aging muscles response to exercise
Aging Muscles: Response to Exercise
  • Strength: maintenance or gains
  • Muscle mass: increased
aging and aerobic capacity
Aging and Aerobic Capacity
  • Peak between 15-30
  • Declines with age
  • Approximately 10% per decade after age 25-30
    • Masters Athletes: 5% per decade
    • Overall: 0.55 decline per year in VO2 max
  • Anaerobic threshold: occurs at lower work rates
aerobic capacity response to exercise
Aerobic Capacity: Response to Exercise
  • VO2 max: exercise attenuates the decline
  • Strength training: little effect
references
References
  • MA Singh. Exercise and Aging, Clin Geriatr Med. (2004) 20: 201-221.
  • RS Schwartz, DM Buchner. Exercise in the Elderly: Physiologic and Functional Effects. In: Hazzard’s Principles of Geriatrics and Gerontology. Fourth Ed.
  • Kerse, et al. Is physical activity counseling effective for older people? A cluster randomized, controlled trial in Primary Care. JAGS. (2005) 53:1951-1956.
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MJ Hessert, et al. Functional Fitness: Maintaining or improving function for elders with chronic disease. Fam Med. (2005) 37(7): 472-6.
  • Pang, et al. A community-based fitness and mobility exercise program for older adults with chronic stroke: A randomized, controlled trial. JAGS. (2005) 53: 1667-1674.