Exercise and Aging

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Exercise and Aging

• Brian K. Unwin, M.D.
• Colonel, United States Army
• Department of Family Medicine
• Uniformed Services University

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Who are you?
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Why are you here?
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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

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By attending this lecture you will
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Exercise and aging physiology
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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

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Physiologic changes with aging (Board Questions)

• 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

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Physiologic Questions

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

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Age Related DeclineWhat is Normal?Hazzard, 4th
Edition, p. 1390
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Exercise and VO2 Max
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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

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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

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What is exercise?

• Lifestyle choices
• Organized sports
• Unstructured play
• Household and Occupational tasks

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Increased Muscle Mass

• Endurance training emphasis
• Walking isnt enough
• Progressive resistance training
• DM prevention?
• Dependency prevention?
• Falls and fractures
• Disuse
• Sarcopenia
• Frailty

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Body composition

• Genetic, lifestyle and disease factors
• Metabolic, cardiovascular and musculoskeletal
  systems impacted
• Lifestyle is under patients control

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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

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Whats 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

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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

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Exercise and prevention
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Common Chronic Diseases

• Genetic
• Environmental factors
• Most chronic illness related to behavior and
  patterns of physical activity
• Exceptions Parkinsons, degenerative neurologic
  diseases
• Exercise may be protective with dementia

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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

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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

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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

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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.

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Arthritis

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

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Cancer

• Potential protective benefits with
• Breast Cancer
• Colon Cancer

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Exercise treatment of chronic disease

• May treat symptoms and disuse and not the
  underlying disease
• Parkinsons
• COPD
• Claudication
• Chronic renal failure
• May reduce recurrence of disease
• ASCVD
• Falls

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Exercise and emotional health and well being
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Emotional well being

• Genetic, social, personality, and psychological
  constructs
• Leading cause of death and disability in
  developed countries

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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

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Exercise and disability
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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

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Fitness and Functional Status
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Exercise relevant in geriatrics

• Exercise appropriate in frail elderly
• Exercise appropriate with comorbidities
• Exercise appropriate in functional impairment and
  disability

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Exercise and longevity
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Exercise Evaluation
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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

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For everyone else

• What does the patient want?
• What does the patient need?
• What are the patients cardiac risk factors?
• What are the patients orthopedic risk factors?

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Risk Factors

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

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Risk Assessment Categories

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

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Exercise Stress Test

• High Risk Individual
• Generally no indication for individual planning
  mild to moderate exercise

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Consider other impairments

• Vision/hearing
• Adaptive devices
• Environmental issues

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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

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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

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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

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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

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More Physiology

• Courtesy
• Col (R) George Fuller, M.D.
• Reference
• Hazzards Practice and Principle of Geriatrics
  and Gerontology, 4thEdition

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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

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Aging CV Physiology

• Preload preserved due to atrial kick
• Afterload increased
• Resting Heart Rate no change
• Maximum attenuated
• Cardiac Output no change

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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

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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

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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

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Aging Lungs Response to Exercise

• Training attenuates decline in lung capacity
• Overall, no limitation in pulmonary function with
  no lung disease

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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

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Aging Muscles Response to Exercise

• Strength maintenance or gains
• Muscle mass increased

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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

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Aerobic Capacity Response to Exercise

• VO2 max exercise attenuates the decline
• Strength training little effect

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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
  Hazzards 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)
  531951-1956.

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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.