Category Archives: aging

What Should Your Maximal Exercise Heart Rate Be?: The Importance Of Using The Right Age-Predicted HRmax Formula

A reader who runs 5Ks posted a question recently which indicated concern that his heart rate during intense exercise was much higher than his age-predicted heart rate.  He writes

I’m 65, exhaustion HRmax is 188, HRave for 5k is usually 152-154 and interval HRmax is usually 175-179 depending on how hard I push”

He wondered if he should be concerned about being a “high-beater.”

This prompted the skeptical cardiologist to examine the literature on age-predicted maximal heart rate which led to the shocking discovery that the wrong formula is being utilized by most exercise trainers and hospitals.

First , some background.

The peak heart rate achieved with maximal exertion or HRmax has long been known to decline with aging for reasons that are unclear.

The HR achieved with exercise divided by the HRmax x 100 (percentage HRmax) is widely used in clinical medicine and physiology as a basis for prescribing exercise intensity in cardiac rehab programs, disease prevention programs and fitness clinics.

During stress tests we seek to have patients exercise at least until  their heart rate gets to at 85% of HRmax.

The Traditional Formula For HRmax

The formula that is widely used for HRmax is

HRmax = 220-age

It appears to have originated from flawed studies in the early 1970s. These studies included subjects with cardiovascular disease, smokers and patients on cardiac medications.

The Improved HRmax Formula

Tanaka, et al in 2001 performed a meta-analysis of previous data on HRmax along with accumulating data in their own lab. This was the first study to examine healthy, unmedicated, nonsmokers. In addition each subject achieved a verified maximal level of effort as documented by metabolic stress testing.

Their analysis obtained the regression equation (which I term the Tanaka equation)

HRmax = 208-(0.7 x age) 

Below is the graph of the laboratory measurements from which the regression equation was obtained.

Relation between maximal heart rate (HRmax) and age obtained from the prospective, laboratory-based study.(Tanaka, et al)

This graph shows how  inaccurate the traditional equation is, especially in older  individuals like my reader:

Regression lines depicting the relation between maximal heart rate (HRmax) and age obtained from the results derived from our equation (208 − 0.7 × age) (solid linewith 95% confidence interval), as compared with the results derived from the traditional 220 − age equation (dashed line). Maximal heart rates predicted by traditional and current equations, as well as the differences between the two equations, are shown in the table format at the top.(from Tanaka, et al)

The traditional equation in comparison to the Tanaka equation  overestimates HRmaxin young adults, intersects with the present equation at age 40 years and then increasingly underestimates HRmaxwith further increases in age. For example, at age 70 years, the difference between the two equations is ∼10 beats/min. Considering the wide range of individual subject values around the regression line for HRmax(SD ∼10 beats/min), the underestimation of HRmaxcould be >20 beats/min for some older adults.

There are likely lots of perfectly healthy individuals in their sixties and seventies then who have heart rates at maximal exertion that exceed by 10 to 20 beats per minute the HR max predicted by the traditional formula.

This is due to a combination of the inaccuracy of the traditional formula and the wide variation in normal HR max at any given age (standard deviation (SD) of approximately 10 beats/min.)

Thus, my reader at age 65 would have a HRmax predicted by the Tanaka equation as

208-0.7 x 65=162

If we allow for a 10 BPM range of normality above and below 162 BPM we reach 172 BPM which gets close to  but doesn’t reach the reader’s 188 BPM.

If you examine the scatterplot of the Tanaka data you can see that several of the points for age 65 reach into the 180s so chances are my reader is still within normal limits

The Bottom Line on HRmax

The widely used traditional formula for predicting HR max is inaccurate.

Athletes, trainers, physicians and hospitals should switch to using the superior Tanaka HR max formula.

Individuals should keep in mind that there is a wide range of HR response to exercise in normals and variations of 10 BPM above and below the predicted response are common and of no concern.

Chronotropically Yours

-ACP

Addendum. The 220-age formula is so heavily etched into my brain that I used 220 instead of 208 when I initially calculated the predicted max HR for my reader. this has been corrected.Thanks to Chris Sivewright for pointing this out.

Thoughts On Physician Assisted Suicide

A beloved patient of the skeptical cardiologist committed suicide two years ago.

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Although 90 years in chronological age, Phyllis appeared and behaved as one much younger. She was full of life, energy and happiness when she came to my office for treatment of her atrial fibrillation and heart failure.

 

Her daughter and I discussed what happened and how it could have been prevented.  Her perspective follows:

My mother, Phyllis, was a complicated woman.  She was intelligent, charming, beautiful, spirited and fun with an inquisitive mind and many interests.  She could play competitive Bridge and win, even in her 90’s. She drove a little red convertible and had the top down whenever possible. She liked to dress stylishly and had excellent taste.  She had a lifelong habit of health and always exercised and ate carefully…except for chocolate.  She had a legendary addiction to chocolate and I think she will be remembered in our family for many generations to come by all of the wonderful chocolate stories. She was always working to improve herself and to that end almost never read fiction, preferring biography or autobiography. In her 40’s she took up synchronized swimming and water ballet.  She was very single minded in her goal to improve her skills, participated in the Sr. Olympics in Denmark in 1989 and won a silver medal!  At the age of 50 she decided to take up skiing and although she gave it up at 65, she did get good enough to ski the black slopes.  She was very happily married to my father, Jack, until his death at 69.  A few years later she married Earl and they had a solid union until his death.

She made the decision to end her life very soberly with much deliberation.  This had been on her mind for years before she actually accomplished it.  The prior Spring she had set a date and only due to much family intervention, involving lots of fun, did she cancel it.  She felt the odds of something happening to her, which would keep her bed or wheelchair bound or would take away her mental facilities, became greater and greater with each passing year. In her final year she could see differences with each passing month.  She never wanted to be dependent on anyone or anything. She was not depressed.  She had several falls in the last few months, nothing serious, just cuts or bruises, but she could see it was just a matter of time before a bad fall could take her out.  She no longer could eat chocolate or drink coffee or wine, all of which had been a great comfort to her. She had developed a heart problem, which she knew would only get worse as she aged. And she was very scared that her lifelong habit of heath would backfire on her.  That she would go on and on and on trapped in a bed or left with no mind.

She had discussed suicide with all her family at great length in the years leading up to her death. She didn’t like the idea anymore that we did but she was afraid that something would happen to her and she would no longer have the ability to make this decision if she felt it was necessary.

So in the early hours of February 19, 2016 she put a gun in her mouth and pulled the trigger.

How unfair that she had to do this gruesome and scary thing all by herself. She would still be alive if she knew that when the time came in which she no longer felt she had an acceptable quality of life she could have taken a pill or be given a shot and then died gently surrounded by all who loved her.

I think everyone needs to look at their own life and ask themselves – what do I want the final years of my life to look like?  Medical science has given us the ability to live much longer healthier lives.  But that comes at a cost.  Many people live on and on in nursing homes, just shells of humans because medical science can keep them alive almost indefinitely.  Is this what the average person wants?  Do most people think to themselves – I’m really looking forward to those years when I’m fed, bathroomed and bathed by strangers?

I think Physician Assisted Suicide can be a good answer for those people who do not want to live in this manner and have made their intentions very clear to family and doctors.

I miss my mom.  I miss our long talks and walks.  I miss lunches out with her. I even miss our disagreements.  And I know that if Physician Assisted Suicide had been legalized in Missouri, she would still be here, playing Bridge, laughing, talking about good books, enjoying family visits, shopping for pretty clothes and getting ready for all the parties of the Holiday season.

 

Physician-Assisted Suicide

Since this happened I have become an advocate of state laws allowing physician-assisted suicide (PAS).  These laws are intended  for patients with terminal disease, but I think if Phyllis had lived in a state where these existed she would not have felt compelled to do what she did.

Physicians are divided on the topic of PAS with 55-65% in state medical society surveys favoring allowing such laws.

Despite this, the American College of Physicians recently published a position paper stating its opposition to PAS:

It is problematic given the nature of the patient–physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession’s role in society. Furthermore, the principles at stake in this debate also underlie medicine’s responsibilities regarding other issues and the physician’s duties to provide care based on clinical judgment, evidence, and ethics. Society’s focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care.

Stat news has two physician-authored pieces on this topic which are well worth reading. In the first article, Ira Byock, M.D., a palliative care physician, writes that “there are some things doctors must not do. Intentionally ending patients’ lives is chief among them.” He decries excessive pain and suffering at the end of life but thinks that “so much of that kind of suffering could have been avoided with good care.”

The second article was written by Roger Kligler a physician in his sixties who is dying of metastatic prostate cancer. He writes:

When my suffering becomes intolerable, I hope my doctors will permit me the option to end it peacefully with medical aid in dying — something I have been working to get explicitly authorized in Massachusetts, where I live. Medical aid in dying gives mentally capable, terminally ill adults with six months or less to live the option to request a prescription medication they can choose to take in order to end unbearable suffering by gently dying in their sleep.

For more information on this topic I recommend the website of Death with Dignity, the organization which authored the Oregon statute governing the prescribing of life-ending medications to eligible terminally ill people. About 100 patients a year have taken advantage of the Oregon Death With Dignity Statute. The website notes that “Overall, 1,545 patients obtained a lethal prescription from 1998 through 2015. On average, 64 percent took the drugs.  Almost all died but six people woke up and died later of natural causes.”

-ACP

 

 

 

Should You Take A Statin If You Are Over 75?: The Value of DeRisking in The Elderly

The NY Times published an article earlier this month with the provocative title “You’re Over 75, and You’re Healthy. Why Are You Taking a Statin?”

It’s actually a balanced presentation of this difficult question (although it includes the seemingly obligatory anecdote of a patient getting severe muscle aches and weakness on Lipitor) and I agree with the concept that patients should demand a good thoughtful explanation from their PCP if they are on a statin.  Shared  physician and patient decision-making should occur irrespective of age when a statin is prescribed.

Unfortunately, the NY Times piece was triggered by and contains references to a weak observational study that was recently published in the Journal of  the American Geriatric Society..

A much better article on this same topic was published earlier in January in what is arguably the most respected cardiology journal in the world (Journal of the American College of Cardiology).

It contains what I think is a very reasonable discussion of the problem: the elderly at are a substantially higher risk of adverse “statin-associated symptoms” but also at much higher risk of stroke, heart attack and cardiovascular-related death than the young.

Key Points To Consider For Use of Statins In Elderly

Some key points from that article to ponder for those over 75 years

  1. Major European and North Americans national guidelines differ markedly in this area as this graphic illustrates

“At one end of the spectrum, the 2016 ESC/EAS guidelines miss great opportunities for safe, cheap, and evidence-based prevention in elderly individuals 66 to 75 years of age. At the other end of the spectrum, the 2014 NICE guideline provides near-universal treatment recommendations well into the very elderly >75 years of age where RCT evidence is sparse and more uncertain.”

2. Data on from 2 large primary prevention trial (JUPITER and HOPE-3) show that rosuvastatin (Ridker, et al)

reduced the risk of a composite endpoint (nonfatal MI, nonfatal stroke, or cardiovascular death) substantially by 49% (RR: 0.51; 95% CI: 0.38 to 0.69), and the risk was reduced by 26% (RR: 0.74; 95% CI: 0.61 to 0.91) in those ≥70 years of age. The efficacy was similar in individuals ≥70 and <65 years of age, indicating little heterogeneity in treatment effect by age. Today, nearly all apparently healthy elderly individuals have RCT evidence supporting statin efficacy.

3. The elderly compared to the younger are much more likely to have a nonfatal event  which does not reduce their longevity but impacts their quality of life.

Thus, patient preferences are critical important for well-informed shared decision-making. If a patient only values longevity, there are little data to support primary prevention with statins in people >65 years of age. On the other hand, if preventing nonfatal and potentially disabling MI or stroke is of value to the patient, it might be reasonable to initiate statin therapy. From this perspective, it is noteworthy that the relative importance that people assign to avoiding death compared with avoiding nonfatal events appears to be highly age dependent. Although younger individuals <65 years of age weigh avoiding death highest, elderly individuals ≥65 years put a much higher weight on avoiding MI or stroke than death, These differences are compatible with elderly individuals having a greater focus on quality of life and avoiding disability than on extending life.

The Value of Derisking and Deprescribing

In my practice, I do a fair amount of deprescribing statins in the elderly. I have a very low threshold for initiating a trial  of temporary statin cessation if there is any question that a patient’s symptoms could be statin-related (see here.)

The older the patient, the higher the bar for initiating statins and I think in all patients a search for subclinical atherosclerosis (coronary calcium scan or vascular ultrasound) helps inform the decision.

Previously, I had no term for this higher bar but I like the  term  the  JACC paper introduces, derisking:

A promising approach to personalize treatment in elderly people is “derisking” by use of negative risk markers (i.e., absence of coronary artery calcification) to identify those at so low risk that statin therapy may safely be withheld . In the BioImage study of elderly individuals, for example, absence of coronary artery calcification was prevalent (≈1 of 3) and associated with exceptionally low ASCVD event rates

If you are >75 ponder all these factors and have an intense discussion with your doctor about taking a statin.

If you are still on the fence after this discussion consider a compromise approach that I have outlined here.

Deriskingly Yours,

-ACP

Exercise As Medicine: Preventing Age-Related Decline in Cardiac Stiffness

As we age our hearts and arteries become stiffer. This cardiovascular stiffening plays a key role in hypertension, atrial fibrillation, and heart failure in older individuals (1).

Age-related cardiac stiffening is worse in those who are sedentary compared to those who exercise regularly (2).

Recent studies strongly suggest that regular exercise can prevent or minimize these age-related changes, thereby hopefully reducing the high rate of heart failure, hypertension and atrial fibrillation in the elderly.

In my post on fitness as a vital sign I briefly mentioned a fascinating study from 2014 which looked at 102 healthy seniors (age>64 years) and stratified them into 1 of 4 groups based on their lifelong histories of endurance exercise training.

Consider which of these 4 categories you fall into:

Sedentary subject-exercised no more than once per week during the prior 25 years.

Casual exercisers-engaged in 2-3 sessions per week

Committed exercisers-performed 4-5 sessions per week

Competitive “Masters level” athletes-trained 6-7 times per week

Exercise sessions were defined as periods of “dynamic activity lasting at least 30 minutes.”

The participants had sophisticated measures of their exercise capacity (max VO2), the size and mass of their left ventricles (cardiac MRI) and the stiffness of their left ventricles (invasive pressure/volume curves to calculate LV compliance and distensibility.)

This graph shows the key finding of the study: a markedly different pressure/volume curve in the sedentary and casual exercisers (blue and red dots) versus the committed or master exercisers. The two curves on the left correspond to a very stiff heart, similar to curves found in patients with heart failure.

The far right curve of competitive exercisers resembles that of a young heart.

The black triangle curve of the committed exerciser is in between these extremes

F5.large-3

The study concludes:

“low doses of casual, lifelong exercise do not prevent the decreased compliance and distensibility observed with healthy, sedentary aging. In contrast, 4 to 5 exercise sessions/week throughout adulthood prevent most of these age-related changes”

It would appear we need at least 4-5 30 minute exercise session per week to forestall the age-related stiffening of the heart and lower our chances of getting heart failure, hypertension and atrial fibrillation.

Since this was an observational study there is always a chance that lack of exercise is not the causes of poor cardiac stiffness.  It is conceivable that those of us with stiffer hearts tend to be more sedentary because of the poor cardiac function.

Can You Reverse The Age-Related Changes In Cardiac Stiffness?

If you have already reached middle age there is still hope for you as these same investigators recently published a study showing that cardiac stiffness can be improved with exercise. These findings imply that lack of exercise is the cause of worsening cardiac stiffness with aging.

This study identified 61 sedentary men in their mid-fifties and randomly assigned them to either 2 years of exercise training or attention control (a combination of yoga, balance, and strength training 3 times per week for 2 years) and measured their LV stiffness and max VO2 before and after intervention.

Max VO2 increased by 18% and LV stiffness declined from .072 to .051 in the exercise group but did not change in the control group.

The exercise training arm of this study involved a mixture of continuous moderate-intensity aerobic exercise combined with high intensity training. The high intensity portion of the program involved exercising at 90-95% of HR maximum for 4 minutes followed by a 3 minute active recovery period, repeated 4 times.

Over a period of 6 months under the guidance of exercise physiologists the participants had their exercise levels gradually increased. After 6 months they were training 5-6 hours per week, including 2 of the “high intensity interval” session and 1 long (>/= 1 hour) and one 30-minute base pace session each week.

By the sixth month, participants were training 5 to 6 hours per week, including 2 interval sessions, and 1 long (at least an hour) and one 30-minute base pace session each week.

How Much Exercise Do We Need To Minimize Cardiac Aging?

This chart from recent European guidelines on lifestyle for prevention of disease describes different intensities of aerobic exercise:

 

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These guidelines suggest that if you engage in vigorous exercise such as running or jogging, cycling fast or singles tennis, you only need to achieve 75 minutes per week. Moderate exercise such as walking or elliptical work-outs requires at least  150 minutes/week.

Based on these recent studies on exercise and cardiac stiffness and the bulk of scientific literature on the overall health benefits of exercise I would advise for all individuals with or without heart disease

-If you are sedentary, become a committed exerciser.

-Committed exercise means some form of dynamic exercise 4-5 times per week

-If you are already a committed exerciser at moderate intensity levels consider adding to your routine one or two sessions of high intensity interval exercise.

-High intensity exercise will require you to get your heart rate up to 90-95% of your maximum 

-Predicted maximal HR=220 -age.  For a 60 year old this equals 160 BPM. 90% of 160 equals 144 BPM. 

Compliantly Yours,

-ACP

 

 

 

 

What Can We Learn About Heart-Healthy Lifestyle From The Tsimane People of the Amazon Rainforest ?

The skeptical cardiologist has been in Washington, DC attending the Scientific Sessions of the American College of Cardiology for the last three days in an attempt to upgrade his cardiology knowledge and obtain CMEs for all the various areas he needs CME (echo/nuclear/CT/vascular).

I’ve written some posts for SERMO, a physician social media site,  on interesting presentations from the meeting.

Here’s my take on one paper (published simultaneously in The Lancet) that is of general interest:

I’m a big advocate of coronary artery calcium (CAC) scans for helping make decisions on individual patients with intemediate risk for CAD. Several speakers at this year’s American College of Cardiology Meetings presented convincing data supporting this approach, providing more information to get patients off the fence about taking statins.

However, CAC apparently would be a useless test in the Tsimane (pronounced chee-MAH-nay) people according to a study presented at  the ACC meeting and published simultaneously in The Lancet.

Researchers performed CT scans on 700 of  these “forager-horticulturalist”  people, indigenous to the Bolivian Amazon Rainforest and found very little calcium suggesting that they have an amazingly low rate of atherosclerosis compared to we who have to live in the industrialized world.

Obviously CT scanners are not portable so the Tsimane traveled by river and jeep from the Amazon rainforest to Trinidad, a city in Bolivia and the nearest city with a CT scanner. It took tribe members one to two days to reach the nearest market town by river, and then another six hours driving to reach Trinidad.

85% of the Tsimane people studied had CAC scores of 0. In those over age 75 years, 65% had CAC scores of 0, and just four individuals in their 80s had moderately elevated CAC (> 100). The incidence of CAC > 100 in the entire Tsimane population was 3%, which is about one tenth the prevalence in a matched industrialized population. In addition, incidences of obesity, hypertension, high glucose concentrations, and cigarette smoking were rare overall.

The Tsimane live a subsistence lifestyle that includes hunting, gathering, fishing, and farming. They don’t eat at McDonalds and the men spend almost 7 hours pers day on physical labor. Their diet consists mostly of unprocessed fiber-rich carbohydrates with rice, plantain, manioc, corn, wild nuts, and fruit composing their staples. Fat consumption is 9% of calories versus 23% in the U.S.

Supporters of plant-based diets, of course, seized on these data to support the unsubstantiated claim that meat and dairy consumption is the main cause of atherosclerosis in western civilization.

Hillard Kaplan, one of the authors and a Professor of anthropology at the University of New Mexico said:

 “Their lifestyle suggests that a diet low in saturated fats and high in non-processed fibre-rich carbohydrates, along with wild game and fish, not smoking and being active throughout the day could help prevent hardening in the arteries of the heart. The loss of subsistence diets and lifestyles could be classed as a new risk factor for vascular aging and we believe that components of this way of life could benefit contemporary sedentary populations.”

However, the real cause of the low levels of coronary artery calcification in the Tsimane remains a mystery because this kind of observational study cannot establish causality. Perhaps it is the 17,000 steps a day that they walk  engaging in foraging and horticulturalism. Could it be due to the absence of processed food and added sugar? The Tsimane have high levels of parasitic infections: perhaps that is protecting them.

Of two things I am certain:

-The Tsimane don’t need statins.

-I prefer my lifestyle to munching on manioc and foraging all day.

Semihorticulturally Yours,

-ACP

 

Longevity: Lifespan, Healthspan and Swimming Underwater At Age 98

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Eugene and Naomi.

The skeptical cardiologist has a few nonagenarian patients who seemingly defy the ravages of aging and remain vibrant and active into their late 90’s.

Eugene, for example, still ballroom
dances regularly with his wife, Naomi and swims underwater significant distances.

In this video, recorded when he was 97, you can see him swim the length of a swimming pool underwater

As life expectancy at birth has increased  from 35 years in 1900 to over 80 years now, we see more and more individuals reaching their nineties. Ongoing research seeks to further extend our lifespan.

But just as important as increasing lifespan is increasing healthspan, the portion of the life span during which function is sufficient to maintain autonomy, control, independence, productivity and well-being.

Eugene is an example of someone with a long lifespan and healthspan and this is what we truly seek, the combination of living well and living long.

Peter Attila writes that lifespan is driven by how long one can avoid the onset of diseases caused by atherosclerosis such heart attacks and strokes (see my  discussions on subclinical atherosclerosis here), cancer and neurodegenerative disease.

Healthspan,  Attila writes, is about preserving three elements of life as long as possible:

  1. Brain—namely, how long can you preserve cognition and executive function

  2. Body—specifically, how long can you maintain muscle mass, functional strength, flexibility, and freedom from pain

  3. “Spirit”—how robust is your social support network and your sense of purpose.

Problems with the body result in frailty, recognized as a major cause of disability and related falls, hospitalizations and death in the elderly.

The single best tool for warding off frailty appears to be physical exercise.

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Eugene and Noami tripping the light fantastic in our exam room

So, if you want to life a long life with lots of quality years at the
end of that life be like Eugene: swim and dance with your loved ones. Keep moving, stretch and exercise in some manner regularly.

Gerontologically Yours,

-ACP

Should Fitness Be A Vital Sign?

The skeptical cardiologist routinely probes his patients’ activity and exercise levels and encourages them to engage in 150 minutes of moderate exercise weekly. However, I’m somewhat skeptical of the benefit of treating such assessments as a vital sign (like blood pressure or heart rate)  as a recent AHA scientific statement suggests.

I can only envision still another item  on a chart checklist that will have to be recorded in the EHR or already over-worked physicians will have their payments withheld.

The AHA statement suggests that ideally we should be measuring  our patients’ fitness by obtaining  maximal oxygen consumption (VO2 max) utilizing an expensive and rarely utilized cardiopulmonary exercise test. Failing that we should consider doing a treadmill stress test. Failing that, rather than utilizing my simple question to patients: “How active have you been?”,  the statement recommends doctors utilize some sort of formal questionnaire to estimate their patients’ cardiorespiratory fitness (CRF) such as the one at World Fitness Level.

I went online to take this CRF estimator (based on this paper) and I remain skeptical.

The online site and  a free smartphone app both ask the following questions:

  • Country and City
  • Ethnicity
  • Highest Level of Education
  • Gender/Age/Height/Weight
  • Resting and Maximal Pulse
  • How often do you exercise?
  • How long is your workout each time? (over/under 30 minutes)
  • How hard do you train? (I had to choose between “I go all out”or “Little hard breathing and sweating”)

 

screen-shot-2016-12-03-at-11-33-13-amWhen you have finished answering the questions you are given an estimate of your fitness age. When I did this online a few days ago and answered truthfully I got the result to the right: I had the fitness of a 41 year old with an estimated VO2 max of 49 ! (interestingly this estimate corresponds exactly with VO2 max derived from a recent stress test I completed.)

I used the app (which unlike the online version did not ask me my waistline measurement) and changed a few parameters:

  • I increased my resting heart rate or pulse  from 60 to 68 beats per minute (BPM)
  • I increased my maximal heart rate from what I know is 158 BPM to what the app calculated (173 BPM, which makes no sense)
  • I switched from exercising 2-3 times per week  and longer than 30 minutes  at “all out” level to the lowest level for all 3 questions.

The change was dramatic and depressing: I went from 39 years old to 67 years old in the bat of an eyelid!img_8073

 

 

 

The app and online site direct you to a non-profit site where you can get information on a 7 week program to increase your fitness level. I haven’t checked this out.

I’ll be trying out this CRF estimator on my patients: assessing whether it adds anything to my usual line of questioning on activity and fitness.

I encourage you to give the CRF estimator a try. Let me know in the comments how you feel it works for you. Does it motivate you to exercise more knowing that, for example, your fitness age is substantially higher than your chronological age?

Happy Birthday, Nonagenarians!: Thoughts On Surgery In The Very Old

On February 26, my dad became a nonagenarian.

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My dad, tripping the light fantastic with grand-daughter-in-law Kelly.

My sister and I, and our offspring, had a brilliant celebratory gathering in Tulsa, Oklahoma for my father’s 90th birthday which included playing “The Priest in the Parish has lost his Considering Cap,” taking photos with queen Elizabeth, dancing to music by Glen Miller and The Beastie Boys, singing karaoke, enchilada and beer consumption, and a Powerpoint presentation on his life.

Nonagenarians, individuals aged 90 to 99 years, are the fastest growing age group in the world: nearly doubling from 6.7 million people in 1995, to 12.2 million people in 2010. Projections suggest that by 2050, there will be 71 million people aged 90 years or older.

Increase In Surgeries In The Very Old

Concomitant with the rise in nonagenarian numbers, we are seeing increasing procedures and surgeries performed on the very old.

My father has had 22 surgeries (itemized in detail in the appendix to Book 2 of his memoirs) including four spinal operations, four hip operations and one total knee replacement at the age of 87.

Obviously, he survived them all, but after one spinal operation, while recuperating at my home in Louisville, he awoke in the middle of the night with severe back pain and the inability to move his legs. He had developed an abscess at the wound site which caused overwhelming sepsis and he spent several weeks in an ICU recuperating from this life-threatening complication.

Is there an age at which individuals should not get elective surgery? Or is it the mileage that counts, not the model year?

Complications of surgery definitely go up with age, but we have all seen 90 year olds like my father who are functioning better mentally  and physically than individuals 20 years younger.

According to the Social Security online calculator, the average man his age can expect to live on average 4.3 more years longer.

A more sophisticated tool is the “Living to 100 Life Expectancy Calculator” which asks 40 questions about your health and family history. When my dad entered his information, it gave him a life expectancy of 98 years (I can expect to live to 99).

If we could be sure that he would continue to have a good quality of life after elective surgery for 4 to 8 years it might makes sense to consider elective procedures and operations that improve mobility and lessen pain.

However, I see a lot of deterioration in the quality of my patients’ lives between the age of 85 and 90, and even more between the age of 90 and 95.

By 95, those who have survived are living a fairly limited life; very few are independent and active, mentally and physically.

Excess and Rationing Of Surgery In The Very Old

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Dr. Michael E. DeBakey, shown with his surgical team in the mid-1960s, has operated on more than 60,000 patients, including Russian President Boris Yeltsin, who called him a “magician of the heart.”

Michael Debakey, the legendary cardiothoracic surgeon (read about his amazing medical contributions in this NYT obit here)  developed a tear in his aorta at the age of 97. He requested that the life-saving, but extremely high risk surgery for the disease (a procedure he had developed 50 years earlier), not be performed on him.

drdebakey01When he lapsed into unconsciousness, his wife insisted on the operation being performed. Dr. Debakey survived the 7  hour surgery but spent 8 months in the hospital recuperating at a cost of over a million dollars. He died two years later at the age of 99.

It’s hard to know what his quality of life was after the operation. The obituary and other reports say that he “returned to his office and an active schedule,” but the skeptic in me suspects that he was wheeled into his office in a wheelchair where he met with admirers as his strength allowed.

Alternatively, you can find cases exmplified by this headline: “Sentenced to death for being old: The NHS denies life-saving treatment to the elderly, as one man’s chilling story reveals.”  The     N HS or British National Health Service is a single payor system, about which concerns have often been raised regarding rationing surgery to the elderly.

In 2010 the anti-health reform group 60 Plus engaged former Surgeon General C.. Everett Koop to appear in a  video which suggests that Democrats were meeting in secret to craft “death panel” legislation that would ration certain surgical procedures.

Factcheck.org, however, debunks Dr. Koop’s claims:

Former U.S. Surgeon General C. Everett Koop claims that the United Kingdom’s health care system would consider seniors “too old” to qualify for the artificial joints, heart pacemakers and coronary stent that he’s received in the U.S.

U.K. guidelines make clear that patients of “any age” may receive pacemakers, for example. And in fact, official statistics show 47 patients aged 100 or older got new or replacement pacemakers in a single recent year.

My dad now tells me he is pondering replacement of his other knee..

Like most treatment decisions doctors make with patients, computers can aid in providing statistics about average complication rates, longevity, and recovery time but ultimately the recommendations for each individual should be based on their unique, often unmeasurable physical, mental and emotional characteristics.

Age alone should never determine our treatment approach.

I  have a feeling my dad will be tripping the light fantastic with his great grandchildren on two artificial knees when we celebrate with profound joy his 95th birthday.

-May you all become  happy centenarians!

-ACP

To learn the answer to questions like, “Why is the actual heart beat so old-fashioned, you know, boom-boom, boom-boom?” watch this Ali G interview of Dr. Koop: