Tag Archives: aging

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

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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

 

 

 

 

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:

 

Burpees and the Dizziness of Aging

Last week a patient that I treat for an arrhythmia who is 60 years old and in outstanding shape told me that he was experiencing dizziness after doing burpees. His personal trainer told him he should talk to his cardiologist about it.

Dizziness is a common complaint of my older patients. Indeed, 30% of individuals older than 65 report dizziness and 50% of the “very old” (older than 85 years) experience dizziness.

If the dizziness is described to me as a sensation that the patient is about to “pass out” or lose consciousness or a feeling of everything turning black I figure it has a cardiovascular cause with the blood pressure in the brain arteries globally reduced transiently. I always take this very seriously as this type of dizziness may be the precursor of total loss of consciousness (syncope) or sudden death.

One study showed that 57% of patients with dizziness age 65-95 were ultimately felt to have a cardiovascular cause.

I find a common cause of dizziness in my patients, especially as they age and if they are on mediations which lower the blood pressure is orthostatic hypotension (.OH)

Orthostatic Hypotension.

Bear with me as I attempt to succinctly describe this very important physiologic phenomenon which everybody has experienced at one time or another.

Orthostatic (meaning related to standing) hypotension (low blood pressure) is defined as a sustained reduction of systolic BP >20 mmHg or diastolic BP >10 mmHg within 3 minutes of standing or following head-up tilt to ≥60o.[

Dizziness due to OH occurs when you stand up quickly or rise from  a kneeling position.

During the process of going from lying or sitting to standing your body has to make some major adjustments to ensure that blood flow to the brain is maintained. As you stand up from lying down your brain suddenly goes from being at the same height as your heart to being (depending on how tall you are) a foot or more higher. Thus, a higher pressure is suddenly needed to keep blood flowing to the brain. The major sensors of blood pressure (baroreceptors) within the vascular system are located in the carotid arteries (large neck arteries providing blood to the brain) and these are constantly sending feedback to the brain.

The carotid sinus baroceptors are stretch sensitive mechanoreceptors that modulate what is called the autonomic nervous system to keep arterial blood pressure constant.

A second process that occurs with standing is pooling of blood due to gravity in veins in the legs and abdomen. This pooling takes blood, in essence, out of the circulatory system, thus lowering the pressure in the heart which in turn can lead to less blood being pumped into the arteries. Part of the autonomic reflex response to standing then involves constricting veins to reduce pooling.

Things that make it more likely you will experience dizziness from OH include

-anything that lowers the volume of blood in your circulatory system. Thus being dehydrated (from vomiting or diarrhea, diuretics, excess alcohol, sweating) or losing blood. A common scenario for passing out from OH is the prep for colonoscopy which induces diarrhea and possible dehydration. Another common scenario is after surgery which causes a combination of blood loss and dehydration (plus other factors) .

-Medications which lower blood pressure

Burpees

burpee 1If you’ve been paying attention and know what a burpee is then you have probably deduced that my patient was suffering from orthostatic hypotension.

I was unaware of the term burpee although I had seen members of my gym (under the watchful eye of their personal trainers who seem to specialize in having their clients undergo bizarre and embarrassing exercises (most likely to justify their fees, After all, you don’t need a personal trainer to show you how to run on a treadmill and properly use resistance machines which, arguably, provides all the aerobic and isometric exercise you need for maintaining optimal cardiovascular and muscular fitness)).

It was named for an American, Royal H. Burpee, who wrote his PhD thesis on this exercise as a measure of fitness. Subsequently, the burpee or squat thrust was adopted by  the US military to assess the fitness of recruits in WWII.

burpee 2According to this Popular Science article from 1944 the army did not consider a soldier ready for the rigors of war until he could do 40 to 50 at an easy pace without resting.

Many personal trainers and boot camps are enamored of this exercise and Men’s fitness magazine  calls them “the most badass exercise”

One personal trainer, Jamie Atlas, believes you should not  do burpees because they put too much stress on the knees and lower back, the two most frequently injured areas of the body. He also points out that the burpee is a good test for a soldier:

the burpee is probably the very best exercise for the military. Or should I say more specifically, for people being shot at by other people with guns. It stands to reason that if a soldier can’t quickly get down to the ground and then quickly get back up again, they’re simply fodder for target practice. A primary need is to be able to drop into a firing position and then bounce back up lightning-fast to move to a safe position — and without a certain standard of ability to complete that particular movement, they are at a significantly higher risk of getting shot than their other, more agile companions.

Burpees and Orthostatic Hypotension

It would be hard to design an exercise that puts a greater stress than multiple burpees on the autonomic reflexes involved in keeping blood flow to the brain constant (I’m somewhat reticent to mention this because I may soon see members of my gym doing it but if you had an exercise that involved standing on your head and suddenly flopping to the ground then jumping up to a standing position that would be a greater stress. If this hasn’t been invented yet, I claim credit and would like it to be called a pearson ©).

My patient said that after doing his required 30 burpees he would stagger around in circles with a sensation that he couldn’t see properly and that he was in imminent danger of passing out and  falling down.

Added to the above-mentioned issues of moving from supine to standing we are now moving from a squat position. In this position the large muscles in the legs are tightened, thus squeezing blood back to the heart and initiating reflexes that are the opposite of those needed to compensate when standing is resumed.

To compound the confusion his body was feeling, my patient’s personal trainer had him jump or spring up from the squat position with his arms raised in the air and his feet leaving the ground. This further adds to the gravitational effects of blood pooling in the legs and abdomen.

Aging and orthostatic hypotension

Dizziness due to OH is more common as we age. We don’t know exactly why but it is likely related to multiple age-related changes in the cardiovascular system and the autonomic nervous system.

Some factors that may play a role include a decrease in baroreflex sensitivity, a decreased vasoconstrictor response to sympathetic stimulation, decreased parasympathetic activity and impaired relaxation of the heart muscle.

It may be possible for the young and fit to do multiple burpees without dizziness but I suspect that the vast majority of sixty somethings are going to notice significant dizziness with this kind of exercise.

Despite what my patient’s personal trainer him, I don’t think dizziness experienced with burpees is a reason to be evaluated by a cardiologist. I think dizziness experienced with burpees is a reason not to do burpees

Perhaps, personal trainers could change from the burpee to the Weak Horse, another exotic exercise and “toughening up” game that comes to us from the military.

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Dizziness experienced with aerobic exercise such as running  or rapid walking can be a sign of a serious cardiovascular disorder and merits being reported to your physician.

-nonburpeeingly yours

ACP

Low T and Me: Does Testosterone Therapy Increase Cardiovascular Risk?

In the last year, several of my patients have asked me whether it is safe for them to take testosterone for “low T.” They were responding to media reports suggesting that testosterone therapy raised heart attack risk by one-third.

I must admit, I had been skeptical of the legitimacy of the “low T” diagnosis.  Many of the symptoms attributed to testosterone (T) deficiency, it seemed, were just part of normal male aging: decreased libido, fatigue, weight gain, and loss of muscle mass.

Perhaps, I thought, men should just be more willing to exercise regularly and lose weight and accept the indignities of aging that result despite our best efforts.

On the other hand, in the back of mind was the idea that perhaps I, as a sixty-something male with declining strength and endurance, could somehow forestall the ravages of aging by taking T.

I googled “low T” and immediately found some sponsored sites, including “is it low T.com,” which appears to be an educational site for patients. However, the one treatment option that they provide links to is made by Abbvie, the somewhat hidden host of the site. Abbvie is a pharmaceutical company that makes Androgel, the most widely prescribed testosterone cream.

lowTquiz

I answered yes to the 3 questions I thought were just uniform consequences of aging:

1. Reduction in strength and/or endurance.

2. Loss of height.

3. Deterioration in your ability to play sports.

After taking the quiz, I was told that answering yes to 3 of the 10 questions strongly suggests you have low T.

In addition, according to the site, if you answered yes to question 1 (decreased libido) or 7 (less strong erections) you have low T.

Based on this quiz, I and 99% of men my age must have low T!!

In the last 10 years, the use of testosterone therapy has quadrupled, driven by better formulations for testosterone delivery and by direct-to-consumer marketing campaigns that suggest that treating low T will reverse these normal consequences of aging.

As a result, in 2013, 2.3 million American men received testosterone therapy and 25% of these men had no baseline testosterone levels tested.

A year ago, the New York Times editorial board opined on the dangers of overprescribing testosterone and the influence of pharmaceutical companies in over-promoting the drug, in a piece entitled “Overprescribing testosterone, dangerously.”  Articles like this are what have raised patients’ concerns about T therapy and increased risk of heart attack.

Testosterone and Mortality

There is a large body of evidence that shows an association between lower T levels and increased mortality and coronary artery disease. Lower T levels are also associated with higher risk of diabetes and the metabolic syndrome.  Studies also show that T therapy in T-deficient men increase lean mass and reduce fat mass and are associated with a reduction in mortality. A recent review article by Morgenthaler, et al in Mayo Clinic Proceedings, provides a detailed and meticulous summary of these studies and data.

Two recent studies contradict this large body of evidence and gained enormous media attention. The first, by Vigen et al in JAMA 2013, was a retrospective analysis of VA patients which has received extensive criticism for its statistical technique and has been corrected twice. The second study was by Finical, et al in PLoS One 2014, suggesting increased mortality in patients for 90 days after receiving their prescription for T. This study also contains methodologic issues and is hardly conclusive.

Is it Safe to Take T for low T

My recommendation to patients who want to take T after looking at all the data is as follows:

-Make sure that you really have low T.  Your total T levels should be less than 300 ng/dL done in a reliable, certified lab.

-At this time, I don’t see solid evidence that taking T, if you definitely have T deficiency, increases the risk of cardiovascular complications or death.

As with all medications, the shortest duration and smallest effective amount is what you should take. All medications have side effects, some that we know and some that we don’t know. Most of the studies that have been published were on small numbers of patients for short periods of time.

-If you are overweight and/or sedentary, there is good evidence that losing weight and exercising will improve many of the symptoms ascribed to low T.  These will also improve your life expectancy and lower your risk of heart attack.

…And you won’t have to worry about any side effects!

Do I have low T? Like all sixty-somethings my T levels are lower than when I was 30. My endurance is less. I’m losing height. Fat wants to build up in my abdomen, despite my best efforts.

It’s only going to get worse, but I’m willing to accept these as normal consequences of the aging process, rather than introduce external T into my system with its unknown consequences.

I will not go gentle into that good night but will continue to rage against the dying of the light without the wonders of pharmaceutical grade T.

Yours in aging,

-ACP