Tag Archives: elderly

Mitigating Sarcopenia In The Elderly: Resistance Training Is A Powerful Potion

While researching afib-detection apps recently, the skeptical cardiologist stumbled across an article with the title “Resistance training – an underutilized drug available in everybody’s medicine cabinet”

This brief post from the British Journal of Sports Medicine blog nicely presents the rationale for using strength training to improve the overall health of the elderly. I have reblogged it below.

Americans spend billions on useless supplements and vitamins in their search for better health but exercise is a superior drug, being free  and without drug-related side effects

I’ve spent a lot of time on this blog emphasizing the importance of aerobic exercise for cardiovascular health but I also am a believer in strength and flexibility training for overall health and longevity.

As we age we suffer more and more from sarcopenia-a gradual decrease in muscle mass.

Scientific reviews note that loss of muscle mass and muscle strengh is quite common in individuals over age 65 and is associated with increased dependence, frailty and mortality

Specific information on progressive resistance training for the elderly is sparse but I found this amusing and helpful video on a Canadian site that provides some guidance for beginners.

 

And below is the referenced blog post:

Resistance training – an underutilised drug available in everybody’s medicine cabinet

By Dr Yorgi Mavros @dryorgimavros

As we get older we begin to lose muscle mass, approximately 1% every year. But more importantly, the decline in muscle strength declines at a rate 3-times greater [1]. The consequences of this decline in strength are significant, with lower muscle strength being associated with an increased risk dementia[2], needing care, and mortality[3]. But should we accept this as our fate, or is there anything we can do prevent, reverse or at least slow this age-related decline?

In 1990, a type of exercise called progressive resistance training, commonly known as strength training, was introduced to 9 nonagenerians living in a nursing home, specifically to treat the loss of muscle mass and strength, and the functional consequences of disability [4]. After just 8 weeks, these older adults saw average strength gains of 174%, with 2 individuals no longer needing a cane to walk. In addition, one out of the three individuals who could not stand from a chair, was now able to stand up independently. Just take a moment to think about the results of that study. If I told you there was a medicine that you or a loved one could take, and it could make either of you strong enough to now get out of a chair, would you take it?

What if you or a loved one had a hip fracture, and I told you that same medicine could help reduce the risk of mortality by 81%, and the risk of going in to a nursing home by 84%, as was shown in this study [5]. Currently, the only way to take this medicine is by lifting weights, or pushing against resistance.

A recent study from Britain, [6] showed an association between adults who participated in 2 days per week of strength training and a 20% reduction in mortality from any cause, and a 43% reduction in cancer mortality. Data from the Women’s Health Study in the US published at a similar time were very similar, with women reporting up to 145 minutes per week of strength training having a 19-27% reduced risk of mortality  from any cause [7].

So where does the benefit of strength training come from? First and foremost, it is anabolic in nature (meaning that it can stimulate muscle growth) making it the only type of exercise that can address the age-associated decline in muscle mass and strength. Within our laboratory at the University of Sydney, we have shown that we can use this type of exercise to improve cognitive function in adults who have subjective complaints about their memory [8]. What’s important though, is that there was a direct relationship between strength gains and improvements in cognition, and so maximizing strength gains should be a key focus if you want to maximize your benefit [9]. This type of exercise has even been taken into hospitals and used in adults with kidney failure undergoing haemodialysis, where it was shown to reduce inflammation, and improve muscle strength and body composition [10].

Other laboratories around the world have also used strength training to increase bone strength in postmenopausal women [11], help manage blood sugar levels in adults with type 2 diabetes [12], as well as to counteract the catabolic side effects of androgen-deprivation therapy for men with prostate cancer [13]. Not to mention its benefits to sleep [14], depression  [15] and recovery from a heart attack  [16].

So it is no surprise to see that the  Australian [17] and UK [18] public health guidelines for physical activity recommend we take part in activities such as strength training 2-to-3 days per week. Unfortunately however, these recommendations lack detail and guidance on intensity and frequency.

A key theme in all the randomized controlled studies discussed above, is that not only were exercises performed at least 2 days per week, but they were fully supervised, used machine and/or free weights, and were done at a high intensity, which is commonly set to 80% of an individual’s peak strength. It is for this reason I like to focus on the guidelines put forward by The American College of Sports Medicine (ACSM) [19]. The ACSM advises that everyone, including older adults do at least 2 days of progressive resistance training, which is to be performed at a moderate (5 – 6) to high/hard (7 – 8) intensity on a scale of 0 to 10, involving the major muscle groups of the body. So if you are looking to maximise the benefit from your time in the gym, or looking to make a positive change to your lifestyle, remember that there is medicine you can take; Try lifting some weights or doing other forms of strength training, 3 days a week, and importantly, make sure it feels moderate to hard. Not only will it add years to your life, but life to your years.


Since college I have regularly done weight training 3 times per week As I get  dangerously close to age 65 and joining the ranks of the “elderly” I have ramped up the intensity of my workouts, working hard to forestall the sarcopenia that will ultimately be my fate.

Antisarcopenically Yours,

-ACP

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Video credit: Produced for the University of British Columbia’s (UBC) Department of Physical Therapy, the Aging, Mobility, and Cognitive Neuroscience Laboratory, the Centre for Hip Health and Mobility and the Brain Research Centre at Vancouver Coastal Health and UBC
hiphealth.ca/news/preventing-dementia

 

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

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

On February 26, my dad became a nonagenarian.

IMG_6325
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

drdebakey02
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: