Functional Decline and Aging: How can exercise influence these changes? Jonathan F. Bean MD, MS, MPH Associate Professor Dept. PM&R, Harvard Medical School

Disclosures Federal Funding NIH NIA, NICHD No other disclosures

Outline Outline Background/conceptual issues Exercise and Functional Activities Exercise and Participation in Life Roles Medical conditions relevant to PM&R care and the maintenance of independence

Aging and Demographics Older adults are the fastest growing segment of the population 10 20 30 1940 1960 1990 2020 2040 Percent Women  65 y Men  65 y U.S. Bureau of the Census, 2000

Changes with Aging Both Strength and power decline after age 35 1995, Metter et al., Baltimore Longitudinal Study on Aging

Percent of Older Persons with Difficulty or Inability in ADLs by Age and Sex, United States, 1995 10 20 30 40 50 60 Difficulty Inability Percent W M W M W M W M W M 70 y 70-74 y 75-79 y 80-84 y 85 y Supplement on Aging II, NCHS

OLDER PATIENTS HAVE HIGH RATES OF COMORBIDITY In 1995, 79% of the 70+ age group had 1 or more of the following chronic disorders: Arthritis Hypertension Heart disease Diabetes mellitus Respiratory disease Cancer Stroke Functional disability is highly associated with chronic disorders

Does the disease model help us conceptually? Geriatric impairments more strongly associated with incident disability than chronic diseases Cardiovascular Health Study Chaudhry et al. JAGS, 2010 MC Escher: http://www.wisdom.weizmann.ac.il/~glasner/courses/CV_2009_2/img/escher-relativity.jpg Let’s consider the disablement model

Mobility is predictive of adverse outcomes 4-year disability rates according to SPPB Short Physical Performance Battery Performance of 3 tasks Each scored between 0-4 Standing Balance Gait Speed over 4 meters 5 repeated chair stands Best performance is 12 From:   Guralnik: N Engl J Med, Volume 332(9).Mar 2, 1995.556-561

JAMA April 2014 “Measuring gait speed is simple, quick, reproducible, inexpensive, and feasible in clinical settings.”

Mobility within the disablement paradigm Body System Impairment Activity Limitation Restricted Participation ICF Model Mobility problems cause limitations that impact participation and disability Disability Impairment Functional Limitation Nagi Model

Clinical Practice Rehabilitative Exercise Falls Disability Morbidity   PRIMARY CARE OF OLDER ADULTS Chronic Disease Management Advocated Mobility Screening Arthritis CHD Stroke Diabetes Osteoporosis Etc. Observed Physical Performance Final Common Pathway Falls Disability Morbidity Mortality Rehabilitative Exercise  

Realties of independent living for older adults

Exercise and Impairment Body System Impairment ICF Model IMPAIRMENT Impairment Nagi Model

Loss of Strength with Aging: a theoretical model % MVC needed to perform ADLs

Strength Training Changes in 1 RM with Progressive Resistance Training among older adults Frontera et al. , 1988

Co-Impairments can have augmentative effects Strength and Balance as predictors of walking ability Rantanen et al., JAGS, 2001 Incidence rates of severe walking disability based on baseline knee-extension strength and standing balance

Changes in Power and CMD in Function Bean et al. J Am Geriatr Soc 2010

Trunk Muscle Integrity and Aging Trunk muscle endurance is also linked to back pain Trunk muscle integrity is critical for optimal peripheral power generation http://www.bandbhac.org.uk www.gc4health.com http://www.brandeis.edu/hbi

Functional Limitation Exercise and Mobility Activity ICF Model Mobility Functional Limitation Nagi Model

What impairments should be prioritized? Balance Strength Power asymmetry Velocity of movement Reaction time Aerobic Capacity Range of Motion Core muscle integrity Kyphosis Obesity Pain Sensory Loss Cognitive Impairment Depression Visual Impairment Rehabilitative Impairments Medical Impairments

The Boston RISE Study Bean et al., Arch Phys Med Rehab; 2013

Multivariable models prediction LLFDI function Note: Standardized estimates presented as absolute values. Both models were adjusted for age, sex, overweight status, obese status, and the manifestation of sensory loss

Issues that may impact design of Exercise Specificity of training New models to optimize compliance and adherence

Exercise for Fall Prevention Sherrington et al Exercise for Fall Prevention Sherrington et al. Effective Exercise for the Prevention of Falls: A Systematic Review and Meta Analysis J Am Geriatr Soc, 2008

Does one size fit all?... Implications of specificity of training RCT comparing two 16-week exercise programs N=138, mean age 75 years 62% had ≥2 chronic musculoskeletal conditions ~30% with h/o heart disease 0.5 units = clinically meaningful difference *Bean, JF et al. Increased Velocity Exercise Specific to Task (InVEST) training vs. the National Institute on Aging’s (NIA) strength training program: changes in limb power and mobility, Jnl Gerontol Med Sci, 2009

Hip Rehab Trial

Hip Rehab Results Main Findings Improvements at 6 months Performance-based Mobility Patient reported Mobility Patient reported Activities Findings persisted till 9 months

Exercise and Disablement ICF Model Participation Disability Nagi Model

Prehabilitation “Prehabilitation” 188 community dwelling older adults (75+ years) Gill, TM et al, NEJM Department of PM&R, Harvard Medical School

LIFE study, JAMA 2014

LIFE study-sub groups

Developing new care paradigms: The Live Long Walk Strong Program Focused on mobility and fall injury prevention Integration with Primary Care Medicare compatible Treats those with MCI

MACIPA PCP P M & R Rehabilitative Care Community The Live Long Walk Strong Program MACIPA PCP P M & R Rehabilitative Care Community PCP SCREEN + _ EDUCATION/ REFERRAL PM&R EVAL + PROGRAM MANAGER PT OT COMMUNITY EXERCISE/ACTIVITY PROGRAMS

How should rehab be designed? http://spauldingrehab.org/conditions-and-treatments/live-long-walk-strong

PCORI/NIA funded trial Implementation Trial Multicenter RCT Targeting the prevention of fall related injuries Pepper Centers Ancillary studies welcomed

Cognitive Function and Mobility Cognitive decline linked to mobility decline Alzheimer’s Mild Cognitive Impairment Role of executive function Dual task performance Walking while talking Predictive of falls and functional decline

MCI and Mobility in Boston RISE

Prevalence of Musculoskeletal Pain Leveille et al; JAMA, 2009

Pain and the onset of mobility problems and disability Eggermont et al. , JAGS, 2014

Mskl Pain and Mobility

Summary Points Exercise can help slow functional decline among older adults We must be aware of conditions such as MCI and Pain that can impact participation PM&R clinicians should embrace this challenge Take advantage of available resources Geriatrics at your finger tips

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