walter r. frontera, md, phd professor and chair department of physical medicine and rehabilitation...

Walter R. Frontera, MD, PhDProfessor and Chair

Department of Physical Medicine and RehabilitationVanderbilt University School of Medicine

And

Medical Director of Rehabilitation ServicesVanderbilt University Medical Center

No disclosures

“Old age is that period of life when more and more things happen for the last time and fewer and fewer things happen for the first time.”

Anonymous

3

Age Structure of Population in Latin America% 65 and over

Chile Colombia Ecuador Honduras Mexico Panama Peru Puerto Rico Uruguay0.0

10.0

20.0

30.0

9.2

5.6 6.24.3

6.0 6.8 6.0

13.0 13.9

17.6

11.5 10.6

6.8

11.3

7.5

10.2

19.4

17.0

2010 2030 (projection)

Source: UN

Relative effort at the knee joint in young and old healthy volunteers

Modified from: Hortobagyi, et al. J Gerontol. 58A(5): 453-460, 2003; relative effort=%left knee extensor moment during an ADL in relation to max knee ext. moment during supine leg press.

Date of download: 12/30/2013Copyright © 2012 American Medical Association.

All rights reserved.

From: Gait Speed and Survival in Older Adults

JAMA. 2011;305(1):50-58. doi:10.1001/jama.2010.1923

A PDF of enlarged graphs is available.

Figure Legend:

Date of download: 3/16/2015Copyright © 2015 American Medical Association.

All rights reserved.

From: A Diagnosis of Dismobility—Giving Mobility Clinical Visibility:  A Mobility Working Group Recommendation

JAMA. 2014;311(20):2061-2062. doi:10.1001/jama.2014.3033

Prevalence of Either Disability for Activities of Daily Living or Mobility Disability by Usual Gait Speed Among Men Aged 80 Years (N = 6534)ADL indicates activities of daily living. Based on data from Guralnik and colleagues.

Figure Legend:

Centenarians

• Centenarian Singh became the oldest person to run a complete marathon when he finished a 26.2-mile race in Toronto October 16, 2011.

9

20 y/o (healthy)

75 y/o (healthy)

SarcopeniaSarx = flex penia = loss

Muscle function in middle-aged and older men(Reid et al., Eur. J. Appl. Physiol 112:2289, 2012)

*=significant overall group differences;

Muscle strength (tertiles) of the knee extensors before and mortality after a bone fracture in older people

From: Rantanen et al., SJMSS, 12:296, 2002.

# deaths/1000 person months

EWGSOP-suggested algorithm for sarcopenia case finding in older individuals (Cruz-Jentoft A J et al. Age Ageing 2010;39:412-423)

.

Prevalence of sarcopenia and sarcopenic obesity by levels of physical activity among respondents aged 65 years and older (weighted %). †P < 0.1, *P < 0.05, ***P < 0.001 (low activity as reference).

Ryu M et al. Age Ageing 2013;ageing.aft063

Physical activity among Hispanics

• In the Latino population, physical inactivity appears to be more prevalent among Hispanics (37%), blacks (33%) and whites (22%)

• All Hispanic groups were less active than were non-Hispanic white individuals

• Variability among sub-groups: Cuban and Dominican participants were the least active (19.8% met recommendation), whereas Mexican American participants were the most active (31.9% met recommendation).

• Women were less active than were men across all subgroups. Among Hispanic women, 74% report that they do not participate in leisure-time physical activity, and this seems to decline with age [14].

15

“There is perhaps nothing in Nature older than motion”

Galileo

Exercise prescription

muscles: knee extensors and flexors

type: progressive resistance (dynamic)

sequence: 3 sets / day / muscle group, 6-9 s / repetition, 8 reps / set

intensity: 80% of 1 RM frequency: 3 days / week total duration: 12 weeks

Strength (60 deg/s) & CSA (CT scan) of the extensors of the knee: effects of aging & strength training

% c

han

ge

From: Frontera et al., JAP 64:1038, 1988 and JAP 88:1321, 2000

TN

F-al

pha

Prot

ein

Con

tent

(pg

mg-1

)

TN

F-al

pha

mR

NA

(Arb

itra

ry u

nits

)

P<0.01 P<0.01

BaselineBaseline Post-TrainingPost-Training

Resistance exercise and tumor necrosis factor in frail elderly humans

Greiwe et al. FASEB J 15:475-482, 2001

Long-term exercise in older adults: 4 year outcomes of music based multitask training (Hars et al., CTI 95:393, 2014)

Continued training

Discontinued training

Additional anabolic strategies

• Diet• high intake of amino acids – leucine

(>2g)

• high levels of total protein (25-30 g)

• blunted response to mixed meal including carbohydrates (insulin resistance?)

• coupling with exercise

Strength = m x a

Power = Force x distance time

Dose-response relationship of resistance training in older adults

Meta-analysis of 29 randomized controlled clinical trials with a total of 1313 subjects

Strong effects of progressive resistance training (PRT) on maximal strength in a dose-dependent manner

PRT was also successful for improving functional outcomes but gains were independent of training intensity

Power training was more effective for improving muscle power and functional outcomes than PRT

Steib et al., MSSE 42:902-914, 2010

Low vs. high intensity power training in mobility-limited older adults

52 subjects (78+5 yrs)

Randomized controlled trial low (40% of 1 RM) vs. high intensity (70% of 1 RM)

Training

Leg extension and knee extension exercises 3 sets of 10 repetitions each 2 sessions per week Total of 16 weeks Concentric phase as quickly as possible Resistance adjusted every 3 weeks

Reid, …. Frontera, Fielding, et al., J Gerontol 70:374, 2015

Low vs. high intensity power training in mobility-limited older adults

1 RM Peak power Velocity SPPB0

10

20

30

40

50

13

34

16

1.4

19

42

22

1.8

LO 40% HI 70%

Significant differences within groups but NOT between groups Reid, …. Frontera, Fielding, et al., J Gerontol 2014 (in press)

Embrace aging