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

2. Disclosures
Federal Funding
NIH
NIA, NICHD
No other disclosures

3. 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

4. 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

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

6. Percent of Older Persons with Difficulty or Inability in ADLs by Age and Sex, United States, 199510 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

7. 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

8. 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:
Let’s consider the disablement model

9. 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,

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

11. 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

12. 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

13. Realties of independent living for older adults

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

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

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

17. 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

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

19. Trunk Muscle Integrity and Aging
Trunk muscle endurance is also linked to back pain
Trunk muscle integrity is critical for optimal peripheral power generation

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

22. 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

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

24. 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

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

26. 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

27. 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

28. Hip Rehab Trial

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

30. Exercise and Disablement
ICF Model
Participation
Disability
Nagi Model

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

32. LIFE study, JAMA 2014

33. LIFE study-sub groups

34. 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

35. 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

36. How should rehab be designed?

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

38. 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

39. MCI and Mobility in Boston RISE

40. Prevalence of Musculoskeletal Pain
Leveille et al; JAMA, 2009

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

42. Mskl Pain and Mobility

43. 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

44. Questions and Comments