Exercise, Aging, and the Benefits of Physical Activity

Educational Objectives

The goal of this program is to improve management of aging patients. After hearing and assimilating this program, the clinician will be better able to:

1. Advise aging patients about updated exercise requirements.
2. Identify the risk factors for osteoarthritis.
3. Educate patients about the benefits of exercise and dietary supplementation with regard to aging.

Summary

Exercise guidelines (2018): include people >65 yr of age; ≥1 hr of vigorous play is recommended for children every day; for adults, the recommendation is ≥150 min of moderate exercise (eg, brisk walking, riding a bike, swimming, pushing a lawnmower) or ≥75 min of vigorous activity (eg, running, hard biking, hard swimming), depending on the person’s capability; resistance training (RT) — 3 sets of 12 to 14 repetitions of exercise for large muscle groups (eg, legs) is important for fall prevention and balance; 2 days of RT with 15 to 20 min of basic exercise to strengthen the legs and core muscles is recommended; balance — balancing on both legs, with progression to just one leg, with closed eyes for as long as possible helps maintain balance and proprioception; flexibility — it is important to do gentle dynamic stretches every day; muscle energy techniques help with hamstring and quadriceps flexibility; exercise frequency — exercising every day or every other day is better than exercising for 150 min on a single day

Aging

Definition: old age varies by perspective; chronologic age is the number of years lived; physiologic age is based on impacts of bodily function on physical appearance; functional age is based on ability to contribute to society

Aging theories: programmed theory — a cell undergoes a preprogrammed number of replications before cell death; error theory — alterations in DNA which accumulate with aging lead to transcription and translation malfunctions that result in illness and cell death; cellular theory — cells wear out over time, change, and die; free radical theory — cell membranes rupture when exposed to radiation or free radicals; nutritional model theory — people with more lean mass and less adipose tissue have greater health and longevity; collagen theory — collagen becomes fibrotic and thickens with age, leading to hypertension and tendinopathy; mutating autoimmune theory — with aging, cells mutate and secrete new products of transcription, which the body considers as foreign materials and triggers an immune response, leading to organ malfunction

Normal aging process

Respiratory: the lungs become more rigid; pulmonary function slowly decreases over time; the number and size of alveoli decrease, as do vital capacity and respiratory fluid levels; the chest cavity becomes less expansile; cartilage becomes stiffer and calcified

Cardiovascular: heart size and elasticity decrease; by age 70 yr, cardiac output is reduced by 70%, compared with younger age; heart valves become sclerotic, the heart muscle becomes more arrhythmogenic, arteries become more rigid, and veins tend to dilate

Neurologic: neuronal transmission slows; the hypothalamus becomes less effective at thermoregulation (heat stroke is more common among elderly individuals); sleep patterns decline; ≈1% of neurons are lost every year after age 50

Musculoskeletal: bone and tissue — without preventive measures, adipose tissue increases, and lean body mass decreases by ≈6% per decade; bone marrow content diminishes, and body height decreases; connective tissue loses resiliency; synovial fluid becomes less viscous (more water-based), decreasing joint lubrication and cushioning, leading to osteoarthritis (OA); exaggerated spinal curvature (eg, kyphosis) may occur; muscles — maintaining muscle mass becomes more difficult; the cross-sectional area of the muscle becomes smaller, and the ability to generate force decreases; ligaments — pain occurring in individuals >40 yr old largely reflects tendinopathy or tendinosis (degenerative changes), rather than tendinitis (inflammation); advise against overhead (>90⁰) shoulder weight-bearing exercises ≥40 yr of age to avoid, eg, rotator cuff problems, arthritis flares

Risk factors (RFs) for OA: a largely hereditary condition; the greatest RF is being overweight, which causes a proinflammatory state; ≥10% of prior hip, knee, or ankle injuries lead to early arthritis; prior joint surgery (even arthroscopic) causes an accelerated degenerative process; OA is defined as thinning of cartilage (normal aspect of aging); articular surfaces wear out and eventually results in bone-on-bone contact that causes pain; radiography is not reliable for predicting OA pain

Impacts on exercise: maximal oxygen consumption (VO₂max) and endurance (aerobic capacity) decline starting after age 30 yr for everyone

Methods to Slow Down Aging

Slowing down the decline in VO₂max: people decline mentally and physically when they become isolated (following, eg, retirement, cessation of driving); people who are active have better sleep quality, consume more calories, live longer, and have better quality of life; it is important to educate patients about brain exercises (eg, social involvement, reading, doing puzzles); untrained individuals who do not exercise lose ≈15% of their VO₂max every decade after 30 yr old; people who are fit (even if overweight) from walking and following exercise guidelines lose ≈10% of their VO₂max per decade; people who are very active and highly trained (eg, running marathons) lose ≈6% of their VO₂max per decade; aerobic training can significantly slow the loss of aerobic capacity, even with simple activities (eg, walking)

Preservation of muscle mass: one study demonstrated that twice-weekly RT (for 30-45 min per session) for 12 wk resulted in ≈300% increase in upper and lower body muscle strength, and some individuals no longer needed walkers or wheelchairs; RT increases muscle mass, force, and strength, even in people ≥50 yr of age; RT is underutilized, and its importance should be emphasized; 40% to 50% of individuals die within 1 yr following a hip fracture because of complications from the fall; RT can prevent falls by strengthening and improving balance and can potentially save lives and increase life expectancy

Effects of exercise on brain function: regular exercise (eg, walking) improves executive function and memory; a regular exercise program (ie, RT and some aerobic activity) reduces the incidence or progression of dementia; several studies show that regular exercise is as effective as selective serotonin reuptake inhibitors (SSRIs) for prevention and treatment of depression; augmenting medication and cognitive behavioral therapy with exercise may be able to decrease the SSRI requirement over time; exercise does not seem to prevent anxiety

Effects of running: several studies show a 45% to 70% reduction in cardiovascular death; running is also protective against development of cancer; every hour of running extends life by ≤7 hr; people who briskly walk for >500 MET minutes per week have a 12% lower risk for death; running alone lowers the risk for death by 27%, and addition of other physical activity (eg, occupation, cycling, swimming, aerobics) lowers the annual death rate by 30% to 40%; running is one of the better activities if the body tolerates it and the individual likes to run; people who run have a 3.2-yr longer life expectancy than people who do not run; only 2% of individuals >65 yr old regularly run (encourage transitioning to walking); risk for injury — the injury rate increases and the protective effect decreases as distance run increases; running 20 to 30 miles/wk provides the maximum benefit with the lowest injury risk; running >35 miles/wk or at faster speed increases the injury rate; most runners know their own “sweet spot” where they feel comfortable before they get sore and start experiencing injuries; arthritis — studies show that especially recreational running does not increase the risk for arthritis of the hip, knees, or ankles; however, running will accelerate joint degeneration in a patient with known arthritis; the risk for arthritis is low with <15 yr of running exposure, though whether >15 yr of recreational running accelerates the process of degeneration is unclear; most studies show that recreational running of 5 to 10 km does not cause joint issues

Cycling: a good alternative for people who do not like to run or walk; tricycles or hand cycles also provide cardiovascular benefits

Walking: benefits are additive (eg, walking 10 min at lunch and 20 min after dinner, parking the car on the far side of the parking lot, using the stairs); walking is tremendous for balance, strength, arthritis reduction, and reducing overall cardiovascular risk; if the weather is too hot, advise walking at a different time of day or walk indoors in air-conditioned areas; try to help patients who are not physically active to overcome any barriers to movement; exercise is beneficial for disease prevention and treatment of, eg, diabetes, hypertension, hyperlipidemia; studies have shown that patients are 50% more likely to comply with exercise when their healthcare provider mentions that they personally exercise

Swimming and water-based (WB) exercise: in people who cannot perform WB exercise, swimming decreases the risk for falls and stimulates appetite (many elderly patients have smaller appetites and have protein malnourishment); exercise studies prove that swimming and RT help maintain bone density in postmenopausal women and in patients who cannot do WB exercise

Golfing: walking on the golf course, especially if carrying a bag, is beneficial for proprioceptive balance and endurance; benefits with regard to life expectancy or mortality are unclear, but walking the golf course is better than just riding in the golf cart

Nutrition: the recommended 1.5 g/kg of daily protein intake for young people also applies to aging athletes; protein is very important for maintaining muscle mass and strength; glucosamine and chondroitin sulfate — studies show mixed results; the GAIT trial (2008) demonstrated a pain relief effect equal to ibuprofen without its adverse effects; glucosamine-chondroitin does not regenerate cartilage, but some studies show that it may slow the progression of arthritis over time; glucosamine-chondroitin can be prescribed for 12 wk for people who have arthralgia and no contraindications, and it can be discontinued if no benefit is noted; glucosamine-chondroitin imparts no adverse effects except for a slight increase in blood glucose (not significant)

Key points: when a patient visits for chronic disease management, ask about exercise as a vital sign (multiply how many days per wk and how many min of exercise per day, and ask about the type of exercise); for optimal health, include “brain exercise” and allow for recovery days, especially as people get older; exercise in moderation, choose variety, and gradually increase exercise; when writing exercise prescriptions, incorporate activities patients enjoy; ensure patients are hydrated and are exercising at the right time of day; patients who use, eg, β-blockers, diuretics, should be cautious with exercise; walk with a pet daily; marriage (or companionship), social engagement, and daily laughter are good for health; consider Tai Chi for balance and flexibility

Readings

Alentorn-Geli E, Samuelsson K, Musahl V, et al. The association of recreational and competitive running with hip and knee osteoarthritis: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2017;47(6):373-390. doi:10.2519/jospt.2017.7137; Lee DC, Brellenthin AG, Thompson PD, et al. Running as a key lifestyle medicine for longevity. Prog Cardiovasc Dis. 2017;60(1):45-55. doi:10.1016/j.pcad.2017.03.005; Lee DC, Pate RR, Lavie CJ, et al. Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol. 2014;64(5):472-81. doi: 10.1016/j.jacc.2014.04.058. Erratum in: J Am Coll Cardiol. 2014 Oct 7;64(14):1537. PMID: 25082581; PMCID: PMC4131752.; McCarthy MM, Hannafin JA. The mature athlete: aging tendon and ligament. Sports Health. 2014;6(1):41-8. doi:10.1177/1941738113485691; National Center for Complimentary and Alternative Medicine. The NIH Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT). J Pain Palliat Care Pharmacother. 2008;22(1):39-43. PMID: 19062354; Netz Y. Is the comparison between exercise and pharmacologic treatment of depression in the clinical practice guideline of the American College of Physicians evidence-based?. Front Pharmacol. 2017;8:257. doi:10.3389/fphar.2017.00257; Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines for Americans. JAMA. 2018;320(19):2020-2028. doi:10.1001/jama.2018.14854; Ponzio DY, Syed UAM, Purcell K, et al. Low prevalence of hip and knee arthritis in active marathon runners. J Bone Joint Surg Am. 2018;100(2):131-137. doi:10.2106/JBJS.16.01071; Rodrigues RN, Carballeira E, Silva F, et al. The effect of a resistance training, detraining and retraining cycle on postural stability and estimated fall risk in institutionalized older persons: a 40-week intervention. Healthcare (Basel). 2022;10(5):776. doi:10.3390/healthcare10050776; Schnohr P, O'Keefe JH, Holtermann A, et al. Various leisure-time physical activities associated with widely divergent life expectancies: the Copenhagen city heart study. Mayo Clin Proc. 2018;93(12):1775-1785. doi:10.1016/j.mayocp.2018.06.025; Trappe SW, Costill DL, Vukovich MD, et al. Aging among elite distance runners: a 22-yr longitudinal study. J Appl Physiol (1985). 1996;80(1):285-90. doi:10.1152/jappl.1996.80.1.285; Willick SE, Hansen PA. Running and osteoarthritis. Clin Sports Med. 2010;29(3):417-28. doi:10.1016/j.csm.2010.03.006.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Brennan was recorded at the 34th Annual Winter Osteopathic Seminar, held January 18-21, 2023, in Clearwater, FL, and presented by the Pinellas County Osteopathic Medical Society. For information about upcoming CME activities from this presenter, please https://www.pcomsociety.com. Audio Digest thanks speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.75 CE contact hours.

Lecture ID:

IM711701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.