Modern medicine has lengthened our lives, but unfortunately, many older people physically deteriorate to a level that makes them vulnerable to minor health setbacks. Frailty is a syndrome marked by weakness, poor mobility, a slow gait, and excessive fatigue. Frail individuals are unable to adequately recover from physical activity or a challenge to their health. Minor illnesses send them to the hospital, nursing home, or assisted living center. Frail individuals are often unable to tolerate beneficial medical procedures and must live with pain and physical restrictions. Frailty is a problem that responds very well to treatment.
In the 65 year old plus population, frailty syndrome is common. Fifteen percent of the non-nursing home population is frail and forty five percent is pre-frail. Frail individuals are far more likely to fall. Forty percent of the frail and twenty two percent of the pre-frail individuals are hospitalized every year. Frailty is a marker for adverse health outcomes and a means of identifying opportunities for intervention in patient care.
Physical activity has been shown to be the best preventative and treatment for frailty. Patients bounce back from surgery much better if they under take a program of prehabilitation exercise prior to surgery. Research on rehabilitation has demonstrated the benefits of exercise to restore strength and mobility in the frail population. Take the time to read, One Last Question Before the Operation: Just How Frail Are You? by Paula Span in the October 27, 2017 issue of the New York Times. Read the article here: https://www.nytimes.com/2017/10/27/health/elderly-surgery-frailty.html
In the senior population, fitness activities must focus on training that maintains functional mobility and an independent lifestyle. You need to stand up and train to be a more graceful and competent walker. Practice drills that improve your capacity to transfer from the floor to standing. Always include balance and reaction exercises that keep you free from falls. Foremost are strengthening activities that maintain bone density and restore capacity to lift, carry, push, and pull.
Michael S. O’Hara, PT, OCS, CSCS
* New York Times, One Last Question Before the Operation: Just How Frail Are You? Paula Span, October 27, 2017
Fitness training for those of us past 40 years of age is more complicated. Physical performance and recovery capacity are dramatically different. If you need proof, look for the forty year olds in the NBA or NFL. The good news is that with proper planning, consistent performance, and the wisdom that comes with age, we can stay fit and active for a lifetime. I have compiled a collection of tips for the forty plus fitness client.
Reduce Sitting in Your Life and Never Sit Down and Exercise
Most of us already spend too much time in a seated position. The last thing you need in your fitness program is more sitting. Movement happens in an upright, standing position. “Seated exercise” is an oxymoron. If you want to improve how your body functions, you must stand up and defy gravity.
Injuries happen in an upright position. I have never treated someone with a recliner related anterior cruciate tear or an office chair induced ankle sprain. Nearly every sport is performed in a standing position. If the goal of your exercise program is to improve how your body functions and reduce the risk of an injury, then your exercise activity should be performed in a standing position.
“But Mike, what about all those fancy machines?” Seated, prone, and supine exercises are devoid of core stabilization and balance demands. Isolated muscles are trained and the remainder of the body is neurologically asleep. Seated exercises also reinforce poor postural habits and diminish your capacity to move. I call it the “illusion of exercise,” and it will always be highly visible in commercial gyms because it is easy to sell.
Researchers on health and longevity have labeled prolonged sitting “the cigarette smoking of fitness.” Prolonged sitting produces all sorts of spinal and joint restrictions that contribute to the postural flaws that are rampant in offices across America. The more worrisome issue is that those of us who spend more time sitting are statistically more likely to die earlier. All things equal, the people who stand more are healthier. They have better blood lipids, less hypertension, and fewer vascular problems. Unfortunately, you cannot undo the ill effects of eight hours of daily sitting with two or three visits to the gym a week.
Make an effort to stand more during your day. Ditch the ergonomic wonder chair in your office and throw out that recliner. Try using a chair that physically reminds you it is time to stand up and move around every twenty minutes. I am a big believer in stand up desks and have created many happy converts.
-Michael S. O’Hara, P.T., OCS, CSCS
Falling In Love With Fitness
Fall Prevention And Intervention
Mrs. J. had pain in her lower back and left hip. The problem had been present for over a year, and she sought treatment in physical therapy because the pain was making it difficult to get in and out of her car and work in the garden. At 73 years of age, Mrs. J. lived in Michigan during the summers and traveled south for the winters. She enjoyed working in her garden, visiting with friends, and walking on the beach in Florida. On further discussion, Mrs. J. reported that she had fallen three times over the previous year. Two falls occurred while getting out of bed and once while working in her yard. She did not bother to tell her doctors about these falls because she had not been injured.
Mrs. J. had all of the factors that placed her at high risk for falling in the future. She was over 65 years of age. She took four medications, two of which had psychoactive effects. She had a prior history of falls in the past and she was weak.
Falls are the leading cause of accidental death for those 65 years and older. Just over a third of the population over 65 falls every year. One half of those falls happen to individuals who have fallen before. It is the most common injury related hospital admission. In 2012, we had over 340 thousand hip fractures from falls in this country.
Risk Factors For Falls
A prior history of falls. If you have fallen in the past you are more likely to fall again.
Balance impairment. If you are unable to balance on one leg or you lose your balance easily when you close your eyes, then you are at greater risk.
Strength deficits. The weaker you are, the more likely you are to fall.
Postural hypotension. A twenty point fall in systolic and/or a ten point drop in diastolic blood pressure on changing position from supine to standing places you at a greater risk of falling.
Visual impairment. If you are unable to see the dog, curb, or chair, you are more likely to have a collision and subsequent fall.
Multiple medications. Taking more than four medications is related to more frequent falls. The risk is amplified if the medications have a psychoactive component. Several studies have identified antiepileptic medications as more problematic.
Dementia. Cognitive impairment doubles the risk of falling.
Post hospital stay. For the two weeks after a hospital stay, you are four times more likely to fall.
What Definitely Helps
Home assessment and modification. In my experience, peace in the Middle East may be more readily attained than getting grandma to move her rug and install a grab bar in the bathroom, but it is what has been shown to reduce falls in higher risk individuals.
Exercise programs. Strength, balance, mobility, and power production activities. The activities should take place in a standing position and should be tailored to the specific needs of those at risk. These programs work–you just need to do them.
What is Likely to Be Beneficial
Vitamin D supplementation. Several studies have documented fewer falls in individuals that supplement with Vitamin D. The mechanism for the decrease in falls is not known, but it seems to work.
Medication review. If possible, minimize psychoactive medications and reduce the total number of medications. Discuss this with your physician before making any changes in your medications.
Assessment and awareness of postural hypotension. If blood pressure drops with transfer from supine to sit to stand, you are at higher risk for falls. A simple blood pressure test performed in the doctor’s office can determine if you have this problem and enable management of this risk factor.
Vision assessment and management program. Get your eyes checked and consult with your doctor on a treatment plan to keep your vision as healthy as possible.
Better footwear. This is the most common sense advice, but it gets the lowest level of compliance. Ladies those shoes look nice, but that pin in your wrist looks a lot worse.
Mrs. J. had a blood pressure assessment that showed her systolic pressure dropped twenty-two points with transfer from supine to standing. We contacted Mrs. Js’ family physician to alert her of her patient’s recent fall episodes and blood pressure findings. Mrs. J. was taken off one of her medications and her blood pressure improved. The pain in her hip and lower back resolved, and she was able to perform a program of exercise to improve balance, strength, and mobility. Mrs. J. completed five weeks of therapy and then continued with her exercise program at our fitness center. She has been exercising three times a week for the last two years and has not had another fall episode during that time.
Michael S. O’Hara, P.T., OCS, CSCS