The Geriatric Athlete



The Geriatric Athlete


Brian K. Unwin



INTRODUCTION



  • Although the challenges of age-related changes may require training modifications and a reassessment of goals, exercise rarely requires complete elimination secondary to a medical disorder.


  • This chapter will discuss the following:



    • The demographic shift in aging of the American population


    • Normal age-related physical and physiologic changes related to aging


    • Physiologic and functional benefits of exercise and activity


    • Preparticipation screening


    • General exercise prescription for the older athlete


THE OLDER ATHLETE



  • For purposes of discussion, an older athlete will be defined as age 65 years or greater.


  • By 2030, about 20% of all Americans (70 million) will be age 65 or older and will outnumber the pediatric population (15).


  • The average 75-year-old has three chronic conditions and is on five prescription medications. Exercise has been demonstrated to have positive effects in preventing a number of chronic diseases and is also an important tool to treat the very same conditions (22).


  • Sedentary lifestyle is the most prevalent modifiable risk factor for heart disease, a condition present in approximately 50% of individuals age 55-64 and 65% of those age 65-74. One-third of all men age 75 or greater and half of all women of the same age report no or limited physical activity (22).


  • Runners age 65 or greater currently make up only 1%-2% of American marathon runners (9,18). Individuals age 50 and older make up 23% of health club members. Adults born from 1946-1964 (“Baby Boomers”) attending health clubs are more likely to cross-train and more likely to attend the club regularly—112 days per year (24).


  • Although less likely to suffer from acute traumatic injury related to exercise, Baby Boomers are more likely to experience overuse injuries (5).


  • The benefits of sports and athletics shift from recreation and cardiovascular fitness in the young to middle-aged individual to preserving physical, cognitive, social, and emotional functioning in the older adult.


  • Preserving function in late life helps mitigate the direct and indirect costs related to the chronic care of older adults. Numerous studies support the contention that exercise is the key factor to minimize late-life disability and premature mortality (6,11,13,19,25).


PHYSICAL AND PHYSIOLOGIC CHANGES RELATED TO AGING



  • Normal physiologic changes related to aging are discussed elsewhere in detail (15). These changes intertwine with common comorbidities in older adults such as hypertension, diabetes, hyperlipidemia, and arthritis (Table 114.1). The key physiologic change for athletes is the decrease in [V with dot above]O2max and maximal heart rate.


  • The older adult additionally copes with aging-associated syndromes such as dementia, depression, disability, falls, incontinence, and frailty. See Table 114.1 for a synopsis of these conditions.


  • An appreciation of this intersection of normal aging changes, common medical comorbidities, and geriatric syndromes is crucial to assist the aging athlete. Examples of this include:



    • The older golfer with hypertension and aortic valvular sclerosis who develops syncope


    • The older postmenopausal female cyclist who develops incontinence


    • Delirium manifesting in an older athlete who has just completed a marathon


    • A runner with refractory gastroesophageal reflux that results in malnutrition


PHYSIOLOGIC AND FUNCTIONAL BENEFITS OF EXERCISE



  • Some of the physiologic effects of exercise are listed in Table 114.1. In addition to the direct effects on the heart and

    muscular system, exercise improves an older adult’s likelihood of preserved long-term, independent functional status (11,19,25).








    Table 114.1 Common Conditions and Exercise Effect in Older Adults













    Aging-Related Physiologic Changes


    Common Comorbid Conditions


    Common Geriatric Syndromes


    Exercise Effects


    Cardiovascular:


      Decreased [V with dot above]O2max


      Decreased maximal heart rate


      Decreased maximal cardiac output


      Rise in systolic blood pressure


      Widening pulse pressure


      Increased large artery stiffness


      Increased fibrosis


      Decreased innervation


      Valve fibrosis


      Myocyte dropout


    Skeletal muscle:


      Sarcopenia


      Loss of Type I and II muscle fibers


      Decreased basal metabolic rate


      Decreased fiber volume


      Muscle denervation


      Decreased mitochondrial volume; increased collagen


      Decreased flexibility


    Pulmonary:


      Lower maximal expiratory flows


      Stable total lung capacity


      Lower diffusing capacity


      Increased ventilation/perfusion mismatch


      Lower respiratory muscle strength


      Loss of lung elastic recoil


      Stiffer chest wall


      Increased airway reactivity


      Lower respiratory drive


      Declining partial pressure of arterial oxygen to age 65


    Bone, ligament, cartilage, meniscus, and tendon


      Bone: loss of mineral density; “tubularization” of diaphyseal bone


      Cartilage: chondromalacia; disuse activity with inactivity


      Ligaments and tendons: stiffness; increased risk for complete


       failure; decreased vascularity


      Meniscus: degeneration; subject to tears; less stress dissipation


    Renal:


      Decreased renal blood flow and glomerular filtration rate


      Age-related glomerulosclerosis


      Impaired concentrating capacity


      Impaired sodium preservation


      Impaired response to vasopressin


      Decreased thirst perception


      Decreased total-body water


      Decreased plasma renin and aldosterone production


    Gastrointestinal:


      Drug interaction


      Cholelithiasis


      Decreased anal sphincter pressure


      Delayed transit


      Decreased lower esophageal pressure


      Dysphagia


    Hematologic:


      Decreased hematopoietic response to stress


    Sensory:


      Presbyopia


      Presbycusis


      Cataracts


    Anemia


    Arthritis


    Atrial fibrillation


    Cancer


    Chronic kidney disease


    Chronic obstructive pulmonary disease


    Constipation


    Diabetes


    Heart disease


    Hyperlipidemia


    Hypertension


    Osteoporosis


    Thyroid disorders


    Vascular disease


    Delirium


    Dementia


    Depression


    Dizziness


    Falls


    Frailty


    Health illiteracy


    Iatrogenic injury


    Immune deficiency


    Impairments of instrumental activities of daily living (IADLs) and activities of daily living (ADLs)


    Incontinence


    Infection


    Insomnia


    Instability (falls)


    Irritable bowels


    Polypharmacy


    Pressure ulcers


    Social isolation


    Syncope


    Temperature dysregulation


    Cardiovascular:


      Increased [V with dot above]O2max


      No change in maximal heart rate


      Increased stroke volume


      Increase in arterial-venous oxygen difference


      Reduced mortality from cardiovascular disease and stroke


      Decreased risk of type 2 diabetes, high blood pressure, dyslipidemia, metabolic syndrome, colon and breast cancers


      Moderate evidence for decreased risk of lung and endometrial cancers


    Metabolic:


      Prevention of weight gain


      Weight loss


      Weight maintenance after weight loss


      Reduced abdominal obesity


    Neuromuscular:


      Increased strength


      Increased Type I and II fibers


      No change in number of fibers


      Increased muscle fiber size and area


      Increased muscle oxidative capacity


      Increased motor unit function


      Fewer falls


    Bone and connective tissue:


      Increased bone mass


      Increased bone strength


      Decreased bone reabsorption


      Decreased risk of hip fracture


    Mood:


      Effective in treatment of depression


      Enhanced self-efficacy


    Cognition:


      Suggestion of preserved cognition


    Function:


      Reduced falls


      Improvements in ADL/IADLs


      Improved quality of life


      Improved sleep quality



  • Exercise increases high-density lipoprotein cholesterol levels, lowers low-density lipoprotein cholesterol levels, lowers blood pressure, improves insulin sensitivity, and decreases blood coagulability (3).


  • Direct effects on the heart muscle include increased myocardial oxygen supply, increased myocardial contraction, and electrical stability (3).


AGE-ASSOCIATED REDUCTIONS IN ENDURANCE EXERCISE PERFORMANCE



  • Masters athletes are older adults (generally defined as age 35 or greater) who have strived to preserve or exceed their prior athletic performance and serve as a model to understand the limits to endurance performance with regard to aging.


  • Peak athletic performance is maintained to approximately age 35, followed by gradual decline to age 60, and accelerated decline thereafter. Examples here are marathon running times and swimming performance (21). See Tables 114.2 and 114.3 for examples of performance levels of older athletes.


  • The primary physiologic determinants to endurance exercise performance are exercise economy, lactate threshold, and maximal aerobic capacity.



    • Exercise economy is the steady-state oxygen consumption that occurs during submaximal exercise below the lactate threshold. Multiple cross-sectional and longitudinal studies demonstrate that running economy does not change in masters athletes trained for endurance activities (20).


    • Lactate threshold does not appear to change with advancing age in masters athletes (20).


    • Maximal aerobic capacity is the primary determinant of decreased endurance exercise performance (10).


PREPARTICIPATION SCREENING OF THE OLDER ATHLETE



  • Responsibility for the preparticipation screening first begins with the athlete contacting a health care provider for assessment. Screening recommendations vary based on the individual’s:



    • General health


    • Medical comorbidities


    • Desired level of activity


  • The clinician should have a clear understanding of the patient’s exercise plan for development of endurance, strength, speed, flexibility, and balance.








    Table 114.2 Examples of Performance Records by Older Athletes (26)



























































































































































































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    May 22, 2016 | Posted by in SPORT MEDICINE | Comments Off on The Geriatric Athlete
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    Women:


    Men:



    Outdoor 100 m



    Outdoor 100 m




    Age 35:10.74




    Age 35: 9.97





    (Merlene Ottney)





    (Linford Chritie)




    Age 50:11.67




    Age 50: 10.88





    (Merlene Ottney)





    (Willie Gault)




    Age 65:14.10




    Age 65:12.37





    (Nadine O’Connor)





    (Stephen Robbins)




    Age 80: 18.42




    Age 80: 14.35





    (Hanna Gilbrich)





    (Payton Jordan)



    Outdoor 1 Mile



    Outdoor 1 Mile




    Age 35: 4:17.33




    Age 35:3:51.38





    (Maricica Puica)





    (Bernand Lagat)




    Age 50:5:00.59




    Age 50: 4:27.90





    (Gitte Karlshoj)





    (Nolan Shaheed)




    Age 65: 6:16.28




    Age 65:4:56.40





    (Marie-Louise Michelson)





    (Derek Turnbull)








    Age 80: 7.09.60 (Joseph King)



    Outdoor Marathon



    Outdoor Marathon




    Age 35: 2:21.29




    Age 35:2:03.59





    (Lyudmila Petrova)





    (Haile Gebrselassie)




    Age 50: 2:48.47




    Age 50:2:19.29





    (Edeltraud Pohl)





    (Titus Mamabolo)




    Age 65: 3:28.10




    Age 65:2:41.57





    (Lieselotte Schultz)