prevent injuries and cognitive decline€¦ · prevent injuries and cognitive decline david...
TRANSCRIPT
Balance Exercises and Fitness to Prevent Injuries and Cognitive Decline
David Raichlen
School of Anthropology
University of Arizona
95%Of hip
fractures come from
falls
Falls are most common cause of TBI
We spend ~$30 Billion/year on fall-related injuries
Outcomes
CDC
CDC
Increased Fall Risk Is NOT Inevitable
Nothing in Biology Makes Sense Except in the Light of Evolution
-Theodosius Dobzhansky
Road map:1) Evolutionary history of aging and exercise2) Exercise and fall risk: predictors and prevention3) What can you do to reduce fall risk?
Road map:1) Evolutionary history of aging and exercise2) Exercise and fall risk: predictors and prevention3) What can you do to reduce fall risk?
Nothing in Biology Makes Sense Except in the Light of Evolution
-Theodosius Dobzhansky
We evolved to get old, but not frail
0102030405060708090
Life
span
Grandparents care for offspring when parents foraging
This lifestyle requires long, physically active days away from camp
Why long life?Grandmother Hypothesis
Must be healthy and active in old age (Falls should be rare!)
Physically active lifestyle was the key to successful aging in our ancestors
Exercise: key to living longer?
Wen et al., 2011
8 year study of over 400,000 Taiwanese men and women
walking
jogging
Staying Healthy Longer Too
Fries, 1996
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
55-59 60-64 65-69 70-74 75-79 80-84
Dis
abili
ty S
core
Runners
NonRunners
Age
Why long life?
Grandmother Hypothesis
Physically active lifestyle the key to successful aging (falls are rare)
We live in a mismatch environment: Our bodies evolved to be active
Road map:1) Evolutionary history of aging and exercise2) Exercise and fall risk: predictors and prevention3) What can you do to reduce fall risk?
Nothing in Biology Makes Sense Except in the Light of Evolution
-Theodosius Dobzhansky
Road map:1) Evolutionary history of aging and exercise2) Exercise and fall risk: predictors and prevention3) What can you do to reduce fall risk?
Nothing in Biology Makes Sense Except in the Light of Evolution
-Theodosius Dobzhansky
What Causes Falls?Most falls occur during walking
Berg et al 1997; Robinovitch et al. 2013
Fall Predictors
1) Muscle weakness (Moreland et al., 2004)
Traditional View:
Instability, poor balance, and lack strength to recover from a trip
Muscle Strength and Fall Risk
Moreland et al. 2004
Meta-analysis (study of studies):Compiled data from 13 studies
Total n = 6146 older adults
Odds of falling in future if subject displays muscle weakness
Muscle Strength and Fall Risk
Moreland et al. 2004
Odds Ratio (OR): Odds that an outcome (fall) will occur given a particular condition (muscle weakness)
1 = no difference
0
0.5
1
1.5
2
2.5
Lower limb Upper Limb
Od
ds
Rat
io
Fall Predictors
1) Muscle weakness
2) Cognitive decline
Traditional View: Novel View:
May be responsible for trips and stumbles
Cognition and Walking
Executive function: Management of cognitive
processes
1) Planning and execution2) Response inhibition3) Task flexibility/multi-task
Walking is a complex task that requires coordination between brain and body
Frontal Lobe
Cognition and Walking
Executive function: Management of cognitive
processes
1) Planning and execution2) Response inhibition3) Task flexibility/multi-task
Walking is a complex task that requires coordination between brain and body
Making decisions in a complex environment
Cognition and Walking
Executive function: Management of cognitive
processes
1) Planning and execution2) Response inhibition3) Task flexibility/multi-task
Walking is a complex task that requires coordination between brain and body
Filter out distractions; Focus attention on gait
Cognition and Walking
Executive function: Management of cognitive
processes
1) Planning and execution2) Response inhibition3) Task flexibility/multi-task
Walking is a complex task that requires coordination between brain and body
Walk and talk at the same time
Decline in EF affects walking
became stronger under dual tasks conditions among el-
derly nondemented fallers and among patients with Par-
kinson’s disease, whereas such associations were not
observed in healthy young adults. Similarly, Hausdorff et
al. showed that better gait performance (e.g., higher gait
speed, lower stride time variability) was associated with
better scores on a “catch game,” a complex motor task,
but this association did not exist for finger tapping, a
relatively simple motor task.30 Associations between EF
and performance of balance and mobility were also ob-
served in stroke patients, even after adjustment for age,
quadriceps strength of the paretic side and current phys-
ical activity level.31
The earlier mentioned studies demonstrate how gait is
related to EF. It appears that this association is stronger
if the locomotor task is more challenging (e.g., obstacle
course) and/or if the normal gait pattern is already altered
(e.g., in patient populations). The results of the InChianti
and other studies suggest that the reliance on EF in-
creases as the locomotor task becomes more difficult and
challenging. Still, many questions remain about these
relationships. For example, while there is some evidence
suggesting that a decline in EF ability may actually
contribute to alterations in walking abilities, cause and
effect has not been definitively demonstrated. In addi-
tion, most studies correlated only selected parameters of
gait (e.g., speed or gait variability) with selected features
of EF. Although associations were observed, the inclu-
sion of a wider array of measures may provide a broader
picture of the interdependence between gait and EF and
may help to define if and how specific EF properties
affect specific aspects of walking.
ATTENTION
Definition of Attention
Attention may be considered a specific example of
EF.7,32 The term covers a “number of different processes
that are related aspects of how the organism becomes
receptive to stimuli and how it may begin processing
incoming or attended-to excitation, whether internal or
external.”5 There is, however, “no single and clear-cut
definition of attention.”5 Posner et al. view attention as
an anatomical network whose “primary purpose is to
influence the operation of other brain networks.”33 At-
tention can be classified into separate functions, includ-
ing focused or selective, sustained, divided and alternat-
ing, although these distinctions are somewhat artificial.
Selective attention, which enables filtering of stimulus
information34 and suppression of distractors, is com-
monly referred to as “concentration.”5 Sustained atten-
tion refers to the ability to maintain attention to a task
over a period of time.5,34 Divided attention refers to the
ability to carry out more than one task at the same time
and alternating attention refers to rapid shifting of atten-
tion from one task to another.5,34 Here we focus primarily
on divided attention. This type of attention plays an
important role in walking in multitasking and changing
situations, serves as a common tool for examining the
attentional demands of various tasks, including walking,
and has clinical implications for fall risk.
Models of Dual Tasking
During the past 2 decades, many studies have inves-
tigated whether gait requires attention. Dual tasking is
the most popular method for testing this question. This
involves challenging attentional capacities, specifically
the ability to divide attention. A priori, if gait is auto-
matic and does not require attention, then simultaneous
execution of an additional task should not affect gait or
the performance of the other task. Before we review the
studies that provide evidence that gait is indeed an at-
tention-demanding, high-level, controlled task, we first
briefly summarize the neuropsychology theories that
have been proposed to explain why there are dual tasking
costs in other situations.
Difficulties in the simultaneous performance of two or
more tasks have led to the development of several neu-
ropsychological theories on human information process-
ing. Explanations generally revolve around the capacity-
sharing theory, the bottleneck theory or the multiple
resource models theory. The capacity-sharing theory
FIG. 1. Association between gait speed and performance on the TMTin the InCHIANTI study. Subjects with poor and intermediate perfor-mance in the TMT (i.e., large increase when going from TMT-A toTMT-B) had decreased gait speed, especially on the obstacle course.From Ble et al.27
332 G. YOGEV-SELIGMANN ET AL.
Movement Disorders, Vol. 23, No. 3, 2008
Yogev-Seligman et al., 2008
Performance on Executive Function TestGood Medium Poor Good Medium Poor
Wal
kin
g sp
eed
(m
/se
c)4-meter course
Usual pace
7-meter course with obstaclesFastpace
Executive Function Predicts Fall Risk
Herman et al. 2010
0
10
20
30
40
50
60
0 5 10 15 20 25
% o
f su
bje
cts
wh
o f
ell
Time to first fall (months)
High Executive Function
Low Executive Function
Dual-task paradigm
0
1
2
3
4
5
6
7
8
9
10
Dual-task Lower limb Upper Limb
Od
ds
Rat
ioOdds of Falling
Beauchot et al., 2008
Odds of falling when gait changes during multi-tasking
1 = no difference
n = 2290 muscle weakness muscle weakness
Fall Risk Model
Reduced Executive Function
Easily Distracted Can’t multi-task
Muscle Weakness(can’t recover)
Increased trips& stumbles Fall
Prevention
Exercise can increase muscle strength
Exercise can improve executive function
Fall Prevention
1) Muscle weakness
Traditional View:
Exercise Improves Muscle Mass
0
5
10
15
20
25
30
35
Baseline 2 months
On
e R
ep
Max
imu
m L
eft
(k
g)
Strength Training Improves Muscle Function
Fiatarone et al. 1990
3 x per week; ~5 minutes of lifts
0
5
10
15
20
25
30
35
Baseline 2 months
On
e R
ep
Max
imu
m L
eft
(k
g)
Strength Training Improves Muscle Function
Fiatarone et al. 1990
0
5
10
15
20
25
30
35
Baseline 2 months
On
e R
ep
Max
imu
m L
eft
(k
g)
3 x per week; ~5 minutes of lifts
Fall Prevention
1) Muscle weakness
2) Cognitive decline (e.g., multi-tasking)
Traditional View: Novel View:
✔
Can exercise reduce cognitive decline?
Aerobic Exercise Improves Cognition
Hillman et al., 2008
Analysis of 18 studies show exercise training benefits for cognition in older adults for multiple cognitive domains, but especially for executive abilities
Size
of
the
Effe
ct
Executive Controlled Spatial Speed
ControlExercise
Aerobic exercise increases brain volume
Healthy elderly adults randomly assigned to aerobic exercise for 6-months, 3 hrs/week had increased brain volume in gray matter (GM; blue) and white matter (WM; yellow) compared to a non-exercise group.
Colcombe et al., 2006
Frontal WM
Frontal GM
59 Participants
Exercise Improves Fall Risk Independent of Muscle Strength
0
20
40
60
80
100
120
Control Exercise
Falls
pe
r 1
00
pe
rso
ns
0
5
10
15
20
25
30
Control Exercise
Kn
ee
ext
en
sor
stre
ngt
h
Exercise program reduces fall risk without increasing muscle strength (meta-analysis of a standard fall prevention program) Robertson et al., 2002
Falls per 100 persons Muscle Strength
Meta-analysis of Exercise Studies
~55% reduction in falls in individuals in exercise programs (aerobic + strength training) Petridou et al., 2009
597 subjects in five RCTs
55%
Fall Prevention
1) Muscle weakness
2) Cognitive declines (e.g., multi-tasking)
Traditional View: Novel View:
✔
✔
Fall Risk Model
Reduced Executive Function
Easily Distracted Can’t multi-task
Muscle Weakness(can’t recover)
Increased trips& stumbles Fall
Fall Risk Model
Reduced Executive Function
Muscle Weakness(can’t recover)
Fall
Road map:1) Evolutionary history of aging and exercise2) Exercise and fall risk: predictors and prevention3) What can you do to reduce fall risk?
Nothing in Biology Makes Sense Except in the Light of Evolution
-Theodosius Dobzhansky
Road map:1) Evolutionary history of aging and exercise2) Exercise and fall risk: predictors and prevention3) What can you do to reduce fall risk?
Nothing in Biology Makes Sense Except in the Light of Evolution
-Theodosius Dobzhansky
What Can You Do?
Focus on two main activities:
– Aerobic
– Strength/balance
Aerobic Exercise
Activities that increase your heart rate: brisk walking, cycling, swimming
Suggestions for daily life changes
AgeMax. HR
(220-Age)Target HRs(60-70%)
65 155 93-109
70 150 90-105
75 145 87-102
80 140 84-98
85 135 81-95
90 130 78-91
Work your way up to moderate intensity
American Heart Association Guidelines
Suggestions for daily life changesWork your way up to moderate intensity
Light intensity:Can talk and sing without problemNo change in breathing patterns Moderate intensity:
Change in breathing, but not out of breathCan talk, but not sing
Strength Training
National Institute on Aging at NIH:http://go4life.nia.nih.gov
National Institute on Aging at NIH:http://go4life.nia.nih.gov
Find Activities and Exercises Here
Suggestions for daily life changes
How to start? Small changes can add up to big results
Increasing stair use can improve aerobic fitness by 10%
Park farther away: Lifestyle change comparable to structured
program in intervention study
Ross and McGuire et al., 2011; Meyer et al., 2010; Dunn et al., 1999
Suggestions for daily life changes
Make it a priority: Schedule exercise into your calendar like an appointment
Making exercise social improves adherence: 84% vs. 60% after 6 monthsCox et al., 2003
Suggestions for daily life changes
Keep it fun: You will keep doing activities if you enjoy them
Ryan et al., 1997Wankel, 1993
Start Today
Remember: Activity is in our Genes
Grandmother Hypothesis
Physically active lifestyle allows for successful aging
Thanks!
Thank You Supporters!
Causes of Falls
1. Accident/environment based (~31%)
2. Gait disorders (~17%)
3. Symptoms of underlying diseases account for rest
Rubenstein 2006 Age and Ageing
Ambrose et al. 2012
Strength
Three Suggestions
• Start small
• Make a plan (exercise is a priority)
• Keep it fun (you do what you enjoy)
Suggestions for daily life changes
Make a plan: Ask a friend to take a walk or join a group exercise class/activity
Making exercise social improves adherence: 84% vs. 60% after 6 months
Cox et al., Prev Med, 2003
Suggestions for daily life changesWork your way up to moderate intensity
Light intensity:Can talk and sing without problemNo change in breathing patterns Moderate intensity:
Change in breathing, but not out of breathCan talk, but not sing
Strength Training Improves Muscle Function
Fiatarone et al. 1990
Strength Training Improves Muscle Function
Fiatarone et al. 1990
Dual-Task Performance and Fall Risk
Beauchot et al., 2008
Odds of falling when gait changes during multi-tasking
1 =
No
dif
fere
nce
in o
dd
s o
f fa
llin
g
Muscle Strength and Fall Risk
Moreland et al. 2004
Odds Ratio (OR): Odds that an outcome (fall) will occur given a particular condition (muscle weakness)
1 = no difference
Higher risk
Strength Training Improves Muscle Function
Fiatarone et al. 1990
Executive Function Predicts Fall Risk
Herman et al. 2010 J. Gerontology
Meta-analysis of Exercise RCTs
~55% reduction in falls in individuals in exercise programs (aerobic + strength training) Petridou et al., 2009
Humans Have Long Lifespans
Finch C E PNAS 2010;107:1718-1724
Odds of Falling
0123456789
10
Retrospective Prospective
Od
ds
Rat
io
Beauchot et al., 2008
Odds of falling when gait changes during multi-tasking
1 = no difference
Hig
her
od
ds
0
1
2
3
4
5
6
Mill
ion
s o
f ye
ars
ago
From ~7-2 Ma: Bipedal fruit eating apes(Australopithecus)
2 Ma: Hunting and gathering (Homo)
Human Evolution
Fall Risk Model
Reduced Cognitive Function
Distraction
Slow decision making
Muscle Weakness(can’t recover)
Increased trips& stumbles
Fall
Exercise Training and Dual-Task Performance
-5
0
5
10
15
20
25
30
35
Simultaneous training Cognitive training Control group
Pe
rce
nt
Re
du
ctio
n in
Gai
t V
aria
bili
ty
Theill et al., 2013
Exercise is Good For Us
We live in a mismatch environment: Our bodies evolved to be active
Exercise is the “magic pill”
Question
Is exercise the key to reducing fall risk?
Hip fractures in 75 and older (per 100k) Nigeria: 8.0Britain: 190.8
Adebajo et al. 1991
Fall risk in more active populations?