Posts Tagged ‘frailty’

A Sociological Look at Frailty and


[A Three Part Series]

Part III

The following is an article that appeared in the Journal of Aging Research (Volume 2013, Article ID 657508, 8 pages. The article was titled, A Review of the Effects of Physical Activity and Exercise on Cognitive and Brain Functions in Older Adults Copyright © 2013 Louis Bherer et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Studies supporting the notion that physical activity and exercise can help alleviate the negative impact of age on the body and the mind abound. This literature review provides an overview of important findings in this fast growing research domain. Results from cross-sectional, longitudinal, and intervention studies with healthy older adults, frail patients, and persons suffering from mild cognitive impairment and dementia are reviewed and discussed. Together these finding suggest that physical exercise is a promising nonpharmaceutical intervention to prevent age-related cognitive decline and neurodegenerative diseases.

  1. Introduction

Chronological aging, or senescence, is associated with an increased risk of chronic conditions and diseases such as cognitive impairment, cardiovascular disease, and metabolic syndrome. Due to prolonged life expectancy, age-related diseases have increased in alarming proportions in recent decades [1]. An increasing body of studies have suggested that lifestyle factors have a significant impact on how well people age. For example, Fratiglioni et al. [2] reported that three lifestyle factors can play a significant role in slowing the rate of cognitive decline and preventing dementia: a socially integrated network, cognitive leisure activity, and regular physical activity. In this review and others [3, 4], it is argued that out of these lifestyle factors, physical activity has the most support as protective against the deleterious effects of age on health and cognition. Broadly defined, physical activity refers to activity that is part of one’s daily life involving bodily movements and the use of skeletal muscles. Physical exercise is a subcategory of physical activity that is planned, structured, and purposive to improve specific physical skills or physical fitness. Evidence suggests that physical activity and exercise can to some extent lower the risk of adverse outcomes associated with advancing age.

Physical activity maintained throughout life is associated with lower incidence and prevalence of chronic diseases such as cancer, diabetes and cardiovascular and coronary heart diseases [5, 6]. Recent studies suggest that physical exercise also protects against dementia [7]. Yet, despite this promise, the ways in which physical activity impacts the rate and prevalence of cognitive decline is still under investigation. Furthermore, several open issues call for further research, such as the dose-response relationship, the level of change or protection provided by physical activity, the biological and/or psychological mechanisms by which these effects occur and whether physical activity can be beneficial despite chronic medical conditions, neurological syndromes such as dementia, and the physical limitations observed in frail patients. Although recent advancements in neuroimaging techniques and genetics have opened new research avenues, more studies are required to provide definitive answers to these important questions. This literature review aims to provide an overview of studies that have attempted to assess whether and how physical activity and exercise positively impact older adults at any age and with various physical and psychological conditions.

  1. Aging and Neurocognitive Functions

It is generally assumed that age brings with it declines in performance in a multitude of cognitive tasks that require a variety of perceptual and cognitive processes (for extensive reviews of the literature see [3, 8, 9]). More specifically, processing speed declines early in the course of aging, which has recently been associated with loss of white matter integrity [10]. Working memory, or the ability to maintain and consciously manipulate information, is also highly age-sensitive. The age-related difference in working memory tends to be greater if executive control processes such as inhibition, updating, and manipulation are required, and even greater if the memory load (i.e., the number of items to be maintained) is high. These deficits have sometimes been associated with reduced task-related activation in older compared to younger adults in frontal regions of the cerebral cortex. Other studies also reported higher task-related activation in older adults, a phenomenon possibly associated with compensation for age-related changes in brain structure and functions [9]. Older adults also tend to show reduced inhibition compared to younger adults. As a result, they are more distracted by irrelevant information and more affected by proactive interference (i.e., interference induced by current learning on further encoding of new information). Furthermore, episodic memory declines in late adulthood, likely due to poor encoding strategies, less use of environmental support, and deficits in binding new information with existing knowledge during encoding.

Structural and functional brain imaging studies have provided insights into potential brain mechanisms of cognitive aging. For instance, changes in brain volume occur faster in adults after 50 years of age, with an annual decline of 0.35% compared to 0.12% in young adults (see [11, 12] for reviews). Ventricle dilatation can approximate 4.25% per year at 70 years of age compared to 0.43% in young adults. The volume of the hippocampus, a cerebral structure that plays a major role in memory formation, is also sensitive to age, with an annual decline of 0.86% per year (from 26 to 82 years), 1.18% per year after 50 years, and 1.85% per year after 70 years. Yet, rate of change is difficult to appreciate due to the lack of longitudinal studies. In a recent study, Raz et al. [13] followed participants over 30 months and observed that the hippocampus, the entorhinal cortex, the orbital-frontal cortex, and the cerebellum showed volumetric changes after only 15 months, while other brain structures showed shrinkage after 30 months, including the caudate nucleus, the prefrontal subcortical white matter, and the corpus callosum. However, some brain structures showed almost no change (the primary visual cortices, the putamen, and the pons). In addition, aging is associated with overall changes in white matter integrity (e.g., leukoaraiosis), with greater changes occurring after the seventh decade, and localized preferentially in the frontal and prefrontal regions [11]. These changes are more pronounced in patients with vascular diseases such as hypertension and type-2 diabetes. Cerebral metabolism is also altered by age, with a reduction in regional cerebral metabolic rate for glucose, oxygen, and blood flow. Although it is frequently assumed that structural changes are associated with a decline in brain metabolism, recent evidence suggests otherwise. For example, Chen et al. [14] observed that, in some brain regions, age-associated reductions in cerebral blood flow could occur independently of regional atrophy [14].

  1. Physical Activity and Cognition in Healthy Seniors

Several studies support the notion that physical activity is a significant moderator of age-related cognitive decline. In cross-sectional studies, age-related differences in cognitive performance observed when older adults are compared to younger participants are reduced if the comparisons involved higher-fit individuals rather than sedentary older adults [1519]. As a whole, these cross-sectional studies suggest that cardiorespiratory fitness is associated with more efficient cognitive functions (emphasis mine).

In longitudinal studies, older adults that participate in physical activity show less cognitive decline over two- to 10-year follow-up periods. For instance, in a study by Barnes et al. [20] cardiorespiratory fitness assessed at baseline predicted cognitive performance six years later in a variety of cognitive domains (working memory, processing speed, attention, and general mental functioning). In nationally representative samples of noninstitutionalized persons aged 50 years and older and across 11 European countries (Austria, Germany, Sweden, Denmark, Switzerland, the Netherlands, Belgium, France, Spain, Italy, and Greece) Aichberger et al. [21] reported that individuals who participated in any type of regular physical activity showed less cognitive decline after 2.5 years, especially when they engaged in vigorous activities more than once a week.

The impact of physical activity on cognition in older adults is more strongly supported by results from intervention studies, which generally show that older adults who have completed a physical activity program that produces significant increases in cardiorespiratory fitness (indexed by direct measures or estimation of) often show enhanced cognitive performance. Dustman et al. [22] compared middle-aged and older individuals who completed a four-month aerobic training program to age-matched controls who participated in strength and flexibility exercises and controls who did not exercise. Only the aerobic training group showed improved cardiorespiratory function, along with improvements on a simple RT task. Similar results were obtained in women aged 57 to 85 years old following a three-year physical training program [23]. Hawkins et al. [24] reported that, in older adults, a 10-week aquatic fitness program led to greater improvement in task conditions that tap dual-task and switching abilities compared to conditions that do not require executive or attentional control processes. In Kramer et al.’s [25] study, older adults who completed a six-month aerobic training program (walking) showed a significant improvement in cognitive performance, unlike those who completed a stretching program. Cognitive improvement was greater in tasks that tapped attentional control or executive control functions and was correlated with improvement in . In another study, Albinet et al. [26] reported that 12 weeks of aerobic training lead to enhanced performance in executive control and increased heart rate variability in older men and women aged 65–78. These results suggest that aerobic exercise may be an important cardiac and brain protective factor as people age. The greater improvement induced by aerobic training in executive control compared to other cognitive domains has also been confirmed by several meta-analyses (see [27] but see [28] for different conclusions).

The selective benefit of aerobic exercise for tasks that tap executive control was also observed in another recent study [29], where 57 older adults completed a 10-month training program (aerobic versus strength and flexibility). The positive effect on executive control was observed after aerobic training only. In another study, Renaud et al. [30] observed that only 12 weeks of aerobic training induced a significant improvement in cardiorespiratory capacity (estimated ) along with enhanced motor response preparation, such that participants maintained response preparation over time more efficiently after the training program. These results provide additional support for the notion that improving aerobic fitness may enhance attentional control mechanisms in older adults. In a meta-analytic review of randomized-control trials of aerobic exercise on neurocognitive functions, Smith et al. [31] examined 29 studies conducted between 1966 and 2009 (including more than 2,000 participants and 234 effect sizes). They found that individuals who were randomly assigned to aerobic exercise training showed modest improvements in attention, processing speed, executive function, and memory, with less convincing effects on working memory. These results, along with those from Colcombe and Kramer [27], suggest a selective effect of aerobic exercise on neurocognitive functions. However, not all studies reported a significant correlation between improvement in cardiorespiratory fitness outcomes and cognitive improvement (see [28, 32] meta-analysis), which suggests that physiological mechanisms supporting cognitive enhancement remain to be fully understood.

Studies reported above highlight that aerobic exercise enhances cognitive function. However, recent evidence now suggests that other types of exercise training, such as resistance training, may also benefit cognition. Cassilhas and colleagues [33] demonstrated that six months of either thrice-weekly moderate or high intensity resistance training improved memory performance and verbal concept formation among 62 community-dwelling senior men aged 65 to 75 years. Liu-Ambrose and colleagues [34] demonstrated that an individualized home-based program of balance and strength retraining significantly improved selective attention and conflict resolution as measured by the Stroop Test after six months among seniors aged 70 years and older with a recent history of falls. The finding of this study is notable given that many have hypothesized that the cognitive and neural benefits of exercise must occur within the context of social engagement for it to be effective [35]. Liu-Ambrose and colleagues [36] also demonstrated that 12 months of either once-weekly or twice-weekly progressive resistance training improved Stroop Test performance among 155 community-dwelling senior women aged 65 to 75 years. Enhanced selective attention and conflict resolution were also associated with increased gait speed. Clinically, improved gait speed predicts a substantial reduction in both morbidity [37] and mortality [38, 39]. These results illustrate the clinical significance of cognitive gains induced by resistance training. Therefore, it seems that in addition to endurance training, resistance training should be seriously considered as a potential modifier of cognitive functions in older adults. Recent studies also suggest that motor learning and coordinative exercise could also be used to enhance cognitive function in this population (see [40]).

  1. Physical Activity and Brain Structures and Functions in Older Adults

The biological mechanisms by which cognition is enhanced through physical exercise training remain to be completely elucidated, although the number of studies that have tried to identify these mechanisms has increased in the last 10 years. For the most part, the studies that support the notion that physical exercise has an impact on brain functions have focused on direct biological effects of exercise using both animal and human models. However, as suggested by Spirduso et al. [41] exercise may enhance cognition indirectly by improving health conditions (stress, sleep) and reducing chronic diseases (coronary heart diseases) that impact neurocognitive functions.

The evidence for the direct effects of exercise on the brain first came from animal studies. In a comprehensive literature review, Lista and Sorrentino [42] suggest that the basic neurobiological mechanisms associated with exercise can occur at two levels, supramolecular and molecular. At the supramolecular level, physical activity has been found to induce angiogenesis or the physiological process by which new blood vessels grow from preexisting vessels [43, 44]. Physical activity has also been associated with neurogenesis, or neural cell proliferation, in the hippocampus in elderly rats [45]. Although the functional significance of this effect remains unclear, there is evidence that newly formed neurons can integrate into a neural network and become functional [46]. Exercise-induced synaptogenesis has also been reported [47, 48].

The molecular mechanisms by which exercise induces angiogenesis, neurogenesis, and synaptogenesis have received growing attention in the last few years. Again, the evidence comes mainly from animal studies that showed exercise-associated changes in molecular growth factors such as brain-derived neurotrophic factor (BDNF), which plays a crucial role in neuroplasticity and neuroprotection, and increased production of insulin-like growth factor 1 (IGF-1), which is involved in both neurogenesis and angiogenesis. Moreover, neurotransmitter systems also seem to be modulated through exercise (see [42]). Until very recently, evidence for the molecular and supramolecular effects of exercise came exclusively from animal studies. However, a very innovative study [49] recently showed that greater exercise-related increases in BDNF were associated with increased hippocampal volume. If reproduced, these results would confirm that physical exercise induces genuine neurotrophic effects on brain structures and functions at the molecular, supramolecular, and structural levels.

In humans, several studies using structural and functional brain imaging, or electrophysiological measures of brain activity, suggest that physical exercise induces transient and permanent changes at the structural and functional levels in the aging brain [5054]. Using voxel-based morphometry (VBM), or detailed image segmentation of high-resolution brain scans, Colcombe et al. [55] reported that a higher cardiorespiratory fitness level ( ) was associated with a reduced loss of grey and white matter in the frontal, prefrontal, and temporal regions in older adults. In another study, Erickson et al. [56] performed a region-of-interest analysis on magnetic resonance images in 165 non-demented older adults and found that higher fitness levels were associated with larger left and right hippocampi that further correlated with better spatial memory performance. These findings suggest that aerobic fitness is associated with changes in brain structures that translate into better cognitive function in older adults (see also [49, 57]).

Even more striking evidence of the benefit of fitness on brain functions comes from functional brain imaging studies (fMRI). It has been shown that enhanced cardiovascular functions after aerobic training are associated with greater task-relevant activity in brain areas recruited in an attentional control task [58]. Similarly, 12 months of resistance training in community-dwelling senior women led to functional changes in two regions of the cortex previously associated with response inhibition processes, the anterior portion of the left middle temporal gyrus, and the left anterior insula extending into lateral orbital frontal cortex [36]. These hemodynamic effects co-occurred with improved task performance. Moreover, Voss et al. [59] found changes in functional connectivity after aerobic exercise training in older adults. They observed that 12 months of training leads to increased connectivity in regional connections that support both the default-mode network and the frontal executive network, suggesting that physical exercise has a restorative effect on large-scale brain circuitry. Changes in these large-scale brain networks have received increasing attention in aging neuroscience, as they indicate massive changes in brain systems.

A complete understanding of the potential for physical activity to protect the brain from the effects of age would require investigating the indirect influences of exercise on cognition. There is growing evidence that exercise has indirect beneficial effects on cognition through its impact on factors that are known to alter neurocognitive integrity [60]. Spirduso et al. [60] suggest three groups of potential mediators in the relationship between exercise and cognition: physical resources, chronic diseases or states, and mental resources. It has been shown that physical exercise enhances mental resources by reducing depression [61], anxiety, and chronic stress and improving self-efficacy [62]. The effect of physical activity on cognitive function might also be mediated by physical resources such as diet [63] and sleep [64, 65]. It remains to be seen whether these factors in fact mediate the positive effects that exercise has on cognitive and brain health.

  1. Physical Activity and Cognition in Frail Older Adults

With increasing age, and specifically with advanced age (i.e., over 75 years), many individuals eventually develop one or more of a group of related medical problems referred to as geriatric syndromes. Perceptual limitations (vision and hearing problems), urinary incontinence, falls, delirium, and dementia are examples of geriatric syndromes. These syndromes are characterized by having more than one cause and by involving several different body systems. An emerging symptom that appears particularly relevant to our purpose is frailty, as it apparently limits physical activity and exercise. Frailty is defined as a complex health state of increased vulnerability to stressors due to impairments in multiple systems. It has been associated with adverse outcomes such as disability, falls, hospitalization, and death [66]. With aging, the prevalence of frailty increases from 7% in older adults aged between 65 and 74 years to 18% between 75 and 84 years and 37% at age 85 years and older [67]. Physical inactivity is a major risk factor for frailty [66]. It is important to note that frailty is not a contraindication for physical activity (Emphasis mine). On the contrary, it may be one of the most compelling reasons to prescribe physical exercise [68].

Results from longitudinal studies show that physical activity and exercise can prevent frailty in older adults. In a recent study, 2,964 older adults were followed for five years to determine the relationship between physical activity and the risk of becoming frail [69]. Results showed that individuals who regularly exercised at baseline were less likely to develop frailty within a five-year period than sedentary individuals, even after adjusting for baseline health conditions and demographic characteristics.

Intervention studies also suggest that physical activity can improve several frailty syndrome components, especially sarcopenia (reduction in skeletal muscle mass) and functional impairment [68]. Moreover, in a recent randomized controlled trial that assessed the impact of a three-month physical training intervention on quality of life in 77 physically frail persons aged 75 years and older [70], it was observed that functional exercises twice a day to improve balance and lower extremity muscle strength, in addition to strength training twice a week, helped to improve psychological well-being associated with physical functioning, emotion, and mental health. To our knowledge, only one study has shown that physical exercise training can help improve cognition in frail older adults. Langlois et al. [71] recently observed that three months of training in frail older adults resulted in significant improvement in both physical capacity and cognitive performance (executive functions, processing speed, and working memory) as well as quality of life associated with leisure activities and satisfaction with physical capacity.

  1. Physical Activity and Cognition in Older Adults with Mild Cognitive Impairment and Dementia

According to the Alzheimer’s Association [72], one in eight people aged 65 and older (13%) and 43% of people 85 and older have Alzheimer’s disease. Currently, there is no cure for Alzheimer’s disease. However, research has suggested that physical activity and exercise can significantly reduce the risk of developing it. In a recent cross-sectional study that compared 198 subjects with mild cognitive impairment (MCI) to 1,126 with normal cognition, Geda et al. [73] observed that moderate activity during midlife was associated with a 39% lower risk of having mild cognitive impairment in later life. Late-life moderate exercise was associated with a 32% lower risk for MCI. Burns et al. [74] explored the effect of exercise on cognitively impaired individuals and found an association between direct measures of cardiorespiratory fitness (VO2 peak) and cognition (neuropsychological test battery) in normal older participants and patients in the early stage of Alzheimer’s dementia (AD). Results showed that cardiorespiratory fitness was modestly reduced in patients with AD compared to participants without dementia. Although no significant association was found between cardiorespiratory fitness and cognition in participants without dementia, higher fitness levels in early AD participants were associated with larger brain volume (less brain atrophy), even when controlling for age, sex, dementia severity, and physical frailty.

In a longitudinal study exploring the association between midlife physical activity and late-life cognitive function and dementia, Chang et al. [75] observed that being active (around 5 hours per week) was associated with higher scores in processing speed, memory, and executive functions, even after controlling for demographic and cardiovascular factors. Moreover, participants who reported being active were significantly less likely to have dementia in later life. In a prospective study following 1,740 persons older than 65 years without cognitive impairment for a period of 6.2 years, Larson et al. [7] reported reduced dementia incidence for individuals who exercised three or more times a week (13 per 1,000 person-years) compared to those who exercised fewer than three times a week (19.7 per 1,000 person-years), demonstrating a 32% reduced risk for dementia.

Interestingly, correlations have also been reported between muscle strength and a lower risk of AD and a slower rate of cognitive decline. Having followed 900 community-based older persons without dementia at baseline, Boyle et al. [76] showed a lower rate of global cognitive decline, MCI and AD in older adults with higher muscle strength. The protective effects remained after adjustment for several covariates, including body mass index, physical activity, pulmonary function, vascular risk factors, vascular diseases, and apolipoprotein E4 status. Furthermore, in a recent meta-analysis of prospective studies that covered 15 prospective studies (12 cohorts) and 33,816 nondemented individuals, 3,210 of which showed cognitive decline during the one- to 12-year follow-up, Sofi et al. [77] observed that physical activity significantly and consistently prevented cognitive decline. Individuals who were highly physically active showed 38% less risk of cognitive decline, and those who did low-to-moderate level exercise also showed a significantly 35% reduced risk.

Results from intervention studies are scarce. A meta-analysis of randomized controlled trials (2,020 participants; 30 trials) [78] reported beneficial effects of physical activity on physical fitness (effect size = 0.69) and cognitive function (effect size = 0.57) in adults with cognitive impairment (MCI and dementia). However, other studies have reported modest benefits [79] or no appreciable effect [80] of physical activity on cognition in patients with cognitive impairment. A recent randomized clinical study evaluated the impact of a six-month aerobic exercise intervention in individuals with mild cognitive impairment [81]. Thirty-three older adults (17 women) with amnestic mild cognitive impairment ranging in age from 55 to 85 years were randomized to either a high intensity aerobic exercise (75–85% of heart rate capacity) or a stretching control group. Results showed beneficial effects of aerobic exercise, especially in speed of processing and executive functioning, although in some tests, gender differences in cognitive improvement were observed, despite comparable gains in cardiorespiratory fitness in men and women. In a randomized controlled study, Kemoun et al. [82] examined the benefits of a 15-week physical activity program in 31 subjects (mean age of 82 years). They reported that a physical activity program can slow cognitive decline and improve quality of walking in elderly persons with dementia. A more recent study assessed the cognitive impact of a Tai-Chi intervention group ( ) compared to a stretching and toning group ( ) in older adults with cognitive impairment [83]. Results showed that both groups improved in global cognitive function, delayed recall, and subjective cognitive complaints. However, improvements in balance, visual span, and Clinical Dementia Rating scores were observed in the intervention group only. Future studies are needed to specify whether interventions should involve aerobic or strength training exercises or both to improve cognition in MCI patients. Nagamatsu et al. [84] recently reported that patients who completed six months of aerobic or strength training exercise showed improved spatial memory performance, but only the aerobic group showed a correlation between physical capacity after intervention and spatial memory performance. The mechanisms by which exercise impacts cognition in this population thus deserve further study.

  1. Conclusions

In recent decades, an increasing number of studies have suggested that people should adopt physical activity and exercise as part of their lifestyle to alleviate the negative impact of aging on the body and the mind. However, we still do not understand how physical activity impacts the rate of cognitive decline. One major issue is whether physical activity broadly defined (i.e., activity that is part of one’s daily life involving bodily movements and the use of skeletal muscles) or structured exercise (i.e., physical activity that is planned, structured, and purposive to improve physical fitness) leads to the same benefits in preventing age-related cognitive decline. Physical exercise often differs from physical activity by being more controlled in terms of intensity and duration, while physical activity studies tend to incorporate a large variety of unspecified activities. Future studies are required to understand the intensity, duration, and types of exercise that better enhance cognitive functions in older adults. Although recent advancements in brain imaging techniques and genetics have opened new research avenues, more studies are required to find definitive answers to these questions. Further research is needed to better document the impact of other forms of exercise as well as the dose-response relationship that governs the positive impact of exercise on brain functions. Hopefully, ongoing randomized trials such as the AIBL Active Trial [85] and the brain-in-motion trial [86] designed to address the relationship between physical exercise intervention and brain function in at-risk individuals will help answer these questions.


The authors wish to thank Francis Langlois for editing and helpful comments. Louis Bherer and Teresa Liu-Ambrose are supported by the Canadian research chair program.


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A Sociological Look at Frailty and Aging

[A Three-Part Series]

Part II


In Part II of this blog I am focusing on exercise and its impact on frailty and aging. Hopefully you are already in some program where you are exercising on a consistent basis. If not, then what follows in the way of research should give you all the motivation you need.


To be sure, many older Americans continue to lead active and productive lives. However, the nation’s increasing longevity is bringing new challenges for health and social programs. Americans’ life span in 2009 was 78.5 years, according to the Centers for Disease Control and Prevention, about three decades more life than in 1900, when the average was only 47.3 years.

“We’ve added 30 years to the human life span, which is an unparalleled success story for public health, medicine and education,” Fried says. “As a result, it is critically important that we help these people who are living longer stay healthy.”

Of those living alone or with families, not in nursing homes or hospitals, about 4 percent of men and 7 percent of women older than 65 were frail, according to the parameters used by Fried and her colleagues in the 2001 study. The researchers, who studied more than 5,000 adults aged 65 and older, also found that the chances of frailty rose sharply after age 85, to about 25 percent. These numbers, the most recent data available, reflected conditions prior to 2001, and leaving “an important but unanswered question as to whether the frequency of frailty is the same, increasing or decreasing” today, Fried said.

Also, women are more likely than men to be frail, possibly because women typically outlive men and “start out with less muscle mass than men and, once they lose it, they may cross the frailty threshold more rapidly than men,” Fried says.

Stephanie Studenski, principal investigator at the Claude D. Pepper Older Americans Independence Center at the University of Pittsburgh, has been practicing in the geriatrics field for more than 30 years and sees “older people across the full spectrum, from frail 60-year-olds to vigorous 95-year-olds,” she says.

For the younger group, who usually are frail because of multiple chronic conditions, “sometimes medications can worsen frailty with their side effects, so adjustments can help,” she says. ” I tell these patients I can often make you better, give you more reserve and increase your resilience although not totally cure you. We can’t change from black to white, but often can push the black into gray.”

For those in their 80s or older, however, the causes of frailty are sometimes less obvious.

Barbara Resnick, a geriatric nurse-practitioner in Baltimore, remembers an 85-year-old woman, living at home, who “stopped going out to dinner with friends; she would say she was too tired and didn’t have the energy. She wasn’t walking out to get her mail anymore. She was eating less and losing weight rapidly.”

Her adult daughter became concerned and brought her mother to Resnick “and asked us to fix the problem,” recalls Resnick, who chairs the board of the American Geriatrics Society.

But there often is no quick fix. Clinicians checked the woman for underlying disease — they found none — and adjusted her medications. They also urged the woman to increase her physical activity, Resnick says. “That’s really the best way to manage frailty: Engage as much as you can; optimize what you can do. What’s important is resilience.”

Similarly, Kaufman recalls “a wonderful gentleman” in his 80s who had been doing quite well until his wife fell, broke her hip and had to enter a nursing home. The couple had been married 60 years. After she left, he began to slow down physically, and he stopped eating.

“He just gave up,” Kaufman says.” There was no one specific thing. But within a few months, he died. What do you put on a death certificate? If it was a pediatric case, we’d say ‘failure to thrive.’ He died of frailty.”

Researchers also are studying the impact of moderate physical exercise in preventing the most powerful indicator of frailty: slow walking speed. An ongoing study of 1600 people between the ages of 70 and 89 is comparing the effects of a moderate-intensity walking and weightlifting program to a program of health education only.

The exercise group walks for 30 minutes several times a week and uses ankle weights to improve lower-body strength. The education group receives information on diet, managing medications and other health-related matters, but not about physical exercise.

A smaller, earlier phase of the study suggested that physical activity was key, with a 26-percent reduction in walking problems among those who worked out regularly.

“You don’t have to go to an exercise program at the gym,” Kaufman says. “Clean your house. Walk to the mailbox to get your mail, or work in your garden. The greatest common denominator of frailty is muscle loss and slowing of gait, and it’s amazing what physical exercise can do.” Walston agrees. “Growing old may be inevitable, but growing frail is not,” he says.

Benefits of Exercise

One of the Healthiest Things You Can Do

Like most people you’ve probably heard that physical activity and exercise are good for you. In fact, being physically active on a regular basis is one of the healthiest things you can do for yourself. Studies have shown that exercise provides many health benefits and that older adults can gain a lot by staying physically active. Even moderate exercise and physical activity can improve the health of people who are frail or who have diseases that accompany aging.

Being physically active can also help you stay strong and fit enough to keep doing the things you like to do as you get older. Making exercise and physical activity a regular part of your life can improve your health and help you maintain your independence as you age.

Be as Active as Possible

Regular physical activity and exercise are important to the physical and mental health of almost everyone, including older adults. Staying physically active and exercising regularly can produce long-term health benefits and even improve health for some older people who already have diseases and disabilities. That’s why health experts say that older adults should aim to be as active as possible.

Being Inactive Can Be Risky

Although exercise and physical activity are among the healthiest things you can do for yourself, some older adults are reluctant to exercise. Some are afraid that exercise will be too hard or that physical activity will harm them. Others might think they have to join a gym or have special equipment. Yet, studies show that “taking it easy” is risky. For the most part, when older people lose their ability to do things on their own, it doesn’t happen just because they’ve aged. It’s usually because they’re not active. Lack of physical activity also can lead to more visits to the doctor, more hospitalizations, and more use of medicines for a variety of illnesses.

Prevent or Delay Disease

Scientists have found that staying physically active and exercising regularly can help prevent or delay many diseases and disabilities. In some cases, exercise is an effective treatment for many chronic conditions. For example, studies show that people with arthritis, heart disease, or diabetes benefit from regular exercise. Exercise also helps people with high blood pressure, balance problems, or difficulty walking.

To learn about exercise and diabetes, see “Exercise and Type 2 Diabetes.” from Go4Life®, the exercise and physical activity campaign from the National Institute on Aging.

Manage Stress, Improve Mood

Regular, moderate physical activity can help manage stress and improve your mood. And, being active on a regular basis may help reduce feelings of depression. Studies also suggest that exercise can improve or maintain some aspects of cognitive function, such as your ability to shift quickly between tasks, plan an activity, and ignore irrelevant information.

Some people may wonder what the difference is between physical activity and exercise. Physical activities are activities that get your body moving such as gardening, walking the dog and taking the stairs instead of the elevator. Exercise is a form of physical activity that is specifically planned, structured, and repetitive such as weight training, tai chi, or an aerobics class. Including both in your life will provide you with health benefits that can help you feel better and enjoy life more as you age.

Strength Training for a Healthy Heart

Regular exercise is a critical part of staying healthy. People who are active live longer and feel better. But what form of exercise is best? The standard teaching has been 30 minutes per day, five days a week of cardiovascular training, and three days a week of strength training. However, there has been a recent breakthrough in training approaches that focus on strength training for cardiovascular health.

The function of the cardiovascular system is to pump oxygen and nutrient-rich blood throughout the body and to remove waste products like carbon dioxide. The heart is a powerful muscle that contracts, expands, and hypertrophies, as other muscles do when worked. As the heart gets stronger, blood pressure and heart rate go down because the heart gets more efficient and can pump out more blood per beat.

Strength training, often called resistance training, refers to exercises that require muscles to exert a force against some form of resistance. The most common form of strength training is lifting weights, e.g., free weights, machines, elastic bands, body weight, or any other form of resistance. These types of exercises are known for developing and toning muscles, helping to develop and maintain the integrity of bones, increasing metabolism by increasing lean muscle mass, building stronger connective tissue and greater joint stability, and decreasing body fat. Strength training is beneficial for everyone. It is especially beneficial as we grow older because muscle mass naturally diminishes with age, and strength training will help prevent this muscle loss and rebuild what may have been lost.

Strength training as a component of a cardiac rehabilitation program is well-recognized by clinicians; however, it is now just coming to the forefront of preventive medicine for its profound effect in reducing the risks of cardiovascular disease. There have been several research studies on the effect of high-intensity, short rest weight training and its effect on cardiovascular health and fitness.

The findings are remarkable as strength training has not generally been thought to improve cardiovascular fitness. Aerobic activities that increase heart rate and make one breathe harder— walking, biking, and jogging—have typically been recommended for cardiovascular fitness. We are now learning that maximum increases in strength and cardiovascular fitness can be obtained from one type of exercise—strength training. Properly applied, strength training simultaneously engages both the muscular system and the cardiovascular system. Recommended intervals are three to five times per week for 20 to 30 minutes at a moderate intensity-level, or two to three times per week for 15 to 20 minutes at a high-intensity level.

The American Heart Association (AHA) says that for healthy adults, a regular program of weight training not only increases muscle strength and endurance, it also improves heart and lung function, enhances glucose metabolism, reduces coronary disease risk factors, and boosts well-being. When our muscles are stronger, there is less demand placed on the heart. This allows the lungs to process more oxygen with less effort, the heart to pump more blood with fewer beats, and the blood supply directed to your muscles to increase.

Strength training provides numerous health benefits. It can be very powerful in preventing and reducing the signs and symptoms of numerous diseases and chronic conditions such as obesity, diabetes, cardiovascular disease, osteoporosis, arthritis, and mild depression.

Additionally, it can help individuals recover from and prevent injury, improve endurance, flexibility, stamina, balance, and coordination. The idea is simple: strength is good. According to the AHA, strength increases “functional capacity,” which is the ability to perform daily activities. Being physically strong will decrease the strain that day-to-day tasks such as lifting, places on the heart.

Prior to beginning any form of exercise program, it’s important to see your physician for a complete physical examination to ensure you are healthy enough to begin an exercise regimen without risk. Share with your doctor your health goals and exercise plan, and seek his/her recommendations, especially those related to nutrition and smoking cessation.

Remember: regular strength training does more than just build better, stronger muscles—it builds a better, stronger, healthier body.

Strength Training for a Healthy Heart is an EHE International publication and is reprinted and distributed with its expressed written permission. EHE International, 10 Rockefeller Plaza, 4th Floor, New York, New York 10020; 212.332.3738; Information@EHEINTL.com.


Part II provided a general overview of the impact of exercise on frailty and aging. As everyone should recall the late Jack LaLanne was the ultimate guru of exercise and fitness. Jack was 96 years old when he came down with pneumonia and passed away. I can’t guarantee that you’ll live to be 96 years of age. But who knows!!! I’m not being facetious. Maybe with an excellent diet and exercise program, you’ll look back one day to a previous decade when you finally reached 100 years of age. Life is great! Even our “bad” days are “good” days. Why? Because we are alive, silly. Do everything you possibly can to live as long as you can. And while you’re doing that—live well and thrive. Enjoy the journey!

In Part III ahead I present data that summarizes major advancements in our knowledge of the impact of exercise on Frailty and Aging.

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A Sociological Look at Frailty and Aging [A Three-Part Series] Part I  


I am initiating a three-part series on frailty and aging. Part I consist of: facts about frailty and aging and attitudes about older people. Part II will cover an overview of important research related to how to stay healthy longer with exercise. Part III will hone in on an important study published recently in 2013 in the Journal of Aging.

The Demographic Picture

In the industrialized countries, life expectancy and, thus, the old age population have increased consistently over the last several decades. In the United States the proportion of people aged 65 or older increased from 4% in 1900 to about 12% in 2000. In 1900 only about 3 million of the nation’s citizens were 65 or older (out of 76 million total American citizens). By 2000, the number of senior citizens had increased to about 35 million (of 280 million US citizens). Population experts estimate that more than 50 million Americans—about 17 percent of the population—will be 65 or older in 2020. By 2050, it is projected that at least 400,000 Americans will be 100 years of age or older. The number of old people is growing around the world chiefly because of the post-World War II baby boom and increases in the provision and standards of health care. By 2050, 33% of the developed world’s population and almost 20% of the less developed world’s population will be over 60 years old. The growing number of people living to their 80s and 90s in the developed world has strained public welfare systems and has also resulted in increased incidence of diseases like cancer and dementia that were rarely seen in pre modern times. When the United States Social Security program was created, persons older than 65 numbered only around 5% of the population and the average life expectancy of a 65-year-old in 1936 was approximately 5 years, while in 2011 it could often range from 10–20 years. Other issues that can arise from an increasing population are growing demands for health care and an increase in demand for different types of services. Of the roughly 150,000 people who die each day across the globe, about two thirds—100,000 per day—die of age-related causes. In industrialized nations the proportion is much higher, reaching 90%.

Attitudes toward Older Citizens

When I was young, I held respect for my parents and grandparents because I, and society, generally held them to be venerable. That was the 1950s and before. That notion of respect for the elderly appears to be an outdated idea in the 21st century. People are not entitled to veneration simply because of their longevity, but rather because of whom they are as a person (what Dr. Martin Luther King referred to as “the content of one’s character”) and their individual behavior. Our attitudes toward older persons back in the 50s were also based on a kind of myth that older people should be venerated. Or, in my view, if a person wants respect— they must first be respectable. Age by itself has nothing to do per se with respect. It is human conduct that matters, not longevity. That being pointed out, it is nevertheless really unfortunate, but society has never really had a very positive view of its older citizens. Even today some folks are antagonistic toward the elderly. And when people discriminate against older citizens—it is called ageism. And ageism certainly does exist in our society. Historical periods reveal a mixed picture of the “position and status” of old people, but there has never been a “golden age of aging.” Studies have disproved the popular belief that in the past old people were venerated by society and cared for by their families. Veneration for and antagonism toward the aged have coexisted in complex relationships throughout history. In ancient times, the very few people who lived beyond 35 physically and mentally healthy, especially those of social status and wealth were treated with “respect and awe.” In contrast, those who were frail were seen as a burden and ignored or, in extreme cases, killed. For example, there once was the Eskimo practice of putting their elders on an ice-berg and saying bye-bye grandma. People were defined as “old” because of their inability to perform useful tasks rather than their years. In any era businesses often fail to recognize the experiences and contributions of long-term employees. In Greek and Roman cultures, old age was denigrated as a time of “decline and decrepitude.” In the Classical period, “beauty and strength” were esteemed and old age was viewed as defiling and ugly. The Medieval and Renaissance periods depicted old age as “cruel or weak.” In the Modern period, the “cultural status” of old people has declined in many cultures. Research on age-related attitudes consistently finds that negative attitudes exceed positive attitudes toward old people because of their looks and behavior. In his study Aging and Old Age, Posner discovers “resentment and disdain of older people” in American society. Harvard University’s Implicit-association test measures implicit “attitudes and beliefs” about Young vis-a-vis Old. Blind Spot: Hidden Biases of Good People, a book about the test, reports that 80% of Americans have an “automatic preference for the young over old” and that attitude is true worldwide. The young are “consistent in their negative attitude” toward the old. Ageism documents that Americans generally have “little tolerance for older persons and very few reservations about harboring negative attitudes” about them. In spite of its prevalence, ageism is seldom the subject of public discourse. So what do we know about this less than venerated segment of the population?

The Four Dimensions of Aging

Old age comprises four dimensions: chronological, biological, psychological, and social. Chronological age may differ considerably from a person’s functional age. The distinguishing marks of old age normally occur in all five senses at different times and different rates for different persons. In addition to chronological age, people can be considered old because of the other three dimensions of old age. For example, people may be considered old when they become grandparents or when they begin to do less or different work in retirement. For many decades doctors used to describe older citizens as inevitably heading toward losing their strength, vitality, stamina, and general health, and attributed these phenomena to “the process of aging or getting older.” This old attitude probably made older people feel helpless, and relegated them to eventually accepting the notion that getting older meant becoming a crippling image of one’s prior self. This also has made many younger people feel that only bad health and eventual demise was all they had to look forward to in their older years. This “one size fits all” characterization of getting older was simplistic, and an inadequate medical explanation of the aging process. Do people eventually get sick and die? Of course they do. But our physical and mental condition during our older “golden years”, until our final days, does not necessarily have to be in a constant state of fragility and disability. Far from it! The lion’s share of older people does enjoy a robust, active, thriving lifestyle. The scientific evidence is clear. Having a healthy lifestyle includes healthy nutritious food, plenty of exercise, and quality health care. This will not only extend a person’s longevity, but a longevity that is also productive, and thriving. Older citizens can therefore enjoy all the satisfactions of being an older citizen like being comfortably retired, and having the freedom to pursue any interest. Is this a utopian view of old age? Well, maybe a little. Other negative factors can alter this positive outlook such as lack of money or other resources, and the absence of family and friends. Losing a spouse or loved one can put tremendous stress, loneliness, fear and anxiety on an older person. Surveys of happiness long ago showed that the happiest years of a person’s life is between 25 and 45 years of age. Not surprisingly that twenty year period (25-45) is the very years when people are raising a family, their careers are taking off, and life in the bedroom is exceptionally good. Quality of life in our older years does not have to suffer, provided one has the proper mindset. People need to possess a research and science-based perspective. So, from a research perspective one needs to ask this sort of question. What differentiates people who become frail in their older years from others who appear to be healthy, robust, thriving and happy? At one level this type of question is antiseptic and rather academic. At another level however, this type of research question has personal implications for how he/she ought to live their life during one’s older years. Everyone needs to look at this question intellectually, but simultaneously ask oneself— what implications do the question and its answer have for me? Connecting the applicability of research findings to oneself is, of course, up to you. I encourage all of you to think long and hard on this. Do you want to be frail, or healthy, robust and thriving as you age? There are no guarantees in life. But for the majority of people at any age you have decisions to make that certainly will determine whether you succumb to frailty, or spend your golden years in good health. So, let’s start by what we know about frailty and what we know about the construct of aging.      I used to think the worst things in life were either death or having a conservative Republican in the White House. Now I know death is the lesser of those two evils. My attitude toward conservative republicans hasn’t changed; however, death is not the worst outcome in life—its frailty. It must be pointed out that aging and frailty is not the same thing.

So what is Frailty?

Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. Frailty is a condition associated with aging, and it has been recognized for centuries. As described by Shakespeare in As You like it, “the sixth age shifts into the lean and slipper’d pantaloon, with spectacles on nose and pouch on side, his youthful hose well sav’d, a world too wide, for his shrunk shank…” The shrunk shank is a result of loss of muscle with aging. It is also a marker of a more widespread syndrome of frailty, with associated weakness, slowing, decreased energy, lower activity, and when severe, unintended weight loss. As a population ages, a central focus of geriatricians and public health practitioners is to understand and then beneficially intervene on, the factors and processes that put elders at such risk, especially the increased vulnerability to stressors (e.g. extremes of heat and cold, infection, injury, or even changes in medication) that characterizes the situation many older adults find themselves experiencing. Frailty is a common geriatric syndrome. Estimates of frailty prevalence in older populations may vary according to a number of factors, including the setting in which the prevalence is being estimated – e.g., nursing home (higher prevalence) vs. community (lower prevalence), and the operational definition used for defining frailty. Using the widely used frailty phenotype framework proposed by Fried et al., (2001), prevalence estimates of 7-16% have been reported in non-institutionalized, community-dwelling older adults. The occurrence of frailty increases incrementally with advancing age, and is more common in older women than men, and among those of lower socio-economic status. Frail older adults are at high risk for major adverse health outcomes, including disability, falls, institutionalization, hospitalization, and mortality.

Prevalence of Frailty

Frailty is a common condition in later old age, but different definitions of frailty produce diverse assessments of prevalence. One study placed the incidence of frailty for ages 65+ at 10.7%. Another study placed the incidence of frailty in age 65+ population at 22% for women and 15% for men. A Canadian study illustrated how frailty increases with age and calculated the prevalence for 65+ as 22.4% and for 85+ as 43.7%. A worldwide study of “patterns of frailty” based on data from 20 nations found (a) a consistent correlation between frailty and age, (b) a higher frequency among women, and (c) more frailty in wealthier nations where greater support and medical care increases longevity. In Norway, a 20 year longitudinal study of 400 people found that bodily failure and greater dependence became prevalent in the 80+ years. The study calls these years the “fourth age” or “old age in the real meaning of the term.” Similarly, the “Berlin Aging Study” rated over-all functionality on four levels: good, medium, poor, and very poor. People in their 70s were mostly rated good. In the 80-90 year range, the four levels of functionality were divided equally. By the 90-100 year range, 60% would be considered frail because of very poor functionality and only 5% still possessed good functionality. In the United States, the 85+ age group is the fastest growing, a group that is almost sure to face the “inevitable decrepitude” of survivors. (frailty and decrepitude are synonyms.)

What are the Marks of Aging?

The distinguishing marks associated with old age comprise both physical and mental characteristics. The marks of old age are so unlike the marks of middle age that it has been suggested that, as an individual transitions into old age, he/she might well be thought of as different persons “time-sharing” the same identity. These marks do not occur at the same chronological age for everyone. Also, they occur at different rates and order for different people. Because each person is unique, marks of old age vary between people, even those of the same chronological age. A basic mark of old age that affects both body and mind is “slowness of behavior.” This “slowing down principle” finds a correlation between advancing age and slowness of reaction and task performance, both physical and mental.

Physical Marks of Old Age

Physical marks of old age include the following:

  • Bone and joint. Old bones are marked by “thinning and shrinkage.” This results in a loss of height (about two inches by age 80), a stooping posture in many people, and a greater susceptibility to bone and joint diseases such as osteoarthritis and osteoporosis.
  • Chronic diseases. Older persons have at least one chronic condition and many have multiple conditions. In 2007-2009, the most frequently occurring conditions among older persons in the United States were uncontrolled hypertension (34%), diagnosed arthritis (50%), and heart disease (32%).
  • Dental problems. Less saliva and less ability for oral hygiene in old age increase the chance of tooth decay and infection.
  • Digestive system. About 40% of the time, old age is marked by digestive disorders such as difficulty in swallowing, inability to eat enough and to absorb nutrition, constipation and bleeding.
  • Eyesight. Diminished eyesight makes it more difficult to read in low lighting and in smaller print. Speed with which an individual reads and the ability to locate objects may also be impaired.
  • Falls. Old age spells risk for injury from falls that might not cause injury to a younger person. Every year, about one-third of those 65 years old and over half of those 80 years old fall. Falls are the leading cause of injury and death for old people.
  • Hair usually becomes thinner and grayer.
  • Hearing. By age 75 and older, 48% of men and 37% of women encounter impairments in hearing. Of the 26.7 million people over age 50 with a hearing impairment, only one in seven uses a hearing aid.
  • Hearts are less efficient in old age with a resulting loss of stamina. In addition, atherosclerosis can constrict blood flow.
  • Immune function. Less efficient immune function (Immunosenescence) is a mark of old age.
  • Lungs expand less well; thus, they provide less oxygen.
  • Pain afflicts old people at least 25% of the time, increasing with age up to 80% for those in nursing homes. Most pains are rheumatological or malignant.
  • Sexual activity decreases significantly with age, especially after age 60, for both women and men. Sexual drive in both men and women decreases as they age.
  • Skin loses elasticity, becomes drier, and more lined and wrinkled.
  • Sleep trouble holds a chronic prevalence of over 50% in old age and results in daytime sleepiness. In a study of 9,000 persons with a mean age of 74, only 12% reported no sleep complaints. By age 65, deep sleep goes down to about 5%.
  • Taste buds diminish so that by age 80 taste buds are down to 50% of normal. Food becomes less appealing and nutrition can suffer.
  • Urinary incontinence is often found in old age.
  • Voice. In old age, vocal cords weaken and vibrate more slowly. This results in a weakened, breathy voice that is sometimes called an “old person’s voice.”

Mental Marks of Old Age

Mental marks of old age include the following.

  • Adaptable describes most people in their old age. In spite the stressfulness of old age; they are described as “agreeable” and “accepting.” However, old age dependence induces feelings of incompetence and worthlessness in a minority.
  • Caution marks old age. This antipathy toward “risk-taking” stems from the fact that old people have less to gain and more to lose than younger people by taking risks.
  • Depressed mood. According to Cox, Abramson, Devine, and Hollon (2012), old age is a risk factor for depression caused by prejudice (i.e., “DE prejudice”). When people are prejudiced against the elderly and then become old themselves, their anti-elderly prejudice turns inward, causing depression. “People with more negative age stereotypes will likely have higher rates of depression as they get older.” Old age depression results in the over-65 population having the highest suicide rate.
  • Fear of crime in old age, especially among the frail, sometimes weighs more heavily than concerns about finances or health, and restricts what they do. The fear persists in spite of the fact that old people are victims of crime less often than younger people.
  • Mental disorders afflict about 15% of people aged 60+ according to estimates by the World Health Organization. Another survey taken in 15 countries reported that mental disorders of adults interfered with their daily activities more than physical problems.
  • Reduced mental and cognitive ability afflicts old age. Memory loss is common in old age due to the decrease in speed of information being encoded, stored, and retrieved. It takes more time to learn new information. Dementia is a general term for memory loss and other intellectual abilities serious enough to interfere with daily life. Its prevalence increases in old age from about 10% at age 65 to about 50% over age 85. Alzheimer’s disease accounts for 50 to 80 percent of dementia cases. Demented behavior can include wandering, physical aggression, verbal outbursts, depression, and psychosis.
  • Set in one’s ways describes a mindset of old age. A study of over 400 distinguished men and women in old age found a “preference for the routine.” Explanations include old age’s toll on the “fluid intelligence” and the “more deeply entrenched” ways of the old.

Epidemiological Research on Frailty

Epidemiologic research to date have led to the identification of a number of risk factors for frailty, including: (a) chronic diseases, such as cardiovascular disease, diabetes, chronic kidney disease, depression, and cognitive impairment; (b) physiologic impairments, such as activation of inflammation and coagulation systems, anemia, atherosclerosis, autonomic dysfunction, hormonal abnormalities, obesity, hypovitaminosis D in men, and environment-related factors such as life space and neighborhood characteristics. Advances in knowledge about potentially modifiable risk factors for frailty now offer the basis for translational research effort aimed at prevention and treatment of frailty in older adults.

The Social Construct of Aging

While I personally tend to think of frailty as a medical condition in need of extensive modern day research and medical treatment, I also tend to think of aging as a social construct dependent upon social definitions and the influence of culture. Much of the interpretation of a social construct like aging often depends on the interaction between culture and individual social perceptions. Like stereotypes, not all individual social perceptions are necessarily wrong.

Variability of Social Definitions

Here following is why I see aging as a social construct. Why? Sociologically speaking, definitions of aging or being an older adult are so variable. The chronological age denoted as “old age” varies culturally and historically. Thus, old age is “a social construct” rather than just a definite “biological stage.” Old age consists of ages nearing or surpassing the life expectancy of human beings, and thus the end of the human life cycle. Euphemisms and terms for old people include old people (worldwide usage), seniors (American usage), senior citizens (British and American usage), older adults (in the social sciences), the elderly, and elders (in many cultures including the cultures of aboriginal people). Sometimes people speak of older people in derogatory terms such as “look at that old bastard,” or old geezer, old fuddy-duddy, old coot, old fogy, old fart, old poop. People can be really mean and insensitive without much justification or reason. Often, the only social crime an elderly person has committed is that—“they got older through no fault of their own.”


Old people often have limited regenerative abilities and are more susceptible to disease, syndromes, and sickness than younger adults. The organic process of ageing is called senescence. The medical study of the aging process is gerontology, and the study of diseases that afflict the elderly is geriatrics. The elderly also face other social issues such as retirement, loneliness, and ageism, issues around money, opportunities, simultaneously experiencing mental and physical decline, and a serious impact on self-esteem; it’s somewhat of an identity crisis. You are no longer the person you were, both inside and out. This identity crisis is, unfortunately, what may be responsible for many older people committing suicide. Recent work on frailty has sought to characterize both the underlying changes in the body and the manifestations that make frailty recognizable. It is well-agreed upon that declines in physiologic reserves and resilience is the essence of being frail. Similarly, scientists agree that the risk of frailty increases with age and with the incidence of diseases. Beyond that, there is now strong evidence to support the theory that the development of frailty involves declines in energy production, energy utilization and repair systems in the body, resulting in declines in the function of many different physiological systems. This decline in multiple systems affects the normal complex adaptive behavior that is essential to health and eventually results in frailty typically manifesting as a syndrome of a constellation of weakness, slowness, reduced activity, low energy and unintended weight loss. When most severe, i.e. when 3 or more of these manifestations are present, the individual is at a high risk of death. The syndrome of geriatric frailty is hypothesized to reflect impairments in the regulation of multiple physiologic systems, embodying a lack of resilience to physiologic challenges and thus elevated risk for a range of deleterious endpoints. Generally speaking, the empirical assessment of geriatric frailty in individuals seeks ultimately to capture this or related features, though distinct approaches to such assessment have been developed in the literature (see de Vries et al., 2011 for a comprehensive review). Two key approaches are discussed below:

Linda Fried / Johns Hopkins Frailty Criteria

A popular approach to the assessment of geriatric frailty encompasses the assessment of five dimensions that are hypothesized to reflect systems whose impaired regulation underlies the syndrome. These five dimensions are: weight loss, exhaustion, weakness, slowness, and low levels of activity. Corresponding to these dimensions are five specific criteria indicating adverse functioning, which are implemented using a combination of self-reported and performance-based measures. Those who meet at least three of the criteria are defined as “frail”, while those not matching any of the five criteria are defined as “robust”. Additional work on the construct is done by Bandeen-Roche et al. (2006), though some of the exact criteria and measures differ. Other studies in the literature have also adopted the general approach of Linda P. Fried et al. (2001) though, again, the exact criteria and their particular measures may vary. This assessment approach was developed and refined by Fried and colleagues at the Johns Hopkins University’s Center on Aging and Health. This Center is home to Johns Hopkins Claude D. Pepper Older Americans Independence Center, which focuses on frailty research.

Misconceptions of Frail People

Johnson and Barer did a pioneering study of Life beyond 85 Years by interviews over a six year period. In talking with 85+ year olds, they found some popular conceptions about old age to be erroneous. Many studies of old age overlook the 85+ survivors so their conclusions do not apply. Such erroneous conceptions include (1) people in old age have a least one family member for support, (2) old age well-being requires social activity, and (3) “successful adaptation” to age-related changes demands a continuity of self-concept. In their interviews, Johnson and Barer found that 24% of the 85+ had no face-to-face family relationships; many have outlived their families. Second, that contrary to popular notions, the interviews revealed that the reduced activity and socializing of the over 85s does not harm their well-being; they “welcome increased detachment.” Third, rather than a continuity of self-concept, as the interviewees faced new situations they changed their “cognitive and emotional processes” and reconstituted their “self–representation.”

Old Age from an Old-Age Perspective

Early old age is a pleasant time: children are grown, retirement from work, time to pursue interests. In contrast, perceptions of old age by writers 80+ years old, “old age in the real meaning of the term,” tend to be negative. Lillian Rubin, active in her 80s as an author, sociologist, and psychotherapist, opens her book 60 on Up: The Truth about Aging in America with “getting old sucks. It always has, it always will.” Dr. Rubin contrasts the “real old age” with the “rosy pictures” painted by middle-age writers. Writing at the age of 87, Mary C. Morrison delineates the heroism required by old age: to live through the disintegration of one’s own body or that of someone you love. Morrison concludes, “old age is not for the fainthearted.” In the book Life beyond 85 Years, the 150 interviewees had to cope with physical and mental debilitation and with losses of loved ones. One interviewee described living in old age as “pure hell.” .Death and Frailty

     Old age, death, and frailty are linked because approximately half the deaths in old age are preceded by months or years of frailty.

     Older Adults’ Views on Death is based on interviews with 109 people in the 70-90 age range, with a mean age of 80.7. Almost 20% of the people wanted to use whatever treatment that might postpone death. About the same number said that given a terminal illness, they would choose assisted suicide. Roughly half chose doing nothing except live day by day until death comes naturally without medical or other intervention designed to prolong life. This choice was coupled with a desire to receive palliative care if needed. About half of older adults suffer multi-morbidity, that is, they have three or more chronic conditions. Medical advances have made it possible to “postpone death,” but in many cases this postponement adds “prolonged sickness, dependence, pain, and suffering,” a time that is costly in social, psychological, economic terms. The longitudinal interviews of 150 age 85+ people summarized in Life Beyond 85 Years found “progressive terminal decline” in the year prior to death: constant fatigue, much sleep, detachment from people, things, and activities, simplified lives. Most of the interviewees did not fear death; some would welcome it. One person said, “Living this long is pure hell.” However, nearly everyone feared a long process of dying. Some wanted to die in their sleep; others wanted to die “on their feet.” The study of Older Adults’ Views on Death found that the more frail people were, the more “pain, suffering, and struggles” they were enduring, the more likely they were to “accept and welcome” death as a release from their misery. Their fear about the process of dying was that it would prolong their distress. Besides being a release from misery, some saw death as a way to reunion with departed loved ones. Others saw death as a way to free their caretakers from the burden of their care. According to Erik Erikson’s “Eight Stages of Life” theory, the human personality is developed in a series of eight stages that take place from the time of birth and continue on throughout an individual’s complete life. He characterizes old age as a period of “Integrity vs. Despair”, during which a person focuses on reflecting back on his life. Those who are unsuccessful during this phase will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death. Coping is a very important skill needed in the aging process to move forward with life and not be ‘stuck’ in the past. The way a person adapts and copes, reflects his aging process on a psycho-social level. Newman & Newman proposed a ninth stage of life, Elderhood. Elderhood refers to those individuals who live past the life expectancy of their birth cohorts. There are two different types of people described in this stage of life. The “young old” are the healthy individuals who can function on their own without assistance and can complete their daily tasks independently. The “old old” are those who depend on specific services due to declining health or diseases. This period of life is characterized as a period of “immortality vs. extinction.” Immortality is the belief that your life will go on past death; some examples are an afterlife or living on through one’s family. Extinction refers to feeling as if life has no purpose. Comments

Theoretically speaking, we all have a lifetime to prepare for old age socially, monetarily, and in terms of long-term care. But the reality is that few of us, particularly when we are young, ever really begin to dwell or think about old age until we are on its doorstep. Many of us should begin to plan for our retirement in our 20s. But most workers don’t begin planning for retirement until their late 30s or early 40s. And for some it’s almost an afterthought. It’s understandable because most people live in the here and now. When younger people are up to their necks in debt, little thought is given to planning for retirement; they think very little what it means to be old. No one can predict what is going to happen in the future. It would be great if we could all plan for every contingency in life. But life has a way of kicking us in the shins when we least expect it (i.e., diagnosis of disease, accidents, loss of a job or loved ones, etc.). Or, as I once heard someone say, “Life’s a bitch—then you die.” Some people like to say, “What will be is what will be, and I can’t do anything about it.” Or, some people will say “I can’t stop myself from aging and have no control over it. If it’s inevitable, I can’t do anything about it.” These expressions project a fatalistic outlook on life. What underlies this type of attitude is an unwillingness to take responsibility, or can be a feeling of helplessness. These rationalizations or feelings are an attitude of resignation in the face of some future events which are thought to be inevitable. As said before, no one can exactly predict what is going to happen in the future. Nevertheless, that does not mean that one can’t take prudent steps to prepare for most of those contingencies (possibly frail health, not enough resources, diseases, etc.) That’s why the life insurance industry is always thriving. Insurance companies use probabilities to determine future outcomes based on group data. Where old age and the possibility of frailty is concerned one most definitely can plan. You know what I’m talking about. It’s about making important lifestyle changes at any time of life i.e., a healthy diet, plenty of exercise, and minimizing risk factors of all kinds (like smoking, drinking excessively, or driving too fast or too carelessly on the freeway). Space in this blog does not permit me the luxury to tackle every aspect of lifestyle changes. I’ve chosen to narrow the scope of Part II and Part III ahead to the impact of exercise on frailty and aging.

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