Feature Preparing for Old(er) Age While it's never too late to help older adults enjoy healthy and active lives, it's a lot easier if you start helping them prepare during their younger years. By Chris Hayhurst | February 2017 If you watched the Olympics last summer, you may have noticed something remarkable: not only the athleticism, which certainly was outstanding, but also the "advanced" age of many of those competing. Most famously, there was Michael Phelps, who at 31 and in his fifth Olympic Games would take home 5 golds and 2 silvers. But there also were a number of lesser-known athletes, many of whom were in their 40s and beyond. Among them: US cyclist Kristin Armstrong, who won her third gold medal in as many Olympic appearances the day before she turned 43; 41-year-old Uzbekistani gymnast Oksana Chusovitina, who didn't win a medal this year but did earn team gold back in 1992; and Australian equestrian Mary Hanna, who at age 61 is a grandmother. "Age Is No Barrier" was a typical headline touting the achievements of the games' "mature" competitors. A BBC story framed it another way: "Rio Olympics: Older athletes still at the top." "It's fabulous and inspirational what these athletes are doing," says Carole Lewis, PT, DPT, PhD, a board-certified clinical specialist in geriatric physical therapy in Washington, DC. While last year's Olympians weren't "old" by conventional measures, they were well beyond what is generally considered to be prime competitive age, she notes. "They really are showing us that anything is possible, that no matter who you are"—world-class athlete or not—" just because you're getting older doesn't mean you have to stop doing the things you love to do." Lewis recalls reading about an 83-year-old bodybuilder who only started lifting weights when she turned 70. And Lewis has seen numerous patients in her own private practice who continued to exercise into their 90s. "As a society, we unfortunately have a lot of misconceptions and prejudices about the potential of people who are older," Lewis says. "Olympians are one thing, but we shouldn't be so surprised every time we see people do something that seems to defy their age. Maybe what they're doing is perfectly normal." Mike Studer, PT, MHS—co-owner of Northwest Rehabilitation Associates, a healthy-aging and neurology outpatient clinic in Salem, Oregon—agrees. "A lot of myths need to be debunked about what normal aging really is," he says. "And we as physical therapists—the 'movement experts'—should be out there leading the way." The Case for Prevention That "normal aging" is not what it seems may be a hard sell to the patient who is older and needs a wheelchair to get around, or to the septuagenarian who's recovering from hip surgery. That's why, Lewis and Studer say, physical therapists (PTs) should be making the case for prevention—working with patients across the lifespan to help them avoid aging's most common pitfalls. "We should be helping people age successfully," Lewis says. "And part of that involves raising public awareness of what we have to offer," whether it's in pediatrics, geriatrics, or to patients and clients in general. "We should show people how we can help them before they break a bone, or before they hurt their shoulder. And we should point to the evidence when we do—the research that shows that if you are strong, if you are flexible, and if you practice balance exercises and work on your endurance, you can not only improve your function but also reduce the chances of injuring yourself." Research also shows that people who reach age 70 in good health are better positioned to stay healthier longer, while people who reach that age in poorer condition are likelier to face deteriorating health earlier and more quickly, notes Linda Fried, dean of public health at Columbia University's Mailman School of Public Health. "We must attend to the health of our population, so that people arrive at age 70 healthy and stay healthy longer," she wrote in The Future of Aging: Realizing the Potential of Longevity.1 In her own practice, Lewis works exclusively with geriatric patients. While some already have experienced debilitating injuries, many others are in relatively good health. "They're a great population to work with because they're starting to see changes," she says, and they're thinking about their future. "They realize that when they walk down the grocery aisle, they can't turn their head side to side. Or they've noticed that when they go to pick up something from the floor, their back is so tight that they have to hold onto something." Her pitch to them, Lewis says, is simple: "'You're still shopping, you're still picking stuff up, and that's great. But wouldn't you like to do those things the best way possible, and learn how to prevent that tightness from getting worse?'" Younger patients, Lewis admits, are less likely to be interested in addressing issues that may not yet seem worth their worry. "Younger patients are working out, running miles every day, lifting weights. Everything seems perfect, except for the injury that's brought them to physical therapy. So what we need to do," Lewis says, "is give them a balance test or something similar. Because, unless they're 20 and a dancer, or they're really in top shape, they're going to show deficits they didn't know they had." From there, Lewis advises, it's just a matter of supplying suggestions for patients to consider the next time they exercise. For example, "Advise patients, 'When you run, try turning your head from side to side to stimulate your vestibular system.'" Studer generally sees 2 types of individuals in his 2 clinics, he says: those with neurologic impairments such as stroke and Parkinson disease, and those recovering from sports injuries or orthopedic challenges. He also offers a service called "GeriAthletics" for competitive athletes older than 65. "These people actively train for events such as marathons and triathlons," Studer says. "They're in the clinic because they know they're going to be pushed, but in a way that respects both their goals and their age." That respect, Studer adds, is rooted in science. "Research has shown that as people age, they need more recovery time, and high-intensity interval training at a very specific dosage may be more effective than just increasing volume." He's been working with a client who just completed his first marathon at age 69. He first came to see Studer several years ago for a hamstring he'd injured while training for a sprint (shorter distance) triathlon. "He recovered from that and was hungry for more. Now he's talking about competing into his 80s. He wants to keep going as long as he can." As a PT, Studer believes he is "in a unique position to take people who currently are well"—and with no falls history—and help them maintain and improve their health, with an eye toward success in older age. "Even if they don't think of themselves as 'athletes,' they're very interested in anything they can do to stay active and remain well," Studer notes. By working with these clients in a wellness capacity rather than on a needs-only basis, "we can make a difference in how they'll do later on in life," he says. A "Cornerstone of Practice" Studer and Lewis hardly are the only PTs encouraging patients and clients to plan for their future. "An emphasis on successful aging should be a cornerstone of every physical therapy practice," says Mindy Renfro, PT, PhD, clinical coordinator of the Missoula-based Montana Adaptive Equipment Program. She helps individuals with developmental disabilities get the tools they need to be functionally independent. At the heart of that process is enabling "aging in place"—something she feels all PTs should attempt to facilitate, regardless of their patient and client population. "The classic example," Renfro says, "is the 55-year-old couple whose youngest child just went off to college. Do they spend money on turning that bedroom into a Jacuzzi space, or do they attach a ramp to the front steps to ensure that the house is accessible in case one of them has an injury and requires the accommodation?" When a person goes into a nursing home because his or her own home wasn't designed to accommodate age-related needs, "their long-term prospects for getting back to their residence dim very quickly," Renfro notes. PTs should make their older patients aware of this, she says, and "have that conversation before it's too late." [For more about aging in place, see "Making a House an Accessible Home" in the September 2016 issue of PT in Motion.] Likewise, says Renfro, who works with patients and clients of all ages, PTs should incorporate "primary prevention for aging" into every treatment plan. "It's about stopping the 'illness' before it occurs," she explains. "Children, 20 year olds, 50 year olds—everyone's aging. There's no way around it." But PTs can do their part, Renfro says, to help prevent conditions that might develop in relative youth, such as obesity, muscle weakness, or poor balance or posture. "We as physical therapists can set our patients up with home programs they can follow over the long term," she says—with resources they can use even after an episode of care has concluded. Such resources might include age-appropriate classes at the local YMCA, or participation in other community programs that promote physical activity. "If your patient weighs 100 pounds more than is recommended, all the quad sets in the world aren't going to cure his knee pain," Renfro notes. "We need to focus on treating the whole person—and not just how the patient feels after leaving the clinic, but how that person is going to do for the rest of his or her life." There are, of course, significant challenges to such an approach. "For physical therapists, it begins with our educational foundation," Renfro says. And that, in turn, is built around the existing health care system. "Students are not taught to think about public health, successful aging, or primary prevention," she notes, "because PTs are paid based on illness and injury. We're not paid to keep people fit." Some PTs, such as Lewis, overcome that financial hurdle by employing cash-based business models. "Many people are ready to pay for this," Lewis says. But even when they aren't ready or are unable to do so, "that doesn't mean we can't talk about aging when they come to see us." What needs to change? In Renfro's view, "We have to move to a single-payer system in which providers are paid per-person for health outcomes. Once we do that," she says, "we'll get serious about prevention and promoting successful aging." Starting Young One PT committed to the cause of healthy aging is Hadiya Guerrero, PT, DPT. Before she was hired by APTA last April as a senior practice specialist, she worked primarily with pediatric patients in the Harlem area of New York City, and at the Mayo Clinic in Minnesota. She recounts 1 of her first early-intervention cases as a PT, and how it framed her vision of what she could do to help her patients become healthy adults. "The patients were twins who had been referred for physical therapy because they were obese," Guerrero says. They were in home care, but Guerrero devoted much of her time to getting the twins out of the house. "The mother was only 15 years old, so their grandmother was there, too. I took the entire family out to the park, and we walked around the neighborhood and looked for ways that everyone could be more active." Guerrero talked to the mother and grandmother about eating well, and showed them where they could find healthful snacks. She explained, too, the importance of leading by example. "Modeling good behaviors is critical in pediatrics," she notes. "Take the stairs instead of the elevator. Pick up grapes and bananas at the corner store for snacks, instead of just buying soda and cupcakes." That was nearly a decade ago, but Guerrero still keeps in touch with the family. The twins, now 12 years old and in seventh grade, no longer are obese, but they are overweight. Guerrero describes them as "works in progress." Still, she adds, the fact that progress is being made gives her hope. "A lot of PTs who work with children may not think about their aging process all that much," Guerrero notes, unless the child is dealing with an issue that always will be a part of his or her life. Instead, she says, there's a tendency to focus on the immediate problem, such as inability to climb stairs or need to rehab an injury. "But that needs to change," Guerrero says. "We should be looking at the big picture—the things we can do now to set children up for their future." She recently attended a 2-day workshop titled "Nutrition Across the Lifespan for Healthy Aging" at the National Academy of Sciences (NAS) in Washington, DC. Guerrero recalls a speaker making the point that one's health outcomes as an adult are in large part predetermined in early childhood. That reinforced Guerrero's point that "we must get involved [in promoting lifelong health] as early as possible, because that's 1 place where we can really make an impact." (See the timeline "Optimizing Bone Health" on pages 18-19 for an example of steps that can be taken to optimize bone health as people age.) Yves Joanette, scientific director of the Institute of Aging at the Canadian Institutes of Health Research, made a similar point in The Future of Aging. "Our susceptibility to various metabolic diseases," he wrote, "will influence our lifelong condition. Nothing can be done about those genes, but the booming science of epigenetics tells us that the nature of our very early exposures can have a major impact on the manner in which our genetic potential actualizes itself. The future of aging would be brighter if there were programs to inform the public about the early-life optimal conditions that favor the good sides of our genes and diminish their dark sides."1 Happiness and Healthy Aging Guerrero, who is working on an APTA report that will detail physical therapy's role in primary care, notes that aging today is different from what it was just a few decades ago. "People now expect to remain healthy and active well into old age," she says. "And we now know what they need to do to help make that possible—how nutrition and exercise factor in." At the NAS gathering, a discussion revolved around biomarkers of aging—how, for example, elevated interleukin-6 serum levels are associated with mobility disabilities in old age. "A biologist who was well into his 80s spoke," Guerrero recalls, "and he said that his 'marker' for healthy aging is whether he's happy and still can do the things he wants to do. That statement struck me as being so simple, yet so perfect. What else is there beyond being able to physically and/or mentally do the things you enjoy in life?" Even more recently, Guerrero says, she was on her way to visit a home care patient and saw a man who was older walking up a steep hill. "He was hunched over, leaning forward, and he kept his hands behind his back." When she was returning to her office after the appointment, the man was continuing on his way. "Slow and steady, getting his exercise," she says. "It was so inspiring to see." Carole Lewis, for her part, has seen many patients over the years in late middle age who have transitioned successfully into becoming high-functioning, active senior citizens. Nevertheless, she says, her goal for this year is to redouble outreach efforts to let the wider world know the ways in which PTs can help people healthily age. She's writing letters to the editors of medical journals and even approaching the physicians who send her patients to offer them free balance screenings and assessments. "When some of these physicians see that they already have a balance deficit even though they're only in their 30s or 40s, they'll be more likely to understand how I might help their patients in primary care," she reasons. Physicians, Lewis says, "are becoming more aware of the preventive piece" and the role that it plays in optimizing health. "But medicine really has no idea how to do this," she adds. "That's a job for which I think PTs are uniquely qualified. Of all the professionals working in health care, I believe that we're in the best position to help people age." Chris Hayhurst is a freelance writer.