Blog:
Last Chapter: New Directions for Old Age
When Monica Graham tore up her clay tennis court to build a new home on the property, she had some unusual design requests for her architect. The new two-story structure had to have elevator access, a master suite;a guest suite; a private apartment for a boarder or future caretaker, and a home office on the first floor where she could see social work clients. Corridors throughout the home had to be extra-wide to accommodate a wheelchair or walker.
A champion tennis player who taught tennis for many years, Graham , 55 at the time of construction, did not give up her tennis court lightly. But like many adult children who have spent years looking after elderly parents, Graham was determined that she was going to be both practical and prepared for her own old age. She was determined to “age in place.”
“There is a tendency for me to inherit Dad’s degenerative disease, spinocerebella, so the first thing I told the architect was that I wanted wide halls and infrastructure for an eventual elevator. I’m not going to install the elevator yet—it costs $340 for an annual inspection-- I’m not going to use it until I need it….My Dad was 62 when he started showing the effects of the disease. I am not going to be caught off guard like Dad was,” Graham vows.
While caring with great difficulty for her disabled parents for several years in the two-story Tudor home next door, the divorced therapist had given lots of thought to her financial, social and care needs in a future old age. Now, having sold her old house and moved into its custom-designed replacement next door, she has retired early, established a private practice in her first floor office, and has rented to boarders to supplement her income. In the future, if she wants a contemporary as a house-mate, the second suite will allow each privacy and independence as well as social interaction. The private apartment with its separate entry , most recently used by a paying boarder, permits the option of having a live-in caregiver down the road.
Not surprisingly, family caregivers who have dedicated years to taking care of their elderly relatives have some very firm ideas about what is acceptable for their own “Golden Years.” They have seen the impersonal regimentation of nursing homes and the shortcomings of assisted living facilities and want something different for themselves. Some already have plans in place to share residences with friends, neighbors, or others with common interests or geography. Others have formed cooperative communities to provide needed services to senior citizens who want to “age in place.”
In this desire, these caregivers echo the priorities of their fellow Baby Boomers; according to a recent survey by the American Association of Retired People (AARP), nearly 90 percent of Baby Boomers want to stay in their homes and close to family and friends as long as possible. Much of this change is due to demographics. In the early twentieth century, life spans were shorter and families less dispersed. The rare individual who lived into his/her 80s or 90s lived with or near offspring. Today in the United States longevity has been extended by good nutrition and medical technology. Baby boomers anticipate living longer than their parents, and, as this generation has done throughout their lives, want to do things differently.
Control over their environments, a sense of community, and cultural/intellectual stimulation figure prominently in the planning of these former caregivers. Phoebe O’Mara, a Harvard University development officer who managed her mother’s care, traveling back and forth to Connecticut over a dozen difficult years, stresses the importance of social and cultural interactions when she talks about her own future retirement years. O’Mara compares her mother’s last years unfavorably with those of her maternal grandmother although both women lived to the age of 92. While her grandmother kept active physically and mentally in old age, and planned for the eventuality of household and personal care help, her mother resisted hiring help and spent more and more time in her house, becoming socially isolated, depressed, and confused.
“My grandmother stayed pretty independent, right up until the end. She was disciplined; she did her exercises, and could touch her toes into her 90s. She played Scrabble and bridge to keep mentally sharp.” O’Mara’s mother, by contrast, began going downhill mentally when she was about 80, after the death of her husband. Possibly due to cigarette smoking, she developed C.O.P.D, a respiratory disease requiring oxygen. Oxygen deprivation exacerbates dementia.
“She drank and the alcohol brought on dementia, as did the smoking. She was a very stubborn woman. It took me years to get her out of that house. She became more and more isolated. At first I got church volunteers to run errands for her, go to the grocery store. Then I started hiring homemakers. She would fire everybody. It was a control issue.”
After her mother sustained a series of small strokes and falls, O’Mara finally persuaded the woman’s physician to mandate a move to an assisted living complex. “It was a very nice place but I didn’t realize what assisted living doesn’t do. I should have hired more help. (Mom) wasn’t with it; she didn’t have a buddy. ...She flooded the apartment twice, causing the assisted living administrator to ask her to leave. She needed something homey but with much more supervision.”
O’Mara has learned from experiences of the two matriarchs. Never married, she has begun discussing some type of retirement cohabitation with high school friends, professional colleagues, even a former beau. “I think I’d like to share space or split expenses with a friend or friends. Currently, I live in a two family house in Boston, but it would require too much work to be suitable for old age. It is important to me that I have my own space. We’ve talked about moving into one large house—one friend has a huge house in Wilton, Connecticut-- or into adjacent units in a condominium community.”
Public transportation, nearby medical clinics or hospitals, some means of having groceries and pharmaceuticals delivered, a library, cultural activities—O’Mara ticks off these as her requirements for a balanced and safe old age. Boston has all she asks for, but she wonders if it is too expensive for retirees on fixed incomes. Maybe, she thinks, a good choice would be a college town such as Hanover, NH, home of Dartmouth College and its distinguished Dartmouth-Hitchcock Medical Center.
Closer to home, one of the options that has caught O’Mara’s eye is Cambridge At Home, a new Cambridge, Massachusetts “virtual retirement community” which allows members who stay in their homes access to free or discounted shopping, home health care, transportation and home repair services as well as exercise and social programs for an annual fee of $900 (individual) or $1200 (couples).Members must be 50 years of age or older.
Joan Van Mehren, 84, who joined Cambridge at Home at its inception in fall, 2007, used its shopping and transportation services in the wake of back and hip surgery rather than leaving her home of nearly 60 years for an assisted living residence. She told the Boston Globe “(Cambridge) is less of a neighborhood than it used to be. One thing that I like about (Cambridge at Home) is you can sign up to help other people, so it encourages sociability.”
Intentional Communities
Cambridge at Home is just one of several emerging “intentional communities” based on a model adapted from Boston’s Beacon Hill Village, a non-profit cooperative of residents of one of Boston’s oldest neighborhoods. In 2002, faced with the prospect of leaving the neighborhood they love in order to obtain the services of a retirement community, a group of long-time Beacon Hill residents created an alternative designed to make remaining at home a safe, comfortable and cost-effective solution for people aged 50 or over. The “intentional” or “cooperative community” movement was born.
For an annual fee of $580 (individuals) or $850 (household), members of Beacon Hill Village can select from an a la carte menu of services such wellness programs, socil and cultural events. The social and wellness programs are part of the membership fee, but other services such as transportation to the grocery store, doctor’s appointments or other destination, hweekly cleaning, home repair and adaptation, computer problem solving or bill paying are charged at a reduced rate because the cooperative buys services from one provider.
Services can be as simple as weekly housecleaning or as complicated as organizing a closet or adapting an interior to meet the demands of a chronic illness or a debilitating stroke. Members of Beacon Hill Village have expedited entry to the Senior Service practice at nearby Massachusetts General Hospital, receive discounts on long-term insurance premiums and can arrange for round-the-clock nursing, home health aides, or assisted living services in the home as the need arises.
“Concierge” services are provided by BHV’s contract with HouseWorks, an in-home service provider which also contracts to Cambridge at Home. Services include transportation, pick up of dry cleaning or prescriptions, packing boxes, mailing packages, procuring tickets for theatre and other cultural events, and watering residents’ plants while they are away. For a fee, HouseWorks personnel will even wait for a repairman, or take a resident’s car or computer in for service.
Beacon Hill is one of Boston's more expensive neighborhoods, so the cooperative, in order to maintain diversity , offers subsidized memberships to lower income residents of the neighborhood to $100 and provides a $250 credit towards various offered services. The subsidies are provided by neighbors, businesses and foundation grants.
Socialization Benefits
While Beacon Hill Village members may have originally joined to receive practical assistance, the cooperative is understandably proud of its large and growing offering of social and cultural events. In 2007, the Village added several new services for members including a new walking group, an adaptive driving program, classes at several athletic facilities in the neighborhood, and “My Way Village” a closed-network system for sharing calendars, photos, and E-mail. BVH members are encouraged to help other members and to be involved in local volunteer organizations..
The monthly BHV “Conversations with…” series in 2007-2008 featured speakers such as a prominent social neuroscientist, a public television executive, the president of the New England Conservatory of Music, the Massachusetts insurance commissioner, a Harvard professor of classical Greek literature and the artistic director of the Huntington Theatre Company. In addition to these “Conversations” and trips to Bay State attractions like Williamstown and Martha’s Vineyard, the Village supports a growing number of member-initiated “interest groups” that meet regularly including a morning coffee and political discussion group, travel and film groups and lunch, dinner and singles’ groups.
Practical Benefits
Beacon Hill Village executive director Judy Willett, a social worker, told AARP Magazine that remaining at home and using the village’s services is in many cases “much cheaper than assisted living.” If someone requires round-the-clock care or other expensive services, she said, the total costs will most likely match those of a nursing home.
The formula seems to be working. Current membership numbers 430 individuals, up from 70 six years ago, Seventy new members joined in 2007 and 88 percent of current members renewed.
Copycat “Villages”
Following articles in the New York Times, The San Francisco Chronicle, and on several television networks, Beacon Hill Village founders have been inundated with requests from communities and governments who want to know how they can replicate the Beacon Hill Village template. Copycat communities are popping up or in formation in Virginia, Maryland, Washington, D.C., and in parts of California, New York and New England.* In response to all the interest, Beacon Hill Village has made available a manual and DVD for individuals and communities who want to age in place. In spring 2007, Beacon Hill Village sponsored a how-to-organize your-own village conference attended by community leaders and individuals from 27 states and as far away as Australia. Some 100 other “villages” were in the planning stages in early 2008, including seven in the Washington, D.C. area, led by the Capital Hill Village which opened in fall, 2007.
Niche Communities
While Beacon Hill Village, Cambridge at Home, and similar communities have sprouted from existing from geographical neighborhoods, developers and organizers also seek to develop communities around areas of interest or lifestyle. For example, in the Fenway area of Boston, the developer of Stonewall Communities is applying for zoning variances that will permit it to build a retirement community for gays and lesbians. If approved, the development will be the third such niche development in the country The Stonewall proposal faces stiff opposition from local neighborhood groups, who oppose not the sexual orientation of prospective owners but rather the 80,000 sq.ft footprint of the proposed complex which they complian will dwarf nearby brownstones.
Back to School
Like Phoebe O’Mara, many retirees and those planning retirement are tempted by the intellectual, cultural, and social stimulation, and, often, low cost of living, available in college communities. David Heskin, 61, a resident of the riverfront town of Brielle in southeast New Jersey, is currently house-hunting in South Bend, Indiana, near his alma mater, the University of Notre Dame. Heskin retired after selling a family business nearly a decade ago, and has spent the balance of those years taking care of an elderly mother and aunt and in multiple charitable activities, including volunteering as a repairman to the community’s elderly residents.
Heskin and his wife, Marilou Brill, focused on a back-to-school retirement because of the perceived lack of stimulation available to their elderly family members, a desire for the cultural and intellectual opportunities afforded by a college campus, and an interest in affordability. Former residents of Manhattan who maintain a time-share apartment there, they also considered, and rejected, the option of retiring near Columbia University, Brill’s alma mater.
“Though (Brielle) is a pleasant place to live, there’s nothing going on here after the sun goes down. And going into NYC is not really a viable alternative on a regular basis…. We were in (Manhattan) for three days during the first week of March but again spent a bundle. ….I really don’t want to live full time in NYC. And since we’re not billionaires, keeping this place and getting a NYC place would be a stretch…. Plus I need to have outdoor activities – running, golf, swimming, etc. easily available.”
Heskin says his wife and he are looking for a sense of community, as well as cultural and intellectual stimulation to result from their back-to-school move.“When we bought our present house 10 years ago, we wanted a large lot and privacy from our neighbors…. As it turned out, the amount of yard work has become a burden...and there isn’t much of a neighborhood here – everyone seems to stick to themselves. At the same time, we came to realize that there really isn’t any culture here – and there never will be. There isn’t really even much adult ed."
Heskin is optimistic that the college community will lead to new friendships and opportunities to engage in intellectual and cultural activities. “ We will be in a place where there are things going on and I’m sure we’ll meet people.… There are a lot of advantages. I looked at the University calendar and there are concerts, lectures, sporting events, etc., throughout the year. Many are free and all are generally open to the public. This solves the question of what to do at night ”
Heskin & Brill, both engineers, have talked about volunteering or seeking part-time teaching positions on the Notre Dame campus or at other area colleges including St. Mary’s College, Holy Cross College, or Indiana University/South Bend. “The trend towards adult education is going to grow, and there are institutions in South Bend. “
Heskin’s biggest problem in contemplating the move is an increasingly common one for would-be retirees: what to do about his 88 year old, blind aunt, who lives nearby in an assisted living complex “I see her at least 2 or 3 times a week. I usually have Sunday lunch with her, bring her to doctors, and generally run her life. She’s gradually getting more feeble and forgetful, but I can see her living for years….I know I will feel very guilty about leaving Jean…. I do have a woman who’s helped for years and whom Jean is very fond of. But all is easier said than done. In the last analysis, Jean, for me, is the biggest piece of the moving puzzle.”
Jim Dougherty, a former financial analyst in Manhattan, chose Bowdoin, ME for many of the same reasons Heskin & Brill are considering when he was contemplating his retirement. The Doughertys bought a small Cape Cod style home with a first floor bedroom on one of the leafy boulevards of this culturally vital town within walking distance of dentists, doctors, post office and restaurants, and within sight of the Bowdoin College campus.
Bowdoin College has an informal relationship with residents of the town of all ages, and with nearby retirement communities. The college encourages community attendance at athletic events, concerts, plays, art exhibits, and lectures, and permits resident seniors to audit college classes. In addition, members of the Association of Bowdoin Friends participate in and support college life by fundraising, hosting undergraduates for meals and holidays, giving them one-on-one attention, rides to the airport, and even storing their stuff at year-end. In exchange, association members receive campus discounts, library privileges at the college library, and the opportunity to participate in faculty-led book discussion groups.
While the Bowdoin/senior citizens relationship is an informal one, the past decade has seen a glut of development aimed at establishing a formal relationship between educational institutions and the expected wave of active Baby Boomers who have begun to take or think about retirement. The attraction on both sides is obvious. The retirees are looking for the abovementioned intellectual, cultural and social stimulation, with perhaps access to university medical services or a teaching hospital thrown in. College administrators are mindful of marketing and fundraising advantages. The Baby Boomers will be hitting the campus just as college admissions begin to drop off in 2010, due to a predicted drop in the 18 year old population. An appeal to mature adults interested in “lifelong learning” allows the colleges to expand course offerings while strengthening their ties to alumnae and other mature learners who may, in turn, boost the institution’s reputation and endowment coffers.
Across the nation, there are at least thirty colleges with formal, financial ties to retirement communities, including The Village at Penn State in State College, Pennsylvania; Oak Hammock at the University of Florida in Gainesville, The Forest at Duke University in Durham, North Carolina; The Colonnades near the University of Virginia at Charlottesville; Holy Cross Village at the University of Notre Dame, Notre Dame, Indiana; and Lasell Village at Lasell College in Newton, Massachusetts. Many, many more retirement communities have no financial link to educational institutions but have sprung up nearby, the product of for-profit developers’ confidence in Baby Boomer enthusiasm for lifelong learning.
Far from bucolic college towns, former MIT president Paul Gray and a group of MIT related investors have formed University Related Communities, LLC with a plan to create a block of 150 units within walking distance of MIT’s East Cambridge campus. Residents will share communal space in a larger building, currently under construction, and basic services such as cleaning, food shopping and transportation. While the URC units will not include assisted living or continuing care facilities, the founders expect residents will be able to access MIT’s healthcare facilities. Although the building to house URC is not yet completed, more than half of the 150 units have already been sold.
At Lasell Village, about 250 retirees live on the Lasell campus near Boston. Living in buildings that include classrooms and fitness centers, Village residents are expected to complete a minimum of 450 hours of learning activity annually, enrolling in college and village-based courses and attending lectures, doing research, and enrolling in travel-plus-study trips.
Lasell Village is a “continuing care retirement community,” or CCRC in social work jargon, which means that able-bodied, active persons age 55 or older can move there expecting to remain for the rest of their lives, drawing on additional health care services such as home health aides, sub-acute nursing care, and long-term care, as needed. While many of these university communities are CCRCs, others are marketed for so-called “active adults,” meaning that they have no healthcare component and residents are expected to live independently or leave. The distinction is an important one.
In the world of back-to-school retirement, Lasell holds the leadership role enjoyed by Beacon Hill Village among the “intentional community” boosters. Established in 2000 to offset slumping undergraduate enrollment, Lasell Village currently has a long waiting list for its apartments and serves as a model of integrated senior learning. Its consulting group, Laselle Consulting Group, is working to spawn similar learning environments in Japan, England, the People’s Republic of China and South Korea.
Options for Aging in Place for the Less Affluent
While some of the “intentional communities” and university-affiliated retirement communities offer subsidies and discounts on services for low income elders, most are marketed to middle class or more affluent members of the 55 plus crowd. However, seniors who want to “age in place” but who have limited assets and fixed incomes do have several options.
Retirees who own their homes or condo units and want to stay put can enter into what is called “reverse mortgages” where they draw against the asset value of the real estate for living expenses during their lifetimes. Upon their deaths, the property will be sold and the reverse mortgage payments, along with interest, taxes and fees, will be deducted from the sales price. Any remaining balance will go to the person’s estate.
The desire of aging people to remain in their own homes turned the reverse mortgage industry into a $20 billion annual business in 2007, with 132,000 homeowners in their sixties or older taking out such mortgages—an increase of 270 percent over 2005. However, reverse mortgages can be complicated and there have been recent lawsuits alleging that unscrupulous brokers have preyed on elderly homeowners who did not understand what they were getting into.
The subprime housing and related economic crisises of 2007 have complicated matters further. Some reverse mortgage borrowers, unaware that the value of their property had diminished in the national housing slump and recession, found that they had borrowed more than their homes are currently worth and they owe the mortgage company money at stiff interest rates. There is a lesson in this. No one should enter into a reverse mortgage without first consulting with a trusted attorney or accountant.
Senior citizens, even those of modest means, can also benefit from living in what is called Naturally Occurring Retirement Communities, or NORCs in government parlance. Your parent or you may already live in a NORC without even knowing it! It’s estimated that twice as many elderly live in NORCs than in apartments or developments designed for the elderly. A NORC is demographic lingo for a development, condo community, apartment building, or neighborhood block where those over 65 years of age constitute a significant --25 percent or more-- portion of the population
Since NORCs are, in effect, unplanned communities, they do not include the types of health and social services that are provided in communities designed for the elderly. Since the mid-1980s state governments have funded programs through local social service non-profit agencies to provide NORC residents with coordinated health, social and related services such as health screening, wellness education and home delivered meals. The objective of such programs is to enable the elderly to remain in their homes or apartments, receiving a range of integrated, community-based services and preventative care which will permit them to continue living independently.
A big part of the mission is educating the at-home elderly about services available to them and facilitating social opportunities to diminish isolation, which is associated with increased risk of cardiovascular and Alzheimer’s disease in older persons. The low income elderly receive these services for free or for a sliding scale fee based on income. The intention is that such a system gives the elderly choices, permitting them (and any caregivers) to play active roles in decision-making about care, and to discover a sense of community through social and wellness-centered events such as lectures about nutrition, fitness programs, lunches, and volunteering in the peer group. Services include transportation, case management, health education, and recreational activities. NORC elders, surveyed by program managers, have repeatedly said that social interaction with their peers and others is the most valuable part of these service programs.
NORC services are organized so that one local non-profit agency spearheads the program in each NORC locale but partners with volunteers, building managers, clergy, civic, and neighborhood organizations to provide a variety of services. The model requires that elders be represented on the boards of service providers and be active participants in making decisions about which services are delvered.
One of America’s biggest health and service providers, United Jewish Communities, runs 41 NORC service programs in 25 states. In 2002 it surveyed adults over the age of 70 in 24 of these communities, asking them about their social activities, service use,, health and volunteer activities since they became involved with UJC’s NORC social service programs. Results of this survey showed that NORC programs are an effective way to increase socialization and decrease social isolation and to link elders in the community to services that can help them age in place.
Of the respondents, two-thirds of whom lived alone, the vast majority said that they know more people and leave their homes more often than they did before they became involved with NORC-programs. Ninety-two percent said that they now know whom to ask for assistance. A much stronger sense of belonging to the community was evidenced among respondents. The survey found increased volunteerism among these elderly residents, and that those involved in NORC programs felt healthier and were likely to remain in the community.
Copyright © Gwynne E. Morgan
Saturday, May 24, 2008
Monday, May 19, 2008
Exercise Deters Falls Among the Elderly
A Good Enough Daughter:
Caring for Your Elderly Parent While Taking Care of Yourself Copyright © Gwynne E. Morgan 1 May 2008
Chapter III: Falls & Fitness in the Elderly
It’s a Tuesday morning at the Hebrew Rehabilitation Center in Boston, MA and Mina Gold, dressed in a flowered jersey warm up suit, is seated on an exercise machine, flexing and straightening her legs against weighted resistance, keeping the soles of her feet perpendicular to the ceiling. Gold, is working on the hamstring muscles at the back of her thighs, as part of an exercise regimen to increase strength, balance and mobility in her upper and lower extremities. Nearby, the exercise physiologist checks her posture, and occasionally adjusts the machine, adding resistance pound by pound.
The only unusual aspect of this scene is that Mina Gold is 95 years old. She is working out, as she does three times a week, as a part of the ten year old “Circle of Fitness” program at the Hebrew Rehabilitation Center, a Boston nursing home and rehabilitation affiliate of Harvard Medical School’s department of geriatric medicine. The program is designed to build strength and restore balance and flexibility to frail elderly residents at this residential facility. That’s right, build and restore. Hebrew Rehab and Harvard are part of a rising tide of researchers, gerontologists, nutritionists and exercise physiologists who maintain that proper exercise and nutrition, including vitamin supplements, can go far to prevent falls and frailty in the elderly population and help many frail elders regain strength, balance and mobility.
Certainly, Mina Gold is a believer. She says she, her adult son and daughter have all noticed that her balance and walking have improved since she began the fitness program. Gold came to live at Hebrew Rehab a year ago after a bad fall in her Connecticut apartment led to hospitalization and stays in a rehabilitation facility and a nursing home. The fall had occurred in the most mundane circumstances: bending to pick up her purse where it lay on the floor, she had lost her balance and toppled over, landing on her forehead.
Gold, who is legally blind, says that she is slowly regaining her confidence and learning to find her way without fear since she began her exercise regimen. This morning she will spend about an hour in the gym, first warming up for 15 minutes on the NuStep recumbent stepper, a bike-like machine which is slightly reclined to take pressure off the spine, and then moving along the specially-designed Keiser resistance machines --leg-press, chest press, knee and leg extension equipment-- as well as machines which strengthen the upper and lower back, all under the watchful eye of Maureen Connerty, the exercise physiologist.
Connerty explains that the specialized Keiser exercise equipment, developed in response to research done by “Circle of Fitness" founder Dr. Maria F. Singh, allows the professional staff to increase resistance in more manageable increments than on machines found in local fitness clubs. “That means that frail seniors get a good work out and experience success without injuring themselves. Mina is one of our best clients, and has been able to substantially increase her strength and resistance. I can see her confidence grow as her strength and balance improve.”
The importance of such an exercise regimen for our elderly parents has become increasingly clear. A spate of studies, conducted over the past three decades by geriatricians and researchers around the globe, points to a common conclusion: When old people fall down, they do more than break bones; they begin to die. Falls are frequently fatal to the old, and represent horrendous health care costs to the systems that treat them if they live. Even for those who survive a fall, the accident usually represents a turning point, after which the quality of their lives deteriorates dramatically, both physically and psychologically.
The impact of falls on the elderly population is not news. A decade ago, researchers at Washington University School of Medicine noted that about one-third of people over age 65 fall at least once a year and that in about 10 to 15 percent of the cases, these falls result in injuries such as fractures of the hip or other bones.
Of the elderly who break a hip during a fall—one of the most common injuries—one-quarter die within the year. Three out of four of the fallen never recover the quality of life they had before the fall, according to the U.S. National Safety Council. The 12 million elderly Americans who fall down every year result in 10,000 fall-related deaths and about $20 billion in medical costs.
Not quantified are the psychological costs, including loss of confidence, withdrawal, depression and a host of physical maladies associated with inactivity. Sometimes it is not the fall itself that does the damage, but rather the mindset created by the fall. People who have fallen fear that they will fall again and rein in their activity in response to that fear. Ironically, it is not their motion, but their lack of motion, that leads to further physical deterioration.
“Use it or lose it.” “Prepare rather than repair.” We all know that we need to exercise. All the catch phrases point to the truism that consistent exercise impacts how long and how well we will live. And yet studies show that about one-third of all American adults participate in no form of physical exercise. Not surprisingly, the prevalence of inactivity is greatest among the old.
Researchers now believe that regular exercise can help to prevent falls, and can begin at any age, even by the so-called “old elderly,” those above the age of 85. Of course, being physically prepared for a healthy old age is the best bet.
We’ve been hearing for years that exercise helps people live longer. Recently, there’s been an effort to quantify how much longer an exercising elder can live. Late in 2005, using data from the Framingham (MA) Heart Study, which has followed more than 50,000 Bay State residents for 46 years, researchers determined that higher levels of physical activity added one to three years to life expectancy—regardless of age, gender or other existing health problems. Moderate to highly active persons also lived more years without cardiovascular disease, so that presumably their quality of life was better.
“The role that physical activity plays in cardiovascular risk management should be emphasized to achieve a worldwide implementation of an active pattern of life,” the researchers concluded. “Our study suggests that following an active lifestyle is an effective way to achieve healthy aging.”
There is evidence that regular exercise benefits the mind as well as the body. Swedish researchers reported in early 2006 that exercising in middle age not only keeps weight down and hearts healthy but can also cut the risk of developing Alzheimer’s disease, the most common form of dementia in the elderly, particularly in high risk persons. People in mid-life who exercised at least twice a week had about a 60 percent lower risk of suffering from dementia than more sedentary people.
Scientists at Sweden’s Karolinska Institute’s Aging Research Center tracked the mental health people between the ages of 65-79 whose leisure activities were monitored for fifteen years. They discovered that the active group, who participated in physical activity like walking or bicycling that caused sweating and strained breathing, was less likely to suffer from Alzheimer’s.
Given these findings, researchers suggest that the huge financial investment expended on treating fallen elders could be better spent on preventive measures such as encouraging t older people to take weight-bearing, and other exercise. and in providing post-fall care. “Ensuring older people are not discharged too early from the hospital and (that they) get the care and support they need at home are crucial steps that could reduce (fall) risk,” British researcher Paul Scuffman wrote in the Journal of Epidemiology and Community Health.
The story of Merton Bergman, a strapping 6 ‘ retired salesman, who shares the gym with Mrs. Gold on a recent morning, underscores the vital roles of regular exercise and professional oversight in fall recovery and confidence-building. Today, Bergman, 88, is gleeful to be back on the Hebrew Rehabilitation Center’s recumbent exercise bike after a hiatus of five weeks for back spasms. He is displeased that the interruption in his regimen has left him with tightness in his thighs and irritating balance issues. “I feel like I’ve definitely lost some ground.”
That Bergman is here at all is nothing short of miraculous and a tribute to both his own indomitable spirit and new exercise technology. Following a fall in October 2003, he spent 22 months in several Boston-area hospitals and convalescent centers, enduring spinal surgery, drug reactions, hallucinations and an infection that nearly ended his life.
Bergmann’s medical sojourn began in much the same way that many elderly begin their downhill slide—with a fall. A recent widower, living alone in his Newton, MA home, Bergman “tried to be smart,” climbing the stairs with both hands full, failing to hold on to the railing. He fell backwards down the steps, landing on his spine. Shaken, but with nothing apparently broken, he did not seek medical treatment but went on with his daily tasks. Six weeks after the fall, Bergmann began experiencing “twinges” in his lower back, usually in the evenings. His daughter, Nancy Bergman Temkin, stopped by one evening and found him struggling to get out of his chair. He was hospitalized and the pain increased, requiring morphine. While in the hospital, he fell several times. Bergman’s geriatrician suggested an MRI, a magnetic resonance imaging or picture of the spine. The news was not good. The doctor diagnosed a fracture of the third lumbar vertebrae, dictating surgery or life in a wheelchair. The orthopedic surgeon was frank, telling Bergmann’s daughter ‘This will not be a home run. I can alleviate his pain, but I cannot promise that he will ever walk again."
Temkin, still reeling from the recent death of her mother, didn’t want her father to undergo surgery. “I said I’d rather have a father in a wheelchair than no father at all.” Friends urged him to seek a second opinion, from a neurologist, but Bergman was resolute.
“I was in my late eighties and I was in pain all the time. I decided I was not going to live like that. I was going to do something about it.” And so, in May 2004, Bergman underwent surgery to fuse the second and damaged third vertebrae.
While Bergman has been released from the Hebrew Rehab Center and now lives with Temkin and her family, the road back has been riddled with potholes. A medication, meant to ease depression, gave him hallucinations. A daily exerciser since undergoing a cardiac quadruple bypass surgery in his 70s, Bergman had hoped to begin physical therapy immediately following surgery. Instead, he developed a life-threatening staph infection which required a second surgery to drain the wound. For more than three months, Bergman received daily three-hour intravenous infusions of antibiotics and antifungal agents. The pain was huge, requiring the stiffest of narcotics--Oxycotin, Oxycodine--and much of that period is now a blur. In three weeks, Bergman shed 15 of his normal 190 pounds and much of his muscle strength. Not surprisingly, when he ended up at Hebrew Rehab his doctors thought he was too frail for the “Circle of Fitness” training regimen, but again, Bergman was determined.
“I was in the fitness room working on one of the machines when I was asked to step aside for a scheduled “Circle of Fitness” patient. I told them I felt I was being treated like a second-class citizen and stormed out of the room. The next day my doctor approved me to join the program.”
Bergman’s progress seems to vindicate the findings of University of Toronto researcher Dr. Roy Shepard who has written extensively about the effectiveness of exercise among the elderly. Dr. Shepard believes that muscle strength can be greatly improved by as little as eight weeks of resisted weight training, even in subjects in their 90s. His research comparing active and inactive older people suggests that much of the wasting of lean tissue can be avoided by regular, resisted exercise, and that strengthened muscles will stabilize arthritic bones, reducing the risk of falls.
So, if your parent or family member is sedentary, or frail because of a medical condition, how much exercise is necessary to improve her health? What type of regimen is best? Such decisions are very individual, depending on your relative’s overall health, spirits, and environment. In general, for all of us, the greatest gains in heart-fitness and health are achieved by a workout that raises a sweat and elevates our heart rates. Because initial fitness is low in the inactive old, heart rates rarely exceed 85 beats a minute, but U/Toronto’s Shepard believes regular training on a machine that encourages aerobic fitness, such as a treadmill, stationary bike or rowing machine, can gradually bring this heart rate up to beneficial levels.
Dr. Shepard also believes that regular, load-bearing exercise can halt, or even reverse, bone mineral loss through the eighth decade of a person’s life. Such a regimen is particularly effective when accompanied by a high calcium diet or about 1500 mg of calcium per day.
Current research suggests that exercise needs to be spread over three modalities: weight training (free weights and weighted resistance machines) to strengthen bones and the muscles that hold them in place; aerobic exercise (walking, rowing, or cycling, outdoors or on stationary machines) to maximize heart and vascular fitness; and some form of balance and flexibility training, such as yoga, dance, and stretching.
If our parents are literally falling apart, why is this? Aging negatively impacts the vascular, skeletal and muscle systems, as well as the body’s metabolism, leading to a progressive decrease in strength and flexibility. Capacity for muscle strength peaks when people are about 25 years old, plateaus at age 35 or 40, and then begins an accelerating decline, so that the average non-exercising 65-year-old has lost about ¼ of the strength he had forty years earlier. Loss of muscle strength can progressively impede everyday living. It becomes difficult to carry a ten pound bag of groceries, to open a vial of medicine, and even to lift the body from a toilet seat.
The elasticity of tendons, ligaments and joint capsules also decreases over the natural process of aging if there is not some type of exercise intervention. Over the span of a working life, adults who don’t exercise regularly lose lower back and hip flexibility, and restricted range of movement at the major joints becomes more pronounced during the retirement years. Eventually, independence can be threatened because the older person can not climb into a car or a bath tub, ascend the steps to his front door or bedroom, or complete the movements required for washing, dressing and combing his hair.
Changes are usually greater in the legs than in the arms, possibly because there is a decrease in the use of the legs as people age. But we know this need not always be true: In Germany and the Netherlands, where the elderly actually increase the time spent walking and cycling after retirement, men live an average of three years longer than Americans and their quality of life is better.
Researchers and physical therapists maintain that flexibility can be conserved or even improved in an elderly person by gently taking the main joints through their full range of motion each day. Even bed-ridden patients can benefit from range-of-motion exercises. If muscle weakness and arthritis are advanced, they suggest that range-of motion exercises be done in the warm water of a bath tub or a heated swimming pool where buoyancy supports body weight and warmth increases the immediate flexibility of the joints.
At the University of Pittsburgh Medical Center’s Sports Medicine Center, Kathleen Brandfass, director of neurological and geriatric outpatient services, is like a mother duck, overseeing a pool full of gently exercising human ducklings. Her clients represent a whole gamut of adult-onset physical limitations—Parkinson’s disease, arthritis, hip replacement surgery, diabetes, multiple sclerosis—who come to the center as out-patients for weekly, or even daily, therapy. The pool with its 100 degree temperature and hovering steam is the starting point for all these patients before they move into the adjacent room for their individualized physical therapy regimens—stretching with a therapist, time on the machines, or negotiating an obstacle course while passing a basketball, a drill that improves balance.
You may be thinking, my 89 year old mother can’t afford a physical therapist or trainer and would never, ever exercise on her own. You are right. Senior citizens, like most Americans, resist exercising. The motivated Merton Bergmans of this world are few and far between. But the scene at the UPMC Sports Medicine Center pool provides a clue to a way to set your recalcitrant parent in motion. Exercise is a social activity and, when performed regularly, promotes more than physical gain. Many of our elders are alone—widowed, never married, having suffered the loss of family and friends. Organized exercise, led by professional trainers in inexpensive venues such as YMCAs and community centers, promotes both physical and emotional health by re-connecting the elderly person to a community with similar goals. Engaged in the task at hand, seniors can find new friendships, and a new sense of empowerment, in the local Y, swimming pool, or fitness club.
Following a traumatic injury or illness, Medicare will pay for a limited number of physical therapy visits to return the elderly person to "base line" or pre-trauma form. Paying privately for physical therapy or a personal trainer is a more expensive matter, but not all exercise needs to break the bank. Indoor pools in large cities such as Boston offer year-round swimming passes for as little as $15, and many communities open their high school pools to residents for a small fee. YMCAs, community centers and similar organizations offer sliding-scale memberships for senior citizens and anyone on limited incomes.
Some health maintenance organizations and insurance companies, acknowledging the role of prevention in health, offer discounts on fitness memberships to their clients. Walking in an indoor mall, with even floors, lots of seating and controlled temperatures, is absolutely free and can be done in icy or humid weather. Merton Bergman remembers making a number of new friends when he walked at a mall near his home while recovering from his bypass surgery. As in so many things, residents of poor and dangerous inner city neighborhoods have fewer choices. A walk around the neighborhood or to the local fitness center may be simply too dangerous for many older people to consider.
If you live near your parent, consider exercising with Mom to set her in motion. It can be something as simple as a walk around the mall or around her block, a swim in the town pool, or following along with stretching exercises on a DVD. For a birthday or holiday gift, you and your siblings could give your mother a membership to the local YMCA or a session with a personal trainer who can outline some exercises she can perform at home. Hiring a trainer for your folks and a couple of elderly friends would make the expense more affordable for the adult offspring and more fun for your parents.
Is it risky to encourage your elderly parent to exercise? Thirty years ago, those who had suffered heart attacks or strokes, like my father, were told to pack in their golf clubs and take a chair. Today, exercise physiologists, like those at Hebrew Rehab routinely work with recovering heart and stroke patients like Hilda Bunn. Bunn, 84, came to Hebrew Rehab in August, 2004 after sustaining two bad falls. The first fall occurred in her driveway, causing a severe break to her left elbow which took a long time and therapy to recover; the second occurred in the shower, where she banged herself up pretty badly but didn’t break any bones.
“I thought I had slipped but it turned out that I had suffered a mild stroke.” Bunn confides. When she lived independently, Bunn worked out at a private gym three days a week and she is convinced that that fitness regimen is the reason she didn’t break her hip in that shower tumble.
Merton Bergman is both realistic and optimistic about his physical future. Since moving in with his daughter's family after release from the Hebrew Rehabilitation Center, he has returned to the Circle of Fitness work-outs with renewed commitment. .He says he realizes that he may never be able to walk without a walker, but is “just glad to be able to get out and about.” The $100, out-of-pocket fee entitles him to two supervised workouts each week for 16 weeks. ‘After that,” he declares, “the good Lord willing, I will renew for another 16 weeks.”
Following a patient health crisis, physicians will seek either a clinical evaluation or a stress electrocardiogram, an electronic monitoring of the heart during exercise, before giving their recovering charges the green light to resume exercise. But, in the absence of a recent health crisis, Roy Shepard doesn’t feel such extensive and expensive testing is necessary. In fact, he says, it may be counter-productive for the older person who isn’t looking to embark on very strenuous competitive training but simply wants to increase slightly his level of daily activity.
“It is usually difficult to motivate older people to exercise regularly. Insistence on extensive screening suggests that physical activity is dangerous, and creates additional barriers of cost and time which reduce the likelihood that an intention to exercise will result in active exercise behavior....,” Shepard has written. “Moreover, the person who begins an exercise program is at a lower overall risk of sudden death than a sedentary peer…. Finally, if a well-loved form of exercise does provoke sudden death in an 80-year-old, this is a more pleasant end than many alternative ways of dying.”
Common-sense precautions apply whether it is you or your elderly parent resuming exercise after a sedentary spell. The dose of exercise should do no more than leave the participant pleasantly tired on the following day. Weight-supported activities such as swimming and aquatic exercises, offered at many community centers, are helpful for the elderly who have joint problems. Very frail elders can exercise from a sitting position or, with assistance, even lying in bed. My mother, whose Parkinson's disease seriously restricted her mobility, climbed two flights of stairs (with assistance) into her 94th year and performed chair and bed exercises daily.
Researchers and physicians are recently putting more emphasis on exercises which focus on balance and agility such as yoga and Tai Chi, a Chinese martial art exercise which looks a lot like slow-motion kung fu to the Western observer.
Hebrew Rehab exercise physiologist Evelyn O’Neill runs a drop-in exercise program called “Get Up and Go” for about thirty men and women from the community who work out entirely with small free weights, ankle weights, straight-backed chairs, and a wall of mirrors. On a recent December day, the four women look like an aging ballet class in their sweats and sneakers, all lined up beside O’Neill, facing the mirrors. They are working on balance. They raise their right feet in unison, weighted by eight pound ankle straps, holding the right leg bent behind them at a 45 degree angle, balancing all their weight on their left legs. O’Neill calls the shots. 1..2..3..4…12 No hands. Heads up. Straight backs.
The women on that day range in age from 58 to 77. The youngest has been seriously ill and is working to build up her strength after a long period of recuperation. The other three are focused on prevention.
Betty Connerty, who is 70 and looks more like 50, says it best: “My mother lived to be 96 so I’m pretty sure I’ve got good genes. If I live as long as Mom did, I want to be sure I’m fit enough to enjoy life.”
END
Footnote: Central to a discussion of bone breaks caused by falls is the whole issue of bone density and erosion of calcium in the elderly. There is a progressive decrease in the calcium content of bones as people age. Scientists aren’t sure to what extent the decrease of habitual physical activity contributes to the age-related calcium loss. Another factor is the presence in the body of vitamin D, since Vitamin D, naturally available in sunlight, helps the body absorb calcium. People of all ages living in dark northern climates and the elderly confined to apartments or nursing homes may need Vitamin D and calcium supplements to preserve bone density.
Structural bone changes are more pronounced in women than in men, due in part to hormonal differences and in part to a lower intake of calcium and good quality protein in women. Frighteningly, calcium loss in women can begin as early as age 30 and accelerates for some 5 years around the menopause. In later old age, the bones may become so weak that a mild fall, a bout of coughing, or even a vigorous muscle spasm can cause a break. As we’ve seen, the fracture of a hip quite commonly leads to irreversible bed rest and death.
Your parent’s individual bone density can be determined by a simple, non-invasive test ordered by her internist. If her bone density is found to be poor, you should be also be aware that a number of commercially available foods—milk, juices, cereals—are now fortified with Vitamin D and calcium. As calcium pills can be constipating, your parent may also need to step up her water and fruit consumption.
1. Framingham Heart Study, Archives of Internal Medicine, November 14, 2005
Caring for Your Elderly Parent While Taking Care of Yourself Copyright © Gwynne E. Morgan 1 May 2008
Chapter III: Falls & Fitness in the Elderly
It’s a Tuesday morning at the Hebrew Rehabilitation Center in Boston, MA and Mina Gold, dressed in a flowered jersey warm up suit, is seated on an exercise machine, flexing and straightening her legs against weighted resistance, keeping the soles of her feet perpendicular to the ceiling. Gold, is working on the hamstring muscles at the back of her thighs, as part of an exercise regimen to increase strength, balance and mobility in her upper and lower extremities. Nearby, the exercise physiologist checks her posture, and occasionally adjusts the machine, adding resistance pound by pound.
The only unusual aspect of this scene is that Mina Gold is 95 years old. She is working out, as she does three times a week, as a part of the ten year old “Circle of Fitness” program at the Hebrew Rehabilitation Center, a Boston nursing home and rehabilitation affiliate of Harvard Medical School’s department of geriatric medicine. The program is designed to build strength and restore balance and flexibility to frail elderly residents at this residential facility. That’s right, build and restore. Hebrew Rehab and Harvard are part of a rising tide of researchers, gerontologists, nutritionists and exercise physiologists who maintain that proper exercise and nutrition, including vitamin supplements, can go far to prevent falls and frailty in the elderly population and help many frail elders regain strength, balance and mobility.
Certainly, Mina Gold is a believer. She says she, her adult son and daughter have all noticed that her balance and walking have improved since she began the fitness program. Gold came to live at Hebrew Rehab a year ago after a bad fall in her Connecticut apartment led to hospitalization and stays in a rehabilitation facility and a nursing home. The fall had occurred in the most mundane circumstances: bending to pick up her purse where it lay on the floor, she had lost her balance and toppled over, landing on her forehead.
Gold, who is legally blind, says that she is slowly regaining her confidence and learning to find her way without fear since she began her exercise regimen. This morning she will spend about an hour in the gym, first warming up for 15 minutes on the NuStep recumbent stepper, a bike-like machine which is slightly reclined to take pressure off the spine, and then moving along the specially-designed Keiser resistance machines --leg-press, chest press, knee and leg extension equipment-- as well as machines which strengthen the upper and lower back, all under the watchful eye of Maureen Connerty, the exercise physiologist.
Connerty explains that the specialized Keiser exercise equipment, developed in response to research done by “Circle of Fitness" founder Dr. Maria F. Singh, allows the professional staff to increase resistance in more manageable increments than on machines found in local fitness clubs. “That means that frail seniors get a good work out and experience success without injuring themselves. Mina is one of our best clients, and has been able to substantially increase her strength and resistance. I can see her confidence grow as her strength and balance improve.”
The importance of such an exercise regimen for our elderly parents has become increasingly clear. A spate of studies, conducted over the past three decades by geriatricians and researchers around the globe, points to a common conclusion: When old people fall down, they do more than break bones; they begin to die. Falls are frequently fatal to the old, and represent horrendous health care costs to the systems that treat them if they live. Even for those who survive a fall, the accident usually represents a turning point, after which the quality of their lives deteriorates dramatically, both physically and psychologically.
The impact of falls on the elderly population is not news. A decade ago, researchers at Washington University School of Medicine noted that about one-third of people over age 65 fall at least once a year and that in about 10 to 15 percent of the cases, these falls result in injuries such as fractures of the hip or other bones.
Of the elderly who break a hip during a fall—one of the most common injuries—one-quarter die within the year. Three out of four of the fallen never recover the quality of life they had before the fall, according to the U.S. National Safety Council. The 12 million elderly Americans who fall down every year result in 10,000 fall-related deaths and about $20 billion in medical costs.
Not quantified are the psychological costs, including loss of confidence, withdrawal, depression and a host of physical maladies associated with inactivity. Sometimes it is not the fall itself that does the damage, but rather the mindset created by the fall. People who have fallen fear that they will fall again and rein in their activity in response to that fear. Ironically, it is not their motion, but their lack of motion, that leads to further physical deterioration.
“Use it or lose it.” “Prepare rather than repair.” We all know that we need to exercise. All the catch phrases point to the truism that consistent exercise impacts how long and how well we will live. And yet studies show that about one-third of all American adults participate in no form of physical exercise. Not surprisingly, the prevalence of inactivity is greatest among the old.
Researchers now believe that regular exercise can help to prevent falls, and can begin at any age, even by the so-called “old elderly,” those above the age of 85. Of course, being physically prepared for a healthy old age is the best bet.
We’ve been hearing for years that exercise helps people live longer. Recently, there’s been an effort to quantify how much longer an exercising elder can live. Late in 2005, using data from the Framingham (MA) Heart Study, which has followed more than 50,000 Bay State residents for 46 years, researchers determined that higher levels of physical activity added one to three years to life expectancy—regardless of age, gender or other existing health problems. Moderate to highly active persons also lived more years without cardiovascular disease, so that presumably their quality of life was better.
“The role that physical activity plays in cardiovascular risk management should be emphasized to achieve a worldwide implementation of an active pattern of life,” the researchers concluded. “Our study suggests that following an active lifestyle is an effective way to achieve healthy aging.”
There is evidence that regular exercise benefits the mind as well as the body. Swedish researchers reported in early 2006 that exercising in middle age not only keeps weight down and hearts healthy but can also cut the risk of developing Alzheimer’s disease, the most common form of dementia in the elderly, particularly in high risk persons. People in mid-life who exercised at least twice a week had about a 60 percent lower risk of suffering from dementia than more sedentary people.
Scientists at Sweden’s Karolinska Institute’s Aging Research Center tracked the mental health people between the ages of 65-79 whose leisure activities were monitored for fifteen years. They discovered that the active group, who participated in physical activity like walking or bicycling that caused sweating and strained breathing, was less likely to suffer from Alzheimer’s.
Given these findings, researchers suggest that the huge financial investment expended on treating fallen elders could be better spent on preventive measures such as encouraging t older people to take weight-bearing, and other exercise. and in providing post-fall care. “Ensuring older people are not discharged too early from the hospital and (that they) get the care and support they need at home are crucial steps that could reduce (fall) risk,” British researcher Paul Scuffman wrote in the Journal of Epidemiology and Community Health.
The story of Merton Bergman, a strapping 6 ‘ retired salesman, who shares the gym with Mrs. Gold on a recent morning, underscores the vital roles of regular exercise and professional oversight in fall recovery and confidence-building. Today, Bergman, 88, is gleeful to be back on the Hebrew Rehabilitation Center’s recumbent exercise bike after a hiatus of five weeks for back spasms. He is displeased that the interruption in his regimen has left him with tightness in his thighs and irritating balance issues. “I feel like I’ve definitely lost some ground.”
That Bergman is here at all is nothing short of miraculous and a tribute to both his own indomitable spirit and new exercise technology. Following a fall in October 2003, he spent 22 months in several Boston-area hospitals and convalescent centers, enduring spinal surgery, drug reactions, hallucinations and an infection that nearly ended his life.
Bergmann’s medical sojourn began in much the same way that many elderly begin their downhill slide—with a fall. A recent widower, living alone in his Newton, MA home, Bergman “tried to be smart,” climbing the stairs with both hands full, failing to hold on to the railing. He fell backwards down the steps, landing on his spine. Shaken, but with nothing apparently broken, he did not seek medical treatment but went on with his daily tasks. Six weeks after the fall, Bergmann began experiencing “twinges” in his lower back, usually in the evenings. His daughter, Nancy Bergman Temkin, stopped by one evening and found him struggling to get out of his chair. He was hospitalized and the pain increased, requiring morphine. While in the hospital, he fell several times. Bergman’s geriatrician suggested an MRI, a magnetic resonance imaging or picture of the spine. The news was not good. The doctor diagnosed a fracture of the third lumbar vertebrae, dictating surgery or life in a wheelchair. The orthopedic surgeon was frank, telling Bergmann’s daughter ‘This will not be a home run. I can alleviate his pain, but I cannot promise that he will ever walk again."
Temkin, still reeling from the recent death of her mother, didn’t want her father to undergo surgery. “I said I’d rather have a father in a wheelchair than no father at all.” Friends urged him to seek a second opinion, from a neurologist, but Bergman was resolute.
“I was in my late eighties and I was in pain all the time. I decided I was not going to live like that. I was going to do something about it.” And so, in May 2004, Bergman underwent surgery to fuse the second and damaged third vertebrae.
While Bergman has been released from the Hebrew Rehab Center and now lives with Temkin and her family, the road back has been riddled with potholes. A medication, meant to ease depression, gave him hallucinations. A daily exerciser since undergoing a cardiac quadruple bypass surgery in his 70s, Bergman had hoped to begin physical therapy immediately following surgery. Instead, he developed a life-threatening staph infection which required a second surgery to drain the wound. For more than three months, Bergman received daily three-hour intravenous infusions of antibiotics and antifungal agents. The pain was huge, requiring the stiffest of narcotics--Oxycotin, Oxycodine--and much of that period is now a blur. In three weeks, Bergman shed 15 of his normal 190 pounds and much of his muscle strength. Not surprisingly, when he ended up at Hebrew Rehab his doctors thought he was too frail for the “Circle of Fitness” training regimen, but again, Bergman was determined.
“I was in the fitness room working on one of the machines when I was asked to step aside for a scheduled “Circle of Fitness” patient. I told them I felt I was being treated like a second-class citizen and stormed out of the room. The next day my doctor approved me to join the program.”
Bergman’s progress seems to vindicate the findings of University of Toronto researcher Dr. Roy Shepard who has written extensively about the effectiveness of exercise among the elderly. Dr. Shepard believes that muscle strength can be greatly improved by as little as eight weeks of resisted weight training, even in subjects in their 90s. His research comparing active and inactive older people suggests that much of the wasting of lean tissue can be avoided by regular, resisted exercise, and that strengthened muscles will stabilize arthritic bones, reducing the risk of falls.
So, if your parent or family member is sedentary, or frail because of a medical condition, how much exercise is necessary to improve her health? What type of regimen is best? Such decisions are very individual, depending on your relative’s overall health, spirits, and environment. In general, for all of us, the greatest gains in heart-fitness and health are achieved by a workout that raises a sweat and elevates our heart rates. Because initial fitness is low in the inactive old, heart rates rarely exceed 85 beats a minute, but U/Toronto’s Shepard believes regular training on a machine that encourages aerobic fitness, such as a treadmill, stationary bike or rowing machine, can gradually bring this heart rate up to beneficial levels.
Dr. Shepard also believes that regular, load-bearing exercise can halt, or even reverse, bone mineral loss through the eighth decade of a person’s life. Such a regimen is particularly effective when accompanied by a high calcium diet or about 1500 mg of calcium per day.
Current research suggests that exercise needs to be spread over three modalities: weight training (free weights and weighted resistance machines) to strengthen bones and the muscles that hold them in place; aerobic exercise (walking, rowing, or cycling, outdoors or on stationary machines) to maximize heart and vascular fitness; and some form of balance and flexibility training, such as yoga, dance, and stretching.
If our parents are literally falling apart, why is this? Aging negatively impacts the vascular, skeletal and muscle systems, as well as the body’s metabolism, leading to a progressive decrease in strength and flexibility. Capacity for muscle strength peaks when people are about 25 years old, plateaus at age 35 or 40, and then begins an accelerating decline, so that the average non-exercising 65-year-old has lost about ¼ of the strength he had forty years earlier. Loss of muscle strength can progressively impede everyday living. It becomes difficult to carry a ten pound bag of groceries, to open a vial of medicine, and even to lift the body from a toilet seat.
The elasticity of tendons, ligaments and joint capsules also decreases over the natural process of aging if there is not some type of exercise intervention. Over the span of a working life, adults who don’t exercise regularly lose lower back and hip flexibility, and restricted range of movement at the major joints becomes more pronounced during the retirement years. Eventually, independence can be threatened because the older person can not climb into a car or a bath tub, ascend the steps to his front door or bedroom, or complete the movements required for washing, dressing and combing his hair.
Changes are usually greater in the legs than in the arms, possibly because there is a decrease in the use of the legs as people age. But we know this need not always be true: In Germany and the Netherlands, where the elderly actually increase the time spent walking and cycling after retirement, men live an average of three years longer than Americans and their quality of life is better.
Researchers and physical therapists maintain that flexibility can be conserved or even improved in an elderly person by gently taking the main joints through their full range of motion each day. Even bed-ridden patients can benefit from range-of-motion exercises. If muscle weakness and arthritis are advanced, they suggest that range-of motion exercises be done in the warm water of a bath tub or a heated swimming pool where buoyancy supports body weight and warmth increases the immediate flexibility of the joints.
At the University of Pittsburgh Medical Center’s Sports Medicine Center, Kathleen Brandfass, director of neurological and geriatric outpatient services, is like a mother duck, overseeing a pool full of gently exercising human ducklings. Her clients represent a whole gamut of adult-onset physical limitations—Parkinson’s disease, arthritis, hip replacement surgery, diabetes, multiple sclerosis—who come to the center as out-patients for weekly, or even daily, therapy. The pool with its 100 degree temperature and hovering steam is the starting point for all these patients before they move into the adjacent room for their individualized physical therapy regimens—stretching with a therapist, time on the machines, or negotiating an obstacle course while passing a basketball, a drill that improves balance.
You may be thinking, my 89 year old mother can’t afford a physical therapist or trainer and would never, ever exercise on her own. You are right. Senior citizens, like most Americans, resist exercising. The motivated Merton Bergmans of this world are few and far between. But the scene at the UPMC Sports Medicine Center pool provides a clue to a way to set your recalcitrant parent in motion. Exercise is a social activity and, when performed regularly, promotes more than physical gain. Many of our elders are alone—widowed, never married, having suffered the loss of family and friends. Organized exercise, led by professional trainers in inexpensive venues such as YMCAs and community centers, promotes both physical and emotional health by re-connecting the elderly person to a community with similar goals. Engaged in the task at hand, seniors can find new friendships, and a new sense of empowerment, in the local Y, swimming pool, or fitness club.
Following a traumatic injury or illness, Medicare will pay for a limited number of physical therapy visits to return the elderly person to "base line" or pre-trauma form. Paying privately for physical therapy or a personal trainer is a more expensive matter, but not all exercise needs to break the bank. Indoor pools in large cities such as Boston offer year-round swimming passes for as little as $15, and many communities open their high school pools to residents for a small fee. YMCAs, community centers and similar organizations offer sliding-scale memberships for senior citizens and anyone on limited incomes.
Some health maintenance organizations and insurance companies, acknowledging the role of prevention in health, offer discounts on fitness memberships to their clients. Walking in an indoor mall, with even floors, lots of seating and controlled temperatures, is absolutely free and can be done in icy or humid weather. Merton Bergman remembers making a number of new friends when he walked at a mall near his home while recovering from his bypass surgery. As in so many things, residents of poor and dangerous inner city neighborhoods have fewer choices. A walk around the neighborhood or to the local fitness center may be simply too dangerous for many older people to consider.
If you live near your parent, consider exercising with Mom to set her in motion. It can be something as simple as a walk around the mall or around her block, a swim in the town pool, or following along with stretching exercises on a DVD. For a birthday or holiday gift, you and your siblings could give your mother a membership to the local YMCA or a session with a personal trainer who can outline some exercises she can perform at home. Hiring a trainer for your folks and a couple of elderly friends would make the expense more affordable for the adult offspring and more fun for your parents.
Is it risky to encourage your elderly parent to exercise? Thirty years ago, those who had suffered heart attacks or strokes, like my father, were told to pack in their golf clubs and take a chair. Today, exercise physiologists, like those at Hebrew Rehab routinely work with recovering heart and stroke patients like Hilda Bunn. Bunn, 84, came to Hebrew Rehab in August, 2004 after sustaining two bad falls. The first fall occurred in her driveway, causing a severe break to her left elbow which took a long time and therapy to recover; the second occurred in the shower, where she banged herself up pretty badly but didn’t break any bones.
“I thought I had slipped but it turned out that I had suffered a mild stroke.” Bunn confides. When she lived independently, Bunn worked out at a private gym three days a week and she is convinced that that fitness regimen is the reason she didn’t break her hip in that shower tumble.
Merton Bergman is both realistic and optimistic about his physical future. Since moving in with his daughter's family after release from the Hebrew Rehabilitation Center, he has returned to the Circle of Fitness work-outs with renewed commitment. .He says he realizes that he may never be able to walk without a walker, but is “just glad to be able to get out and about.” The $100, out-of-pocket fee entitles him to two supervised workouts each week for 16 weeks. ‘After that,” he declares, “the good Lord willing, I will renew for another 16 weeks.”
Following a patient health crisis, physicians will seek either a clinical evaluation or a stress electrocardiogram, an electronic monitoring of the heart during exercise, before giving their recovering charges the green light to resume exercise. But, in the absence of a recent health crisis, Roy Shepard doesn’t feel such extensive and expensive testing is necessary. In fact, he says, it may be counter-productive for the older person who isn’t looking to embark on very strenuous competitive training but simply wants to increase slightly his level of daily activity.
“It is usually difficult to motivate older people to exercise regularly. Insistence on extensive screening suggests that physical activity is dangerous, and creates additional barriers of cost and time which reduce the likelihood that an intention to exercise will result in active exercise behavior....,” Shepard has written. “Moreover, the person who begins an exercise program is at a lower overall risk of sudden death than a sedentary peer…. Finally, if a well-loved form of exercise does provoke sudden death in an 80-year-old, this is a more pleasant end than many alternative ways of dying.”
Common-sense precautions apply whether it is you or your elderly parent resuming exercise after a sedentary spell. The dose of exercise should do no more than leave the participant pleasantly tired on the following day. Weight-supported activities such as swimming and aquatic exercises, offered at many community centers, are helpful for the elderly who have joint problems. Very frail elders can exercise from a sitting position or, with assistance, even lying in bed. My mother, whose Parkinson's disease seriously restricted her mobility, climbed two flights of stairs (with assistance) into her 94th year and performed chair and bed exercises daily.
Researchers and physicians are recently putting more emphasis on exercises which focus on balance and agility such as yoga and Tai Chi, a Chinese martial art exercise which looks a lot like slow-motion kung fu to the Western observer.
Hebrew Rehab exercise physiologist Evelyn O’Neill runs a drop-in exercise program called “Get Up and Go” for about thirty men and women from the community who work out entirely with small free weights, ankle weights, straight-backed chairs, and a wall of mirrors. On a recent December day, the four women look like an aging ballet class in their sweats and sneakers, all lined up beside O’Neill, facing the mirrors. They are working on balance. They raise their right feet in unison, weighted by eight pound ankle straps, holding the right leg bent behind them at a 45 degree angle, balancing all their weight on their left legs. O’Neill calls the shots. 1..2..3..4…12 No hands. Heads up. Straight backs.
The women on that day range in age from 58 to 77. The youngest has been seriously ill and is working to build up her strength after a long period of recuperation. The other three are focused on prevention.
Betty Connerty, who is 70 and looks more like 50, says it best: “My mother lived to be 96 so I’m pretty sure I’ve got good genes. If I live as long as Mom did, I want to be sure I’m fit enough to enjoy life.”
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Footnote: Central to a discussion of bone breaks caused by falls is the whole issue of bone density and erosion of calcium in the elderly. There is a progressive decrease in the calcium content of bones as people age. Scientists aren’t sure to what extent the decrease of habitual physical activity contributes to the age-related calcium loss. Another factor is the presence in the body of vitamin D, since Vitamin D, naturally available in sunlight, helps the body absorb calcium. People of all ages living in dark northern climates and the elderly confined to apartments or nursing homes may need Vitamin D and calcium supplements to preserve bone density.
Structural bone changes are more pronounced in women than in men, due in part to hormonal differences and in part to a lower intake of calcium and good quality protein in women. Frighteningly, calcium loss in women can begin as early as age 30 and accelerates for some 5 years around the menopause. In later old age, the bones may become so weak that a mild fall, a bout of coughing, or even a vigorous muscle spasm can cause a break. As we’ve seen, the fracture of a hip quite commonly leads to irreversible bed rest and death.
Your parent’s individual bone density can be determined by a simple, non-invasive test ordered by her internist. If her bone density is found to be poor, you should be also be aware that a number of commercially available foods—milk, juices, cereals—are now fortified with Vitamin D and calcium. As calcium pills can be constipating, your parent may also need to step up her water and fruit consumption.
1. Framingham Heart Study, Archives of Internal Medicine, November 14, 2005
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