Seeking to outmuscle frailty
Philadelphia Inquirer (PA)
April 23--It was 8 a.m., and 86-year-old Allan Ford had delayed his breakfast to help researchers at the Hospital of the University of Pennsylvania figure out whether a hormone called ghrelin can combat frailty -- a combination of muscle loss and fatigue -- in the elderly by making them eat more.
Clinical trials have been something of an avocation for Ford, a former marketing and advertising man from Wynnewood, since the mid 1990s. With no chronic illnesses, he was always in the healthy control groups. But this time, even though he looks young for his age and is mentally sharp, he was weak and physically slow enough to qualify for the treatment.
While many U.S. researchers want to block ghrelin in the obese, Anne Cappola, an endocrinologist who is leading the Penn study, hopes the appetite stimulant will counteract the weight loss and weakness that often accompany aging. Many older people complain that they're just not hungry.
That recent morning, Ford got a shot of the hormone under the skin of his belly, then waited half an hour before eating a hearty breakfast of eggs, bacon, cereal, and toast from two trays. An earlier arm of the study had proven he ate more after the shot. This part was to find out whether he could learn to give the daily shot himself. (He could.)
Next, Cappola's team will test what happens when the drug is combined with exercise.
Many people still believe that the words old and frail naturally go together, but aging experts increasingly view frailty as a separate syndrome that often can be prevented and treated.
"While death is inevitable, this kind of long, slow decline into frailty and . . . disability is not really inevitable," said William Evans, an expert on aging, exercise, and nutrition who heads GlaxoSmithKline's muscle metabolism discovery performance unit in North Carolina. His group is studying drugs that may help build muscle or improve its quality. There may be human trials next year.
If doctors can figure out how to keep people stronger, that could lead to longer, more independent lives for the elderly and lower health costs for everybody.
The issue is gaining importance as baby boomers enter their final decades. Many will be prime candidates for frailty because of unhealthy lifestyle habits.
"It's going to be an enormous problem in the next 10 to 20 years," said Evans, who taught at Penn State in the 1990s. "The societal cost of nursing homes and institutionalization is enormous."
In a paper to be published in June, a consensus group representing six international geriatrics groups will recommend that both primary care doctors and specialists screen all patients older than 70 for frailty. Early identification, the group says, will help the elderly achieve one of their highest priorities -- aging at home -- and reduce costs.
Because cancer and its treatments seem to accelerate frailty, the National Cancer Institute has made research on frailty one of its funding priorities this year, said Catherine Alfano, deputy director of the office of cancer survivorship.
What exactly is frailty? For years, doctors agreed they knew it when they saw it, but had no definition. We all can picture the shrunken, old lady who needs help with her grocery bags and walks at a snail's pace. Linda Fried, then an aging expert at Johns Hopkins University, came up with the first definition for the syndrome about 10 years ago.
People with three of these five symptoms are considered frail: slow walking speed, weakness as measured by hand grip, physical inactivity, exhaustion, and unintentional weight loss of more than 10 pounds in a year.
Others have somewhat different definitions, and doctors now realize that obese patients also are often frail. The bottom line is that frail people are weak and at high risk of death and disability. They don't bounce back well from injury or surgery.
While frailty can occur in people like Ford with no chronic health problems, it is also common in people with cancer, heart failure, and chronic obstructive pulmonary disease.
Cappola said 7 percent of people 65 and older and 15 percent of those in their 80s are frail. A much higher percentage are "pre-frail," a group experts want to target for help.
Researchers are focusing on the physiological underpinnings of the syndrome, which Fried says involve poorer coordination between bodily systems. Inflammation is one possible culprit; genetics is another. Vitamin D has potential to help.
Evans also has developed a urine test -- not yet FDA approved -- that will for the first time help doctors measure how much muscle patients have.
As all that is sorted out, the advice is the same as for so many health problems: exercise more and eat better. People naturally lose muscle mass and quality as they age, but many are declining too fast due to the way they live.
"We're an aging population, and we're aging faster than we need to," said Kathryn Schmitz, an exercise physiologist at Penn who has studied exercise in breast cancer survivors and will soon work with Cappola's study subjects.
Many elderly people complain they've lost their appetite -- hence the ghrelin trial. They may need to focus on eating more, especially more protein, which is needed for muscle building. Eating less saturated fat may improve muscle quality, Evans said.
Moving more is key. "It's the single most important thing you can do for healthy aging," Alfano said. "Everyone's looking for the magic pill. We have it. It's exercise."
Aging experts strongly recommend exercising all through life, but studies have shown that aerobic activity and weight lifting can help even very old, very weak people.
Getting older people to exercise can be challenging. "The real problem often is attitude," Evans said. "Older people think that frailty and weakness are inevitable."
It often helps when a family member exercises too. Many a daughter has told him, , "This has been the most important thing I've ever done with my mother."
Fried, who is now dean of Columbia University's Mailman School of Public Health, said society needs to make keeping citizens strong a priority.
"This is one of the things we need to invest in . . . as we become a society of longer lives," she said.
Once 6 feet, Ford said he is now 5-foot-9 and 150 pounds. He looks good, but his arms and legs are thin. He likes to hold onto things as he walks and admits that he gets "more mental exercise than physical exercise."
A reporter wasn't allowed to watch Ford eat for fear it would affect the study results, but he reported a robust meal. "I ate the whole first tray and. . . practically the whole second tray. I was hungry."
Contact Stacey Burling at 215-854-4944 or firstname.lastname@example.org.
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