Don’t kill Granny
Send her to the gym!
“Granny” has recently been identified as the archetypal elderly person who is very likely to die if she catches Covid. The presumption is that Granny is not only old but also frail, dependent and probably in a care home. All of these factors certainly make her vulnerable. The accepted solution is to keep her isolated in the care home, lonely and unvisited by family or friends for fear they might infect her with the deadly virus — until she either gets infected anyway or dies from something else.
No-one mentions prevention or treatment of Granny’s frailty. But frailty is not inevitable. The best thing we can do is to prevent Granny (and I include Grandad, so nearly all of us in the long term) getting frail in the first place.
What is frailty?
Frailty is officially described as “a clinically recognisable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day activities or acute stressors is compromised”! In brief, old and feeble or weak and debilitated. Some of the essential features include low grip strength, low energy, slowed walking speed, low physical activity, and/or unintentional weight loss.
Frailty is closely allied to loss of muscle tissue. As we age we all lose muscle mass and strength, a condition called sarcopenia. The prevalence of sarcopenia increases with each 5-year age group from about 15% among the 65 to 70 year olds to as much as 50% in the over 85s and probably becoming increasingly common thereafter. It accelerates with the passing of the years. As the age of the population grows so will the numbers with sarcopenia.
The ability of Grannies to function independently in the community depends largely on them maintaining sufficient physical fitness and muscle strength to perform the activities of daily living. Tasks perceived as requiring substantial effort in deconditioned individuals tend to be avoided, setting off a vicious circle of further reduction in physical fitness causing further avoidance of physical activity and further loss of muscle mass and strength — and so on…..
The effect of frailty is seen most obviously in the ability of old people like Granny to undertake daily tasks such as getting up and dressed without help or getting out of the chair to go to the loo or make a cup of tea. Just looking after herself demands that Granny has a degree of physical fitness. If she can’t do these things she will become dependent on others to help. She will then need regular visits from carers or, worse still, admission to a care home.
A degree of age-related sarcopenia is unavoidable but the rate at which we lose muscle is largely dependent on how much exercise we take. This is what frailty is all about — and it is not an inevitable consequence of ageing but, at least in part, a lifestyle choice.
How has Granny got like this?
Frailty means loss of muscle strength and cardiorespiratory fitness. It is caused by taking very little exercise over a very long period. The resulting weakness is greatly aggravated by developing one or more of the degenerative diseases of later life. These include obesity, heart disease, diabetes, lung disease, osteoporosis, loss of balance — together called non-communicable diseases (NCDs). They are all promoted by lack of exercise — a double whammy, further decreasing physical fitness and leading to the downhill spiral into frailty. For many older people hospital admission is the final straw. Weakness makes Granny unsteady on her feet and at risk of falling. If she falls and is admitted she is in trouble. A week in hospital has been equated to an extra ten years of loss of strength and mobility.
Frailty is not inevitable
We all know people who are active and energetic into their late eighties and nineties. As a GP, I had many patients who told me how lucky they were to be so well in old age. My response was always the same. They weren’t lucky; they had looked after themselves, mainly by keeping very active.
The effect of exercise on later life fitness was seen in a study of cycling club members aged 55 to 79. This group had high levels of fitness. For those aged 55 the fitness was equivalent to the average for 20 year olds, for those aged 65 it was equivalent to the average for 25 year olds and for those aged 75 it was equivalent to 35 year olds!
A study of runners aged over 50 had similar findings. Over 500 members of a running club, aged 50 or more, were followed up over nine years and compared to a similar number of non-running members of the same community. The disability scores were low in both groups at the start of the study and remained so in the runners over the whole period of follow-up. However the disability scores in the non-runners rose steadily. After 19 years the average time until the onset of measurable disability was 16 years later for the runners than it was for the controls. The health gap between the groups increased throughout the period of study and was still widening into the tenth decade of life.
Granny does not need to be a cyclist or a runner to accrue some of these benefits. She does, however, need to be physically active. The Department of Health recommends taking 150 minutes per week of moderate intensity exercise with strength/balance exercise on two days of the week.
The improved health status of elderly people who have kept themselves fit was well illustrated by one study which found that the average 65-year-old can expect an additional 12.7 years of healthy life — meaning that he or she will live disability free until aged 77.7. Highly active 65-years-olds, however, have an additional 5.7 years of healthy life expectancy — they will remain disability-free until age 83.4.
Lifespan and Healthspan
Another way of viewing the effects of regular exercise on the ageing process is provided by the notion of “Healthspan”. We are all familiar with the term Lifespan indicating total length of life. Healthspan is the length of healthy life and is I believe far more important than Lifespan. The time between the end of a healthy living and end of life is the period of living with one or more disabilities. These include frailty and such non-communicable diseases as heart disease, osteoarthritis and general weakness and loss of balance which can limit activity and general enjoyment of life. This time is sometimes referred to as “terminal morbidity” — years defined by pain, disease, frailty and immobility.
The more physically active you are, the longer are both your Healthspan and your Lifespan. But the increase in Healthspan is greater than the increase in Lifespan so the period of terminal morbidity is lessened. If Granny exercises regularly, her period of dependence at the end of life is greatly shortened — she lives well and long to the end or near the end of her life.
What about Covid?
Regular exercise and keeping fit or getting fitter are really important in the fight against Covid. A high level of physical fitness does not protect against catching virus infections such as colds, flu or Covid. However it does improve immune response and shortens the period and severity of the illness and of any complications. Physically active people have a 40–50% reduction in the days they are ill with respiratory virus infections. For older people this may make the difference between being able to stay at home or needing hospital admission, between simple hospital treatment or needing intensive care, between surviving or dying from the virus.
So what should Granny do?
In the ideal world, Granny is an active and physically fit person who is as well protected as she can be by her healthy lifestyle. It is important that she maintains this lifestyle despite any limitations put on her by the restrictions or lockdowns. Unfortunately the restrictions imposed upon the population in response to the pandemic has led to a general decrease in physical activity and contributed to cardiopulmonary deconditioning. Already vulnerable older people have been made even more vulnerable.
To reverse this trend, Granny needs more exercise to prepare her to combat any infection. The idea of this “prehabilitation” is not new. It was used soon after World War 2 and nowadays is applied to improve the outcome of major surgery for unfit patients. If Granny is inactive and unfit she will also benefit from prehabilitation to improve her ability to fight infection and survive the Covid if she is unlucky enough to catch it.
The best protection for Granny in these uncertain times is getting fitter. She can go the gym (when it reopens), walk more, cycle (three wheelers are ideal), do more in the garden or around the house or join a Zoom exercise group. These are much better options than condemning her to a lonely death in a care home or incarcerated in her own home, visited only by professional carers.
The greater good
If enough Grannies follow this advice, many more will be able stay at home and look after themselves. Care homes will not become totally redundant but their resident populations will shrink considerably. This will benefit Grannies’ physical, mental and financial health. It will also benefit their families’ finances and the finances of the country as a whole.
So, don’t kill Granny — save her life by sending her to the gym (as soon as it opens!).
Hugh Bethell MD FRCP FRCGP
