During an Annual Meeting symposium on considerations in treating the aging athletic patient, a panel of surgeons covered both injuries and treatment for “weekend warriors” and the science of aging. They agreed that orthopaedists have a role both in injury repair and in counseling patients about exercise and good health habits.
Bryan D. Den Hartog, MD, of the University of South Dakota, said his prescription for maintaining fitness and dealing with the “cold reality” of decline is to work out assiduously and intelligently. “You have to be fairly intense to maintain aerobic capacity and performance with age,” he said. “Short, hard, repeated bursts of exercise—such as sprinting for a quarter mile, resting a few minutes, then sprinting again—are necessary to be competitive.”
However, he noted, “the hard reality of aging for most athletes is that they simply cannot work out and race as often. For reasons science has not fully explained, they need more rest.” He recommended starting slowly, finding a sport, and giving it time.
Christopher W. DiGiovanni, MD, of Massachusetts General Hospital, surveyed some strategies based on pharmaceuticals, nutrition, and endocrinology. Determinants of aging in any individual involve both nature and nurture (ie, time and genetics as well as lifestyle choices and environmental factors), he noted, and age is often a subjective concept.
“We tend to view ‘old’ as 20 years older than we are at any given moment,” he quipped. “Certainly from a chronological standpoint, aging is a one-way street that affects every organ system.”
Although the U.S. Food and Drug Administration does not recognize aging as a disease or specific medical condition, he said, “Still, the world insists on knowing: Can we reverse this process physiologically?”
In an interview with AAOS Now before the symposium, Dr. DiGiovanni elaborated on the evolving views of aging and efforts to mitigate its effects. “We have an obligation to be up-to-date on this information and support better science to help separate sound medical advice from hucksterism. Our patients are increasingly demanding these answers,” he said.
AAOS Now: Where do we stand on the anti-aging front?
Dr. DiGiovanni: I think there’s more talk about “healthspan” and less about lifespan these days. Patients are less concerned with increasing life expectancy from the 80s to the late 90s and more concerned about living as if they were 40 into their 80s. If that were possible—and some science suggests it might be—I agree it would be a worthwhile goal.
In the United States, bone and joint disorders account for more than half of chronic pain, disability, and healthcare costs in patients older than age 50. They account for almost 6 percent of the U.S. gross domestic product, more than any other disease state, and yet they are grossly under-researched compared to other fields.
Most people would welcome the ability to “trick age” and stay young physiologically. As a country, we tend to want to remedy things with the simplicity of a pill, which dovetails with what we are seeing in the promotion of testosterone, human growth hormone (HGH), and other supplements. Years ago, it was basically only elite athletes at the top of their game who sought these supplements. Now, the curiosity and the fascination factor with these agents have begun to reach well into the general population.
Of course, much of the legitimate discussion and excitement about any potential behind anti-aging modalities revolves more around maximizing musculoskeletal function and physiologic health rather than enhancing performance for sheer athletic prowess. I think there is currently enough science to make this worth exploring further, but not yet enough to believe any of it. I hope the medical community will give this more attention and credence than it has in years past.
AAOS Now: What are potential benefits and harms of supplemental hormones?
Dr. DiGiovanni: I think most orthopaedic surgeons would agree that it is wrong to prescribe HGH, testosterone/estrogen derivatives, oxytocin, parathyroid hormone, or many other supplements to someone with “normal” levels and no clinical symptoms of legitimate end organ disease—just so the patient can do more or go longer. One major hurdle is that we do not know what the “normal” levels should be for ideal physiologic function during aging. What if low-normal levels in otherwise phenotypically asymptomatic patients are found to correlate with an initially silent but faster physiologic (age) deterioration? If we could prevent that by keeping levels at some scientifically defined level, then intermittent monitoring for certain agents might become appropriate.
Obviously this would require more research, but the concept of “habitually refilling the oil in the tank to keep it topped off so the engine runs longer” may make sense as long as it can be done without adding risk or alternative compromise. Investigating for any potential to preserve healthspan instead of prolong lifespan raises both scientific and ethical questions, and I suspect it would generate an interesting debate given our aging population.
The cost effectiveness of investing in this science would also become quite relevant. In the long run, it might be far more cost-conscious to prevent disease and improve wellness and function during the aging process rather than focus on simply prolonging life and treating diseases and disabilities as they occur.
We know that subphysiologic levels of certain naturally occurring agents, in association with certain symptomatic (phenotypically manifest) disease states in affected patients, can and should be addressed with replacement therapy. Someday, we may have convincing evidence that monitoring and maintaining “high normal” levels of certain agents in otherwise “normal” patients actually promote physiologic well-being and delays cellular aging. To be compelling, however, any research in this area would also need to definitively show that doing so would not incur the same potentially serious side effects that result from performance enhancement drugs.
AAOS Now: What about costs and reimbursements?
Dr. DiGiovanni: Government has made it clear—and for good reason, given the relative lack of science in this area—that it will not pay for replacement therapy in the absence of any well-documented need, such as a physiologic deficiency or syndrome known to benefit from supplementation.
Increased attention, however, is now being paid to the merit of treating age-related “adult deficiency” of hormones, such as growth hormone. The science on this issue is still lacking, though, because no consensus exists on what a “normal lab value” is or what clinical situation should be considered legitimately worthy of treatment. This position is unlikely to change until sufficiently robust data clearly demonstrate clinical health benefits to using these therapies with either no or an acceptable level of risk—or until society agrees that the concept of improving healthspan is both possible and of equal or greater value than improving lifespan.
AAOS Now: What do we still need to know?
Dr. DiGiovanni: In the United States, we are making progress in educating the public and changing habits with respect to the importance of daily exercise and maintaining proper nutrition. Overall, however, there is still not enough research support for learning how exercise, nutrition, and potential supplementation agents might affect the human aging process. Any substantive change in this area will also require sufficient buy-in from the medical community.
AAOS Now: What about other products—herbs, fish oil, creatine?
Dr. DiGiovanni: With a few exceptions, these comprise a large, heterogeneous group of agents that the body does not naturally have. Although studying herbals, antioxidants, and other types of supplements may offer some value, source reliability and consistency remain suspect and little evidence currently supports any of these as truly effective promoters of wellness or overall health.
I think the more interesting focus should be on the endogenous compounds that appear to decline with age. I believe existing anecdotal evidence is sufficient to support further study. The available science has certainly been convincing enough to justify the creation of board certification in anti-aging medicine. Nationally recognized professional societies such as the American Academy of Anti-Aging Medicine and other fellowship training opportunities are increasingly being recognized by governing bodies such as the Accreditation Council for Graduate Medical Education. Maybe we orthopaedists should be paying more attention too?
AAOS Now: Where is the role of the orthopaedist in this?
Dr. DiGiovanni: I recently spoke to a large elderly audience about musculoskeletal problems. As a foot and ankle specialist, I focused my discussion on what I’ve noticed seems most important to these patients—being able to mow the lawn, shop, play with grandkids, drive, and walk for more than 15 minutes at a time. They want to maintain a level of function and independence that enables them to continue to experience the basic pleasures in life that younger people take for granted. What truly made them happiest was not what I would have guessed, and this has changed my perceptions of how to deal with the aging process.
As orthopaedists, we deal with fairly heterogeneous patient populations and we need to know our audiences to deliver what matters most and what will make the most profound difference in their lives. Personally, however, I don’t think that we are the ideal group to be testing or monitoring older patients who want to become candidates for anti-aging replacement therapy. I believe the emerging body of fellowship-trained anti-aging physicians is more qualified for that. Given our specific expertise, though, I think we are the appropriate referral providers to be consulted when general function and mobility questions arise in relation to the musculoskeletal system.
AAOS Now: What does the future hold?
Dr. DiGiovanni: I expect that this topic is going to continue to grow as the population ages and continues to focus more on health and wellness with the expectation that these functions should be independent of age. I anticipate the field of longevity to become a broader academic, scientific, professional, and societal topic, and I predict that future generation of physicians will begin studying this earlier in their educational paths—along with having this specialty as a career direction. I am convinced that the anti-aging movement is becoming accepted as a legitimate clinical entity, and I believe it is here to stay. As our patients grow older but try to remain younger, we will have these conversations more frequently. Clearly, though, the dedication of more science, greater resources, and additional highly qualified personnel are needed to help us determine whether this is more marvel than magic.
Both Dr. Den Hartog and Dr. DiGiovanni report potential conflicts of interest. For more information, visit www.aaos.org/disclosure
Terry Stanton is a senior science writer for AAOS NOW. He can be reached at email@example.com