Danilovich is the senior director of the Leonard Schanfield Research Institute at CJE SeniorLife in Chicago. She is also an adjunct assistant professor at Northwestern University, where she directs the dual-degree Doctor of Physical Therapy and Master of Public Health program. A board-certified geriatric physical therapist, Danilovich’s research focuses on exercise interventions to reduce frailty among older adults.
Defining Health Terms: What Is Frailty?
Terri Wilder: Can you start off by telling me a little bit more about the work you do at the research institute?
Margaret Danilovich: CJE is a large senior-care organization in Chicago with residential services, housing for older adults—all the way from independent living, down through nursing-home care, with assisted living, and with affordable or subsidized housing in between. The organization also offers about 35 different programs in the community for older adults—things like home-delivered meals, care management, outpatient psychotherapy, and counseling services—and serves about 1,800 Holocaust survivors who are living in Chicago.
Our research institute works both internally and externally, doing a variety of research across the agency in the areas of program evaluation, implementation science, quality improvement—and then also has external funding and collaborates with institutions across the country interested in researching older adults. My specific area of research is in the area of exercise and physical activity, specifically for older adults with frailty. Right now, we do a lot of clinical trials, looking at optimal exercise prescriptions and dosages to reverse frailty among older adults.
Wilder: What is frailty?
Danilovich: That is a great question. There are a lot of definitions out there right now, which is sort of the problem. In the United States, we don’t actually have what’s called an ICD-10—the billing code that people use for a diagnosis for frailty.
But broadly speaking, there are two conceptual models for how we look at frailty. One is a model that was developed by Ken Rockwood, a geriatrician up in Canada, that looks at frailty as an index. It’s the number of conditions or impairments or comorbidities that someone has out of a total number of items that has been evaluated, with a higher index score indicating that a person is more frail.
The other model that’s widely used is a model that was put forth by geriatrician and epidemiologist Linda Fried. In the Fried model of frailty, she proposes that frailty really is a phenotype. Frailty as a phenotype means that we can kind of diagnose frailty based on five criteria: weakness, slow walking speed, unintentional weight loss, exhaustion, and low levels of physical activity. A person would be frail if they had three of the five clinical features, and pre-frail if they have one or two.
In our work, we sort of ascribe to the phenotype model, because it identifies clinical features that would be appropriate targets and, therapeutically, could improve. We can work on people’s walking speed. We can address their weight loss. We can address their low levels of physical activity. And so, it gives us some targets for how we would set up our interventions to address these issues.
HIV and Aging: What’s Normal, and What’s Not?
Wilder: At the beginning of your presentation, you talked about the aging process. You had this beautiful slide describing what happens to muscle, neurologic, pulmonary, and cardiovascular systems. Can you talk about what happens to those systems as people age?
Danilovich: Across aging, we can broadly generalize it as a period of slowing down and lowering the amount of output that we see in all of our body systems. It is normal that people might lose up to about 50% of their strength between the ages of 30 and 80. That’s a normal kind of lowering of the muscle source output that we see with aging.
All of our body systems, then, start to incur this “slow and low” phenomenon, leading to changes in everything that occurs systemically—which is what makes aging and working in aging more of a challenge. When is this a normal amount of loss, versus when is it a pathological amount of loss?
Unlike at the opposite age spectrum, where we have babies, and there are growth charts, and we know there are milestones that children meet at established time points, we don’t really have the same thing for older adults. Which is why sometimes I think it’s hard for people as they’re aging to know what they should expect, and what should be normal. What we can expect normally is this slow and low kind of process that occurs. But what would be abnormal would be an interference in our physical, our cognitive, and our mental functioning.
It’s absolutely normal that between the ages of 30 and 80 you’re going to lose strength. It’s not normal—and it’s a sign that warrants intervention—if your muscle weakness has progressed to a level where you can’t get out of a chair independently.
Wilder: I feel like there’s some confusion about what is normal, and what should and shouldn’t happen. You hear people say, “I have a lot of pain. I have a lot of fatigue. I’m not able to do certain things.” And they’ll say, “You know, I guess that’s just what happens when you get old.” Can you talk about what is normal, what is not normal?
Danilovich: That’s a really good question. And it’s something that I hear quite often, as a physical therapist. Either it’s people themselves saying, “You know, I’m old. I can’t do that.”
It’s their family members saying, “Oh, she’s old. He’s old. They can’t. They shouldn’t do that.” But it’s also physicians who will hear someone’s report of pain and make comments like, “Well, you’re old. What do you expect?” And because we don’t have a lot of these thresholds for how someone—like, what normal aging would be—it makes it difficult to really determine.
What I can say is, pain is not a normal part of aging. So if someone is having pain, regardless of their age, that is a symptom that warrants workup and investigation.
In our muscular system, the loss of strength is normal, but the loss of function is not normal. When people say they have difficulty getting out of a chair, they can’t shower because they can’t step over the tub, or they can’t put away their groceries because they can’t lift them into the shelves, those are signs that weakness is starting to impact, or is impacting, someone’s function. That’s not a normal part of aging.
Same thing, neurologically. We know that there are going to be issues of having less balance and more unsteadiness as one ages. But falls are not a normal part of aging. There might be more slowness of cognition and some normal sorts of memory slips: “Where did I put my keys?” “Where did I put this?” Forgetting your home address or how to navigate from point A to point B would not be a normal part of aging.
What I really want people to know and to advocate for—for themselves, family members, and loved ones, is that we need to be watchful for these functional impacts—anything that is starting to impact how we move, live, and go about our day-to-day activities. If we start to see declines in those areas, that would suggest a more pathological form of aging.
Measures of Aging With HIV: Frailty, Falls, and Walking Speed
Wilder: You talked about what happens to a person with HIV as they age, and you compared it to what you describe in terms of the aging process. Can you share more about the unique aspects of aging with HIV?
Danilovich: We see some of that same phenomena of slow and low with HIV at all sorts of ages. People with HIV, for example, because of the virus itself and because of antiretrovirals, they have more pronounced peripheral neuropathy. They have more balance changes. We also see that same thing occur with aging—that our nervous system slows down; we have sensory changes. People have more balance deficits at 80, compared to at 30.
People aging with HIV are sort of subject to this issue of double jeopardy. They have factors that are related to normal, age-related changes, and they have factors that are related to the separate HIV changes. Both are happening and influencing their body and their health at the same time. So, they have these double challenges that they must face in their day-to-day lives.
Wilder: One of the surprising areas of research you discussed was the reduction in gait speed in aging people with HIV, compared to aging people without HIV. Can you share more on that?
Danilovich: There’s been a lot of research in general for the older adult population on the importance of gait speed. Gait speed has been proposed for older adults as almost a vital sign—that we can infer a lot about someone’s physical and cognitive functioning based on the speed at which they walk. There are validated thresholds that relate to the amount of physical functioning someone might have, or their likelihood of ending up in a nursing home or a hospital.
More recent work has started to look at walking speed in specific populations, like that of people with HIV. What they’ve shown is that, compared to peers of the same age without HIV, people aging with HIV have slower walking speeds. The concern is—knowing that walking speed is a predictor of independence, ability to live in the community, and ending up in a hospital—the slower one’s gait speed becomes, the more concern for their overall health.
If people with HIV are having slower walking speeds across the board, it really sends a signal that this is something we need to evaluate at doctor appointments and make sure people are getting screened. Then, should people have a slower walking speed, begin to intervene with physical activity and exercise interventions to improve their walking speed and maintain their health.
Wilder: Risk for falls is an issue that older adults and their family members are always concerned about. You talked about a paper from 2016 by Dr. [Kristine] Erlandson on fall frequency and associated factors among men and women with or at risk for HIV. Can you say more about the findings from that paper?
Danilovich: Dr. Erlandson looked at participants who had been followed long-term in the MACS study, the Multicenter AIDS Cohort Study. Among the sample of older people with and without HIV, what was the prevalence of falling? She found that for people without HIV, 18% had had a fall in the previous year, compared to 24% of people with HIV in the previous year.
These numbers are not statistically significant—meaning that there’s statistically not a difference between groups. But what I think we need to recognize is the aging-with-HIV population is somewhat in its infancy. Over the next 10 to 20 years, we’re going to see the current population get even older, and we’re going to see many, many more people age into older adulthood with HIV. So while the numbers right now from people who were in the cohort might not indicate that there’s a significant difference, we have to also realize and recognize that the people in this cohort are fairly young.
We’re thinking, people with HIV are older adults if they are 50 years of age or more. If they’re already falling at a 6% greater prevalence, compared to their peers, we should be thoughtful about what’s going to happen to them in 10 or 20 years, as they have even more cumulative effects of normal aging and HIV.
We know across the board that of all older adults over the age of 65, about one in three will fall every year. And that number increases to about one in two, or even about three in four, as we’re looking at people who reside in nursing homes or have more mobility impairments.
So, if we can proactively look at the population of people with HIV and consider their needs that they might have over the next 10 to 20 years as they’re aging, we could hopefully really start to prevent some of these falls that they may incur.
Can Physical Activity Reduce Aging-Related Risks for People Living With HIV?
Wilder: You discussed a 2018 article that provided information about the association between low levels of physical activity among older persons living with HIV and AIDS and poor physical function. What were some of the findings from that study?
Danilovich: This is one of the first studies that looked at objectively evaluating physical activities in older people living with HIV. A lot of times, physical activity is self-reported. It’s, “How many times did you exercise last week?” We know that that’s subject to a whole host of different forms of bias that limit the accuracy and validity of those results.
In this study, they had 21 people who wore an accelerometer over the course of a week, measuring their number of steps, the intensity of their physical activity, and their energy expenditure.
What they found was that the average number of steps people were taking per day was only about 3,400. We know from the U.S. Physical Activity Guidelines that the goal and target should be 10,000 steps per day. So this group of older people living with AIDS—or HIV—was very, very, very under what that target would be for optimal health outcomes.
They spent about 75% of their waking hours in sedentary, seated behaviors. They only achieved five minutes per day on average of moderate to vigorous physical activity, where we know that the guidelines would suggest 150 minutes per week. So across all of these physical activity categories, the group of older people with HIV was really falling short and showing that people are not achieving the recommended levels that we know provide optimal health benefits. The study points to the need for better awareness, education, and interventions, specifically for older people aging with HIV, to promote their physical activity levels.
Wilder: What kind of exercise should older adults with HIV engage in?
Danilovich: For the best, most comprehensive treatment or approach, people need to be achieving 150 minutes per week of aerobic exercise. Aerobics would be anything that elevates your heart rate: walking, jogging, swimming, biking, anything of that nature. Ideally, you want that to be in a moderate to vigorous activity level so that, as you’re doing the activity, you’re getting a little more out of breath, breaking a little sweat, and reporting that you feel like you’re working somewhat hard to hard.
People should also do resistance exercise. Resistance is something that the person is moving their limbs or moving their body against resistance. So, whether the resistance is in the form of weights, or a machine, or their own body weight and gravity, they need to be pushing or pulling against something.
Those types of resistance exercises should be done twice a week.
We want people to be working at a fairly high level. They should be lifting heavier weights, but a weight that they can lift for about 10 repetitions, one to two sets, and really focusing on major muscle groups: your quadriceps, glutes, biceps, triceps, and chest. Big muscle groups are important for function.
Lastly, people should consider, particularly as they’re aging, incorporating balance exercises. Balance exercises can be anything that is challenging one’s stability. It depends on what a person’s balance levels are, but you should feel somewhat unstable as you’re doing a balance exercise, to start to help your body train and improve those processes important for maintaining our balance.
Wilder: Can you give an example of a balance exercise?
Danilovich: One easy exercise is standing on one leg. In general, the principles would be to vary the base of support that you’re standing on. So, normally, we stand with our feet about shoulder-width apart. You can put your feet close together. You can stand on one foot or on something that is a more compliant or wobbly surface.
We also rely on our vision to keep us upright. Taking your vision out of the equation by even standing and closing your eyes, or varying your base of support and closing your eyes, can also really work on that balance.
Then we want to think about incorporating some of our vestibular, or inner ear, since that also helps us to maintain an upright position and stay stable. Turning your head while walking or moving is a way to kind of challenge that system to work on your balance.
In general, I think balance is the hardest area for people to work on, on their own. My overall recommendation is always, if people are in need of balance exercises, to seek out the services of a physical therapist to provide that individualized prescription for balance, based on an assessment and evaluation of where a person’s at. Or check out a number of the evidence-based falls prevention programs sponsored by the National Council on Aging. These are community-based programs that address balance exercises, specifically.
Wilder: In your presentation, you said that exercise is medicine. Then you shared a great, inspirational story of an older adult. Can you share more about this person?
Danilovich: The picture was of a woman who, if you looked at the picture, you would say, “Oh, that woman’s probably in her 80s or 90s.” She [was] what I termed frail, as an adjective. We would look at her and say, “Oh, she looks frail, as if a strong gust of wind could knock her over.” She’s sitting, and her face looks kind of gaunt. She’s got glasses. She’s kind of hunched over, drinking something out of a coffee mug.
I think a lot of times, particularly health care providers, we might look at someone like that who walks into our clinic and say, “Oh, that person’s very frail. They can’t do too much. They don’t have much capacity. I’m going to be really cautious with them.”
But, in reality, the woman that was pictured was Katherine Beiers, who, at the age of 85 years old, ran all 26.2 miles of the Boston Marathon. So, particularly with aging, the challenge, but also the joy, of working with an older adult population, is that looks are very deceiving. We can’t simply look at an older person and make a judgment about what they can do and what their physical functioning or cognitive functioning is. We really need to go in and do thorough assessments and evaluation to provide more of a data-driven decision-making process for their care.
Wilder: This is why I loved your last quote in your presentation: “To age well, the best physical activity is one you actually do. Sit less and move more.”
Wilder: I think it speaks to her story that when people ask you and other medical providers, “What’s the best physical activity to do?” the answer is, “Well, the one that you actually do!”
Danilovich: Right. I can tell you what the best exercise prescription is: “You need to do 150 minutes [a week] of aerobic exercise and two days a week of resistance exercise.”
But at the end of the day, if someone hates doing something, why do things that you’re going to hate to do? If you can find activities that you enjoy, that provide these health benefits, that’s really the best.
We know that people aren’t adherent to physical activity. And no one gets as much exercise as they need. The physical activity rates in the U.S. across all populations and ages are very low.
So, we all need to sit less and move more. Do things that we enjoy, and, if possible, then increase the intensity of those activities to really reap the best health benefits.