Good afternoon. Welcome to the educational session of the American Academy of PM&R. On behalf of the geriatric community, I'm honored to invite you all for this session with very exciting topics and speakers. Our very first speaker, our guest speaker, is Dr. Susan Friedman. She's a professor of medicine and geriatrics, a board member, director of clinical studies of Rochester Lifestyle Medicine, and also the medical director of Lifestyle Medicine Group at the University of Rochester in Rochester, New York. Please welcome Dr. Friedman. She is going to be talking to us on nuts and bolts of healthy aging and the emerging importance of PM&R in healthy aging. She will be presenting a novel approach in integrating the care of older adults in our practices and help our patients to remain healthy and maintain high levels of independence and function. And our second speaker is Dr. Dale Strasser. He will be speaking on polypharmacy in medical rehabilitation. In that, he will talk about recognizing polypharmacy in PM&R, describing strategies for promoting optimal medication prescribing, and incorporate insights into polypharmacy into pain, spasticity, depression, and also the use of neurostimulants. And our last speaker is Dr. Patrick Corbine. He will present on sarcopenia. He will give you a summary of a history of definitions of sarcopenia and our role, our physiatrist role, in evaluating, diagnosing, and treating sarcopenia in patients with a rehab diagnosis. Thank you, Dr. Friedman, Dr. Strasser, and Dr. Corbine for participating in this session. And I would like to begin our very first session with Dr. Susan Friedman. Dr. Friedman, you're on. Okay. Thank you. Let me just share my screen. And it looks like it's disappeared. Sorry, let me, let me try this again. There you go. Is that it. Yep. Okay. Perfect. Okay. Okay. So you can see that. Okay, Dr Friedman we're seeing the presenter view is this time we're seeing the presenter view. Give it a good. Yeah. Okay, this is good. All right. So thank you very much for this opportunity to talk to you about a topic that is really near and dear to my heart which is healthy aging. As Dr. Paduri said I am a board member of Rochester Lifestyle Medicine Institute and the director of studies there. That is a nonprofit organization with a goal of trying to teach people about the pillars of lifestyle medicine things like physical health, obesity and nutrition in trying to prevent and manage chronic disease and I'm also medical director at the clinical side of that. So I'm going to cover several different topics in the next 25 minutes or so, starting with what do we even mean by healthy aging. And what do in particular what do older adults want. I'm going to talk about some trends in healthy in health. Recently, and then I'm going to step back to talk about age friendly health systems, because I think that really the health systems drive a lot of our outcomes. And then I'm going to touch briefly about healthy aging as a lifecycle effort. And then finally I will finish up talking a little bit about lifestyle and health, and some of the literature that looks at that. Why are definitions important. Well, there was a systematic review done by depth and just looking at healthy aging. And when they surveyed these different studies that looked at this they found a prevalence that range from less than 1% to over 95%. So clearly, people are perceiving different things when they talk about healthy aging. So the first thing is that we really need a common language. And why is that necessary well it's necessary because that allows us to assess prevalence to compare the prevalence to look at both predictors and outcomes to track people over time and systems over time to develop interventions and then be able to study them to be able to generalize programs which then in turn, drive public health and public policy, and really allow us to plan for the future. And so, with that in mind, I'm going to walk through a few pictures that I think describe healthy aging. And I think the first few, you'll have no trouble in agreeing that these are healthy agers but I hope that you'll see that there's some elements among the latter pictures that that also show us some examples of healthy aging. So this is a picture of Peggy McAlpine who at the age of 104 became the oldest person to become a paraglider. And she set the record at age 100 but then 101 year old beat her record so she had to come back four years later and do it again. This is a picture of Fajah Singh, who at the age of 100 became the oldest person to ever run a marathon. And one thing that I find particularly heartening is that he really didn't take up serious running until he was in his mid 80s. And so one of the points that I'm hoping to make during this talk is that even though I firmly recommend that you start healthy aging as early as possible. It's almost never too late. This is a picture of Yasuo Itomen, who is a person who lives, a woman who lives in Okinawa, Japan, which is one of the blue zones around the world, which blue zones are areas where people live long and live with high levels of health and function to their And here she's pictured enjoying some of the carrots that she grows in her garden and uses to cook for her multigenerational family. But I'd like to show you a few more pictures that show some elements of healthy aging. Here we have a picture of a gentleman who The suggestion is that he has multiple chronic conditions, but and chronic conditions to the point where he needs to take pills, more than once a day, but he's clearly managing those pills. He has the social support that he needs and the assistive help that he needs, as well as an infrastructure in order to keep track of those medications and seems to be taking charge of his health. This is a picture of three older adults who live in an assisted living facility, and they discovered they didn't know each other when they moved in but discovered to their delight that they shared a passion for music and so they meet multiple times a week and play music together. So even though they live in a sheltered environment, they are able to do things that bring joy and meaning to their lives. And then finally, this is a picture of my mother about 10 years ago or so who in her mid 80s got to the point where her mobility was not good. She could only take several steps at a time. But that did not stop her from traveling to Europe to visit family and didn't stop her from coming back to the welcome of her three grandsons who were delighted to see her. And so when we think about healthy aging, I think there are a couple of definitions that we can think of. The first is one that was put forward by the World Health Organization, and that is a state of complete physical, mental, and social well-being and not only the absence of disease or infirmity. So a high bar, but a multifaceted construct. And then the second one is allowing each individual to live their best lives possible at every stage. And what it is not is a process of turning back the clock. So what do older adults want? This is another systematic review looking at older adults' perspectives on successful aging. And I think there are a lot of take-home messages from this graph. The first is that this is a really broad construct, and people have many different pieces that they think of when they think of successful aging. The second thing is that of all of the different types of successes, psychosocial success or psychosocial issues are really preeminent. And so when you survey older adults, the things that they are most concerned about are things like engagement, perspective, self-awareness, and independence. And then the final take-home point is that if you look at the very right-hand side of this graph, what you see is longevity, which is the least likely to be ranked as being important in successful aging. So let me turn to a graph that really depicts a central idea of geriatrics for the past several decades. So this is the idea of compression of morbidity that was put forward by James Freese in 1980. And this can really be accomplished in several different ways. One is by delaying the onset of chronic disease and disability. And then another is by reducing the impact that disabilities or functional impairments may have. And then kind of putting some of these ideas together, I wanted to review with you what perhaps is the most well-known framework for successful aging in geriatrics. And this was put forward by Jack Rowe and Robert Kahn, and they suggested that there were really three components. The first is avoiding disease. The second is maintaining high cognitive and physical function. And then the third is remaining engaged with life. So I'd like to review each of those three components. So the first is in terms of trends in health. One of the things that we have seen in recent decades is an increase in chronic disease. So this was from the Health and Retirement Study, and what they showed was basically every chronic condition that they looked at increased over the period of a decade. And going along with that, and I think this probably rings true for anyone who has worked with older adults, is that the prevalence of, you know, the likelihood of getting to old age without having any chronic conditions has decreased over time. And another sort of concept that we think of a lot in geriatrics is the idea of multimorbidity. And so the prevalence of four or more chronic diseases, and that has certainly increased over time. So what are we seeing in terms of function? Well, at the end of the last century, what we saw was a significant improvement in the function of older adults in the 1990s. And it looks like there's a generational shift so that those trends persisted for those who are over the age of 85 and stayed fairly level for older adults in general. But the concerning thing is that we are seeing increasing rates of disability in people who are middle-aged and approaching old age. So that the likelihood is that over time we are going to see rising rates of disability in old age. And when we look at life expectancy, now there have been some trends actually down recently, but life expectancy since the last century has increased. And if you're a glass is half full kind of person, you'll say the years spent in good health have increased, but we also see that the years spent in poor health have increased. And so, you know, that suggests that we're not actually compressing morbidity. And when we think of function and functional capacity, and Dr. Cordevine is going to talk a lot more about sarcopenia, but I just want to mention this concept of frailty, which is kind of a central concept within geriatrics and has received a lot of attention. In terms of our research in the past couple of decades. That functional ability really does drive this frailty cycle so that it can lead to increased levels of fatigue and decreased energy, which then leads to a decrease in physical activity because it's difficult to sustain that physical activity, leading to muscle wasting, which decreases physical exercise capacity and then that cycle continues. So turning to the third sort of circle within that Rowan Kahn model is engagement. And when we think about older adults, there are several barriers to engagement. The first, or at least potential barriers. The first is sensory impairment, so visual, vision, and hearing impairment. Function, so physical and cognitive function, you know, one of those other circles within that model can certainly impact engagement or one's ability and desire to engage. Psychological health, so depression and anxiety. The built environment, so one's home and one's community can impact. And then we know that family structures and family mobility has certainly changed. And then with the recent coronavirus pandemic, that has really brought into focus some of the technological issues that can limit engagement. And that kind of dovetails with loneliness, and that is something that in geriatrics we're focusing more attention on recently with the realization that about one in four older adults experience loneliness, and that in turn is a risk factor for physical and mental illness and physical function decline, as well as depression and dementia. And so when you think about those three realms, you know, preventing or limiting chronic illness, preserving functional and cognitive, physical and cognitive function, and preserving engagement, you begin to think, well, how are we doing as a system? And there's a saying that I really think about a lot, which is every system is perfectly designed to get the results that it gets. And so if we want to really optimize those outcomes and optimize healthy aging, we need to think about changing the system. And so I wanted to bring to your attention two different frameworks that have been put forward recently. The first was by the National Prevention, Health Promotion, and Public Health Council under Vivek Murthy, who was the Surgeon General at the time in 2016. And they put together a national prevention strategy for healthy aging that included healthy and safe community environments, clinical and community preventive services, empowering people, and then eliminating health disparities. And this is a phenomenal piece of work that they put together, and I would recommend reading the guide at your leisure. The second is the 4M model, which was really put forward by the Institute for Healthcare Improvement with the help of the John A. Hartford Foundation. And the goal of it was really to make all of healthcare for older adults age-friendly. This is based on evidence, and the goal is to really align with patients' goals and their families' goals. And so really they cover four M's, and at the very top is what matters. So understanding what your patient's goals are, talking with them, talking with their family members, and really targeting your healthcare towards what matters to the patient. Medications, where Dr. Strasser is going to talk about that, and then thinking about mentation or cognition and mobility, which is sort of front and center. The other thing that I have really come to appreciate as a geriatrician who deals with older adults is that there's really, it's never too early to start thinking about healthy aging. And just as a couple of examples, you know, the hip fracture that we see in an 80- or 90-year-old is really in part a function of their peak bone mass that they get to at age 30, and that's a function of their physical activity and nutrition as a youngster. And their ability to preserve their physical function and bone and muscle mass as they age. And another example of this is the heart attack that happens in a person who's 50 or 60 or 70. You know, we see the earliest evidence of atherosclerosis as early as teenagers, and probably these days even earlier than that. And so really thinking about prevention and health promotion across the life cycle is important. And that gets me to another saying, which is you aren't just the age you are, you're all the ages that you've ever been, which, you know, you carry all of those life events and your health along the way with you as you get to old age. And so then thinking about that, thinking about systems and thinking about life cycle brings us to this idea of really trying to address the root causes of chronic illness, what we call in lifestyle medicine the lifestyle pillars. We're sort of trained to deal with the consequences, but we really need to get to the root causes as much as we can. So thinking about a few different things, obesity has really skyrocketed in this country over the past several decades, to the point where more than two thirds of our country is either overweight or obese. If we look at four really straightforward lifestyle issues, never smoking, BMI less than 30, so non-obese, physical activity of three and a half hours per week, so half an hour per day, and a high intake of fruits, vegetables, whole grain, and low intake of meat. What we see is that if you have all of these different protective factors, you can prevent 90% of diabetes, about 80% of MIs, about 60% of stroke, and about 40% of cancers. And when we look at older adults and healthy lifestyle, what we find is that we can reduce the risk of disability. So this was a prospective study, and just looking at a, again, a multifaceted construct. And what they found was that thinking about years of overall life expectancy was higher for the people who had a healthy lifestyle. The number of years of non-disabled years or active life was higher than the overall life expectancy for each of these groups, and the proportion of time spent being disabled was smaller. So with healthy lifestyle, that does suggest that we can compress morbidity for older adults. Exercise and healthy aging, again, thinking back to our 100-year-old marathoner, this was a longitudinal study in England looking at the likelihood of healthy aging with exercise. What they found was that in a period of eight years, not only the people who were active at the beginning, which you would expect, but people who became active were much more likely to experience healthy aging, so about three and a half times more likely to experience healthy aging. This was a randomized controlled trial looking at diet and exercise in sedentary obese older adults and found that the combination helps with physical function, aerobic capacity, and functional status. With the idea being that it's almost never too late to try to do this, this was a landmark study that was done over 25 years ago now in nursing home residents, aged 87 on average, and they did a 10-week intervention trial of resistance training and found not only did things like strength and gait speed and stair climbing improve, but again, thinking of that frailty cycle and the spontaneous activity, so people were getting up and moving around more after this because the barriers were lower. Just a brief word about diet, because diet has overtaken tobacco as a leading risk factor for disability-adjusted life years in the past decade. Looking at the outcome of frailty and the Mediterranean diet, which is one of the better studied dietary patterns, this was almost 6,000 community-long older adults, and the more they were adherent to a Mediterranean diet, the lower their likelihood of developing frailty, so it dropped their risk by about a half. To sum it all up, our goal is to really try to optimize all of these different realms of successful aging, avoiding disease, maintaining high physical and cognitive function, and remaining engaged with life, but it is important to note that there are many people who feel that their ability to experience a happy and productive life goes beyond the intersection of these three realms, and so many people would define themselves as experiencing successful aging even if they're not able to avoid disease and to avoid some measure of functional decline. To conclude, healthy aging is a multifaceted concept that involves issues of engagement, limiting chronic illness, and optimizing function. The triad of healthy or successful aging is interconnected. We are seeing earlier onset of chronic illness, which will impact healthy aging, and in thinking about healthy aging, it's almost never too late, but best to start early. Two other things are that systems are really critically important in promoting healthy aging, and finally, remember the root causes of illness. These are a few references. This was a white paper that the American Geriatric Society put together as a framework for healthy aging, the 4M framework that I mentioned in the Healthy Aging in Action document that's available online, and I think that we're going to defer any questions till the end unless there's some clarifications. With that, I guess I will turn it back to Dr. Puduri. Thank you. Our next speaker is Dr. Diaz-Strosser. Thank you, Dr. Friedman. It was very useful to know what is important to be an adult that has health promoted to healthy aging. Now, one of the components that you mentioned was medications, and I think Dr. Strosser is going to talk to us about polypharmacy and also its applications in PM&R. Dr. Strosser? Yes. It's really a pleasure to talk to this group, and I want to also thank Dr. Friedman. What a wonderful and informative lecture. The whole notion of compression of morbidity certainly fits in a cross-cutting theme. Anyway, I'm Dale Strosser. I've been at Emory for about 32 years and one of the few physiatrists who actually did a fellowship in geriatric medicine a generation ago at Northwestern Hospital. It's a pleasure to talk with you, and we can go to the next slide. Here are the learning objectives. One, I want you to appreciate the impact of polypharmacy. Two, explain the interactions of geriatric syndromes in polypharmacy. Three, review side effects of common medications in PM&R. Four, describe deep prescribing strategies. Five, discuss effective QI efforts in PM&R. And six, utilize distinctive principles of PM&R to promote appropriate prescribing. You can go to the next slide. So just a review of what I've called core themes in geriatrics and geriatric rehabilitation. To a significant extent, the recognition of polypharmacy emerges from the medical specialty of geriatric medicine concurrent with the recognition of a need for different approaches for specific populations. Geriatrics and rehabilitation share common origins as healthcare specialties which embrace a whole person orientation for a, quote, at risk, unquote, population for which a traditional medical model was inadequate. We know the story of PM&R well with its foundational roots in the care of injured soldiers in the early to mid 20th century. A parallel movement emerged in the 1930s in the United Kingdom for the care of the frail elderly and was dubbed geriatric medicine. The shared philosophical tenets between the two fields are uncanny. A patient centered approach which utilizes an interdisciplinary team to provide interventions to optimize function and quality of life along with a practical emphasis on function in the patient. The remarkable woman on the right is Marjorie Warren. She was an amazing woman who pioneered some of the key components of both geriatric medicine and frankly, rehabilitation medicine. As a young attending, she assumed medical directorship of a hospital, now get this, I believe the title was Hospital of the Incurables. In the mid 1930s, there was approximately 500 residents in this hospital. Kind of single handedly, she developed, cajoled, and came up with a whole notions of functional evaluation, interdisciplinary teams, mobilization techniques, and after a couple of years, I believe she had reduced the inpatient census to a little over 100. So her name is Marjorie Warren, kind of an unsung hero of geriatric rehabilitation. So as you look at this slide, I've identified some common themes between the two areas of geriatrics and rehabilitation, including an emphasis on function and quality of life, the importance of mobilization and exercise, where small gains can have significant impact, the use of an interdisciplinary or interprofessional teams, and of course, an underlying notion particularly relevant in geriatrics, but also geriatric medicine in general medical rehab and that is do no harm, whether it's use of medication, excessive test, excessive bed rest, or over-reliance on the medical model. You can go to the next slide. So here, as I've started this talk out on polypharmacy, I've spent a few minutes just reviewing some of the principles of geriatrics and geriatric medicine as it relates to PM&R. On the one side, you see the biology of aging. These components should be familiar to everyone watching this, but as we, as a quick reminder, body composition changes as we get older, the increased amount of adipose tissues increase, so pharmacokinetics and pharmacodynamics change, blood flow to the GI tract, including liver, kidney, and cardiovascular systems, all of these show some changes. There's changes in the central nervous system along with sensitivity of the pain modulation, connective tissues as we're familiar with the cross linkages, and the increased incidence of contractures and things like that, and muscle composition with the relative atrophy of type one muscles. Geriatric syndrome, I think, is a pillar component of the revolution that geriatrics brought to contemporary modern medicine, and that is there are these entities which are constellation of syndromes, multifactorial, which, with an interaction, which have significant impact on a quality of life. They include falls, delirium, malnutrition, urinary incontinence, pressure ulcers, and functional decline. There tends to be a synergy with these syndromes where if you have one, you're likely to have more than one, and the specific risk factors are similar, and one of the most common ones is, of course, polypharmacy. So we can go to the next slide. So polypharmacy has multiple definitions. The one that I've chosen is one that I've seen reference to, and that is a large number of medications. Some people like the use of five or more medications. People who study the field like the term PIM or PIP, PIN standing for Potentially Inappropriate Medications, while PIP stands for Potentially Inappropriate Prescribing. So I guess you're talking about the person doing it or the item received. Polypharmacy is also associated with the duplication of prescribed agents and can also be the underuse of medications contrary to instructions. Next slide. So polypharmacy and Potentially Inappropriate Medications, clear statistical associations with each of these items listed, malnutrition, falls, hip fractures, urinary incontinence, loss of mobility, hospitalization rates, and resource utilization and cost. The numbers I have down there that polypharmacy has been estimated to be $76.7 billion in the ambulatory setting and $20 billion in hospitalization is probably understated because when I look back at the reference, the reference is well over 15 years old, so that's probably increased. Still, it's a lot of money. Next slide. We all, clinicians are all familiar with the notion of the prescribing cascade. So the prescribing cascade is something like where there's a symptom, a well-meaning clinician will prescribe a medication. There's a side effect to that medication for which another medication intervention is given and then another side effect. So here, one of my former residents put together two prescribing cascades. You can see the one on the left, familiar particularly in neurorehab, agitation, treatment with antipsychotic medications, tardive dyskinesia, and so on. And then on the right, one with pain. Let's say you choose a treatment of an NSAID, associated hypertension, the need for antihypertensive medications and the different side effects that those can cause. I think we're all also familiar with the use of opioids and other pain medications where you can get constipation, CNS effects, and others. The whole notion here is prescribing cascades and trying to prevent those. Next slide. So I think that there is, no one disagrees, I think, with being concerned about polypharmacy, but it is a challenge to follow through an appropriate prescribing. One of the first tenets is, of course, medications have side effects, and surprise, surprise, more medications equal more side effects. What's also challenging for those of us in contemporary healthcare and in medical rehabilitation is that there's an increasing number, sometimes a very highly effective medications, and these are frequently initiated by other medical specialists. And so how you go about participating in that demands some cross-collaboration, not familiarity with other areas, and talking to your colleagues. And I think perhaps the thing we spend little time talking on, but it's a profound impact and is many non-medication strategies can be challenging to actually implement. So go on to the next. So appropriate prescribing and PM&R, so I'm going to spend a few minutes talking about some of the particular challenges in physical medicine and rehabilitation. I would submit that one of the challenges is that a lot of the conditions that we prescribe medications for and other interventions have either imprecise outcomes or the outcomes are frequently interpreted as imprecise. So items such as pain, whether it be musculoskeletal and neuropathic, neurostimulants, spasticity in tone, the evaluation of exactly what the outcome is can be challenging. I would also submit we have some unique opportunities in physical medicine and rehabilitation to participate in this national challenge of reducing polypharmacy. We are arguably the medical specialty that's most truly team-based. We truly believe in patient engagement. We involve the perspectives of other healthcare professionals who spend different time and different amounts of time with patients. And that can be a knowledge base to help guide the physician in terms of what is the impact of a particularly prescribed medication. Many times I will spend anywhere from five to 15 minutes with a patient in the morning. The collective rehab staff that I work with will have spent 18 hours. And so I do listen to the rehab staff on whether or not there's changes during the day. What is the impact of this tone-reducing agent? What are the physical examples of manifestations of pain or affect changes? And that can be quite illustrative in helping you to fine-tune your medication. And likely also I think one of the things we also share with geriatric medicine is we really believe in patient engagement. We try to empower our patients. So for instance, the spinal cord injury patient can learn to self-direct care. And I think the principle extends beyond. And so as rehab professionals, we can engage the patients to ask questions about the medicines they're on. One of the statements that I personally have found effective is I look a patient in the eye and I say, I think you're on too many medications. And nine times out of 10, I get a head nodding. And then I start talking about the potential side effects of medications. And that can help change the discussion. There was a time really early in my training where patients felt like they weren't getting adequate care if they didn't get a pill for the reason that they came in to see you. And I think you want to sort of flip that by proposing the idea that there really aren't too many medications and that we should think about deprescribing. Can we go to the next slide? So here are some opportunities in PMNR. I mentioned the team-based, that we can have a broad input on a medication response. And these are in diverse areas, behavior and participation, level of alertness, orthostasis and incontinence. So two areas I particularly want to emphasize is orthostasis and incontinence. I find the vast majority of the time, the most useful vital signs that I get are from active therapists because they tell me what the cardiovascular response is to exercise. Frequently orthostasis is poorly recognized and we can address it if we know about it. Likewise, if it's more severe orthostasis, like a neurogenic orthostasis, how you utilize and titrate medications like midrogen can be important. Likewise, in treating incontinence, of course, it's much more than medications. In the rehab setting, incontinence involves a person with physical disabilities. They may have neurocognitive perceptual disabilities. And the effective interventions almost always involve a behavioral component. Yes, we have to treat the UTI. Yes, if it's an overactive bladder, an agent may be useful. If it's an atonic bladder, an agent may be useful or some therapies. But also there are non-medication issues that can be quite helpful anywhere from modified Kegel exercises to transfer training to the use of pictures to communicate incontinence need along with scheduled toileting. I think as a team-based specialty, we also have educational opportunities with our patients. I have found that rehab professionals from activities therapists to OT to speech to physical therapists, if you bring them on board on why you're proposing a certain alternative to a medication, let's say with regards to pain or tone, they'll readily get on board. And they'll readily help you to sort of sell that intervention and also help you to interpret the medication responses. And then finally, it's not just what the physician says, but it's what the whole team says in terms of what the goals of the intervention are, what are the goals, whether it be pain, tone, anxiety. And what we're trying to foster, of course, is the buy-in to the appropriate dosing of medications and also to any alternatives which may exist. So we can go on to the next slide. I'm just going to very briefly run through this. At the end of the slide series, I have a couple of slides on references. Each of these slides, the concepts are expanded much more in detail in the references. But it's important for us as rehab professionals to have a good grasp on what the common side effects of particularly of the medicines that we are apt to institute. So that includes neurostimulants, methylphenidate, modafinil, dinosacryl, bromoceptin, and amantadine. You can go on to the next slide. Antipsychotics and antidepressants, all of these have known side effects, and we need to be quite familiar with those. These should be familiar to everyone watching this because we use these both in approved ways and also off labor. Next. Antispasmodics, practically all of them cause some level of sedation, weakness, GI symptoms, confusion, a change of seizure threshold. They can have problems with abrupt withdrawal, can affect, some of them affect LFTs, and have anticholinergic properties. When I'm evaluating the dosing of my antispasmodics, I include not only the patient, but what the therapist are observing, and how it's manifested at different times of the day and in different activities and different body levels. Next slide. So I want to introduce a notion, and I love the term medication debridement. It sort of gets everyone excited about it. But it is something that I find mostly in the geriatric literature. It's been particularly championed by nursing home physicians, but it's equally relevant in PMNR, and that is asking some real simple questions. Is the medication relevant, and is a valid indication still exist? What are the potential benefits? Do the potential benefits outweigh any known possible adverse reactions? Adverse symptoms or signs may be related to the drug. That's one of the first things I always try to teach residents. When a new symptom appears, let's first look at the medication list before we start adding to the problem. Do safer alternatives exist? Can the dose be reduced without significant risk? And then, of course, if one or two is yes, then continue the drug. If three, four, or five, consider alternatives. Next slide. There is a host of explicit and implicit criteria that are outpublished. Again, these are referenced in the literature at the end of this. Probably the best known is the Beers Criteria, and we're going to be going through that in some detail. But there's a lot of explicit and implicit criteria. They can be useful guideposts. Many of these relate to sort of classic internal medicine sorts of issues. And so they are relevant to our concerns. But sometimes the medications are ones that we may not have initially instituted, though we're tasked with managing them. Next slide. So I'm speaking briefly about the Beers Criteria. Beers is named for Dr. Beers. Dr. Friedman may remember when the first one was published. I think it was the early 1990s. This has now been updated four or five times. It's available either for free or acute reduced cost at the American Geriatrics Society. They come in different pocket-held pamphlets. And this happens to be, if you do look it up, the different tables, potentially inappropriate medications that give you inappropriate medications, particular drug disease syndromes, the drugs to use with caution, the drug-drug interactions to avoid, and, of course, the importance of kidney function. In addition, probably the single most common thread of medication side effects and inappropriate side effects are anticholinergic medications. And I think Table 9 of the Beers also goes through specifically anticholinergic medications and those in which you either want to avoid or you're conscious of what you're doing, you're conscious of what you're using when you prescribe a certain medication. Next slide. So here is just some suggested drugs and drug types to avoid and to limit in the tool. My residents adapted this from the Beers criteria and the STOP tool. You can see those, many of those have various uses within PMNR. Next slide. Then I'm going to spend a couple of slides, you know, I've been doing this long enough now where I can be really proud of what some of my residents have done. And several of my residents over the years have taken on aspects of polypharmacy or rational prescribing as research projects, and they have done just stellar jobs. I'm just going to highlight two of them and say that this can be a meaningful resident quality improvement project. It's not that difficult to get pharmacists and hospital administration behind it. And it's something that everyone sort of will buy into. So I'm, this one here was presented here at Emory in 2015, and it's called the Rational Prescribing Initiative. And it was head up by Amika Shukalan and his colleagues. Next. So what Misha did is that with the help of his wife, who's a actuarial, he developed what's called the medication assessment tool. And he developed this taking existing criteria. At the time, he used the 2012 Beers criteria. He used the anticholinergic burden list, and then he used medications that had been identified in that New England Journal article as associated with medication-related hospitalizations. And then we used a, we collected that data in everyone. We can go to the next slide. And the actual intervention included weekly polypharmacy rounds on all patients 65 and older who had been admitted to Emory Rehab Hospital. And the participants in these rounds included me, the clinical pharmacist, one of the residents, and one of the residents who was on service at that time. And then at the same time, the items which had been highlighted on this medication assessment tool, including the total anticholinergic burden, the total number of medications, and some of the other sort of high risk were identified. So it was basically, the intervention was this weekly rounds. And then we'll go to the next slide. And here you see, I've skipped over some, but here you see the outcomes of the intervention, and particularly the total number of medications showed a modest reduction, but not statistically significant. What's particularly important is that potentially inappropriate medications at discharge clearly showed a clinically and statistically significant reduction. And there was very close to a statistically significant reduction in the anticholinergic burden scale, as you can see. So we'll go on to the next. So here I'm going to brag on another quality improvement project, again, that was initiated here. This was initiated by Kunj Patel and his colleagues, and it was an effort to reduce opioid treatment in the rehab setting. So please go on. So the intervention included sort of two educational aspects of it. One, which I'm not really going over in too much detail, was simply an education for residents and attendings on how to minimize or sort of downscale different opioids, and that was really medication driven. And then the other one was to really highlight the non-opioid options to consider. In the chat room, someone commented quite appropriately that, of course, acupuncture should be considered as part of a pain management strategy. So what Kunj and his colleagues did was really took this to heart. He had meetings with physical therapists, with nurses, with the neuropsychologists here, trying to get everyone on board of utilizing, in appropriate cases, these different techniques, whether it was mindfulness, TENS units, various other physical modalities that are used along with lower toxicity medications. So go on to the next slide. Well, Kunj did quite well in this project, and he did quite so well that he was even featured on a nationally broadcast radio television show with it. But here you see the percentage of patients with a morphine equivalent dose greater than 50. That went down from 23% to 12% during the intervention time. So we can go on. I do want to give a special thanks to, these are five of my former trainees. They all contributed to significant chapters or peer review articles. I failed to put in Kunj Patel or Chris Williamson here simply because they weren't on this slide, but they were equally. So it is a fun and stimulating area that residents can can bite into. And then if you just flip to the next couple of slides, I wanted to show you I have added several useful references here. These are ones that are readily available. You can keep going. And the geriatrics at your fingertip, I actually just got a notice from the HES. They're offering a sale on this. It comes out annually. I think you can get a digital version almost for free, and you get the printed version. It's not that much. It's updated yearly. And then there's the website to the BEERS criteria for potentially inappropriate medications. And then here's, I'm very proud of different peer review articles that have come out of some of the work we've done. And I refer you to those also. So I believe that, let me see if there's any specific questions. I do like the, I certainly buy into the safer alternatives, and I would like to just add that you can make this a team activity. You can really get your inpatient team behind the topic. So I believe I'll turn it back over to Dr. Praduri, who will introduce our last speaker. Thank you, Dr. Strasser. That's such a useful and practical topic that we all need on a day-to-day basis. It's not just read one time and put it aside. Either inpatient, outpatient, or in the nursing home setting, polypharmacy has been a big problem in the older adults. And as we talked about geriatric symptoms and geriatric syndromes, polypharmacy leads to those. That's very practical in terms of reducing the polypharmacy to avoid geriatric symptoms. It's a fabulous lecture, and we thank you very much. And I'll introduce you now to Dr. Patrick Corbain. He's from the VA hospital in Mathur, California. He's going to enlighten us about the recent definitions of sarcopenia and how do we identify, how do we diagnose, and how do we treat the symptom of sarcopenia in older adults. Without much of a delay, I would like to introduce Dr. Corbain. Dr. Corbain, are you there? Yep, I'm here. Everybody can hear me, hopefully? Yes, we can. Thank you. Okay. All right, so I'm going to... Hopefully this works. Okay. So yes, thanks to Drs. Friedman and Strasser for those prior talks. Those were great. Thanks for everybody who's attending today. That's great to have such a good turnout. So as mentioned, I'm going to talk about sarcopenia and really what I think that we as physiatrists can really have a big role in the diagnosis and treatment of this condition. So just quickly, I don't have any financial disclosures and just because I do work for the VA, just nothing I'm saying, of course, is the view of the VA or the government. So as noted, I'm going to go over the origins and the evolution of sarcopenia because it has evolved, frankly, as a condition since first coined about 30 years ago. Talk about the diagnostic evaluation of patients at risk for this condition and focus on our role as physiatrists, Joel, and then talk about treatment interventions for sarcopenia. So first off, so this is the term sarcopenia, and I'll even kind of look at that, but this is from an article back in 1989 by Dr. Rosenberg, and as you'll note that I've underlined at the bottom there, he suggested a couple of terms. Sarcopenia is the one that is hung on, but he was focused, if you look at the top, that interested in the loss of lean body mass with aging, and so that has really the evolution of the term more than 30 years ago. And as I think everybody, I suspect, on listening in understands that both the U.S. and the world is graying, so to speak, with time. So this graph shows from 1900 up to what's projected in 2050. The blue is absolute numbers, the blue bars, the yellow, I'm sorry, the red line is proportion, and you see that 2020 is around 15% of the population is over the age of 65. By 2050, that's expected to be in the mid 20% range. So sarcopenia has for many years been defined as noted there in the first item, so age-related loss of muscle mass and function, and the focus on mass, as noted in that article back in the late 80s, was somewhat, the thought was initially, well, this will be analogous to osteoporosis and bone. If we can, we'll focus on mass, and that will be, will sort of be a done deal as far as using osteoporosis as an analogous problem, and we can emulate what's been done for that, and we'll have the same success, so to speak, with muscle, and it's not been that simple, for sure. So the second diagnosis you see here is from a European working group, and we'll talk about their work, a consensus statement they came up with late 18, early 19, and they described it as a progressive generalized skeletal muscle disorder. So even, and I'll show, this group had a consensus statement in 2010 and came up with an update, and that's changed, so things are still evolving, really, with sarcopenia. It's been enigmatic would be a word to say to kind of pin it down to a discrete condition, but the consequences of sarcopenia are pretty well recognized, but it does, as you might expect, impact function and impairing mobility and ADL abilities, loss of independence. These patients with sarcopenia are more likely to be admitted to a nursing home, more likely to have fall fractures, and also increases in mortality. So again, back to the definition, as I alluded to, it was initially mass, muscle mass focus, now it's focused more on function. If you were not aware, there is an ICD code that came out in 2016, I believe, which is noted there, so you can use or diagnose somebody with sarcopenia, you know, getting down to the diagnosis, though a little bit challenging, but there is an ICD-10 code. I'm not sure how much it's used. I did look, I think it was last year, at how frequently it was used in our, this is basically, we covered northern California from San Francisco up to the Oregon border, and it wasn't used once in the entire year, so I suspect it's not used a whole lot. So the diagnostic criteria have really been based on expert opinion. There's been some recent studies where they've tried to use large data sets to come up with more actual patient or population data, but it's still largely expert opinion, and the prevalence varies quite a bit. It's really been limited to individuals over the age of 65, which you I think probably can appreciate as a arbitrary cutoff point, but that is the age that's been used, and it varies by the different diagnostic criteria from anywhere from two to five percent up into the twenty, thirty percent range, and as you might also anticipate, individuals that are older, so in their 80s, 90s, there's a higher prevalence in that age range as opposed to in the latter 60s. In clinical practice, or the consequences, so to speak, it seems like there's a pretty poor recognition by non-geriatricians, so primary care providers who are probably providing the bulk of care to older adults. There's not a lot of individuals who necessarily recognize or are familiar with sarcopenia, and also I think there's an issue of relevance, so we know sarcopenia can be a bad thing, but where does it fit in the relevance of other medical conditions, so somebody who's got coronary disease or diabetes, probably most primary care would say, well, those are more relevant conditions, so I think that's been an issue as far as gaining attraction with the use of the term sarcopenia and getting people to recognize it. So as with virtually all geriatric conditions, this is a multifactorial problem of pathophysiology for sarcopenia, so there's neurologic, and I've just listed out the different items that might be causing or contributing to sarcopenia that have been proposed to be. Hormonal factors, there's intrinsic muscle factors, and then there's other conditions that have been alluded to, so inactivity, low protein intake, the generalized inflammatory state of many older adults, so all these things are felt to be contributing factors to sarcopenia, which of course makes the challenge, though, for instance, treating it. And just the graphic there is just to show you that we're really talking about if you take the all older adults and we're categorizing muscle mass and function, it should be a bell-shaped curve, and we're really talking about that small segment of the population down on the left hand. Portion of the curve. So the key variables in the diagnosis are, as I mentioned, muscle mass, that could either be, I'll show you some examples, absolute values or scaled typically to height, but some to BMI, muscle strength, grip strength being the most common, but there's also chair rise is used for lower extremity strength assessment, and then physical performance with gait speed being the one that's been most commonly used. And this table shows you these are five different definitions for sarcopenia, so if you look on the left hand side there, the European working group, there's an international working group, there's a society of sarcopenia, etc. So these, you know, there's not one group that's focused on this. There's a lot of them. If you look at the parameters for mass, strength, and physical performance, they're all, you know, similar. They all have a metric for the definition, except if you look at the very last one, the FNIH one, which was in fact based on some data from actual studies. You see physical performance is not applicable because they used a cutoff, a gait speed cutoff of 0.8 meters per second, which you see in the one above as well. So there's, again, there's not even full consensus within all the groups that are looking at sarcopenia as to what are the specific criteria we should be using. We'll talk about that in a little bit as well. So if you move on, so this European working group is probably, I would say, the most recognized set of criteria that are out there. And as I alluded to previously, they came out with some initial criteria in 2010, and then in late 2018, publication date was actually 2019, they came out with some updated operational definition. And you see in the table there, low muscle strength is an indication of probable sarcopenia. So that's the first criteria you're looking at. And then if you have low muscle quality, low physical performance, just with number two, the muscle, that means you got a diagnosis of sarcopenia. If you have low physical performance, then it's considered severe. Now if you contrast this with their 2010 criteria, you see that low muscle mass was the criterion that they were using as the probable sarcopenia. And then if you had strength and physical performance deficits, then it's confirmatory. The other thing that came up in this 2018 statement was they defined primary versus secondary. And this is controversial because sarcopenia, again, is meant to be an age-related phenomenon. They're talking about primary being an aging phenomenon and then a secondary sarcopenia, which would be, say, muscle wasting due to a specific disease or injury. Frankly, it seems to kind of confuse the issue because there already are criteria out there for muscle wasting conditions. And they also defined or added subcategories of acute or chronic. So using six months, again, arbitrarily as a cutoff. And that may be a little confusing as well. So this is an aging phenomenon. How can it really be acute? And the other relevant thing, again, back to the criterion, is they advocated here that strength is really the most relevant criterion because it has a more direct impact on function. I'm going to show you in a little bit, but as you maybe are not surprised to hear, muscle mass in and of itself has a very poor correlation with function. These are the cut points that they came up with, and you can see there's grip strength, chair stand for men. There's just a grip strength for women. There's low muscle quantity, and this is appendicular skeletal muscle, either the absolute value or corrected for height, so the values for men and women. And then gait speed, short physical performance battery, the timed up and go, and the 400-meter walk. There's a number of different options for physical performance measures. And this is the algorithm that they proposed. So they indicated that you should find cases using either clinical suspicion or a questionnaire called the SARCF, which we're going to go into in a minute. And if that's positive, then check someone's muscle strength, whether that's through a grip strength measure or a chair stand test. And if that's low, then you could go on to do a measure of muscle quality or quantity using either DEXA, bioelectric impedance, CT, MRI, so a fair number of options there. And if you have all of those, then the SARCF is confirmed. And if it's, again, low, then it would be in the severe category for this guidance. So I'm going to talk about focus, and we're going to run a little bit talking about the SARCF itself, because I think this is where our physicians can have a real impact on evaluation of these patients. Just to go on. So the second part of the algorithm, we finished up here, the last slide. So if muscle quantity is low, they've got sarcopenia, and then you can confirm the severity with one of those physical performance measures. And if that's low, then you have severe sarcopenia. And just to give you a little insight into, again, another group in there that just came out earlier this year. So this is the Sarcopenia Definition and Outcomes Consortium, which is based out of the U.S., the group in the U.S. primarily. And as you see there, their goal to develop evidence-based definition cut points for mean mass and strength to identify persons with sarcopenia. And they came up with 13 summary statement points. I'm showing you the last two, because they're the most relevant, and I'm going to talk about one other. And that is that low grip strength and low gait speed are independent predictors of adverse health outcomes. And so both of those should be included in the definition of sarcopenia. So the next thing they said was that lean mass by DEXA measurements. So DEXA, you know, doesn't specifically measure muscle. It measures lean tissue. And so they said that that particular lean mass measured by DEXA is not a good predictor of adverse health-related outcomes. So it should not be used in the definition of sarcopenia. They're not saying that muscle mass shouldn't be used, but just DEXA itself as a measure. People may well know, so bioelectric impedance is actually probably more as well. So you're kind of left a little bit with CT or MRI. Some people mentioned ultrasound. There's a creatine dilution technique that is coming around, and there's certainly some interest in that. So moving on to the back to the European Working Group evaluation. So what you see there is the SARC-F. That's the screening questionnaire for sarcopenia. And so there's questions related to strength, assistance in walking, rising from a chair, climbing stairs, and falls. And as you look at all the questions, it says how much difficulty for those first four. So it's a subjective assessment by the patient. And then falls is, frankly, somewhat subjective as well. How many times have you fallen? There's unfortunately many people don't remember or they don't want to remember how many falls they've had. And then if you look at the scoring, each one is scored from zero to two. So you can have a total score of 10. And the score greater than or equal to four is relevant. That would be then, according to the algorithm, would be a reason to then go on and check someone's strength. So for me, as a physiatrist, and hopefully others, you look at this and somebody says, if they respond in the affirmative to these questions, particularly difficulty lifting things or walking or transferring or stairs, the question that comes to mind to me is, well, why? Is it pain? What exactly is the problem that you're unable to do these things? And I think we would just go, oh, you've got this. Okay, well, let's just assume it's sarcopenia that you've got. So I think the things that would come to mind to me would be things like, okay, you have difficulty walking or doing stairs or rising from a chair. Is that because you have hip or knee arthritis, for instance? Do you have back pain? Walking difficulty, is that because you have cardiac problems or COPD? And then neurologic things. And this is not necessarily going to be something you're going to necessarily get from this questionnaire. Patients with neurogenic glycogen, of course, have difficulty ambulating distances. People with peripheral neuropathy, they're going to fall more. They're going to probably have difficulty walking because they don't feel safe. So I think for me, as a physiatrist, this is where I think we can really take a step in and go, okay, so let's try and sort out why you're having trouble instead of immediately going, oh, well, your score is over four. Okay, ergo, let's just go check your strength because we're going to get on the track that you have sarcopenia as the primary cause for your difficulties. The other thing to consider is that these are not mutually exclusive, right? It's certainly very conceivable. Somebody has sarcopenia and they've also got knee osteoarthritis or hip osteoarthritis or any one of these other conditions. And they may have a greater degree of one than the other. But the treatment, if somebody's got bad knee arthritis, there's treatments for that. So I think, again, from my perspective, I think from a PNR perspective, this is where, just even starting here, we can have a significant impact on older adults' life and their function and mobility. So as far as treatment, resistance exercise is the primary treatment. And that's really, I think, all we hope to expect. It should be functionally specific with a focus on the lower extremities, the hip and knee extensors in particular, more so than the upper extremities. Well, that, of course, can be tailored to the individual. So for instance, somebody who has difficulty lifting a carton of milk, that would be weak, frankly, and you can certainly increase their upper extremity strength. The other item that is mentioned or proposed is to optimize nutrition, protein in particular. So other things like creatine and hydroxymethylbutyrate or over-the-counter supplements, not great evidence to have dramatic impact. In fact, when there's not great evidence, that protein supplementation is going to be a miracle cure. But nonetheless, with a focus on resistance training and optimizing protein, it should have a benefit. And of course, there's food options. There's also supplements, which you want to be careful with if somebody's trying to optimize their protein intake with supplements that they're not then decreasing their total caloric intake to compensate for that supplement. People may consider medications, testosterone being one that's readily available. And this is a study, the testosterone trials was a group of studies in older men with low testosterone, and they got treated for a year. And this was published back in 2018. And this is a summary. And I've underlined in green there, not a dramatic impact on these older men on their function. Improved their walking distance a little bit, but it was not a dramatic impact. You can see it had some other benefits as far as improving hemoglobin and improving their bone strength. It didn't look specifically for adverse outcomes or power to that, but it didn't look like there was adverse problems with it. But it really, frankly, didn't have a big impact on function. So not really something that's a go-to. There also are some other medication, lots of, you can see here, I've just listed a number of the drugs that have been proposed to be used for sarcopenia. I was fortunate to work on the one on the left, with the top being the Grumav. I worked for Nomartis for a bit. None of these are FDA approved. There have been, Lilly tried to do one looking at a study looking at older adults who were falling, and unfortunately it didn't pan out. As we know, so if you're looking at falling again, back to that differential, lots of reasons that people fall. Being weak is certainly one reason, and may well be a contributing factor. But if all you're doing is increasing muscle mass, not really doing any therapy or strength training, you may not have the benefit. Unfortunately, that's what they found. They did increase muscle mass, but it had no impact on fall prevention. So take-home points regarding sarcopenia. So it is a relatively a common cause of functional decline and adverse outcomes in older adults. Diagnostic evaluation is the three key items that I've mentioned there. And I think, again, we as physiatrists can really look at that physical function and have a good significant impact, I think, on somebody's quality of life to determine why exactly they have poor function, whether it's mobility or just overall function. And then the treatment, I mean, frankly, and this has been, Dr. Friedman mentioned this, I mean, these are things that as far as physical activity, physical exercise, all older adults should be doing those things. So resistance exercise, functionally oriented resistance exercise, every older adult should really be doing this to prevent functional decline. And then lastly, the nutrition, if you're going to remember one thing, I would just say, think of optimizing protein intake. And that is it. So thanks much for your attention, appreciate it. I think all of us are happy to answer any questions. Thank you. I think we can open up for questions for everyone, for Dr. Friedman, Dr. Strasser, and Dr. Corbin. Any questions for them? And I have a couple of questions, I'll reserve them for last. All right, let me start the conversation with my questions. Now, Dr. Corbin mentioned that it's age-related sarcopenia. And then Dr. Friedman has mentioned that to provide our patients with education and promote healthy aging, we need to promote good nutrition and good physical activity, right? So with those two combined, we know that age-related sarcopenia and polypharmacy added to that is going to result in decreased mobility, decreased function, and then adverse events. How do we prevent that to promote healthy aging? I mean, some of them are inherent, some of them are added by us. Those are not going to go away, right? We are still going to age and get sarcopenia. And we are going to have polypharmacy as long as the specialists exist, and then each patient have more than three physicians. Average, I think, is about four physicians. And the polypharmacy is impacting on the activity and also in the well-being of the patients. How do we promote healthy aging in spite of these things that are in the back of us? Dr. Friedman? Sure. So, as you say, there are processes that occur as part of aging. And, you know, we can't change those fundamental processes, but I think we can alter their trajectory. And as a result, we can change the functional impact of them. So I think it's sort of a complex answer to your question. I mean, the first thing is really to focus on, now putting on my lifestyle medicine physician hat, you know, there are six pillars of lifestyle medicine, which are the mnemonic is feet, forks, fingers, sleep, stress, love. So it's feet, so physical activity, forks, what you put in your mouth, fingers, avoiding toxins like smoking and excess alcohol and other drugs, and then sleep, stress, and social connectedness. And the suggestion is that if we were able to optimize all of those things, we could prevent a large part of our chronic disease, which in turn could impact functional status. So, you know, just the idea of sarcopenia as one of those outcomes. I mean, if we were able to really optimize our physical activity as kids and as young adults and middle-aged adults, by the time we get to old age, we have more reserve. A lot of geriatrics has to do with preserving homeostasis and, you know, sort of avoiding getting that sort of off kilter. So that the less of a decline, once we get to that peak function that happens, sort of, well, it depends, you know, the kind of things that you're measuring, but like I mentioned about bone mass, which you reach peak bone mass at age 30, it's, you can sort of slow down the trajectory through focusing on those sort of lifestyle pillars. And then as I think, you know, Dr. Strasser had talked about very eloquently in his talk about multidisciplinary teams, really kind of working together to try to look at this issue from various perspectives to try to slow down the process. Thank you. I think there are modifiable and non-modifiable factors. I think polypharmacy is definitely a modifiable, you know, and preventable. And as we talked about sarcopenia resulting in fractures and, you know, narcotic abuse in older adults definitely results. And I have seen at least five cases where patients are given for hip fractures narcotics, and they come back in two months with the other hip being broken. So these are modifiable things that I think we're not emphasizing enough to the physicians as well as for the patients. And then again, given the importance of patients to be responsible for their own medications, I think makes a big sense. And again, if you have cognitive decline, it's very hard, right? Yeah. So getting back to the idea of systems and how do we create systems that really help to optimize this? And I really do like the 4M framework because it starts with, you know, what does the patient want? What does their family want? And sort of keeping that front and center, and then thinking about things like medication use and polypharmacy, how people are moving and their mentation. Yeah. Sorry to interject. There were a couple of questions I did want to address. One was about power versus strength. The question was, is anybody looking at this force over distance? And yes, there's been a tremendous amount of interest in that. Lots of studies looking at power, including Jonathan Bean, who's a PM&R physician up in Boston affiliated with Harvard with the VA there. Power is of great interest and found to be much more relevant than strength itself. The problem has become, well, how do you measure power? People talk about, you know, chair rises are somewhat the measure of power, but there's a ceiling effect. And if we're going to try and identify this early on, you're not going to find it in pretty young, older people with just a chair rise test. People have looked at jumping, for instance, but then you become into the, you know, the whole problem becomes a power assessment. How do you evaluate that in the clinic? You have patients jump in a credit where you could, but there's potentially, you know, a safety issue. So people have, I think, been reluctant to do that. So yeah, lots of interest, lots of, there was a greater measure of power more effectively in a clinical setting. People would be, I think, be all over that. It would be a great interest. The other question was about distinguishing sarcopenia from atrophy of disuse. So as I hopefully alluded to, you got the sense of inactivity. I mean, people probably heard that. I mean, I heard this rather though, that it's only around 15, 18% perhaps of the population and probably less as you get older are doing the minimum, minimum required amounts of physical activity. So 30 minutes, five days a week doing any resistance exercise. We have a very limited percentage of the population doing even the minimum amount of physical activity. So that's how the component of, so most older adults, probably physical inactivity is probably a contributing factor. But if we're talking about disuse atrophy, of course, that varies very much from individual to individual. And then all the other factors that contribute to sarcopenia. We know we lose out the motor neurons as we get older. They're typically type two, type two fibers. So all these hormonal changes, inflammatory processes, those are going on to varying degrees. So it's very difficult to even determine frankly, what is causing sarcopenia. That's been a big challenge. All these things are felt to be contributing factors. Again, if you're going to treatments, the focus of course has been on, well, let's just add more muscle. Well, if you just add more muscle and the person's not using it, it's not going to be necessarily effective. In fact, it might just be extra weight, frankly, for them to move around. And most people in their 80s, I mean, their VO2 max, their cardiopulmonary function, they're almost freaking it out doing ADL activities, just walking at 0.8 meters per second, one meter per second, two, two and a half miles an hour. That's a major physical challenge for a lot of people. So, yeah, no, you can't distinguish really between, well, you can't, between sarcopenia and disuse. Right. Thank you, Dr. Corbin. In the interest of time, I think we need to wrap up our session. Dr. Friedman, Dr. Strasser, Dr. Corbin, thank you for the great elaborated presentations. And we really thank you for joining us at the Academy and also representing the geriatric community. I extend my thanks on behalf of all the members as well. And I think these are very healthy conversations and we can continue through our community platform. Thank you very much. And you have less than a week. Great job. Thank you. Thank you. Thank you.

PM&R

healthy aging

chronic diseases

physical function

age-friendly health systems

diet

exercise

polypharmacy

falls

imprecise outcomes

non-medication strategies

sarcopenia

multidisciplinary approach