Physical Resilience to Health Stressors: Can we Predict...

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Physical Resilience to Health Stressors: Can we Predict and

Promote Recovery?

Heather Whitson, MD, MHSAssociate Professor of Medicine

Deputy Director, Duke Aging Center

All Rights Reserved, Duke Medicine 2007

Objectives

• Define emerging concept of “physical resilience” and its relevance to clinical medicine

• Describe how the “Pillars of Aging” may be related to biological mechanisms that support physical resilience

• List clinical test paradigms that may predict resilience

• Describe intervention strategies to promote resilience

Disclosures: None

PATIENT PRESENTATION


Mrs Thomas

76 year old woman with obesity, hypertension, arthritis, and history of depression.

She is primary caregiver for her husband who has advanced Parkinson’s Disease.

In February 2016, she was diagnosed with Colon Cancer.

She underwent open colectomy and was foundto have Stage I disease.


Mr Lee75 year old man with hypertension and history of heart disease status post CABG three years ago. Completed cardiac rehab.

He is a retired attorney. He is married with two adult daughters in the area. He golfs and plays tennis several times a week, though admits his “game isn’t what it used to be.”

In February 2016, he was diagnosed with Colon Cancer.

He underwent lap colectomy (converted to open) and was diagnosed with Stage III disease, necessitating chemotherapy.


After the Stressor: Mrs. Thomas

0102030405060708090

100

Pre-Stress Discharge 1 mo 2 mo 3 mo

% A

ge

Co

rrec

ted

No

rms

ADL Function 6 min walk LE Functional Scale

Su

rger

y

2


After the Stressor: Mr. Lee

0102030405060708090

100

% A

ge

Mat

ched

No

rms

ADL Gait Speed TUG

Su

rger

y

Do

se r

edu

ced

20%

Sta

rts

Ch

emo


Resilience: A Key Ingredient of Health, Across the Lifespan

DEFINITIONS AND CONCEPTS OF PHYSICAL RESILIENCE


All Rights Reserved, Duke Medicine 2007 All Rights Reserved, Duke Medicine 2007

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Working Definitions

Physical Resilience = ability to avoid or recover from functional decline following acute or chronic health stressors

Resiliencies = resilience within an organ system to a particular stressor

Reserve = potential capacity of a cell, tissue, or organ system to function beyond its basal level in response to demands (stressors)


Phenotyping Resilience after the stressor


What determines recovery trajectories after health stressors?


Geroscience Initiative – The Pillars of Aging

From Kennedy et al. Cell 159; 2014

7 intertwined and potentially modifiable pathways affected by age

Hypothesis:Favorable biology in these pathways maycut across organ systems to support resilience at the whole-person level.


Working Conceptual Model

Physical Resilience

Outcomes/Resiliency Phenotypes

Res

erve

Psy

chol

ogy

So

cial

Env

ironm

ent

Pillars of Aging

Stressor


Resilience is related to the concept of Frailty

Robust

Frail

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Resilience is About What Happens After the Stressor

The spectrum from robust to frail may reflect an individual’s degree of physical reserve (potential capacity)

Resilience reflects the actualization of that potential.


Contrasting Resilience and Frailty:What if potential for recovery is mediated by different mechanisms than the mechanisms that contribute to frailty?

The Metaphor of the Castle Under Siege


Geroscience – The Pillars of Aging

From Kennedy et al. Cell 159; 2014

Clinical Tests that may indicate level of resilience to some future stressor


Biomarkers that indicate….?

• Efficient energy management

• Adaptive response to Stress:• Heat shock

proteins• Autophagy

• Well-regulated immune response

• Repair mechanisms


Predicting Resilience – Provocative Tests

• Stimulus-Response

• Examples in use:– Response to vaccine

– Glucose tolerance test

– Gait lab challenge

– Dual tasking tests

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Predicting Resilience – Dynamic physiologic output

Lipsitz et al. JAMA 1992All Rights Reserved, Duke Medicine 2007

Postural Sway Complexity and Falls

Force Platform

Multiple, interconnected inputs = complex output

Zhou et al. Sci Reports 2017

Resilience Promoting Interventions


Example of Resilience Intervention: STRIDE

Supervised Walking Program for Hospitalized Veterans


Example of Resilience Intervention: STRIDE

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1

2

3

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Length of stay, median (days)

STRIDE, n=92

Usual Care, n=35

↓ Length of Stay (average of 1 day)↑ Discharge to Home (92% vs. 73%, p =0.007)Annual cost-savings to VA based on bed

days of care: $958,348

Hastings SN et al. J Am Geriatr Soc. 2014 Nov;62(11):2180-4.


Ultimate Resilience-Promoting Interventions:Healthy Diet and Exercise

Kitzman DW et al. JAMA. 2016;315(1):36-46

RCT of Obese Seniors with HFpEF

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Promoting Resilience : The Platform Metaphor Conclusions


Ursus WehrliAll Rights Reserved, Duke Medicine 2007

Clinical Take Homes

• Recognize the heterogeneity in resilience to stressors in older adults

• Consider using gait speed and provocative tests to predict resilience

– Biomarkers, complexity tests in the future?

• Consider prehabilitation, encourage healthy diet and exercise for seniors in anticipation of stressors

– Pharmacologic resilience –enhancers in the future?


Thank you to many collaborators

Physical Resilience to Health Stressors: Can we Predict...

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