What happens as athletes age? The physiological changes are important to note, so that training, recovery and overal healthcare can adapt to maximize the athlete's performance year after year. Dr. David Carfagno offers a unique insider's perspective, as a practitioner of sports medicine, internal medicine and a competitive athlete.

1. The Aging Adult
Athlete
David Carfagno,DO,CAQSM
Scottsdale Sports Medicine
Warthog PCSM 1998

2. CDC Healthy People
2020
• By 2030, number of Americans aged 65
and older is estimated to be 71.5 million
• Goal 150 minutes/week of moderate
intensity or 75 minutes/week of vigorous
exercise or equivalent combination.
• Target 48% of population (Currently
43.5% in 2008)
• Target 35.9% of over 65 yo population
(32.6% in 2008)
National Health Interview Survey, CDC, NCHS, 2008

3. Continuum of Your Life
T = 10 ng/dl T = 7000 ng/dl
• Cardiac, Pulmonary, GI, Renal, Endo, Vitamins, Minerals,
Mitochondrial, Derm
CPA of Physiological Metrics

4. Balanced Approach
Anabolic Catabolic
Training, RT/Aerobic
Protein
Hydration
Rest
Testosterone
HGH?
Supplementation
Over/No Training
Inadequate Protein
Dehydration
No rest/stress
Low Testosterone
Vitamin Deficiency

5. My Life: Sports Med,
Adrenaline

6. My Life: Internal Med,
Pensive
Men’s Health Package ~375 patients
Women’s Health Package ~75
Executive Physical ~5 corporations
Metabolic Weight Loss Program ~10 q 3 mos
Metabolic Weight Gain Program ~ 5-10 off season
Team Physician Package ~25
Fatigued Athlete Package *new
Osteoarthritis Package *new

7. AGING PHYSIOLOGY
As we age, our bodies will lose….
Hormones, lean mass, vitamins, strength,
mitochondria….
• Strax, T., et al. Physiologic Effects of Aging. Physical Medicine and Rehabilitation
Board Review. Cuccurullo S, editor. New York: Demos Medical Publishing; 2004.

8. 3
Scottsdale Sports
Medicine Institute
•Men’s & Women’s Health Program
•Systems-based evaluation (Attention to prevention of
disease and enhancement of the system)
•CardioPulmonary, GI, Renal, Endocrine, Neuro,
Ortho, Derm, Cellular Fxn
•Focus on the static as well as dynamic physiology
(fueling/exercise)
3

9. Effects of Aging
Strax, T., et al. Physiologic Effects of Aging. Physical Medicine and Rehabilitation Board Review. Cuccurullo S, editor. New York:
Demos Medical Publishing; 2004.

10. Effects of Aging, cont
• Decr↓ # of motor units
• ↑ body fat (15% increase at 30, 30%
increase at 80)
• Bone density ↓ 0.5% each year after 25
• GH ↓ (155-puberty to 25 @ 55yrs)
Hersch, E., and Merriam, G. Growth Hormone Releasing Hormone and Growth Hormone Secretagogues in Normal Aging- Fountain of
Youth or Pool of Tantalus? Clin Interv Aging. 2008 March; 3(1): 121-129
Strax, T., et al. Physiologic Effects of Aging. Physical Medicine and Rehabilitation Board Review. Cuccurullo S, editor. New York:
Demos Medical Publishing; 2004.

11. Iron
Thiamine,
Riboflavin, B-6
Antioxidants
IL-1, IL-6
Lactate
IGF-1
Athletes
Aging Adult
Vitamin D
Testosterone
GH
Vitamin B-12
VO2 max
Mitochondrial Fxn
LDL
Hcys

12. Aging Adult Athlete
Iron
Thiamine,
Riboflavin, B-6
Vitamin D
Vitamin B-12
Antioxidants
Testosterone
GH
VO2 max
IL-1, IL-6
Lactate
IGF-1
Homocysteine
LDL, TGs

13. Effects of Aging
Sarcopenia:
• Cross sectional studies of subjects >75 y.o.,
estimate annual muscle mass loss of 0.8-0.9% in
men and 0.64-0.70% in women (Miller, et al, 2012)
• Exercise is essential for rebuilding strength and
decreasing risk of falls, CV events and bone loss
in elderly pts (Allen, et al, 2011)
Mitchell,W.K., Williams, J., Atherton, P., Larvin, M., Lund, J., and Narici, M. (2012) Sarcopenia, dynapenia, and the impact of
advancing age on human skeletal muscle size and strength; a quantitative review. Front.Physiol. 3:260.
Allen J, Morelli V. Aging and exercise. Clin Geriatr Med. 2011 Nov;27(4):661-71.

14. VO2 Max
• Maximal oxygen uptake. Evaluation of
Cardiopulmonary Fitness
• Measured ml O2/kg/min

15. Normative Values

16. VO2 Decrease w/
Aging
• Sedentary: non-linear loss starting in
20’s/30’s
• Active: non-linear loss upon ceasing
activity
• 70’s: Lose up to 22%/yr, non-linear
regardless of activity
• Baseline 6-10% decline per decade
regardless of activity level
Hawkins, S., and Wiswell, R. Rate and Mechanism of MaximalOxygen Consumption Decline with Aging:
Implications for Exercise Training. Sports Med. 2003; 33(12):877-88

17. Mech of Max O2
Consumption Decline w/
Aging
• HR max ↓ 3-5% (regardless of exercise
or sex) *major role
• Max CO reduced in athletic older adults
• Decreased LBM (up to 35% decline in
VO2)
Hawkins, S., and Wiswell, R. Rate and Mechanism of MaximalOxygen Consumption Decline with Aging:
Implications for Exercise Training. Sports Med. 2003; 33(12):877-88

18. Mitochondrial Dysfxn
Mitochondria Function:
o oxidative metabolism creating energy
from fat, cho, protein
o Involved with free radical formation
o Thought to be a cause of aging. Cellular
death, apoptosis
o “Inflamaging”-Telomere Shortening
Melov S., Tarnopolsky MA. Resistance exercise reverses aging in Human skeletal muscle. PloS ONE, 2007.

19. Mitochondrial Dysfxn
• Endurance exercise partly normalized
age-related mitochondrial dysfunction
• Found to increase skeletal muscle-
mitochondrial electron transport chain
activity in older men/women
Lanza, I., et al. Endurance Exercise as a Countermeasure for Aging. Diabetes. November 2008. 57(11):2933-2942.
Menshikova, E., et al. Effects of Exercise on Mitochondrial Content and Function in Aging Human Skeletal Muscle. J
Gerontol A Biol Sci Med Sci. 2006, June; 61(6): 534-540

20. Hormonal “Burnout”
• Pic of pituitary and hormones and low T,
E, thyroid and HGH
• FSH, LH: Estrogen,Testosterone (free &
total)
• TSH,T4/T3
• Cortisol
• DHEA-S
• IGF-1
• Female: Above + Estradiol, Progesterone, Prolactin
.
Bhasin, S., et al. Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrine Society
Clinical Practice Guideline. The Journal of Clinical Endocrinology and Metabolism. June 2010, Vol 95(6):2536-
2559

21. Testosterone
ScreeningA.M. Total & free testosterone
•Tx levels: Total <300, Free <5
• Check the whole hypothalamic-pituitary-end organ axis,
determine primary vs secondary failure
• Baltimore Longitudinal Questionairre
•Araujo, A., et al. Prevalence of Symptomatic Androgen Deficiency in Men. The Journal of Clinical Endocrinology
& Metabolism 92(11):4241– 4247
•Bhasin, S. et al.. Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrine
Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism. June 2010. Vol 95(6):
2536-2559.

22. Not all libido &
muscles...
Low T and CV Disease
• Low Testosterone found to increase
mortality from cardiovascular disease
• Assoc w/ insulin resistance, metabolic
syndrome, and DMII
• Tx improves lipid profile, abd obesity,
insulin sensitivity
Hyde, Z., et al. Low Free Testosterone Predicts Mortality from Cardiovascular disease but Not Other Causes:
The Health in Men Study. The Journal of Clinical Endocrinology & Metabolism. January 2012; 97: 1179-1189.

23. Benefits of Testosterone
Replacement
•Body composition – increased lean body
mass (+2.7 kg) and increased fat loss (-2.0
kg) according to ACE systematic review
•Muscle strength – improvement in grip
strength than placebo, but no conclusive
data on LE muscle mass
•QoL – physical function quality of life
questionnaires demonstrated significant
improvement after testosterone replacement
Bhasin, S. Cunningham, GR. Hayes, FJ. Matsumoto, AM. Snyder, PJ. Swerdloff, RS. Montori, VM. Testosterone
Therapy in Adult Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline.
Journal of Clinical Endocrinology & Metabolism. June 2010. Vol 95(6): 2536-2559.

24. Androstenedione/Dehydroepiandrostero
ne
• No increase testosterone
levels, strength, or
performance in clinical studies.
• Norandrostenediol/19-
norandrostenedione show no
increase in young men
• May increase levels up to
35% in men
age 30-60 years & to lesser
degree in women

25. Adverse Effects
Males
Testicular Atrophy (↓ LH), Decreased spermatogenesis (↓ LH),
Gynecomastia (↑ estrogens), Balding (↑ DHT), Dyslipidemia,
BPH, Worsening of sleep apnea
Females
Acne, Hirsuitism, Aggressive Behavior, Alopecia

26. Human Growth Hormone
“anti-aging”
OTC HGH
IGF-1
Well-being
Boron&Boulpaep, Medical Physiology, 2nd ed, 2008
Juhn, MS. Sports Medicine, 2003
Thickening
IGF-1

27. Human Growth Hormone
• Meta-analysis of 44 studies in the literature on HGH and
athletes
• No beneficial in strength or exercise capacity in trained
athletes.
• Side effects: soft tissue edema, arthralgias, carpal tunnel,
insulin resistance
• .Weaknesses: physically fit (mean vo2 51 ml/kg/min, mean
age 27 males, 36 ug/kg dosage, avg duration 20 days.
Systematic Review: The Effects of Growth Hormone on Athletic
Performance
Hau Liu, et al.
Ann Intern Med. 2008;148(10):747-758. doi:10.7326

28. Wellness Screening of
Aging Athlete
• Beyond the standard PCP guidelines?
• USTASK Force guidelines, are they
enough to preserve health? Improve?
• Identify the aging athlete

29. SSMI MEN’S AND
WOMEN’S HEALTH
PROGRAM
Initial Medical Evaluation- 4 hoursInitial Medical Evaluation- 4 hours
History & PhysicalHistory & Physical
Labs may include one or more of the following-Labs may include one or more of the following-
Routine Wellness labs (CBC, CMP, Lipids,Routine Wellness labs (CBC, CMP, Lipids,
PSA)PSA)
Hormonal evaluation (Testosterone, Estradiol,Hormonal evaluation (Testosterone, Estradiol,
Prolactin, FSH, LH, AM Cortisol, DHEA, IGF-1)Prolactin, FSH, LH, AM Cortisol, DHEA, IGF-1)
Vitamin testing (30+ micronutrients), GeneticVitamin testing (30+ micronutrients), Genetic
MetricsMetrics
Resting Metabolic Rate,Resting Metabolic Rate, Fatigued athlete
screening…training and fueling diary

30. Annual Medical Evaluation- 60 minsAnnual Medical Evaluation- 60 mins
VO2 submax testing, DEXA Scan BodyVO2 submax testing, DEXA Scan Body
Composition Testing (GXT/PFT whenComposition Testing (GXT/PFT when
indicated)indicated)
Lab and Test reviewLab and Test review
Rx for Testosterone based on EndocrineRx for Testosterone based on Endocrine
Society’s Guidelines (see attached)Society’s Guidelines (see attached)
Rx dispensed based on individualRx dispensed based on individual
preference:preference:
Intramuscular InjectableIntramuscular Injectable
Topical Cream or GelTopical Cream or Gel

31. Quarterly lab reviews- 30 minsQuarterly lab reviews- 30 mins
Labs may include one or more of theLabs may include one or more of the
followingfollowing
Testosterone, Estradiol, Vitamin TestingTestosterone, Estradiol, Vitamin Testing
**Certain tests/supplements not covered by**Certain tests/supplements not covered by
most insurance plansmost insurance plans

32. Management:Exercise Implications for
VO2 Decline
• VO2 max significantly greater in active
indiv
• CV system adaptable to training at any
age
• Strength training to increase LBM-
related drop in VO2
Hawkins, S., and Wiswell, R. Rate and Mechanism of MaximalOxygen Consumption Decline with Aging:
Implications for Exercise Training. Sports Med. 2003; 33(12):877-88

33. • Prescribing Exercise (Elite vs. WW)
• Progression, periodization, adaptation,
taper, rest, recovery
• iMETT (portable metabolic testing)
• VO2, AT
• Optimal HR-zones
• Indices to reflect stages (labs, Vit,
iMETT improvements)
• ACSM recs: 150min mod aerobic
activ/wk

34. Management:Mitochondrial Dysfxn
o Low Intensity days as we age
o Remove eccentric loading to reduce
muscle damage, i.e. 3x/week circuit RT,
recovery enhanced.
o Endurax-Combo of Endurance and
Resistance. Starting? Initiate with RT to
train mitochondria then add Endurance
Melov S., Tarnopolsky MA. Resistance exercise reverses aging in Human skeletal muscle. PloS ONE, 2007.

35. Testosterone Tx – ACE
Guidelines
Injectables: Testosterone
Enanthate vs. Cypionate
• 150-200 mg IM q 14 days
or 75-100 mg IM q 7 days
Topicals: Typically 1-2%
• Fortesta, Androgel, Axiron
• 5-10 g of T gel delivering 50-100
mg T q 24 hrs

36. Vitamin testing
VITAMINS
Vitamin A
Vitamin B1
Vitamin B2
Vitamin B3
Vitamin B6
Vitamin B12
Biotin
Folate
Pantothenate
Vitamin C
Vitamin D
Vitamin K
AMINO ACIDS
Asparagine
Glutamine
Serine
MINERALS
Calcium
Magnesium
Manganese
Zinc
Copper
ANTIOXIDANT
Alpha Lipoic Acid
Coenzyme Q10
Cysteine
Glutathione
Selenium
Vitamin E
FATTY ACIDS
Oleic Acid
SPECTROX™
for Total
Antioxidant Function
IMMUNIDEX™
Immune Response Score
CARBOHYDRATE
METABOLISM
Chromium
Fructose Sensitivity
Glucose-Insulin
Metabolism
METABOLITES
Choline
Inositol
Carnitine
• Replete with Fuel based (Healthy Food Shopping)
• Symptomatic, add supplements.
• Recheck 3 months

37. Continuum of Your Life
Where do you want your levels to be?
T = 10 ng/dl T = 7000 ng/dl

38. Provocative Dialogue
• “Treating Everyone Fairly doesn’t mean treating everyone the
same”
• What is normal
• What is true measure of performance enhancement?
• What role do unique bodies play in this issue?
• 18 yo athlete with testosterone level of 1500 vs 35 yo
athlete, same sport with 300?
• What about our non-professional athletes and active
population? How far do you go with treatment in a solid
clinical, evidence based setting?

39. In my opinion
We have the population
And the 360 approach.
We need research
On
the
Athletes we manage,
who want to
push the upper limits of
normal
on existing replacement
Testosterone…