Sports medicine

July 2016

FocusSports medicine

Clinical considerations for the ageing athlete

Volume 45, No.7, July 2016 Pages 478-483

Shane P Brun

Background

Many older people are participating in high-intensity activities and sports. Clinicians need to be aware of the physiology of ageing relative to the demands of higher intensity sport. Patient expectations, comorbidities and medication use are important aspects to consider when advising the ageing athlete appropriately.

Objective/s

This article highlights the important aspects of maintaining a physically active lifestyle. For the ageing athlete, there are differing needs as well as risks associated with higher intensity physical activity. This article will outline how to cater for these needs and minimise the potential risks.

Discussion

Appreciating the importance of physical activity as a major public health intervention is essential for all clinicians. Ensuring that the ageing athlete is able to participate safely and optimally in higher intensity physical activity is an increasing expectation.

It is apparent that Australians are becoming less physically active.1 As overall life expectancy is increasing,2 proportionally, we are seeing more people in the older age groups participating in competitive and higher intensity sports.3 With the increasing aged and aged-athlete population comes a greater demand for health services able to cater to the needs of the more active older population.

Although the process of ageing is dependent on many extrinsic and intrinsic variables, for the purpose of this paper, the American College of Sports Medicine and American Heart Association definition of 65 years of age or older, or 50–64 years of age with clinically significant chronic conditions and/or functional limitations4 will be used. ‘Athlete’ will be defined as a person who commits to their sport or activity at least five times weekly – and especially those who compete in organised events – with the activity level achieved being more than what is recommended for general health benefits, and resulting in the heart beating significantly faster and accompanied by shortness of breath that makes talking difficult between deep breaths.5 This group of people are often referred to as ‘master’ or ‘veteran athletes’.

This paper will focus on the ageing athlete, as defined above, whose physical demands are significantly greater than their non-athlete, age-matched peers. For this identified group, discussion will focus on the following:

  • benefits of physical activity
  • potential risks associated with physical activity and how to minimise these risks
  • nutritional and hydration needs
  • use of certain medications and their impact on physical activity, safety and wellbeing.

The benefits of physical activity

Before one is able to understand and appreciate the needs and demands of the ageing athlete, it is first important to recognise the significant benefits afforded at a population level by becoming or remaining physically active.

Box 1. Benefits of physical activity21,22
  • Decreased risk for the development and progression of:
    • dementia
    • frank diabetes mellitus
    • depression
    • anxiety
    • fatigue
  • 23% reduction in risk of cardiac death
  • Up to 50% reduction in the risk of ischaemic heart disease

The overall health benefits of physical activity are irrefutable.6–13 As physical activity increases so too does overall function, and the rate of physical and cognitive decline decreases.14–17 The holistic benefits of 30 minutes of daily physical activity make it the most effective and compelling public health intervention we have available.6–11,18–20 It is therefore the responsibility of the clinician to ensure that the prescription for physical activity be provided at each patient encounter. Box 1 lists some of the proven benefits of physical activity. It is important to recognise that proportionally, the musculoskeletal and cardiovascular benefits of physical activity for the older person are much greater than those for a younger person.21,22

The potential risks of physical activity for the ageing athlete and how to decrease these risks

Although the ageing competitive athlete may be somewhat more prone to injury than their non-athletic peers,21 the overall health benefits far outweigh these potential risks.6–9,11,18–20 The ageing athlete is no more prone to injuries than younger athletes who train and compete at a comparable level.23–28 There must always be an individual and informed approach when determining how much and which type of physical activity, and what intensity is appropriate, especially with the ageing athlete. For the majority of older people, there are very few absolute contraindications to physical activity. The intensity of the exercise is relative and multifactorial. The risk of injury increases with obesity, volume of exercise and participation in vigorous exercise such as competitive sports,29 although this is a common trend throughout all ages and not specific to the ageing athlete.

Performing a focused history and a system-specific focused physical examination are essential and, with respect to the ageing athlete, should always include the cardiovascular, respiratory and musculoskeletal systems. Appropriate investigations will be guided by the focused history and focused examination. As part of a thorough assessment and screening intervention, as a guide, it may be helpful to review The Royal Australian College of General Practitioners’ (RACGP) Guidelines for preventive activities in general practice (the Red book),30 particularly sections 5, 7 and 8. There are certain physical features that should preclude the ageing athlete from high-intensity sports;18,31 these mandate further investigation and appropriate referral. Box 2 lists some of these physical features.

Once all appropriate information has been obtained, the clinician is now in a better position to risk-stratify the patient and determine if there is a need for further investigations. It may be appropriate to consider referral to a sports physiotherapist, sports doctor/physician or sports dietitian if any uncertainty or concerns are present. Recommended guidelines are available to help minimise the risks associated with commencing an exercise program in previously sedentary older people,22 although discussion of these is outside the scope of this paper.

Box 2. Features likely to preclude athletes from
high-intensity sport18,31
  • Left ventricular ejection fraction <50%
  • Evidence of exercise-induced myocardial ischemia
  • Exercise-induced ventricular arrhythmia
  • Exercise-induced systolic hypotension

The more common and potentially more serious risks for the ageing athlete remaining highly active in their chosen sports are threefold:

  • an ischaemic cardiac event
  • dehydration, electrolyte imbalance and heat-related illness
  • musculoskeletal injury.

The risk of an acute ischaemic cardiac event

A major concern among clinicians regarding the ageing athlete is the risk of a fatal cardiac event while exercising. In the majority of cases, the risk of myocardial infarction associated with exercise is very unlikely;32 as an example, the risk while jogging is 1 in 396,000 person-hours of activity.33 The causes of sudden death in athletes are essentially the same as those in non-athletes.33

Box 3. Potential ECG changes in high performance athletes
  • Abnormal repolarisation pattern
  • Increased R or S wave voltage
  • Apparent left ventricular hypertrophy
  • Diffusely distributed and deeply inverted T waves
  • Supraventricular rhythms
  • Complex ventricular dysrhythmias
  • Profound bradyarrhythmias
  • Ventricular ectopic beats

If there is any clinical concern, further assessment and investigation must always be considered. Although certain investigations may be indicated, exercise stress testing may not be the most appropriate first-line screening test. The usefulness and efficacy of routine exercise stress testing before the initiation of a vigorous exercise program in healthy men >45 and women >55 years of age is not well established.29

As previously identified, it is essential to obtain a thorough history, including family history, current and past personal health issues, medication use and patients’ expectations. As part of the full patient assessment, the clinician may consider performing a resting electrocardiogram (ECG). It is important to recognise that up to 40% of athletes have ECG changes that may not necessarily indicate underlying cardiac disease or abnormalities.34,35 It is appropriate to always seek expert cardiology opinion when attempting to interpret an apparently abnormal ECG. Box 3 outlines some of the possible ECG changes in the athletic population.

The risk of dehydration, electrolyte imbalance and heat-related illness and how to decrease 
the risk

Ageing is associated with a reduced sensation of thirst.36 In a hot and dry environment, older athletes produce substantially less sweat than the younger athlete.36 The combination of a decreased sensitivity to thirst and variable sweating patterns place the ageing athlete at potential risk of fluid and electrolyte imbalance as well as heat-related illnesses.37

The ageing athlete should be provided with accurate hydration advice and guidance, as individual needs will vary depending on the activity and environment. The risk of dehydration and fluid and electrolyte imbalance needs to be tempered with the significant risk of hyponatraemia associated with overhydration.38–40 Athletes of all ages, especially the ageing athlete, should be encouraged to determine their individual hydration needs by pre-activity and post-activity body weight,40 which is simple to perform and reliable. Relying on the sensation of thirst or hydrating for the sake of hydrating poses significant risks and the advice and guidance of a sports dietitian may be appropriate.

Musculoskeletal injuries and how to minimise the risk

The ageing athlete’s reaction time and ability to focus attention on a specific task during a stressful situation becomes diminished.21 Subsequently, acute injuries tend to occur in ageing athletes participating in sports or activities that demand high coordination, reaction time and balance capabilities.21 A thorough musculoskeletal history and physical examination, including a GALS (gait, arms, legs and spine) screen,41,42 are mandatory in essentially all cases and will rapidly identify any potential or current problems of the musculoskeletal system.

The most common injuries seen in the older athlete are muscle and joint injuries.21,29,43 Seventy-five per cent of these injuries involve the lower extremities,21,43 with the knee being the most commonly injured body site followed by the foot and ankle.43 The most common mechanism of acute injury in the ageing endurance athlete is a fall or slip.43 Athletes involved in strength or power sports sustain mostly acute sprains.43

The management principles of musculoskeletal injuries in the ageing athlete are no different from those in the younger athlete, although a longer rehabilitation and recovery time may be expected. Early involvement of a sports physiotherapist should always be considered when managing musculoskeletal injuries and associated rehabilitation.

The musculoskeletal system and central nervous system are two of the main systems regulating postural stability. Proprioceptive input from the sole of the foot, sacroiliac joint and cervical spine, as a looped feedback system, are the main postural regulators.44,45 Subsequently focusing on maintaining and improving the accuracy of this feedback loop is a major determinant in reducing the risk of injury.

Balance re-training has been used successfully in an attempt to maintain the integrity and accuracy of balance and postural stability.46–49 Most of the balance re-training program may be undertaken in the athlete’s own time and incorporated into their daily fitness program. Initially, prescription and supervision of a balance re-training program is best undertaken by a skilled clinician, usually a sports physiotherapist or exercise physiologist trained in the technique.

Balance re-training is a graded technique introducing an unstable surface and degree of unpredictability.50–52 The ageing athlete progresses through the three stages of re-training – static, functional and dynamic50 – in a graded and supervised program. This technique may significantly improve strength, balance and coordination, compared with no intervention, or with strength training or resistance training alone.46–49

Nutritional needs

Compared with their younger counterparts, the average ageing athlete requires a lower amount of energy for body-weight maintenance53 as their lean body mass is less. Compared with their non-athlete peers, their energy consumption needs are greater.54

Although the absolute nutritional needs for the ageing athlete do not appear to be significantly different from those of their younger or non-athlete counterpart, there are some aspects that may require refinement. In the majority of cases, dietary supplementation is not indicated and any need for additional nutrients should be achieved solely through the diet. In very rare cases this may not be possible, in which case dietary supplementation may be indicated.55 If supplementation is clinically indicated, it should be an informed and combined decision between the treating clinician, sports dietitian and athlete. The ageing athlete requires higher amounts of protein to maintain their lean body mass.53,56–61 In essentially all cases, this can be achieved by a balanced and appropriately planned diet without the need for supplementation.60,61

Because of the physiology in older people and increased physical demands, the ageing athlete may require an increased dietary intake of vitamin D,62 B group vitamins (especially B663 
and B12),55 vitamin E,64 vitamin C64 and calcium.65 The required levels of these vitamins can be achieved without supplementation. To ensure appropriate dietary intake, the advice of a sports dietitian may be appropriate.

Medications and the ageing athlete

Many older Australians take prescription or over-the-counter medications. In a recent study, 66% of older Australians reported taking five or more medicines and more than 20% reported using 10 or more.66 Many Australians are taking additional medications that their general practitioner (GP) did not prescribe and is not aware they are using.67,68 In combination with drug interaction and medication side effects, the end result may potentially place the ageing athlete at risk of an adverse event.

Of all medicines prescribed for older people, antihypertensive medications and nonsteroidal anti-inflammatory drugs (NSAIDs)are among the most common.66 These two medication groups alone can potentially have a significant adverse impact on athletic performance and increase the risk of adverse outcomes for the ageing athlete. It may be appropriate to discuss the athlete’s current medication use, and potential interactions and risks with a pharmacist. Table 1 outlines some common medications, their impact and potential risks.

The doctor treating athletes participating at a national or international level must recognise the legitimate use of drugs in sport and the potential for drug-testing. Subsequently, although it is the absolute responsibility of all athletes competing at these levels to consult the World Anti-Doping Agency (WADA, www.wada-ama.org) and the Australian Sports Anti-Doping Authority (ASADA, www.asada.gov.au), the prescribing doctor should also consult these organisations when considering drug prescription for athletes.

Table 1. Impact and potential risks of medications for the ageing athlete
Medication classImpact and potential risks
Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers
  • Do not limit maximal oxygen uptake
  • Hypotension and dehydration secondary to vasodilatory effect
Diuretics
  • Fluid and electrolyte imbalance
  • Dehydration
  • Increasing risk for heat-related illness
Beta-blockers
  • Limited exercise capacity at high intensity
  • Hypotension with potential for loss of balance, falls and collapse
Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors
  • Fatal upper gastrointestinal tract bleeding and perforation
  • Fatal and non-fatal cardiovascular events
  • Renal damage
  • Fluid and electrolyte imbalance
Statins
  • Myopathy
  • Elevated creatinine kinase levels

Cardiovascular medications

Many of the cardiovascular medications, especially the antihypertensive group, affect the maintenance of cerebral perfusion during increased physical demand by decreasing cardiac output. As a drug group, their use may result in fluid and electrolyte imbalance, decreased exercise capacity, and risk of balance disturbance and falls.36,37,69,70

Nonsteroidal anti-inflammatory drugs

As NSAIDs may be purchased over the counter, the prevalence of use is likely to be much higher than reported.66 It is possible that the ageing athlete may use this medication more than their non-athlete, age-matched peers. As a drug class, NSAIDs have the potential to pose significant risks.71–74 For this reason, NSAIDs should be prescribed at the lowest effective dose and for the shortest time necessary to control symptoms.

Key points

  • Proportionally, more people in older age groups are participating in high-intensity physical activity.
  • The holistic health and wellbeing benefits associated with increased physical activity are compelling.
  • A focused history and examination should always include the respiratory, cardiovascular and musculoskeletal systems.
  • Investigations are not always indicated but may be considered if further assessment is indicated.
  • Careful and appropriate screening can help identify athletes at potential risk of an adverse cardiac event.
  • Fluid intake must be closely determined and monitored by each individual athlete.
  • Musculoskeletal injuries often result from deteriorating balance, which can be improved and maintained by appropriately prescribed balance re-training.
  • Essentially all nutritional needs can be accommodated by a suitably planned diet, and in most cases, dietary supplementation is neither indicated nor appropriate.
  • Many commonly prescribed and over-the-counter medications have the potential for significant impact on physical performance and safety.

Author

Shane P Brun FFSEM(UK), FASMF, FACRRM, FRACGP, FARGP, MSpMed, GradDipEd, GradDipRMed, MBBS, BAppSc, DCH, Associate Professor, Musculoskeletal and Sports Medicine, James Cook University, Townsville, Qld; Elite Medical Officer, Medical Instructor and Doping Control Officer with the Asian Football Confederation (AFC) and Fédération Internationale de Football Association (FIFA); Visiting Professor, Sports Medicine Unit, University of Malaya, Jalan Universiti, 50603 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia. shane.brun@jcu.edu.au

Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.

References

  1. Bauman A, Armstrong T, Davies J, et al. Trends in physical activity participation and the impact of integrated campaigns among Australian adults, 1997–99. Aust N Z J Public Health 2003;27(1):76–79.
  2. Binns C, Howat P, Jancey J. Health promotion success in Australia and a note of warning. Health Promot J Austr 2014;25(3):157–59.
  3. Menard D, Stanish WD. The aging athlete. Am J Sports Med 1989;17(2):187–96.
  4. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation 2007;116(9):1094–105.
  5. Glasgow RE, Ory MG, Klesges LM, Cifuentes M, Fernald DH, Green LA. Practical and relevant self-report measures of patient health behaviors for primary care research. Ann Fam Med 2005;3(1):73–81.
  6. Netz Y, Wu MJ, Becker BJ, Tenenbaum G. Physical activity and psychological well-being in advanced age: A meta-analysis of intervention studies. Psychol Aging 2005;20(2):272–84.
  7. Paffenbarger RS Jr, Wing AL, Hyde RT. Physical activity as an index of heart attack risk in college alumni. Am J Epidemiol 1978;108(3):161–75.
  8. Sesso HD, Paffenbarger RS Jr, Lee IM. Physical activity and coronary heart disease in men: The Harvard Alumni Health Study. Circulation 2000;102(9):975–80.
  9. Baer HJ, Glynn RJ, Hu FB, et al. Risk factors for mortality in the nurses’ health study: A competing risks analysis. Am J Epidemiol 2011;173(3):319–29.
  10. Hambrecht R, Walther C, Mobius-Winkler S, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: A randomized trial. Circulation 2004;109(11):1371–78.
  11. Stofan JR, DiPietro L, Davis D, Kohl HW 3rd, Blair SN. Physical activity patterns associated with cardiorespiratory fitness and reduced mortality: The Aerobics Center Longitudinal Study. Am J Public Health 1998;88(12):1807–13.
  12. Christmas C, Andersen RA. Exercise and older patients: Guidelines for the clinician. J Am Geriatr Soc 2000;48(3):318–24.
  13. Daley MJ, Spinks WL. Exercise, mobility and aging. Sports Med 2000;29(1):1–12.
  14. Keysor JJ. Does late-life physical activity or exercise prevent or minimize disablement? A critical review of the scientific evidence. Am J Prev Med 2003;25(3 Suppl 2):129–36.
  15. Sun Q, Hu FB, Grodstein F. Invited commentary – Physical activity benefits various aspects of healthy aging: Comment on ‘Physical activity at midlife and health-related quality of life in older men’. Arch Int Med 2010;170(13):1172–73.
  16. Simonsick EM, Guralnik JM, Volpato S, Balfour J, Fried LP. Just get out the door! Importance of walking outside the home for maintaining mobility: Findings from the women’s health and aging study. J of the Am Geriatr Soc 2005;53(2):198–203.
  17. Meisner BA, Dogra S, Logan AJ, Baker J, Weir PL. Do or decline?: Comparing the effects of physical inactivity on biopsychosocial components of successful aging. J Health Psychol 2010;15(5):688–96.
  18. Concannon LG, Grierson MJ, Harrast MA. Exercise in the older adult: From the sedentary elderly to the masters athlete. PM R 2012;4(11):833–39.
  19. Ganse B, Degens H, Drey M, et al. Impact of age, performance and athletic event on injury rates in master athletics – First results from an ongoing prospective study. J Musculoskelet Neuronal Interact 2014;14(2):148–54.
  20. DiPietro L. Physical activity in aging: Changes in patterns and their relationship to health and function. J Gerontol A Biol Sci Med Sci 2001;56 Spec No 2:13–22.
  21. Kallinen M, Markku A. Aging, physical activity and sports injuries. An overview of common sports injuries in the elderly. Sports Med 1995;20(1):41–52.
  22. Gill TM, DiPietro L, Krumholz HM. Role of exercise stress testing and safety monitoring for older persons starting an exercise program. JAMA 2000;284(3):342–49.
  23. Hogan DB, Cape RD. Marathoners over sixty years of age: Results of a survey. J Am Geriatr Soc 1984;32(2):121–23.
  24. Koplan JP, Powell KE, Sikes RK, Shirley RW, Campbell CC. An epidemiologic study of the benefits and risks of running. JAMA 1982;248(23):3118–21.
  25. Lane NE, Bloch DA, Wood PD, Fries JF. Aging, long-distance running, and the development of musculoskeletal disability. A controlled study. Am J Med 1987;82(4):772–80.
  26. Carroll JF, Pollock ML, Graves JE, Leggett SH, Spitler DL, Lowenthal DT. Incidence of injury during moderate- and high-intensity walking training in the elderly. J Gerontol 1992;47(3):M61–66.
  27. Coleman EA, Buchner DM, Cress ME, Chan BK, de Lateur BJ. The relationshipof joint symptoms with exercise performance in older adults. J Am Geriatr Soc 1996;44(1):14–21.
  28. Pollock ML, Carroll JF, Graves JE, et al. Injuries and adherence to walk/jog and resistance training programs in the elderly. Med Sci Sports Exerc 1991;23(10):1194–200.
  29. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation 2003;107(24):3109–16.
  30. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. East Melbourne, Vic: RACGP, 2013. Available at www.racgp.org.au/your-practice/guidelines/redbook [Accessed 23 May 2016].
  31. Maron BJ, Araujo CG, Thompson PD, et al. Recommendations for preparticipation screening and the assessment of cardiovascular disease in masters athletes: An advisory for healthcare professionals from the working groups of the World Heart Federation, the International Federation of Sports Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 2001;103(2):327–34.
  32. Fried LP, Borhani NO, Enright P, et al. The Cardiovascular Health Study: Design and rationale. Ann Epidemiol 1991;1(3):263–76.
  33. Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association. Circulation 1996;94(4):850–56.
  34. Pelliccia A, Di Paolo FM, Maron BJ. The athlete’s heart: Remodeling, electrocardiogram and preparticipation screening. Cardiol Rev 2002;10(2):85–90.
  35. Pelliccia A, Maron BJ, Culasso F, et al. Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000;102(3):278–84.
  36. Kenney WL, Anderson RK. Responses of older and younger women to exercise in dry and humid heat without fluid replacement. Med Sci Sports Exerc 1988;20(2):155–60.
  37. Kenney WL, Munce TA. Invited review: Aging and human temperature regulation. J Applied Physiol 2003;95(6):2598–603.
  38. Rosner MH. Exercise-associated hyponatremia. Phys Sportsmed 2008;36(1):55–61.
  39. Garth AK, Burke LM. What do athletes drink during competitive sporting activities? Sports Med 2013;43(7):539–64.
  40. Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the 3rd International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Br J Sports Med 2015;49(22):1432–46.
  41. Doherty M, Dacre J, Dieppe P, Snaith M. The ‘GALS’ locomotor screen. Ann Rheum Dis 1992;51(10):1165–69.
  42. Beattie KA, Bobba R, Bayoumi I, et al. Validation of the GALS musculoskeletal screening exam for use in primary care: A pilot study. BMC Musculoskelet Disord 2008;9:115.
  43. Kallinen M, Alen M. Sports-related injuries in elderly men still active in sports. Br J Sports Med 1994;28(1):52–55.
  44. Abrahams VC. The physiology of neck muscles; their role in head movement and maintenance of posture. Can J Physiol Pharmacol 1977;55(3):332–38.
  45. Freeman MA, Wyke B. Articular reflexes at the ankle joint: An electromyographic study of normal and abnormal influences of ankle-joint mechanoreceptors upon reflex activity in the leg muscles. Br J Surg 1967;54(12):990–1001.
  46. Eils E, Rosenbaum D. A multi-station proprioceptive exercise program in patients with ankle instability. Med Sci Sports Exerc 2001;33(12):1991–98.
  47. Islam MM, Nasu E, Rogers ME, Koizumi D, Rogers NL, Takeshima N. Effects of combined sensory and muscular training on balance in Japanese older adults. Prev Med 2004;39(6):1148–55.
  48. Tropp H, Odenrick P. Postural control in single-limb stance. J Orthop Res 1988;6(6):833–39.
  49. Freeman MA. Co-ordination exercises in the treatment of functional instability of the foot. Physiotherapy 1965;51(12):393–95.
  50. Rogers ME, Page P, Takeshima N. Balance training for the older athlete. Int J Sports Phys Ther 2013;8(4):517–30.
  51. Takeshima N, Islam MM, Rogers ME, et al. Pattern of age-associated decline of static and dynamic balance in community-dwelling older women. Geriatr Gerontol Int 2014;14(3):556–60.
  52. Sturnieks DL, Menant J, Delbaere K, et al. Force-controlled balance perturbations associated with falls in older people: A prospective cohort study. PloS One 2013;8(8):e70981.
  53. Evans WJ. Exercise, nutrition, and aging. Clin Geriatr Med 1995;11(4):725–34.
  54. Owen OE, Holup JL, D’Alessio DA, et al. A reappraisal of the caloric requirements of men. Am J Clin Nutr 1987;46(6):875–85.
  55. Russell RM, Suter PM. Vitamin requirements of elderly people: An update. Am J Clin Nutr 1993;58(1):4–14.
  56. Evans WJ. Exercise, nutrition and aging. J Nutr 1992;122(3 Suppl):796–801.
  57. Campbell WW. Synergistic use of higher-protein diets or nutritional supplements with resistance training to counter sarcopenia. Nutr Rev 2007;65(9):416–22.
  58. Campbell WW, Barton ML Jr, Cyr-Campbell D, et al. Effects of an omnivorous diet compared with a lactoovovegetarian diet on resistance-training-induced changes in body composition and skeletal muscle in older men. Am J Clin Nutr 1999;70(6):1032–39.
  59. Campbell WW, Joseph LJ, Davey SL, Cyr-Campbell D, Anderson RA, Evans WJ. Effects of resistance training and chromium picolinate on body composition and skeletal muscle in older men. J Appl Physiol 1999;86(1):29–39.
  60. Campbell WW, Leidy HJ. Dietary protein and resistance training effects on muscle and body composition in older persons. J Am Coll Nutr 2007;26(6):696–703S.
  61. Haub MD, Wells AM, Tarnopolsky MA, Campbell WW. Effect of protein source on resistive-training-induced changes in body composition and muscle size in older men. Am J Clin Nutr 2002;76(3):511–17.
  62. Krall EA, Sahyoun N, Tannenbaum S, Dallal GE, Dawson-Hughes B. Effect of vitamin D intake on seasonal variations in parathyroid hormone secretion in postmenopausal women. N Engl J Med 1989;321(26):1777–83.
  63. Ribaya-Mercado JD, Russell RM, Sahyoun N, Morrow FD, Gershoff SN. Vitamin B-6 requirements of elderly men and women. J Nutr 1991;121(7):1062–74.
  64. Blumberg J. Nutrient requirements of the healthy elderly – Should there be specific RDAs? Nutr Rev 1994;52(8 Pt 2):S 15–18.
  65. Kendrick ZV, Nelson-Steen S, Scafidi K. Exercise, aging, and nutrition. South Med J 1994;87(5):S 50–60.
  66. Morgan TK, Williamson M, Pirotta M, Stewart K, Myers SP, Barnes J. A national census of medicines use: A 24-hour snapshot of Australians aged 50 years and older. Med J Aust 2012;196(1):50–53.
  67. Lowthian JA, Diug BO, Evans SM, et al. Who is responsible for the care of patients treated with warfarin therapy? Med J Aust 2009;190(12):674–77.
  68. Bell JS, Whitehead P, Aslani P, McLachlan AJ, Chen TF. Drug-related problems in the community setting: Pharmacists’ findings and recommendations for people with mental illnesses. Clin Drug Investig 2006;26(7):415–25.
  69. Callisaya ML, Sharman JE, Close J, Lord SR, Srikanth VK. Greater daily defined dose of antihypertensive medication increases the risk of falls in older people – a population-based study. J Am Geriatr Soc 2014;62(8):1527–33.
  70. Gribbin J, Hubbard R, Gladman JR, Smith C, Lewis S. Risk of falls associated with antihypertensive medication: Population-based case-control study. Age Ageing 2010;39(5):592–97.
  71. McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: A systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase 2. JAMA 2006;296(13):1633–44.
  72. Fosbol EL, Gislason GH, Jacobsen S, et al. Risk of myocardial infarction and death associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) among healthy individuals: A nationwide cohort study. Clin Pharmacol Ther 2009;85(2):190–97.
  73. Gislason GH, Rasmussen JN, Abildstrom SZ, et al. Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Internal Med 2009;169(2):141–49.
  74. Whelton A. Renal and related cardiovascular effects of conventional and COX-2-specific NSAIDs and non-NSAID analgesics. Am J Ther 2000;7(2):63–74.

Correspondence afp@racgp.org.au

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