Chapter 101 Elders in the Wilderness

There is still no cure for the common birthday.

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“The elderly still climb mountains: it’s just that their definition of mountains has changed considerably.”¹⁶ The Gray Eagles prove the point. This organization consists of elders with a passion who venture regularly into the wilderness.¹³ They recognize that they are not champions, but enjoy the fellowship, camaraderie, and adventure of wilderness activities. However, altered physiologic function, unrecognized impairments, or the effects of illness and their various treatments can cause serious health issues among elders. Consequently, in the elder population, health problems and untoward medical events associated with outdoor activities can be found more frequently than in younger, more resilient participants. Prevention of such problems is of utmost importance. Intervention may be critical for relief or can even be lifesaving (see Counseling and Teaching Elders Before Wilderness Ventures: The Gray Eagles, later).

Most extreme performance ventures do not include elders, but there are instances of incredible physical performance from older individuals. Ulrich Inderbinen (Figure 101-1), born in the shadow of the Matterhorn in Zermatt, Switzerland, was a mountain guide who climbed the Matterhorn 370 times, the last time at age 90. He died in 2004 at age 103.⁴⁷ Keizo Miura (1904-2006), a Japanese ski legend in his own time, became the oldest man to climb Mt Kilimanjaro in 1981, skied down Mont Blanc at age 99, and was a dynamo even beyond his 100th birthday.¹⁹

FIGURE 101-1 Ulrich Inderbinen, the world’s oldest mountain guide, died in 2004 at his home in Zermatt, Switzerland, at age 103. He lived his entire life in the shadow of the Matterhorn, which he climbed 370 times, the last time when he was 90 years old.

(From Ulrich Inderbinen, The World’s Oldest Mountain Guide [obituary], The Economist 86, 2004. Courtesy Corbis.)

Data regarding elders come from organizations and government services, such as the National Park Service and some local, county, and state emergency medical services, which maintain and report records of wilderness emergencies. The highly respected Explorers Club and the American Alpine Club report on and can advise on health hazards and their preventive measures. Great Old Broads for Wilderness is a vigorous elder women’s group, which, in its own words, “transformed the image of helpless old ladies to one of power and strength as they unite to protect America’s roadless wild lands.”⁴⁶ Other active organizations, some of which have medical links, can be found on the Internet.

The Aging Process

Aging is a natural consequence of life. It leads to anatomic, biochemical, and physiologic alterations in every organ system (Table 101-1). Common degenerative disorders and diseases include atherosclerotic and cerebrovascular disease; chronic obstructive pulmonary disease; emphysema; diabetes mellitus; arthritis; emotional, mood, and memory disorders (e.g., depression, Alzheimer’s disease); and impaired thermoregulation. Polypharmacy (including excesses in medication intake) is a problem. Accidents due to unsteadiness, falls, forgetfulness, and operating machinery and vehicles take their toll. The cumulative effect of these changes on elders subjected to stressful environments produces a major increase in health risk and health care demand.^4,¹⁵

TABLE 101-1 Age-Related Biologic Changes and Their Functional Consequences

Anatomic changes are organ specific, because organs appear to age independently and not necessarily in parallel fashion. Furthermore, laboratory tests must be carefully interpreted. For example, glomerular filtration rate (GFR) and renal blood flow (RBF) decrease with age, but many elders have normal serum creatinine levels because there is a concomitant loss of muscle mass due to aging and, as a result, lower creatinine production. Physical and physiologic alterations may occur slowly. They may not be apparent for many years, yet result in “silent” functional and anatomic changes.

The degree of loss of function in various physiologic systems can be approximated by using the “1% rule,” which states that “most organ systems lose function at roughly 1% per year after the age of 30 years.”³⁰ Some age-related biologic changes and their resulting functional changes are listed in Table 101-1.

Inasmuch as aging reflects the effects of the passage of time, injuries and illnesses that occur along the path of life may produce cumulative anatomic scars, which, when combined with the degenerative changes of aging, may result in a functionally impaired older adult. The risk may be greatly exaggerated by wilderness ventures. The challenge to health professionals is to determine the extent of that risk and take appropriate action.

Etiology of the Aging Process

Some individuals age faster than others. Lifestyle and genetic predisposition are the most commonly incriminated “causes,” but this does not explain the biologic basis for aging.²⁵ Genetic events may somehow determine longevity. For example, there is an increased risk for development of Alzheimer’s disease in the presence of an allele of apolipoprotein E (ApoE) gene, which encodes a carrier of cholesterol.² Selman and colleagues have proposed that deletion of ribosomal S6 protein kinase 1 (S6K1) leads to an extended life span and resistance to age-related processes in mice.⁴⁴ Nevertheless, support for genetic determination of tissue longevity is scant. Most researchers believe that the processes of aging are multifactorial. Speculative theories suggest that damage to deoxyribonucleic acid (DNA) and proteins occurs from a variety of sources, such as reactive oxygen species, including superoxide, the hydroxyl radical, and hydrogen peroxide. According to Hoeijmakers, damage to DNA has implications both for cancer and acceleration of the aging process.²⁶

Hayflick observed that each body cell undergoes a finite number of divisions, roughly 50, after which the cell dies.²⁵ This number of divisions is known as the “Hayflick limit.” Each cell replication has a span of about 18 months and may be a predictor of individual human longevity. For example, with a cellular life span of 18 months, 50 doublings would result in a human life span of 75 years. Variation in the duration of each doubling has been speculated to be a predictor of length of life.

The Hayflick limit is a function of caps, called telomeres, at each end of the chromosomes. Each cap is a DNA-protein complex, which shortens after each cell division, protected by a cellular enzyme, telomerase. Eventually, after about 50 divisions, the telomeres become too short for further division and the cell dies.

Molecular concomitants of aging include alteration in chromosomal structure, mitochondrial deterioration, DNA cross-linking and single strand breaks, decline in DNA methylation, and loss of telomeric sequencing.

Other theories on the aging process include cellular changes, autoimmune mechanisms, neuroendocrine factors, and even a “biological clock,” but Strehler ⁴⁴ feels that the cause should explain the progressive deleterious and intrinsic changes universal within the species. For example, some animals, usually cold-blooded fish or amphibians, which may grow to an indeterminate size, may also have an indeterminate life span, whereas warm-blooded animals with a limited or fixed size after maturation may die at a more predictable time and at an actuarially determined rate.⁴⁵

Questions concerning the nature and cause of aging include the following:

• Does aging affect everybody? Yes, but with considerable variation.

• Is aging a disease? Are there decrements in or natural losses of function and anatomic content representing “normal aging”? If so, there must be such a thing as “abnormal aging.”

• Is aging genetically programmed as a sequence of events? Evidence suggests that genetic events may influence longevity, especially by modifying various influences, such as cholesterol and blood glucose levels. Three genetic theories include (1) mutations that impair long-term survival, (2) pleiotropic antagonism affecting the genes, and (3) variations in environmental survival hazards among clans.

• Is aging a result of natural selection? Darwin’s laws of natural selection and evolution have been considered, but in the 2 to 3 million years of human existence, there have, until recently, been too few old humans in any generation to provide proof of a selective advantage favoring genetic expressions related to aging.

• Is there a finite number of population doublings of human fibroblasts? As noted earlier, Hayflick suggested that there are 50 doublings of fibroblasts during their life span (the “Hayflick limit”).

• Is an individual responsible for personal longevity? Lifestyle factors—such as lack of exercise, dietary habits, tobacco use, and drug and alcohol use—not only influence anatomic and functional characteristics, but also may have deleterious effects on health and length of life.

In perhaps the clearest summation of these theories, Hayflick suggests that the ultimate effect from the many factors influencing and affecting human life is that we simply exceed our reserve capacity. This lends support to the mountaineering dictum, “Always keep your reserve,” which is particularly appropriate for elders.

Definition of Elders

Classifying Elders by Age and Health

According to the World Health Organization, although there are commonly used definitions of old age, there is no consensus on when a person becomes old.⁴⁹ Barry and Eathorne³ suggested classifying elders as the hale or the frail. This is a delightful play on words but lacks the precision needed for medical decision making. Smith⁴⁰ (as reported by Howley) recommends a classification according to chronologic age: (1) athletic old (younger than 55 years), (2) young old (55 to 75 years of age), and (3) old old (older than 75 years of age). However, this classification focuses only on the chronologic age and fails to recognize nonuniform functional change during the passage of years and residual effects of remote illnesses and injuries.

A more precise and comprehensive classification that consists of three separate components is preferred: (1) chronologic: simple time-based classification of years (e.g., age 55, age 63); (2) pathologic: describing morphologic and anatomic changes associated with disease or degenerative processes; and (3) functional: describing changes in function resulting from impairment.

Functional classification of individuals is based on an idealized bell-shaped distribution curve that places participants in one of five categories labeled alphabetically, as explained later in this chapter: (A) high-performance persons, (B) healthy vigorous persons, (C) healthy deconditioned persons, (D) persons with risk factors, and (E) persons who are manifestly ill. Specific aerobic capacity, defined as maximal physical work capacity (PWCmax), can be derived from graded exercise testing. Other specific functional data can be determined from testing physical modalities in a human performance laboratory, cardiac rehabilitation center, or physical/occupational therapy unit. This classification is useful for matching an individual with various wilderness activities according to physical and environmental demands, described in Matching Individuals With Widerness Physical Activities, later.

As an example of this classification scheme, a patient who is 58 years of age, has coronary artery disease and angina with a stent in place, and who is symptomatic during a graded exercise test at 6 METs would be functionally classified as:

1 Chronologic: 58 years of age

2 Pathologic: stented coronary artery disease

3 Functional: symptomatic (angina) 6-MET maximal physical work capacity

This person is manifestly ill and is considered class E.

Demography of Elders and the Wilderness

A striking increase in longevity during the 20th century has changed the age composition of Western civilization. Life spans have continued to increase in the 21st century. The median age in the United States in the year 1900 was 23 years. It rose to 30 years in 1950, 33 years in 1990, and 36 years in 2000. More important, the population in the United States older than 65 years has been projected to increase from 35 million (12.4%) in the year 2000 to 71 million (19.6%) in 2030.⁶ Octogenarians numbered 9.3 million (3.3%) in 2000 and will reach 19.5 million (5.4%) in 2030.

It is not simply the size and growth of this group of seniors that are responsible for its changing medical needs, but rather the nature of the lifestyle and activities adopted by them. Of the 18 million persons between the ages of 65 and 74 years, most are retirees who have stimulated a surge in vigorous outdoor recreational activities. Many are at medical risk. The largest increases in elders leading up to 1990 occurred in regions in the United States most commonly associated with active outdoor lifestyles.^11,²⁰ Florida led the way in 1995, when 19% of the population exceeded 65 years of age. A consequent increase in medical needs warrants consideration of the nature of illnesses, injuries, and services unique to the older adult.

Lifestyle is considered important as a major factor in longevity. Leaf reported three locations in the world where individuals not only live to ages beyond 100 years, but are expected to do so.³³ These locations are in relatively remote mountainous areas: the Caucasus Mountains in Georgia, the Andes in Ecuador, and the Karakoram range in Pakistan-controlled Kashmir. Speculation suggests that this longevity is due to a combination of factors, including genetic selection and a physically active lifestyle.

In keeping with these data and exposure to various life events, it is helpful to classify wilderness ventures according to demands required by the activity. A useful classification includes (1) extreme-performance ventures, (2) high-performance ventures, (3) recreational activities, and (4) therapeutic activities (Table 101-2). Mechanics for matching individuals according to their functional classification with the demands of the venture are described in Matching Individuals With Widerness Physical Activities, later.

TABLE 101-2 Classification of Wilderness Ventures

Class	General Description	Examples
1	Extreme-performance ventures	High-altitude mountaineering, such as a Mt Everest climb or other Himalayan trekking
2	High-performance ventures	Remote hunting activities, particularly at high altitude or under stresses of heat, dust, or cold Jungle trekking
3	Recreational activities	Trail walking is generally considered recreational, but because of endurance demands and environmental risks, it may present physiologic hazards Other activities that may fit this classification: Alpine hiking National park trail walking Forest-based orienteering
4	Therapeutic activities	For more than a century, physical activity has been recommended for certain individuals with cardiovascular disease and other physical limitations to improve their functional capacity

Why Some Elders Venture Into the Wilderness

Hard work, family and fiscal responsibilities, and delayed gratification are characteristics of Western industrialized cultures. As retirement years approach and leisure time increases, seniors begin to increase their participation in recreational and outdoor activities.

The U.S. National Park System studied the frequency of recreational activities in the National Parks from 1982 to 1983 and found, in order of frequency, the following activities: driving for pleasure, sightseeing, walking for pleasure, picnicking, stream/lake/pool swimming, and motor boating.⁹

A repeat survey, completed by the National Park Service in 1994, found that walking has become the most popular single outdoor activity and now involves over 134 million participants. Walking is especially attractive for an older person because it is healthful, self-paced, and socially rewarding when enjoyed with others. With population increases of persons age 70 and older, predictions indicate that many new trails and walking venues will be needed. The most striking change in activities is the dramatic increase in bird watching, having risen from 21 million in 1982 to 54 million in 1994, an increase of 155%. Growth in participation within other activities includes hiking (94%), backpacking (73%), downhill skiing (59%), and primitive area camping (58%).¹⁰

Nash concluded that the personal reasons for elders to venture into the wilderness are for enjoyment of nature, physical fitness, tension reduction, tranquility and solitude away from noise and crowds, experiences with friends, enhancement of skill and competency, and excitement or even the thrill of risk-taking ³⁶ (Figure 101-2, online). Some ventures, however, such as off-road motorcycling, kayaking, and cross-country skiing, take place in difficult and inaccessible areas under extraordinary environmental circumstances (cold, altitude, rough terrain). If an emergency occurs in such locations and circumstances, search and rescue services or medical intervention may be required.

FIGURE 101-2 President George H. W. Bush lives up to his remark, “Even old guys can still do stuff!,” on his 75th and 80th birthday parachute jumps.

(From Perspectives, Newsweek, June 21, 1999. Courtesy George Bush Presidential Library.)

Physical Activities of Elders in the Wilderness

For elders, the physical and environmental demands of certain activities may be excessive. The physical workload of a wilderness venture depends on its nature and the characteristics of its component parts. For example, is the venture a walk or a climb? What is the nature of the terrain? What is the altitude? What is the ambient temperature? It is prudent for elders to examine plans for prospective wilderness ventures and to select activities consistent with their personal capacity, skill, and tolerance.

Wilderness activities can be classified according to their physical, technical, and environmental characteristics. The skill, judgment, and capacity of all participants, elders included, can be matched with the characteristics of the venture to determine whether individual capacity is adequate for the demands.

Classifying Wilderness Ventures

One classification scheme for wilderness ventures ranges from those that are extremely demanding and risky undertakings to those with minimal physical and environmental requirements (see Table 101-2). Although this classification is very general, it can be helpful in examining prospective participants and matching demands of the wilderness task or activity facing that individual.^12,¹⁴

Physiologic Workload of Wilderness Activities

Workload of wilderness ventures and functional capacity of individuals can be defined with a degree of precision by using measurements of energy demands from indirect calorimetry derived from oxygen consumption techniques. Oxygen consumption may be expressed as , calories (1000 cal = 1 Kcal or 1 C [Cal]) or as metabolic equivalents (METs).

The term MET, considered to be the energy cost of sitting, is defined by convention as 3.5 mL oxygen per kilogram of body weight per minute. Multiples of the MET are used to define the energy cost of various activities. For example, walking 2 miles an hour on a level, smooth surface requires 7 to 9 mL O₂/kg/min or approximately 2 METs; 3 miles an hour requires 10.5 mL O₂/kg/min or 3 METs, and so on. Lists of the energy cost of various activities given in calories or METs are available. Most activities of daily living (ADLs) require an energy expenditure of less than 3 METs. When a task is complex, there may be several levels of energy cost of various components.

Armed with the energy cost of a planned activity, a venture planner can proceed with a comparison of the task requirements and the functional capacity of the participant. The average 40-year-old man in this country can reach a 10-MET activity at the point of exhaustion, the PWCmax. Derived from this is a useful scale of 1 to 10; that is, 1 MET is the energy cost of sitting, increasing to 10 METs as the PWCmax of the average 40-year-old man. Tolerance to physical activity among women, increasing for several decades, is now within 1 to 2 METs of that of men. Well-conditioned athletes can reach a PWCmax of around 13 to 23 METs.

A natural decline in PWCmax occurs with age and results in a loss of roughly 1 MET of PWCmax per decade after 40 years of age. The average maximal functional capacity of a healthy 70-year-old man is approximately 7 METs.

It has been empirically observed that a healthy individual can function at an energy expenditure of about 25% to 40% of personal PWCmax over an 8-hour period of time without being too exhausted to get up the next morning and repeat that level of energy expenditure. A healthy person with a 10-MET PWCmax should be able to handle roughly a 3-MET activity for 8 hours.

These figures are very general approximations only, and the circumstances of each prospective venturer need to be considered individually. Of course, skill and experience with any activity are the best predictors of a safe and successful venture.

Classification of Individuals Considering Wilderness Ventures

Two basic physiologic factors affect the physical relationship between the venture and the participant: (1) the physical workload of the activity and (2) the capacity of the individual to tolerate the physical workload as influenced by the environmental stressors. Physical demands of the venture were classified previously. A similar classification assists in matching the participant with the venture (Table 101-3). The populations presenting to the physician may fit the distribution curve shown in Figure 101-3, where the groups defined in Table 101-3 are graphed. These classifications serve as starting places for more precise recommendations for the individual presenting to the physician for advice concerning physiologic capacity to tolerate the physical demands of a specific adventure.^12,^14,¹⁵

TABLE 101-3 Classification of Participants in Wilderness Ventures

Group	General Description	Examples
A	Demonstrated high-performance individuals	Athletes in training
		Mountaineers continually active and in training
		Workers involved with heavy physical tasks
B	Healthy, vigorous individuals	Athletes
B	Healthy, vigorous individuals	Active hunting guides
C	Healthy deconditioned individuals	Young to middle-aged, healthy business and professional people who are moderately active
D	Individuals with risk factors	Individuals at risk because of age, lifestyle, smoking, excessive alcohol consumption, or factors not under their control. Most elders are in this group
E	Individuals who are manifestly ill	People at any age with chronic illness or physical limitations, such as heart disease, diabetes, or neuromuscular or orthopedic problems

FIGURE 101-3 Classifying prospective participants according to physical characteristics, functional capacity, and experience helps match the candidate with demands of the venture. Here, prospective participants are arranged with an idealized representation of participants divided by standard deviations according to the classifications in Table 101-3.

Matching Individuals With Wilderness Physical Activities

Individuals who plan to participate in wilderness ventures probably have already been through a form of natural selection. For example, a person who aspires to participate in an expedition to Mt Everest will in all likelihood have already participated in a similar activity and will have proved his or her capacity to function at an extreme level of performance. This person would most likely be in participant group A or B. An individual who is healthy but has not recently been involved in vigorous activities and has become “deconditioned” may be in group C. The motivation may be a desire to reaffirm youth or vigor in some form of exciting or hazardous activity. These individuals deserve the scrutiny of alert organizers with, perhaps, an assessment before the venture in order to consider risk factors or occult health problems.

Particular attention should be directed toward any individual at risk of illness or injury (group D), even though manifesting evidence of disease may not be superficially apparent. For example, cardiovascular risk factors, such as smoking, a fat-laden diet, and high blood pressure, may warrant detailed medical examination to determine level of functional capacity considered safe for that individual. An examination may even disclose the presence of diseases, asymptomatic or symptomatic.

Group E includes persons with definite manifestations of illness. Supervised outdoor activities can still be of value in such cases and have even been used as a form of physical therapy and rehabilitation for persons with various illnesses, including cardiovascular disease. Persons in this category should be individualized in their assessment and require a high degree of medical evaluation and supervision.

Physical Conditioning to Prepare Elders for Wilderness Ventures

Elders considering wilderness activities should consider the appropriateness of their participation in a contemplated venture. After a medical and functional examination, the classification may suggest the need for a physical conditioning program to increase individual reserve capacity. An individual can tolerate an energy cost of approximately one-fourth to one-third of his or her maximal physical work capacity over a period of 8 hours. If the demands of a venture exceed predicted tolerance, PWCmax can be enhanced by 15% or more by a 3- to 6-month graduated conditioning program. A conditioning program should begin with a warm-up session that includes flexion and extension exercises, followed by a cardiovascular conditioning component and a cool-down component. The aerobic component should last at least 20 minutes at a level of about 50% of individual PWCmax. Some persons can learn to monitor the pulse rate corresponding to this level of activity as a monitoring technique. Mouth breathing, which usually occurs at about 60% of maximal work capacity, is also a useful body signal for marking the intensity of the activity. As intensity increases, catecholamines increase. Above 70% of maximal work capacity, the catecholamine level may be hazardous for an individual with subtle cardiovascular disease. Consequently, if the subject keeps the intensity of the activity below that requiring mouth breathing, the aerobic activity should be in the range below 60% of the individual maximal capacity, a relatively safe range in healthy individuals. This level of conditioning is helpful and may be reasonably safe for seniors, although not at the level necessary for conditioning competitive athletes. If cardiovascular disease is present, a conditioning program should be individualized and supervised. A structured program is an ideal time for teaching an individual to read his or her personal body signals, a collection of markers for physiologic responses to activity (Box 101-1).

BOX 101-1 Body Signals

Secondary

Gastrointestinal

Abdominal distention (with flatus), high-altitude flatus expulsion (HAFE)

Dry mouth: dehydration

Loss of appetite: altitude or dehydration

Genitourinary

Urinary frequency: altitude (the Hochdiurese [“high-altitude diuresis”] of alpine mountaineers)

The American College of Sports Medicine has developed a position paper on exercise and physical activity for older adults. This should be reviewed by any serious student of the subject.¹ Recommendations include endurance training to help maintain and improve cardiovascular function and strength training to help offset loss of muscle mass. Standards for exercise programs for subjects with cardiovascular disease have been available from the American Heart Association since 1979.¹⁷ Additional benefits from regular exercise include improved bone health, reduction of risk from osteoporosis, improved postural stability, and increased flexibility and range of motion. Psychological benefits include a feeling of well-being, relief of symptoms of depression often associated with older adults, and a general joie de vivre.

Environmental Stresses and Elders

Environmental variables encountered in the great diversity of outdoor wilderness activities may produce significant physiologic stresses. These variables include extremes of heat and cold, high altitude, water immersion, tropical humidity, desert aridity, and ultraviolet exposure. The common denominator in nearly all wilderness ventures is physical activity, often at extreme levels. To compound the complexity of physical activity influenced by environmental stress, the physician may have to care for a senior afflicted with subclinical or manifesting disease. When the physiologic demands from environmental stresses are added to the increased and prevalent degenerative conditions and diseases associated with aging, risk for illness and injury is multiplied. The complete package of age, conditioning, environment, nature of the activity, and experience must be considered when an elder is advised or treated in the wilderness.

Heat

Heat-related illnesses (see Chapters 4, 10, and 11) range from heat edema to life-threatening heat stroke. Tolerance to heat depends on characteristics of the host, including health status, medications, frequency and duration of exposure, history of recent acclimatization, and prevalent environmental factors. Industry has considered levels for permissible exposure limits (PEL), threshold limit values (TLV), and standards for maximal exposure, but there has been no consensus on an exact environmental stress index for heat.

Elders in a hot wilderness setting may have personal host characteristics, in addition to the environment, that further limit tolerance and safety. Weight, fractionated body mass, cardiovascular, renal or pulmonary problems, and the presence of various medications may influence individual response to heat.

Regulation of body heat may be affected by altered function of the thermoregulatory center located in the anterior preoptic hypothalamic nuclei, by deranged skin sensors, or by medications used to treat various diseases. These include anticholinergics, beta-adrenergic blockers, antipsychotic medications, and major tranquilizers. Side effects influence adaptation of sweat mechanisms to thermal stress. Diuretics may produce hypovolemia with loss of adequate subcutaneous circulation for heat dissipation. Because elders as a rule consume more medications than do younger persons, it is very important to approach heat injury from a position of prevention.

The cardiovascular system plays a major role in heat regulation through heat dissipation. Circulatory abnormalities, peripheral vascular disease, hypertension, and reduced cardiac output may modify heat dissipation, resulting in vulnerability to heat injury. Physical work capacity as measured by maximal oxygen consumption (max) decreases 5% to 15% per decade after age 25 years. β-adrenergic blockers and calcium channel blockers may also influence cardiac output by modifying heart rate and myocardial contractility.