Geriatric medicine and Olympic elite sports—parallels and philosophies

Abstract

The 30th Olympiad took place in July 2024. At first glance, sports science and training of elite athletes may appear to be of little relevance to geriatric medicine. However, there are important parallels between the practice of geriatric medicine and elite sports and lessons that we can learn from our sports science colleagues. Elite athletes and older people are operating at the margins of physiological capacity. Both benefit from tailored, scientifically informed training programmes delivered and monitored by a multidisciplinary team. There are parallels between the comprehensive geriatric assessment and the philosophy of marginal gains pioneered by British Cycling. Insights into the biology of skeletal muscle function are beginning to translate into the development of clinical interventions and substances that offer an unfair advantage in sport by improving muscle strength and physical performance may be of therapeutic benefit in sarcopenia. The 2024 Olympics provide an opportunity for us to learn lessons for excellence in our research and provide an opportunity to promote exercise across the life course—important for healthy ageing.

Key Points

• Elite athletes and older people with frailty operate at the edge of the physiological envelope.

• There are parallels between geriatric medicine and elite sports. The philosophies of marginal gains and comprehensive geriatric assessment are analogous.

• The 2024 Olympics allowed geriatricians to reflect on the lessons we can learn from elite sports.

• Substances abused to enhance performance in elite sports may be therapeutic in later life, but research is required.

• Sport can promote excellence in caring for older people and inspire improved therapeutic approaches to maintaining function.

Commentary

On 26 July 2024, Paris hosted the 30th Olympiad. Since first hosting the modern Olympics in 1900, French life expectancy has nearly doubled from 46 to 82 years [1]. At first glance, the feats of athleticism and competition to which we were treated to in July may appear to have little in common with the declines in physical performance that many older people have to contend with [2–4]—if anything the mean age of Olympic competitors has fallen over the last century (from 29 years in 1900 to 26 years in 2016) [5]. However, there are important parallels between the practice of geriatric medicine and elite sports and lessons that we can learn from our athletes and sports science colleagues.

A first and obvious parallel is the power of a multidisciplinary team (MDT). MDT working is central to the philosophy and practice of geriatric medicine, and in recent decades, elite sport has unwittingly copied our model, surrounding elite athletes with physiotherapy, dietetics, psychology, sports science and engineering expertise. Human genetics have not changed in the last century, but elite athletic performance has improved immeasurably as evidenced by the continual breaking of world records—data that brook no argument. The lesson for all delivering care for older people is that data count, and we need to ensure that we measure the benefits of our MDT approach to make the case to governments and policymakers for expanded investment.

A second parallel is in physical performance. Although the level of absolute performance may be very different between elite athletes and older people with frailty, both are in fact operating at the limit of their physiological envelope [6]. In both cases, individuals benefit most from structured, carefully tailored exercise training programmes [6]. A detailed understanding of skeletal muscle and cardiovascular physiology, coupled with a structured approach, careful monitoring and sufficient progression, are all essential ingredients for success in both elite sport and exercise-based rehabilitation for older people. This is increasingly apparent for conditions as diverse as sarcopenia [7], stroke [8] and heart failure [9]. The lesson for geriatric medicine is to apply some of the rigour of elite sport training if we want the best outcomes for our patients.

This approach within elite sport has in turn given rise to the third parallel—the philosophy of marginal gains. First pioneered within British cycling [10], this philosophy contends that small, incremental improvements across a broad range of components lead to substantial improvements in overall performance—e.g. combining 1% improvements in diet, bicycle engineering, strength training and mental approach. In elite sport, where success is measured in hundredths of seconds, such an approach can be transformative. Our approach within geriatric medicine often implicitly, if not explicitly, parallels this philosophy—small improvements and adaptations across a range of functional domains can add up to significant enhancement of independence and quality of life. When an individual is using almost all of their leg strength to transfer or walk, and independence is threatened by inability to rise from a chair, these marginal gains can be just as transformational as those seen in elite sport.

A final area of commonality is in the search for ways to improve physical performance using pharmacological methods. For older people, sarcopenia is a major threat to daily activity and independence [11]. While resistance exercise training is a highly effective intervention for sarcopenia, not everyone can or wants to exercise, and alternative therapies are desirable, both to substitute for exercise, but also to augment the effect of exercise training. We have discovered a great deal about the biology of skeletal muscle function and dysfunction [12], and these insights are beginning to translate into human interventions.

There are of course many areas where the practice of geriatric medicine and elite sports differ. For example, abuse of artificial and frequently banned substance to improve muscle strength and physical performance is widespread in sport. However, while performance enhancing drugs offer an unfair advantage in the competitive arena, they may be of therapeutic benefit in sarcopenia. The World Anti-Doping Authority (WADA) list of banned substance includes several drug classes with potential to enhance muscle mass and function (Table 1) [13, 14], however well-designed clinical trials testing the safety and efficacy of these of the drug in sarcopenia are lacking. Conversely, as successful pharmacological interventions are developed for sarcopenia these agents are likely to be misused by individuals and organisations seeking enhanced performance in sport. Banned drug lists will expand as an increasing range of substances are identified with potential muscle enhancing properties. Furthermore, testing regimes, designed to detect doping, will need to develop mechanisms not only to detect pharmacological doping but to detect gene doping, abuse of stem cell therapies and other advanced therapeutics [15]. Our challenge in translational sarcopenia research is not to condone or facilitate unfair competitive advantage in sport, but to ensure that insights from research in elite sport relevant to older people with sarcopenia are sought and properly evaluated in clinical trials rather than ignored.

Table 1.

Substances prohibited by WADA with potential to enhance muscle mass or muscle function

Substance	Effects on muscle
Exogenous testosterone and anabolic androgenic steroids (AAS)	Aid growth and repair of muscle with gains in muscle strength and mass
Erythropoietin (EPO)	Increase red cell mass; may have direct effects on skeletal muscle cells
Selective androgen receptor modulators (SARMs),	Similar to testosterone in action
Growth hormone, insulin like growth factor,	Widespread anabolic functions, including on skeletal muscle via IGF-1 pathway
Beta 2 agonists	Anabolic effects, improving muscle strength and mass and reducing fat mass.
Agents acting of myostatin/activin pathway	Increase muscle mass via blocking of the inhibitory myostatin/actvin pathway

Much is often made of the power of the Olympics to inspire physical activity and influence the health of a population. While evidence for such effects is contested [16], there is no doubt that global events such as the Olympics both raise the profile of sport and exercise, and also provide an intergenerational touchpoint, where young and old can join together to discuss, celebrate and share the sporting experience. The Olympics therefore provide an opportunity to reinforce social and intergenerational bonds and to promote exercise across the life course—both important for healthy ageing. The practice of geriatric medicine and elite sports may have more in common than is immediately apparent and the 2024 Olympics provided an opportunity for us to learn lessons for excellence in our research and practice as we celebrated sporting excellence.

Declaration of Conflicts of Interest:

None declared.

Declaration of Sources of Funding:

This research was supported by the National Institute for Health and Care Research (NIHR) Newcastle Biomedical Research Centre awarded to Newcastle upon Tyne Hospitals NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University and by the ART (Ageing Research Translation) of Healthy Ageing Network which is funded by UK Research and Innovation (Grant Ref: BB/W018209/1)”.