rehabilitating elderly cardiac patients

REHABILITATING ELDERLY CARDIAC PATIENTS

By Tiffany Steele, SPTA

Objectives: 1. Cardiovascular Disease (CVD) statistics 2. Pathophysiological conditions that

underlie CVD 3. The effects of selected medications on

Heart Rate (HR), Blood Pressure (BP) responses during exercise/ exercise performance.

4. Benefits of exercise for CV conditions 5. Common considerations / precautions

and contraindications to exercise.

Cardiovascular Disease in Older Adults:

Cardiovascular disease remains the leading cause of death in the United States, including those over the age of 85 years.

An estimated 80.7 million Americans have one or more types of CVD. Approximately 38.2 million are individuals older than age 60 years.

The total direct and indirect costs of CVD and stroke were an estimated $448.5 billion in 2008.

These numbers support the ongoing need for chronic disease management in the elderly and the potential role cardiac rehabilitation may play.

Pathophysiogical Conditions:

Atherosclerosis Altered myocardial muscle mechanics Valvular dysfunction Arrhythmias Hypertension

Disabling Effects from CVD:

Hypertension Orthopnea (difficulty breathing while laying

flat) Palpitations Dyspnea Peripheral edema Chronic medications Apprehension, anxiety…threat of MI Arrhythmias Restricted activity

Atherosclerosis A disease in which lipid laden plaque (lesions) is formed within the inner layer of the blood vessel of moderate and large size arteries.

It is also the primary contributor to CVD and PVD.

Altered Myocardial Muscle Mechanics & Valvular Dysfunctions

Involves the systolic and/ or diastolic properties of the myocardium, resulting in an impairment of LV function.

Referred to as CHF when accompanied by signs and symptoms of edema.

Other causes include, myocardial scarring/ remodeling as result of MI, cardiomyopathy or impairment in valvular function, especially the mitral and aortic valves.

Arrhythmias Caused by a disturbance in the electrical activity of the heart, resulting in impaired electrical impulse formation or conduction.

Irregular, rapid heart rate that commonly causes poor blood flow to the body.

Most common in elderly the population would be atrial fibrillation (a-fib

Hypertension Most prevalent CVD in the US and one of the most powerful contributors to cardiovascular morbidity and mortality.

Systolic is above 140 mm Hg Diastolic is above 90 mm Hg Three Stages:1. 130-140 / 90-1002. 140-160 / 100-1103. >160 / >110

Effects of Medications on HR, BP and Exercise:Beta Blockers: Used to treat high BP, heart failure, angina, arrhythmia, MI

Slows the heart rate and reduces the force with which the heart muscle contracts, thereby lowering blood pressure.

Decreases HR and BP at rest and exercise

Effects of Medications on HR, BP and Exercise continued:

Calcium Channel Blockers: Used to treat high BP, angina, arrhythmia.

Reduce electrical conduction within the heart, decrease the force of contraction (work) of the muscle cells, and dilate arteries.

Dilation of the arteries reduces blood pressure and thereby the effort the heart must exert to pump blood.

Increases/decreases HR and decreases BP at rest and exercise.

Effects of Medications on HR, BP and Exercise continued:

Vasodilators: Used to treat high BP

Dilates blood vessels, blood flows more easily through your arteries, your heart doesn't have to pump as hard and your blood pressure is reduced.

Increases HR and decreases BP at rest and exercise.

ACE Inhibitors: Used to treat high BP

Dilates blood vessels to improve the amount of blood the heart pumps and lowers blood pressure.

Decreases BP at rest and exercise.

Effects of Medications on HR, BP and Exercise continued:

Digitalis: Used to treat CHF, arrhythmia, to increase blood flow throughout your body.

Strengthens the force of the heartbeat by increasing the amount of calcium in the heart's cells.

As calcium builds up in the cells, it causes a stronger heartbeat.

Decreased HR in patient’s w/ atrial fibrillation and CHF, no effect on BP at rest and exercise.

Effects of Medications on HR, BP and Exercise continued:

Diuretics: Used to treat high BP, edema, heart failure, kidney & liver problems.

Help your body get rid of unneeded water and salt through the urine. Getting rid of excess fluid makes it easier for your heart to pump and controls blood pressure.

No effect on HR , BP decrease/or may have no effect at rest or exercise.

Effects of Medications on HR, BP and Exercise:Nitrates: Used to treat chest pain, angina, CHF

Nitrates are a vasodilator, improving blood flow and allowing more oxygen-rich blood to reach the heart muscle. Increases HR and decreases BP at rest and exercise.

How can we help? Cardiac rehabilitation is a

multidisciplinary approach to chronic disease management that encompasses nutrition consultation, psychosocial services, lifestyle modification, and risk factor modification management, in addition to aerobic and resistance training.

Benefits of Cardiac Therapy:

Strengthen your heart and cardiovascular system. Improve your circulation and help your body use oxygen better. Improve your symptoms of congestive heart failure. Increase energy levels so you can do more activities without becoming

tired or short of breath. Increase endurance. Lower blood pressure Improve muscle tone and strength. Improve balance and joint flexibility. Strengthen bones. Help reduce body fat and help you reach a healthy weight. Help reduce stress, tension, anxiety, and depression. Boost self-image and self-esteem. Improve sleep. Make you feel more relaxed and rested. Make you look fit and feel healthy.

General Benefits of Exercise for CV Conditions:

Improved cardiorespiratory function Improved coronary artery disease risk

factors: cholesterol, hypertension, stress, weight, diabetes, smoking

Improved mental health Decreased morbidity and mortality

Patients who can benefit from cardiac rehabilitation:

Medical: Patients with stable angina Myocardial Infarction CHF

Postsurgical:Patients who have undergone: Coronary artery bypass grafting (CABG) Congestive heart failure Percutaneous transluminal coronary angioplasty (to open

blocked coronary arteries caused by CAD) Heart transplantation Heart-valve surgery

Exercise Perscription: The duration of a common aerobic exercise

training sessions vary from 20 – 40 minutes at an intensity approximating 70%–85%of the max HR.

A deconditioned patient may be aerobically trained at as low as 50%–60%.

Exercise prescriptions are based on: Frequency Intensity Time (duration) Type (mode)

Exercise Prescription (FITT Principle):

Aerobic F: (Frequency): 4-7 days per week I: (Intensity): 50-85% VO2 max/HR max, RPE of

11-13 T: (Time): 30-60 min/session T: (Type) Large muscles, aerobic

Resistance training F: (Frequency): 2-3 days per week I: (Intensity) Low resistance and high reps T: (Time) 1-3 sets; up to 30 minutes/session

Pulse Rate: Normal pulse rate for an adult is 60 – 100 bpm Although there's a wide range of normal, an unusually high

or low heart rate may indicate an underlying problem. Tachycardia- HR that is consistently above 100 beats a

minute. Bradycardia- HR that is below 60 beats a minute Signs or symptoms- fainting, dizziness or shortness of

breath, palpitations, angina, and lightheadedness.

Fitness level significantly impacts the normal pulse rate for older adults. It is lower if you are well conditioned and higher if you are not.

Factors that influence the pulse rate:

Age Sex Activity level Fitness level Air temperature Body position (standing up or lying down,

for example) Emotions Body size Medication use

How aging affects the pulse rate:

Your heart rate tends to increase as you age because your heart is not as strong or efficient as it used to be. Aging can also lead to stiffer arteries that are sometimes clogged with fat, increasing your heart's workload even further.

Exercise Prescription: THR

Target Heart Rate: is the desired percent of the exercise intensity, times the Max HR (220 - age)

Example : 185 (Max HR: 220-35) X 70% (Intensity) = THR (130)

Exercise Prescription: THRAge 50% of Max

HR85% of Max HR

Max HR

50 90 bpm 153 bpm 17055 83 bpm 140 bpm 16560 80 bpm 136 bpm 16065 78 bpm 132 bpm 15570 75 bpm 128 bpm 15080 70 bpm 119 bpm 14585 67 bpm 114 bpm 14090 65 bpm 110 bpm 130

Exercise Consideration: VO2max: volume of oxygen you can

consume while exercising at your maximum capacity. As we get older our VO2max

decreases. The decline is due to a number of factors including a reduction in maximal heart rate and maximum stoke volume (the amount of blood pumped by the left ventricle of the heart in one contraction), cardiac output (CO): the amount of blood that leaves the ventricles.

Exercise Considerations:

Medications Post exercise hypotension -Longer cool down Monitor BP Hydrate Avoid isometric activities (patients tends to hold

their breath) Avoid vigorous activities Avoid valsalva maneuver (breath holding and

bearing down) Lifestyle modification

Exercise Considerations:

RELATIVE ABSOLUTE Stable cardiovascular disease

(stenosis, blocks, previous MI, CHF, PVD)

Electrolyte abnormalities Irregular heart beat Hypertension: 200/110 mm Hg NM, MSK, rheumatoid disorder

exacerbation Uncontrolled metabolic disease

(diabetes) Chronic infectious disease Move forward after careful

evaluation

Recent significant change in ECG

Unstable cardiovascular disease (angina, stenosis, heart failure)

Uncontrolled arrhythmias Hypertension: 200/110 mmHg Pulmonary embolus Myo/perocarditis Aneurysm Acute infections Need to wait to be cleared

Exercise Considerations: The Borg RPE Scale

6 No exertion at all 7 8 Extremely light 9 Very light 10 11 Light 12 13 Somewhat hard 14 15 Hard (heavy) 16 17 Very hard 18 19 Extremely hard 20 Maximal exertion

RPE should stay between 11-13

Cardiac Precautions:

Top 5 sternal precautions reported by PT’s in order of importance:

1. Lifting no more than 10 pounds of weight bilaterally

2. No hand over head activities bilaterally3. Bilateral sports restrictions (No hand over

head activities bilaterally)4. No driving5. Active bilateral shoulder flexion no greater

than 90°

Cardiac Precautions:

Cardiac Precautions:

Cardiac Precautions:Vitals: Contraindicatio

nsPrecautions Termination

Pulse Rate < 50 or >120 bpm 100 – 120 RP 20 – 30 bpm above rest

Respiration Rate > 30 bpm Post CABG 30 bpm above restPost MI/ CHF 20 bpm above rest

Systolic BP < 80 or >180 MM Hg

Decreased SBP of 10-20 mm Hg

>20 mm Hg drop>200-220 mm Hg

Diastolic BP >110 mm Hg >110 – 120 mm HgO2 Saturation <88% w no pulm dz

<85% w pulm dz<90%

Glucose <70 or >300 g/dLOther • Unstable angina

• Recent embolism• Arrhythmias• Active peri or myocarditis

• Slow recovery time• Fatigue p 1-2 hrs• Lack of excessive BP response to activity• Arrhythmias• LE claudication

• Angina• Confusion• Fatigue• Dizziness

Educational Topics for Cardiac Rehabilitation:

Risk factors associated with CAD Anatomy and physiology of the heart: What is

a heart attack? Angina: What is chest pain? Relation of diet to heart disease Diet and weight control Stress and stress management Cigarette smoking in relation to heart disease Drugs used in management of heart disease

and their relationship to exercise

References: Physical Rehabilitation 5th Edition, Susan B O’ Sullivan Effects of Cardiovascular Medications on Exercise

responses: http://ptjournal.apta.org/content/75/5/387 Sternal Precautions:

http://cpptjournal.org/pdfs/members/fulltext/2011/march/sternal_precautions.pdf

American College of Sports Editions Medicine Guidelines for Exercise Testing and Prescriptions, 8th Edition

Cardiac Rehabilitation in Older Adults: Benefits and Barriers: http://www.clinicalgeriatrics.com/articles/Cardiac-Rehabilitation-Older-Adults-Benefits-and-Barriers?page=0,0

Heart and Vascular Health & Prevention: http://my.clevelandclinic.org/heart/prevention/exercise/pulsethr.aspx

Cardiovascular Risk-Factor Reduction in Elderly Patients With Cardiac Disease http://ptjournal.apta.org/content/76/5/469.full.pdf+html

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