Rehabilitating elderly cardiac patients

1. Rehabilitating elderly cardiac patients By Tiffany Steele, SPTA

2. 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 / precautionsand contraindications to exercise.

3. 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.

4. Pathophysiogical Conditions: • Atherosclerosis • Altered myocardial muscle mechanics • Valvular dysfunction • Arrhythmias • Hypertension

5. 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

6. 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.

7. 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.

8. 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

9. 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: 130-140 / 90-100 140-160 / 100-110 >160 / >110

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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

19. 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 • Percutaneoustransluminal coronary angioplasty (to open blocked coronary arteries caused by CAD) • Heart transplantation • Heart-valve surgery

20. 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)

21. 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

22. 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.

23. 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

24. 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.

25. 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)

26. Exercise Prescription: THR

27. 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.

28. 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

29. 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

30. 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

31. Cardiac Precautions: • Top 5 sternal precautions reported by PT’s in order of importance: • Lifting no more than 10 pounds of weight bilaterally • No hand over head activities bilaterally • Bilateral sports restrictions (No hand over head activities bilaterally) • No driving • Active bilateral shoulder flexion no greater than 90°

32. Cardiac Precautions:

33. Cardiac Precautions:

34. Cardiac Precautions:

35. 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

36. 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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