Cardiovascular & Pulmonary Concerns

At what intensity of exercise does HR and BP start to increase when someone has been sedentary?

Low intensity

Does BP increase or decrease with immobility?

Increase

Endothelial dysfunction associated with immobility increases the risk of what?

• Heart attack

• Stroke

An impaired aerobic capacity and endurance are associated with what?

A decline in functional mobility and a loss of independence down the road

A decrease in arterial compliance will result in an increase in what?

SBP

A thickening of the LV wall will lead to a decrease in what?

Diastolic filling

A decrease in max HR and VO2 max is a normal part of aging. True or false?

True!

With normal aging, our LV wall will start to thicken. True or false?

True!

With normal aging, we will have an increase in arterial compliance. True or false?

False! Arterial compliance will decrease with normal aging

Resting CO will often decrease as we age. True or false?

False! It doesn’t normally change

After the age of ___, our aerobic capacity will decrease ___ to ___% per decade

5-15%

What factors can increase the rate of our aerobic capacity decline?

• Chronic diseases

• Poor lifestyle factors (smoking, inactivity, poor diet, etc.)

When HR < 100, HR will increase via what?

Inhibition of vagal tone

When HR > 100, HR will increase how?

Via stimulation of sympathetic tone

As we age, our autonomic nervous system declines in function. What does this lead to?

• HR variability

• Dysrhythmias

• AV blocks

• Sick sinus syndrome

Why does resting HR decrease with aerobic training?

We get an increase in parasympathetic activity and a decrease in sympathetic activity

What is known as the clinical representation of SV?

Ejection fraction

As we age, our EF at maximal exercise will decrease. True or false?

False! It doesn’t normally not decline

What is the formula to calculate CO?

SV x HR

What is the formula to calculate VO2?

CO x arterivenous O2 difference

What kind of relationship do CO, HR, and SV have?

Directly proportional (if one declines, the others will as well and vice versa)

What is the main stimulus for increasing CO during exercise?

Oxygen demand

What factors determine venous oxygen levels?

• Oxygen delivery

• Oxygen uptake

• Oxygen use in peripheral tissue

What pathological changes influenced by age can impact arterial and venous O2 lvls?

• COPD (causes thickening of alveolar-capillary membrane)

• Restrictive lung diseases (cause a low alveolar oxygen pressure)

• PAD, DM (impaired macrovascular or microvascular blood flow)

• Bed rest or immobility (skeletal muscle loses oxidative capacity)

During aerobic activity, does venous oxygen content increase or decrease. Why?

It decreases because of the greater O2 demand by various body structures/organs

Does arteriovenous oxygen difference increase or decrease with exercise?

Increase

Will arterial stiffness increase or decrease after load?

Increase

What will an increase in after load result in?

• Increased systolic HTN

• Increased myocardial workload

What are some autonomic changes that happen to our body with aging? What do these changes result in?

• Decreased baroreceptor sensitivity & decreased responsiveness to beta-adrenergic stimulation

• Results in hypotension and a blunted HR response

Appropriate exercise prescription can reduce systolic and diastolic BP by ___ to ___ mmHg

5-10 mmHg

What is post-exercise hypotension (PEH)?

A condition where a peep experiences a temporary reduction in BP after engaging in physical exercise

What are the benefits of PEH in older adults?

• Can help with long term BP reduction

• Reduces the risk of a heart attack or stroke

What are some risks and considerations you need to take into account when working with an older adult with PEH?

• Could result in OH

• Meds could amplify the drop in BP

• If pt has a hx of CVD, need to monitor BP more closely

What are some ways to reduce the risk of PEH resulting in poor outcomes?

• 10-15 gradual cooldown

• Hydrate

• Make sure pt is properly supervised

What is aortic stenosis?

A calcification near the heart valves the decreases the outflow of blood

What are the S/S of aortic stenosis?

• Angina

• Exertional syncope

• Heart failure S/S (JVD, LE edema)

• Drop in BP with exercise

If someone has a mild degree of aortic stenosis, what precautions need to be taken during exercise?

• Just don’t get them to the point where they start to demonstrate S/S

If someone has a moderate or severe degree of aortic stenosis, what precautions need to be taken during exercise?

• Avoid high load exercises

• Monitor closely during cardio

• Use machines

What is orthostatic hypotension?

Drop in SBP by 20+ or DPB by 10+ within 3 minutes of standing up

What are some of the functional implications of cardiovascular aging?

• Decrease in aerobic capacity

• Slower recovery post-exertion

What is the most prevalent CV condition in older adults?

HTN

If you are working with a pt with HTN, what are some things you need to consider for your PT session?

• Check BP before and after activity

• Avoid the valsalva

• Modify intensity via RPE if BP is poorly controlled

What causes CAD?

Plaque buildup that results in ischemia

What are the S/S of CAD?

• Angina

• Fatigue

• SOB

If working with a pt with CAD, what are some things you gotta consider as the PT?

• Look out for angina equivalents (something other than SOB that indicates limited blood flow to the heart)

• Gotta use RPE to monitor intensity

• Educate pt on proper nitroglycerin use

If someone has CAD, how long do they typically do cardiac rehab?

4-6 wks

What are the S/S of a MI in older adults?

• Crushing chest pain

• Fatigue

• Confusion

• Dyspnea

• L arm pain

What is the most validated tool to examine HF?

Fried frailty

What are the common S/S of HF?

• Edema

• Fatigue

• Dyspnea on exertion

What should your eval include when the pt has HF?

• Ask ‘bout symptoms

• Ask about pain

• Ask about orthopnea

• Ask about…

  • Nocturnal dyspnea

  • Fluid retention

  • Reported activity tolerance

What are the different types of HF? Describe them

• Heart failure with preserved ejection fraction (HFpEF)

  • Also known as diastolic HF where the heart muscle contracts normally but the ventricles struggle to relax and fill with blood even tho ya got a normalish EF

• Heart failure with reduced ejection fracture (HFrEF)

  • Also known as systolic HF where the heart muscle doesn’t contract effectively which results in a lower than normal EF

What benefits can exercise have on someone with HF?

• Improve peak VO2

• Improve QoL

• Decrease hospital admissions

Symptoms of HF typically present around ___ MET activities

5

What are the implications for PT when working with someone with HF?

• Reduce the intensity

• Long durations at low work rate with lots of breaks

• Extended warm ups

• Monitor for S/S of worsening HF (weight gain, breath sounds, JVD)

• Avoid supine if orthopnea is present

What kind of rhythm does Afib cause?

Irregularly irregular rhythm

What are the S/S of Afib?

• Fatigue

• Palpation

• SOB

Afib can increase the risk of what?

• Falls

• Stroke

What are the implications for PT when working with someone with Afib?

• Monitor HR variability

• Check if pt on an anticoagulants

• Use RPE to monitor intensity

What is the hallmark symptom of PAD?

Intermittent claudication

What is the gold standard for rehab for a pt with PAD?

Walking program

A cardiomyopathy will often lead to symptoms similar to what other condition?

HF

What valvular diseases are common in older adults?

• Aortic stenosis

• Mitral regurgitation

What restriction does someone have after getting a pacemaker or ICD?

No overhead movements for 2 wks

After someone gets a pacemaker or ICD, what S/S should ya watch out for?

Arrhythmia symptoms (SOB, palpitations)

What are the clinical implications of normal aging cardiovascular changes?

• Lower HR max

• Decrease blood flow to working muscles

• Reduced ability to use O2 that gets to skeletal muscle

• Reduced exercise capacity

• Blunted exercise response

• Increased PB

• Increased risk for HTN, Afib, aortic stenosis, and cardiovascular disease

What normal pulmonary change that occurs with aging increases pneumonia risk?

Decreased cough reflex

What is the purpose of the physical activity scale for the elderly (PASE)?

Assess PA in peeps over 65 years

What is the point of the Duke Activity Status index?

Gives us a rough estimate of VO2 peak and MET lvl in geriatric pts

What are the clinical implications of age-related pulmonary changes?

• Reduced vital capacity and maximal ventilatory capacity

• Reduced FEV1

• 20% increase in work for respiratory muscles

• Ventilation/perfusion mismatch

• Decrease in cough strength/force

• Risk of respiratory infections

• Increase in SOB frequency

• Comorbidities musculoskeletal changes (kyphoscoliosis)

What is the pathophysiology of emphysema ?

Alveolar destruction which leads to air trapping which will decrease gas exchange, increasing the work of breathing

What is the pathophysiology of chronic bronchitis?

Excessive mucus which leads to inflammation which will decrease gas exchange causing an increase in the work of breathing

What percentage of FEV1 would a mild case of COPD be?

80%+

What percentage of FEV1 would a moderate case of COPD be?

50-79%

What percentage of FEV1 would a severe case of COPD be?

30-49%

What are the goals of pulmonary rehab when working with someone with COPD?

• Improve QoL

• Reduce hospitalizations

What is the purposes of pursed lip breathing?

• Slow exhalation

• Prevent air trapping

What are the PT implications when working with a pt with COPD?

• Watch for SOB, O2 drops, and/or fatigue

• Gradually increase exercise

• Stop exercise if there’s severe desaturation or an increase in pt distress

What are the S/S of pneumonia in older adults?

• Fever

• Fatigue

• Confusion

• Decrease in appetite

What are the risk factors for pneumonia?

• 65+ years old

• Dysphagia

• Immobility

• Cognitive impairment

• Chronic illness (DM, COPD, HF)

• Aspiration risks (Stroke, sedation)

When is the key to preventing complications in someone with pneumonia?

Early mobilization

Older adults who develop COVID 19 are at a higher risk for what?

• Severe illness

• Hospitalization

• Post acute sequelae (long COVID)

What are the S/S of long COVID? What impact does this have on their life?

• S/S: fatigue, dyspnea, tachycardia, cognitive troubles

• Impact: deconditioning, fear, ADL decline

What are the PT implications when working with someone post COVID?

• Start slow and progress slowly

• Monitor closely

• 1:2 rest activity ratio

Exercise should be stopped if SBP gets over what?

250 mmHg

What do ACE inhibitors prevent?

Vasoconstriction

What condition would someone take an ACE inhibitor for?

HTN

What do diuretics do?

• Reduce fluid overload volume

• Cause hypo/hyperkalemia

What conditions might someone take a nitrate for?

• OH

• Angina

What do nitrates do?

Cause rapid vasodilation

What med may have the side effects of ankle swelling?

Calcium channel blockers

Does the med Digitalis decrease or increase HR?

Decrease

Does the med Digitalis increase or decreased SV?

Increase

What can Digitalis toxicity cause?

• Confusion/CNS dysfunction

• Fatigue

• Arrhythmias

What side effects do beta blockers, diuretics, and ACE inhibitors all share?

• OH

• Fatigue

• Dizziness

• Electrolyte imbalance

What is an ADR of diuretics?

Electrolyte imbalance

What is an ADR of nitrates?

Vasodilation

What is an ADR of statins?

Myopathy

What is an ADR of anti-coagulants?

Hemorrhage

What conditions may someone take a bronchodilator for?

• COPD

• Asthma

Give some examples of bronchodilators

• Beta-agonists

• Anticholinergics