Age-related Changes and Response to Exercise: CVP focus and Exercise Prescription

What are Age-Related Cardiovascular Changes which increase

- Left ventricular wall thickness

- Thickening of valve structures

- Epicardial fat

- Peripheral vascular resistance

What are the consequences of increased Left ventricular wall thickness due to Age-Related Cardiovascular Changes

- amount of blood the chamber can hold may decrease

- heart filling more slowly

What are the consequences of increased Thickening of valve structures due to Age-Related Cardiovascular Changes

If the valves thicken or stiffen blood cannot pass through as well and create rhythm problems

What are the consequences of increased Epicardial fat due to Age-Related Cardiovascular Changes

If too weak makes it hard to pump blood

What are the consequences of increased Peripheral vascular resistance due to Age-Related Cardiovascular Changes

Peripheral resistance goes up leads to higher BP

What are cardiovascular decreases that are seen due to age-related changes

- Diastolic filling

- Compliance of large arteries

- Sensitivity of baroreceptors

- Speed of red blood cell production (delayed healing response)

- Maximal heart rate

- Cardiac output

- Stroke volume

- Max V02

- Blood flow to skeletal muscles

- Capillary density

What are pulmonary factors that increase as a result of Age-Related Pulmonary Changes

- Stiffness of chest wall

- Number of mucus-producing cells

- Residual volume

- Functional Residual Capacity

- Respiratory rate

What are the functional Implications of age-related Pulmonary Changes

- Increased work of respiratory muscles (up to 20%)

- Ventilation/perfusion mismatch

- Increased risk of respiratory infection

- Increased episodes of shortness of breath (SOB)

- Frequent and shallow respirations

Clinical Implications of Cardiovascular Medications: Antihypertensives

ACE-Inhibitors prevent vasoconstriction

Clinical Implications of Cardiovascular Medications: Diuretics

- reduce fluid overload volume,

- Can also cause hypo/hyperkalemia (cramping, fatigue, arrhythmias)

Clinical Implications of Cardiovascular Medications: Nitrates

- rapid vasodilation to decrease BP

- Orthostatic Hypotension, angina

Clinical Implications of Cardiovascular Medications: Antiarrhythmics

- Beta Blockers decrease heart rate, BP, and angina and cause blunted response to demand of exercise

- Calcium Channel blockers decrease arrhythmias, (maybe not during exercise) and may cause ankle swelling

- Digitalis decreases HR, improves SV (Watch for toxicity signs- confusion, fatigue)

Clinical Implications of Pulmonary Medications: Bronchodilators

- relaxes smooth muscle in airways, used with COPD, Asthma

- Beta-agonists, anticholinergics

- May produce dysrhythmias, may increase HR or BP

Clinical Implications of Pulmonary Medications: Anti-inflammatory agents

- corticosteroids/steroids, COPD, Asthma

- Inhalers, side effects with prolonged use- weight gain, osteoporosis

Clinical Implications of Pulmonary Medications: Decongestants

- constrict dilated blood vessels in nose, sinus

- Act as a stimulant, may alter heart rhythm, increase BP

Clinical Implications of Pulmonary Medications: Antihistamines

- block histamine, used in upper respiratory infections

- Drowsiness, increased fall risk

What are normal heart rate responses seen from exercise

- Increase in HR with increasing work intensities

- Stabilization of HR (steady-state) during each workload

- HR should stabilize during recovery (May take longer than 5 minutes)

What are abnormal heart rate responses seen from exercise

- HR fails to rise with increase in workload

- Noticeable change in heart rhythm

- Onset of angina or angina-like symptoms

What are Exercise Age-related CV Changes

- Decreased stroke volume and cardiac output

- Reduced blood flow and oxygen to muscles

Exercise Implications of Age-related CV Changes: Decreased stroke volume and cardiac output

- Increased BP which impacts exercise response

- Higher HR at rest impacts max HR

Exercise Implications of Age-related CV Changes: Reduced blood flow and oxygen to muscles

Muscle fatigue and cramping with exercise

What are Exercise Age-related Pulmonary Changes

- Decreased vital capacity

- Chest wall stiffness

Exercise Implications of Age-related Pulmonary Changes: Decreased vital capacity

Increase and shallow respirations, lower threshold for shortness of breath

Exercise Implications of Age-related Pulmonary Changes: Chest wall stiffness

Shallow breaths, more vulnerable to respiratory infections

What are factors that affect Exercise based on Age-related MSK Changes?

- Increased muscle fat/decreased lean muscle fibers

- Cross linkage of muscle connective tissue

- Decreased bone mass

What are the effects of Increased muscle fat/decreased lean muscle fibers as a result of Age-related MSK Changes?

Decreased strength and endurance

What are the effects of increased cross linkage of muscle connective tissue as a result of Age-related MSK Changes?

Decreased tissue extensibility/flexibility/ROM, Increased stiffness, risk for contractures

What are the effects of Decreased bone mass as a result of Age-related MSK Changes?

Increased risk of fracture and decreased load tolerance

What are age related neurological changes that can impact exercise

- Decreased nerve cells and brain size (atrophy)

- Decreased impulse transmission

- Decreased # of receptors and transmitters

What are the Exercise Implications of Age-related Neurological Changes due to decreased nerve cells and brain size (atrophy)?

- Decreased coordination

- Increased reaction times

- Difficulty learning/adapting

- Increased risk for TBI

- Memory/cognitive decline

What are the Exercise Implications of Age-related Neurological Changes due to Decreased impulse transmission # of receptors and transmitters

- Decreased coordination

- Increased reaction times

- Decreased sensations

What are tests and measures we can use to assess age related cardiovascular and pulmonary changes

- 6-minute Walk Test (gold standard)

- 2-minute Walk Test

- 2-minute Step Test

When do we want to check vitals when examining geriatric patients?

Before, During, and After physical activity

What should we pay attention to/observe when examining geriatric patients?

- Reports of orthopnea

- rapid weight gain

- Cough assessment

- Breathing pattern assessment

What are tests and measures that can be used to examine vitals/baseline for geriatric patients

- Ankle Brachial Index

- Heart & Lung Auscultation

- Girth measurements

- Digital Cyanosis

- Capillary refill

- HR, RR, BP, O2Sat, + RPE

When conducting an RPE talk test, what is the target range of effort

- moderately hard

- brisk walking, able to carry on a conversation

- 70-75%

What are key points about the 6-MINUTE WALK TEST

- Walk as far as possible for 6 minutes

- Able to use assistive device, supplemental O2

- Set up 30-meter path, minimal turns

- Do not talk during testing

- Standing rest breaks ok, but no sitting (record time rested)

- After 6 minutes, sit to check vital signs, then measure distance walked

What is an important consideration when conducting the 6-MINUTE WALK TEST

After 6 minutes, sit to check vital signs, then measure distance walked

How do you conclude the 6-Minute Walk Test

After 6 minutes, or patient can no longer continue, sit down and check vitals before calculating distance (meters) covered.

What are age-related norms for the 6-Minute Walk Test

- Men 60-69: 560m

- Women 60-69: 505m

- Men 70-79: 530m

- Women 70-79: 490m

- Men 80-89: 446m

- Women 80-89: 382m

What are key points about the 2-MINUTE WALK TEST

- Walk as far as possible for 2 minutes

- Able to use assistive device, supplemental O2

- Set up 15 meter path, minimal turns

- Do not talk during testing

- Standing rest breaks ok, but no sitting (record time rested)

- After 2 minutes, sit to check vital signs, then measure the distance walked

How do we conclude the 2-MINUTE WALK TEST

After 2 minutes, sit to check vital signs, then measure the distance walked

Age-related norms for the 2-MINUTE WALK TEST

- Men 60-69: 183 (169-197) meters

- Women 60-69: 164 (150-177) meters

- Men 70-79: 163 (153-173) meters

- Women 70-79: 150 (148-153) meters

- Men 80-85: 144 (140-148) meters

- Women 80-85: 134 (132-136) meters

What is the procedure for conducting the 2-MINUTE STEP TEST

1. Take pre-test vital signs

2. Find center point between the iliac crest and the knee joint space

3. Mark wall for marching height

4. March: Count the number of times the right knee comes to the mark for 2 minutes

5. If knee height not maintained, have subject slow until proper height achieved

6. Standing Rest and holding on for balance are allowed

7. Take post-test vital signs immediately upon completion

What are the benefits of exercise

- Decreased fatigue

- Improved performance at work and sports

- Improved blood lipid profiles

- Enhanced immune function

- Improved glucose tolerance and insulin sensitivity

- Improved body composition

- Improved sense of well being

- Decreased risk of many diseases ex. CAD, CA, OP

- ↑ Joint mobility

- ↑ Flexibility

- ↑ Bone mass

- ↑ Bone size

- ↓ Disability and pain in patients with OA

- Change in bone microarchitecture

What are physical adaptations that occur from exercise

- ↑ Postural control (especially static balance)

- ↑ Neuromuscular control

- ↑ Contractile time

- ↑ Speed of movement

- ↓ Falls

- Improved Reaction time

- Improved body sway (Eyes open/closed on compliant and firm surfaces)

- Preservation of visual attention skills

What are psychological/emotional/cognitive adaptations that occur from exercise

- ↑ Self-respect

- ↓ Anxiety

- ↓ Depressive symptoms

- Less likely to develop cognitive decline

- ↑ in brain volume, in both gray & white matter    

Exercise and Physical Activity for Older Adults: Position statement of the ACSM

“Although no amount of physical activity can stop the biological aging process, there is evidence that regular exercise can minimize the physiological effects of an otherwise sedentary lifestyle and increase active life expectancy by limiting the development and progression of chronic disease and disabling conditions”

What are important areas of exercise prescription for aging adults

- AEROBIC CAPACITY/ ENDURANCE CONDITIONING

- MUSCLE PERFORMANCE

- FLEXIBILITY

- BALANCE, COORDINATION, AND AGILITY TRAINING

what does moderate intensity aerobic exercise entail

- RPE = 5-6

- Duration: ≥30 mins (or up to 60 mins for greater benefit) in bouts ≥10 mins total 150-300 mins/wk

- Frequency: At least 5 days/wk of Mod intensity

what does vigorous intensity aerobic exercise entail

- RPE = 7-8

- Duration: ≥20-30 mins/day to total 75-100 mins/wk

- Frequency: 3 days/wk of Vigorous

what does combined moderate and vigorous intensity aerobic exercise entail

- Duration: An equivalent combination of moderate and vigorous

- Frequency: Combination Mod / Vigorous 3-5 days/wk

What are key points about muscle performance training for healthy aging adults entail

- Intensity: Between Moderate (5-6) and Vigorous (7-8) on 0-10 scale

- Mode: 8-10 exercises involving major muscle groups; 10-15 repetitions each; Include stair climbing, and other strengthening activities

- Frequency: At least 2 days/wk

What are key points about flexibility training for healthy aging adults entail

- Intensity: Moderate (5-6 on 0-10 scale)

- Mode: Any activities that maintain or increase flexibility using sustained stretches for each major muscle group; static rather than ballistic

- Frequency: At least 2 days/wk

What are key points about balance training for healthy aging adults entail

- Intensity: Progressively difficult

- Mode: Neuromuscular training combining balance, agility and proprioceptive training

- Frequency: 2-3 days/wk

TARGET HR Range (Tanaka formula)

HRmax = 208 - (0.7 x age)

THR = [(HRmax - HRrest) x % intensity] + HRrest

Getting started with Strength training & Aerobic training...Avers and Brown (2009) White Paper: Exercise Prescription for Older Adults recommendations

- 8-12 repetitions at moderate resistance (60-80% RPE) per set for healthy sedentary adults

- 10-15 repetitions at a low level of resistance (<50%) for frail or deconditioned patients (Single set performed 2 days/wk)

- Involve the major muscle groups of the upper and lower extremities

- Plus Aerobic exercise at 60-80% RPE 5-7 days per week to 150 minutes

Strength: Number of Repetitions Required to Predict Amount of Resistance

- 60% RM = 17 reps

- 70% RM = 12 reps

- 80% RM = 8 reps

- 90% RM = 5 reps

- 100% RM = 1 rep

Exercise Prescription recommended for acute conditions

- More frequent, lower levels of intensity

- 1,2,5,10 minute sessions, several times a day

Exercise Prescription recommended for chronic or sub-acute conditions

- Longer duration, higher levels of intensity

- Leading up to 30 minutes or more, 5-7 days per week

EXERCISE RESPONSE PARAMETERS for normal responses

- RPE = 13/20 (or 4-6/10) on Borg scale

- Rise in SBP of 20-30 mm Hg

- BP returns to within 10 mm Hg and HR returns to within 10 bpm of pre-exercise value within 5 minutes of stopping exercise while sitting

EXERCISE RESPONSE PARAMETERS for abnormal responses

- Failure to return to baseline as described above

- DBP drops 10-20 mm Hg below baseline

- SSP > 210-240

- DBP > 110

- HR drops > 10 bpm below baseline

- HR rises > 50 bpm with low level activity

what is a consideration for exercise HR response in aging adults

In aging adults, HR response to exercise may be less brisk. Max HR will not rise as high as normal younger individuals

what is a medication consideration for exercise HR response in aging adults

If individual is taking a beta blocker, their HR response to exercise will be blunted, therefore HR is not a reliable measure of their exercise stress - use the Borg Scale along with vital signs

Sample aerobic exercise plan

- Any large muscle activity

- 40-70% heart rate reserve

- 11-14 (6-20 scale) Borg RPE

- 3-7 days per week

- 20-60 min/session or multiple 10 min sessions/day

Sample strength training plan

- Circuit training, weight machines, free weights, isometric exercises

- 1-3 sets of 10-15 repetitions

- 8-10 exercises involving major muscle groups

- 2-3 days/week

Sample flexibility program

- Stretching (10-30 sec)

- Before or after aerobic and strength training

- 2-3 days/week

Sample Exercise guidelines for neuromuscular training

- Coordination and balance activities

- 2-3 days/week

What are take home messages about exercise prescription and training for aging adults

- Do NOT underdose

- Strength and mobility gains are possible for aging adults with a Specific and Progressive Exercise Plan of Care