COMPS:Cardiopulmonary and Neurological Issues in Older Adults Flashcards
America’s leading health problem, AND leading cause of death
CVD
Cardiopulmonary disease
Tobacco
- single largest preventable cause of death and disease in the US
- Kills > 480,000 Am’s ea. year
- >41,000 from secondhand smoke
*Higher nicotine addiction= harder to quit=more problems
Smoking and PAD
smoking more closely related to getting PAD than any other risk factor
PAD INCs 4x if you smoke or have hx of smoking
*Among adults aged >65→ 12-20% may have PAD→ Risk inc’s w/ older age combined w/ smoking or DM
WATCH YOUTUBE VIDEOS MENTIONED ON SLIDE 5!!!
*******
Heart Sounds
S1
Closing of mitral & tricuspid
Heart Sounds
S2
Closing of pulmonary & aortic
Heart Sounds
*Development of an S3 heart sound w/ exercise
- S3 sound produced during passive LV filling
- LOWER in pitch and may indicate CHF
Heart Sounds
What else are s/s of decompensated CHF?
- INC SOB,
- B/L pedal edema
- crackles
- JVD
- gain 2-3lb
- Cor Pulmonale → cond that causes R. side of heart to fail
- LT HTN in the arteries of the lung and R. Vent can lead to cor pulmonale
R. Side vs. L. Side HF
- R. Side→
- periph swelling, congestion
- L. Side→
- SOB
Heart Sounds
APT-M 2245
- Dr. Dieter’s
- Aortic area
- Pulmonic area
- Erb’s Point
- Tricuspid area
- Apex (Mitral)→ where S3 most commonly heard
General Risk Stratification
Info gathered from PMH
- Ejection Fraction (EF)
- >/=60%→ NORMAL
- 50-59%→ LOW RISK
- 31-49%→ MOD RISK
- =30%→ HIGH RISK
- Hx of angina
- Hx of arrhythmia’s
- Hx of MI or CHF
Cardiac Meds
Usually Stepwise approach
Looking @ HTN..
- Lifestyle mods
-
Progression of meds:
- Diuretics→ ACE inhibitors→ Beta-Blockers→ Ca Channel Blockers
- Will also use “Cocktails” of meds for Cardiac meds
Cardiac Meds
Diuretics
- Lowers BP
- Diff types
- can cause electrolyte imbals
Cardiac Meds
Beta Blockers
-olol
-Olol
- Blunt HR
- Need to use RPE, talk test
Cardiac Meds
ACE Inhibitors
-pril
-pril
- SE’s
- Periph edema
- chronic cough
Cardiac Meds
*Ca Channel Blockers
-ipine
-ipine
- Blunt HR
- Need to use RPE
Cardiac Meds
*Nitroglycerin
“nitro”
“nitro”
- usually put under tongue for Angina
Cardiac Meds
*Digoxin (Digitalis)
*think Toxicity!!!
- Used for A-Fib and/or CHF
- For CHF→ reduces force of heart→ works less hard
- *Toxicity→ more common in older adults
Cardiac Monitoring
3 methods:
- Mean Arterial Pressure (MAP)
- HR Recovery
- Angina Presentation Pattern
Cardiac Monitoring:
MAP
- Avg blood pressure during cardiac cycle
- “Perfusion pressure”
-
MAP= DBP + ⅓ (SBP-DBP
- HIGH= inc risk stroke, organ failure
- LOW= not enough blood to organs (ex. brain)
- NORMAL= 70-110 mmHg
Cardiac Monitoring
*HR Recovery
- Quick/easy measure of cardiac health
-
NOTE***= 12 beat recovery in 1 min
- → higher mortality in next 6 yrs
Cardiac Monitoring
*Angina presentation patterns
-
MALES
- L. shoulder
- Neck
- Jaw
- Teeth
- Upper back
-
FEMALES
- Fatigue
- Breathlessness
- Pain mid-back (often missed**)
Pulmonary Monitoring
2 ways:
- Breath Sounds
- Looking for changes @ rest OR w/ exercise
- O2 Sats
- >/= 90% → NORMAL
- *Medicare will pay for O2 if =88%
Breath Sounds
Normal vs. Abnormal
- Normal→ Bronchovesicular
- Abnormal→
- Crackles (rales)
- Wheezing (rhonchi)
- Stridor→ high pitched, foreign body (choking)
Breath Sounds
Abnormal→ Crackles (rales)
- bottom lungs
- Usually Inspiration
- PNA, CHF
Breath Sounds
Abnormal→ Wheezing (rhonchi)
- Usually Expiration
- Asthma, COPD
Breath Sounds
Abnormal→ Stridor (think choking, kids)
- HIGH pitched,
- foreign body
Breath Sounds
Pitch
Low
Med
High
Breath Sounds
Intensity
Soft, medium, loud
- Diminished/Soft→ Emphysema, hypERinflation, atelectasis
- Loud/ringing→ PNA
VO2max
- Point @ which 02 consumption does not inc w/ inc’d intensity
- ml/kg/min OR L/min
- Avg= 30-40ml/kg/min
- 3.5ml/kg/min= 1 MET @ rest
VO2====
CO x (a-VO2)
- CO x diff bw arterial and oxygen concentrations
- diff in O2 drop
- V= ventilation= pulmonary component
- a= HgB carried in arteries (little “a” is arteries)
- CO= Cardiac Output (SVxHR)
- a-VO2== how much HgB “let go” in peripheral arteries
HR
beats/min
Stroke Volume
SV= EDV-ESV
- Avg= 70mL
- EDV= mL blood @ end of diastole (relaxation)
- 110-130
- ESV= mL blood @ end of systole (contraction)→ 2nd systolic
- 30
Regulation of SV
-
Preload→ blood returning to heart or EDV
-
Frank-Starling Mech
- Inc’ing preload== inc’ing SV until plateaus
- SV plateaus bc we all have MAX SV
- Inc’ing preload== inc’ing SV until plateaus
-
Frank-Starling Mech
-
Afterload→ same as TPR
- blood ejected OUT of heart influenced by pressure gen’d in ventricle compared to pressure in systemic vasculature
- INC TPR== DEC SV
- blood ejected OUT of heart influenced by pressure gen’d in ventricle compared to pressure in systemic vasculature
-
Contractility/Inotropy→ contraction of heart muscles
- INC + inotropic (caffeine)= INC SV
Cardiac Output
CO= HR x SV
- Vol of blood ejected out of L. ventricle into systemic vasculature per minute
- blood ejected out of L. vent/minute
- Avg= 70mL x 70bpm = 5L/min
Cardiac Output
Coronary Blood Flow
- perfuse myocardium during cardiac cycle
- Myoglobin in the myocardium releases O2 during systole
- Reg’d by ANS
- *NOTE: SNS inc’s vasodilation
Blood Pressure
BP
*measurement of arterial blood flow and resistance to that flow
- BP= CO x TPR
- *CO= HR x SV
-
Components:
- Systolic
- Diastolic
Blood Pressure
MAP
MAP= (SBP + 2DBP)/3 or ⅓SBP + ⅔DBP
- Ex. BP= 120/80
- (120+2)(80))/3= ~90 MAP
Blood Pressure
Mean Venous Pressure
MVP= CVP (Central Venous Pressure)
- 0-8mmHg
- Ohm’s Law
- High resist to Low resist
Pulse Pressure
PP= Systolic - Diastolic
ex. 120/80→ 120-80= 40PP
a-VO2
how much HgB “let go” in peripheral arteries
PVR
Pulmonary Vascular Pressure
Resistance that must be overcome to push blood through the circulatory system and create flow
RR
Respiratory Rate
of breaths/min
NORM= 12-20
Dyspnea
Diff or labored breathing
SOB
Functional Outcome Measures
Be Familiar…
- 2 min Step Tests
- Walking Tests (6m or 2m)
- TM Tests
- Borg Scale
- Dyspnea Scale
- Angina Scale
6MWT for…
Pulmonary and CV Dis. Pts
- Stopwatch, hallway
- HR before administration, self-selected speed, resting permitted, HR AFTER test and distance recorded, RPE determined
- NO quantitative info on aerobic power
Interventions:
Significant benefits of exercise in older adults:
- improved max O2 uptake (VO2max)
- reduction in coronary risk factors w/ program adherence
- marked improvement w/ ex tolerance
- adaptations in Sk. mm
- reduction in symptoms
- overall improvement in functional capacity and mental status
Interventions:
Keep in mind…
Pts willingness to adhere to regular training that has appropriate intensity w/out producing limiting sx’s
Guidelines for Aerobic Activity
What are we looking for?
OPTION 1
Option 1
2 hours and 30 mins (150mins or 30min/day 5d/week) of moderate intensity aerobic activity ea. week
*Muscle strengthening exercise on 2 or more days a week working all major muscle groups (legs, back, abs, chest, shoulders, arms)
Guidelines for Aerobic Activity
Option 2
OPTION 2
1 hour and 15 mins (75mins) or vigorous intensity aerobic activity ea. week
*Muscle strengthening exercise on 2 ore more days a week working all major muscle groups
Guidelines for Aerobic Activity
OPTION 3
OPTION 3
An Equivalent mix of moderate- and vigorous-intensity aerobic activity
*Muscle strengthening exercise on 2 or more days a week working all major muscle groups
Aerobic Activities
Intensity
MODERATE
MODERATE
- 60% MHR
- 11-12 Borg
- 3-4 Mod Borg***
- Perceived Workload Scale→ fairly light/somewhat hard
- Talk Test→ steady pace, not breathless
Aerobic Activities: Intensity
Vigorous
Vigorous
- 80%MHR
- 15-16 on Borg
- 5-6 Mod Borg***
- Perceived Workload Scale→ Hard
- Talk Test→ Very brisk walking, must take breath bw 4-5 words
Rehab Dosage
Aerobic Capacity
See pics
Be familiar w/ zones
- 50-60%→ Mod activity (maintenance/warm up)
- 60-70%→ Weight control (Fitness/fat burn)
- 70-80%→ Aerobic (cardio training/endurance)
- 80-90%→ Anaerobic (Hardcore training)
- >90%→ VO2max (Max Effort)
Interventions
A balanced fitness training program includes____________
includes activities to inc flexibility, strength, and CV endurance
Interventions:
The most effective exercise prescription begins w/ ____________
a type of aerobic activity the patient enjoys. A prescribed schedule of stepwise increments in freq, duration, and intensity gradually leads to an optimum lvl of fitness
Interventions
CV and Pulmonary dysfunctions
REVIEW EXERCISE GUIDELINES IN CPPT!!!!!!!!!!!!!!!
Interventions:
Many older adults w/ cardiopulmonary impairments require__________
supplemental O2 and it is considered a drug (>21%) when breathed in higher conc’s than that found in atm cond’s (20.98%)
Intervention:
The most common reason for O2 use is _____________
arterial hypoxia. PTs working w/ pts who require supp O2 should have knowledge base of the pros and cons of O2 tx
Interventions:
The pts exercise prescription may req _______________
modification of O2 dosage and this change should be discussed w/ pts physician
MAJOR patho affecting older adults in US….
Parkinson’s (PD)
*majority of indiv’s are >50yo when dx w/ PD
PWP may have wide variety of s/s w/ diff rates of dis. progression
Ex’s
- Tremor
- bradykinesia
- rigidity
- postural instab
- deficits in motor planning
- diff w/ dual-tasking
- loss of automaticity
- have to think about everything→ auto things no longer auto
- dystonia
- dec’d speed
- altered stride rate
- variable stride length
- GI sx’s
- soft voice
- mumbled OR fast speech
- loss of facial express (masked face)
- trouble swallowing → dysphagia
- diff chewing and probs communicating
PWP
Ex and Rehab programs
must be tailored to the individual
*PWP need to dev. long-term exercise habits
Data released from the National Parkinson’s Foundation’s Parkinson’s Outcome Project
shows PWP who start exercising earlier experience a significantly slower decline in QOL vs those who start later
PD Eval
Do you have a hx of falls and near falls?
How many in last 2 yrs?
*Indicator of fx risk and lvl of impair.
PD Eval
Do you see a neurologist regularly?
*Regular neuro care could save the lives of 1000s ea yr
- If no→ refer to one!
- If yes→ ASK:
-
Have you been staged using a formal scale?
- Hoehn and Yahr Scale OR Unified PD Rating Scale
- UPDRS rates PD as postural instability and gait disorder predominant (PIGD) OR Tremor Dominant
- PIGD→ faster disease progress, more diff w/ ADLs, greater disability, more intellectual impairment, higher depression rates, lack of motivation
-
Have you been staged using a formal scale?
postural instability and gait disorder predominant (PIGD)
PIGD→ faster disease progress, more diff w/ ADLs, greater disability, more intellectual impairment, higher depression rates, lack of motivation
PD Eval
What is your current level of exercise participation?
PWP NEED to dev. long-term exercise habits
PD Meds
What meds are you taking?
*name, dosage, timing and SEs→ “On/Off times”
*is pt tolerating meds? Has another provider prescribed additional meds? Did pt try a med and then stop?
Ex’s of meds:
- Cholinesterase Inhibitors
- Antipsychotics
- L-dopa
- SSRIs
- Clonazepam
PD Meds
Cholinesterase Inhibitors
*used to tx thinking changes in dementia
*can help w/ visual hallucinations, sleep disturbs, changes in thinking/behavior
PD Meds:
Antipsychotics
- Used to tx behavioral sx’s
- MAY cause serious SEs in up to 50% of those w/ PD dementia
- Can cause sudden changes in:
- impaired swallowing
- acute confusion
- eps of hallucinations
- appearance of worsening related to PD sx’s
PD meds:
L-dopa
- Chief tx for PD movement sx’s
- can aggravate hallucinations and confusion in those w/ PD dementia
PD meds:
SSRIs
- Selective Serotonin Reuptake Inhibitors→ tx depression
PD Meds:
Clonazepam
Can tx REM disorder
PD Assessment
IPE Approach
see pics
PD Tests and Measures
APTA Clinical Summary
*Evidenced Based approaches!!
Tests & Measures to perform
PD Interventions:
4 Key Elements:
- Promotion of task specific phys activity and lifelong participation in ex. program
- Strategy training→ impacted by cognition
- Mgmt of 2* Sequelae
- lack of consensus regarding rehab and fatigue lvls
- Fall prevention and risk reduction
PD Strategies
See pics of chart
PD Strategies
Mid/Early Stages
- Vigorous activity→ high intensity
- Task specific practice of relevant skills
- Standardized tx→ LSVT BIG
- Cog decline begins to become apparent→ try to get ahead of this
- retains ability to relearn motor skills
- Maint of flex, strength, CV function
- LSVT BIG
PD Strategies
Mod/Middle Stage
- Strategies similar to those used in Early stage, but w/ progress. LESS emphasis on impairs
- Cog ability becomes an issue
PD Strategies
Severe/Late Stage SAFETY
- Focus on compensatory strategies and safety
- Cog ability becomes issue
PD Strategies
Types of activities
- Resistance ex
- aerobic cond (neuro protective)
- balance re-ed
- dancing, boxing
- flexibility
PD Strategies
Mgmt of 2* Sequelae
Lack of consensus regarding rehab and fatigue lvls
PD Strategies
Dosage→ No consensus
- Lack Larger scale studies report:
- @ least 6 sessions of 45-60mins over 8 wks
- @ least 2.5 hours/week slows decline in QOL
1
PD Take Homes:
- Tx demos significnt short-term benefits→ ESP early/mid-stage dis.
- Need to teach long-term strategies and skills to maintain and slow progression
- education on HEP
- Clinicians should consider role of client cognition/non-motor sx’s and progress to compensatory strategies/education in LATER stage dis.
- Utilize client preferences to maximize long term adherence and determine specificity of task
- Specificity of task is shown to be HIGHLY IMPORTANT when selecting intervention strategies
2
PD Take Homes
- Task specific better than non-specific training
- Dual task activity performance show better carryover
- Auditory, rhythmic (music) cues help regulate walking (compared to visual or tactile)
- No matter the intervention, intensity appears to be the KEY COMPONENT
