Introduction
The number of older people is growing rapidly worldwide. Today, more than 580 million people are older than 60 years and the number is pro- jected to rise to 1000 million by 2020. The pro- portion of the population over 80 years, the so-called “old-old,” is increasing most rapidly. Life expectancy at all ages is also increasing. At 65 years, life expectancy ranges from 14.9 to 18.9 years and at 80 years from 6.9 to 9.1 years for men and women, respectively. With the increase in life expectancy, the leading causes of death have shifted dramatically from infectious diseases to non-communicable diseases. Cardiovascular dis- ease is the most frequent single cause of death in persons over 65 years of age, and most impor- tantly it is responsible for considerable morbidity and a large burden of disease, particularly in the community.1
Age-Related Structural Changes
Cardiovascular pathologies such as hypertension and cerebrovascular diseases and heart diseases such as coronary artery disease, arrhythmias, and heart failure increase in incidence with increasing age.2Age per se is the major risk factor for car- diovascular diseases because specific pathophysi- ological mechanisms that underlie these diseases become superimposed on cardiac and vascular substrates that have been modified by the “aging process.”3–6 Age-related changes are most likely to be seen in the “old-old” who have escaped
cardiovascular pathology earlier in life. This group demonstrates the dual processes, often interacting, of biological aging of the cardiovas- cular system and age-related pathology (Table 47-1). Age-related structural changes in the heart include increased left ventricular wall thickness independent of any increase in blood pressure,3 increased fibrosis and calcification of the valves, particularly the mitral annulus and the aortic valve,4,5and loss of cells in the sinoatrial node.5 The age-related vascular changes include increased stiffness of peripheral and central arter- ies,6increase in number of sites for lipid deposi- tion, and more diffuse coronary artery changes.
Age-Related Functional Changes
Age-related functional changes are determined by heart rate, preload and afterload, muscle perfor- mance, and neurohormonal regulation, all of which may be influenced by age. There is little change in left ventricular systolic function with increasing age, although cardiac output may decrease in parallel with a reduction in lean body mass.7Increases in heart rate in response to exer- cise or stress caused by non-cardiovascular ill- nesses, particularly infections, are attenuated with increasing age.8Stroke volume increases only by
“moving up” the Frank–Starling curve.9,10 Thus end-diastolic volume increases. These age-related changes in cardiac response to exercise are mim- icked by β-adrenergic blockade,11but β-adrener- gic agonists do not reverse this aging process.12 The decline in exercise performance with age may
47
Rehabilitation in Elderly Patients
Hugo Saner
383
additionally relate to peripheral factors, blood flow, and muscle mass rather than being solely the consequence of cardiac performance changes.
Diastolic function is a major determinant of cardiac output in elderly persons. The rate and volume of early diastolic filling decreases with age.13The aged heart requires atrial contraction to maintain adequate diastolic filling, so atrial fibrillation being common in older people has a disproportionate effect on cardiac function.7 Reduced ventricular compliance results in higher left ventricular diastolic pressure at rest and during exercise.8,13As a result, pulmonary and sys- temic venous congestion may occur in the pres- ence of normal systolic function.14With increased afterload on the left ventricle, left ventricular hypertrophy occurs, even in the absence of hyper- tension or aortic stenosis. Diastolic dysfunction, at least in the early stages, may be a feature of normal aging. Later, however, it is a pathological process leading to significant left ventricular hypertrophy. At this stage, coronary heart disease, hypertension, or other pathologies are probably involved.
Complicating Factors in Elderly Patients with Heart Disease
Elderly patients constitute a high percentage of patients with myocardial infarction, heart surgery, and percutaneous transluminal coronary angio- plasty (PTCA). Elderly patients are also at high risk of disability following a cardiovascular event (Table 47-2). The prevalence of diabetes and arte- rial hypertension is relatively high. There is also an increased incidence of complicated forms of coronary disease such as multi-vessel disease and left main coronary artery disease, severe and unstable angina as well as sinus node dysfunction, conduction disturbances, and heart failure.
The risk of complications is increased in elderly patients after myocardial infarction, coronary angiography, PTCA, and surgery of the heart or the thoracic aorta. The duration of hospitalization is usually prolonged. Severe deconditioning may be a consequence of prolonged immobility. The risk of neurological complications and also of cognitive defects after heart surgery is increased.
There is also a high incidence of co-morbidities.
The rate of negative side-effects of medications is increased. Degenerative changes of the muscu- loskeletal system may add to the difficulties which may be encountered during follow-up and reha- bilitation of such patients.
Cardiovascular Risk Factors
Regardless of predisposing factors, diet and lifestyle influence morbidity and mortality during the course of life. Because of the cumulative effect TABLE47-1. Cardiovascular adaptions in the elderly
– Increase in vascular stiffness and systolic blood pressure – Left ventricular hypertrophy
– Diastolic dysfunction and relaxation abnormality – Lower peak heart rate
– Slightly reduced cardiac output – Increased peripheral vascular resistance – Reduced peak oxygen consumption – Lower plasma renin activity – Reduced sensitivity to catecholamines – Reduction in skin blood flow
TABLE47-2. Complicating factors in elderly patients with cardiovascular disease – Diabetes mellitus and arterial hypertension
– Complicated forms of coronary disease (multi-vessel disease, left main artery disease) – Sinus node dysfunction, conduction disturbances
– Heart failure
– Increased complication rates after myocardial infarction, coronary arteriography, PTCA and heart surgery
– Prolonged hospitalization with severe deconditioning – Mental disturbances and cognitive deficits after heart surgery – Co-morbidities
– Increased rate of side-effects and dosage problems with medications – Musculoskeletal problems
because many studies observed an independent effect of alcohol on survival. This seems also to be true in elderly persons.23However, when interpret- ing the results of these studies it has to be kept in mind that the main focus of these studies is on primary prevention and that studies about the effects of dietary habits on cardiovascular events and mortality in the setting of secondary preven- tion are not yet based on solid scientific evidence.
Smoking Cessation
Smoking cessation has immediate positive conse- quences not only in younger, but also in elderly patients. Smoking cessation after aortocoronary bypass surgery in patients over 65 years of age decreases the mortality within a year after surgery by approximately 40%.24 Smoking leads to an immediate increase in blood pressure, peripheral vascular resistance and heart rate and leads to a decrease in flow-mediated vasodilatation of the arteries with concomitant increase in clotting ten- dency and a decrease in HDL cholesterol.25This indicates that elderly smokers should be encour- aged to stop smoking as is done in younger patients and they should also be offered nicotine replacement medications for suppression of craving if necessary. This recommendation is appropriate up to the age of 75–80 years; in old-old patients smoking cessation counseling becomes somewhat questionable, especially if patients are socially isolated after the loss of their friends and if they have the feeling that smoking is part of their quality of life.
Physical Activity
Physical activity is a key element for health in younger and in older people. There is good scientific evidence that physical training leads to improved cardiovascular fitness in elderly patients.26–28The risk of complications with phys- ical exertion is acceptable if the training is pre- ceded by screening for contraindications and followed by recommendations in regard to train- ing intensity.29,30 Furthermore regular physical activity helps to prevent important conditions in older age such as osteoporosis, non-insulin- dependent diabetes mellitus, hypertension, stroke, and perhaps even some cancers such as colon of adverse factors throughout life, it is particularly
important for elderly persons to adopt diet and lifestyle practices that minimize their risk of death from morbidity and maximize their prospects for healthful aging.
The cardiovascular risk profile in elderly patients differs considerably from that in younger patients (Table 47-3). There are fewer smokers but more patients with diabetes and arterial hypertension. The body mass generally decreases with age. The lipid profile shows generally lower triglycerides and a higher HDL cholesterol. Psy- chosocial risk factors such as hostility, anxiety, and stress are encountered with lower frequency compared to younger patients.15–17
The treatment of cardiovascular risk factors in elderly patients is as important as in younger patients. This is mainly due to the fact that car- diovascular disease is more prominent and the risk of acute complications is increased. The treat- ment includes a combination of lifestyle interven- tions with optimal medical therapy.
Nutrition
Although diet and lifestyle habits can change over time, generally they are characteristic of a person’s way of living and reflect life-long health.18This is mainly true for dietary patterns. The risk of cardiovascular complications and death in rela- tion to dietary habits has also been studied exten- sively in elderly patients.19–22 Adherence to a Mediterranean type diet decreases the risk of car- diovascular events as well as cardiovascular and all-cause mortality and cancer. The strongest asso- ciation was observed for coronary heart disease. In some Mediterranean diet scores alcohol has been included. However, moderate alcohol consump- tion is considered as a separate lifestyle factor TABLE47-3. Coronary risk profile in elderly cardiac patients – Lower body mass index
– Lower triglycerides – Higher HDL cholesterol – Reduced exercise capacity – More hypertension – More diabetes – Less smoking
– Less hostility, anxiety, and stress
cle. It has been shown that regular physical train- ing on 4 days a week over a time period of 12 months at 60–80% of maximal VO2 leads to an increase of the left ventricular ejection fraction of up to 20% in healthy elderly persons.33The effects of physical training on diastolic left ventricular function are less clear.
A comprehensive exercise program for elderly patients includes activities to develop strength, endurance, flexibility, and coordination in a pro- gressive and enjoyable way. It must use all major muscle groups in exercises that train through each individual’s fullest possible pain-free ranges of movement. An exercise program for elderly patients must also aim to load the bones; target major functional, postural and pelvic floor muscles; include practice of functional move- ments; and emphasize the development of body awareness and balance skill. A combination of regular recreational walking and water gymnas- tics (both at an intensity that is comfortably chal- lenging), preferably combined with specific exercises to improve strength and flexibility such as weight training, circuit training, step training, exercise to music, dancing, and Qi Gong,34 will meet most of these criteria for most people.
Psychosocial Aspects
Psychosocial aspects and mental health can be seriously affected in elderly patients with cardio- vascular disease. The impact of a cardiovascular event or intervention is usually more pronounced in elderly than in younger patients. Although per- sonality factors such as anger and hostility may be encountered less frequently in elderly than in younger patients, a pre-existing tendency to anxiety and depression may be more prominent after an acute cardiovascular event or intervention or new symptoms of depression may evolve. Cog- nitive impairment after heart surgery with extra- corporeal circulation may add to the psychosocial problems under such circumstances. Elderly patients often fear losing their independence by not being able to return to their own homes and the surroundings they are accustomed to. In such situations rehabilitative measures often con- tribute to a significant improvement of the physi- cal and psychological deficiencies, increasing the chances that the patient may be able to return cancer (Table 47-4). Its function-preserving
effects are also important.
Even healthy elderly people lose strength at a rate of 1–2% a year and power at a rate of 3–4% a year. The resulting weakness has important func- tional consequences for the performance of every- day activities. A similar argument applies for endurance capacity: 80% of women and 35% of men aged 70–74 years had an aerobic power to weight ratio so low that they would be unable to sustain comfortably a walk at 5 km/h.29
Regular exercise increases strength, endurance, and flexibility.30–32 In percentage terms, the improvements seen in elderly people are similar to those in younger people. However, there is a larger variation due to patient selection in regard to gender, initial fitness and type, intensity, fre- quency, and duration of the training program. The maximal increase of aerobic capacity with train- ing in elderly patients is about 35–40%. General training recommendations are similar in younger and in elderly patients. A stress test is mandatory before starting a physical training program in elderly patients. To achieve a sustained benefit from physical training this has to be performed at least 2–3 times a week for 20–30 minutes with a minimum heart rate of 50% of the maximal heart rate that has been achieved during a stress test on a treadmill or bicycle ergometer. An increase in training intensity up to 75–85% of the maximal heart rate that has been achieved during the stress test leads to a further improvement of aerobic capacity. These effects can be maintained through continuing training over months and years.
Physical training in elderly patients not only improves functional abilities, endurance, and strength but seems to have beneficial effects directly on the systolic function of the left ventri- TABLE 47-4. General benefits of physical training in elderly patients
– Emotional well-being, improved cognitive functions, and better mental health
– Physical well-being – Functional abilities
– Endurance and strength (with decreased risk of falls) – Decrease of blood pressure, blood glucose and blood lipids – Prevention of osteoporosis
– Psychosocial benefits including prevention of social isolation
home to a life as independent as possible. Depres- sion may lead to loneliness and a feeling of help- lessness with the consequence of social isolation.
Cardiovascular rehabilitation programs in elderly patients have to be targeted to help the patient during this difficult phase after an acute event by counseling, care, and physical training. Progress during physical training often leads to positive psychosocial changes including a decrease in anxiety and depression and improved social inte- gration.35,36Elderly patients take particular advan- tage of group dynamics when participating in a physical training program that is offered in groups.
Pharmacological Interventions in Secondary Prevention
A study involving a large number of patients showed a 4.5% absolute risk reduction for cardio- vascular events in high-risk patients aged 64 or older.37The patients in this study received differ- ent platelet aggregation inhibitors. However, pos- itive results in these elderly men and women have only been achieved by using aspirin as monother- apy. The number needed to treat to prevent a car- diovascular event was 20 over a period of 2 years.
The absolute risk of gastrointestinal bleeding with aspirin in those aged 70 years is about 3%, whereas the risk of a hemorrhagic cerebrovascu- lar insult is increased by 40%. There is also an increased tendency with age to become anemic with aspirin use. However, despite the somewhat increased risk for bleeding complications there is consensus that aspirin should be recommended to elderly patients in secondary prevention of car- diovascular diseases.38There is emerging evidence that clopidogrel may become a valuable substitute if aspirin is not well tolerated. Clopidogrel leads to an even more pronounced decrease of cardiovas- cular events than aspirin with a similar incidence of hemorrhagic complications.
Beta-Blockers
A meta-analysis of three placebo-controlled studies with beta-blockers after myocardial infarction shows a 6% reduction in total mortal- ity in patients aged 65–75 years compared to a
reduction of 2.1% in younger patients.39This indi- cates that the use of beta-blockers in elderly patients is even more efficient than in younger patients.40The number needed to treat in patients aged 65–75 years is 20 to avoid one death within 2 years.41 Despite these positive effects, elderly patients are less often treated with beta-blockers than younger patients. This is in part due to the fact that important contraindications for beta- blockers are more often encountered in elderly patients including asthma, chronic obstructive pulmonary disease, peripheral arterial disease, and the risk of hypoglycemia in patients with dia- betes. Furthermore beta-blockers lead more often to hypotension, symptomatic bradycardia, and bronchospasm in elderly compared to younger patients. In patients older than 80 years there is no scientific evidence to use beta-blockers in secondary prevention.
ACE Inhibitors
There are four larger studies indicating that the use of ACE inhibitors in patients after myocardial infarction is also beneficial in the age group between 65 and 80 years.40 The GISSI-3 study included 27% of patients older than 70 years; the absolute risk reduction for combined cardiovas- cular endpoints and mortality was 3.5 in this sub- population; the number needed to treat for 6 weeks after infarction to prevent such an event was 30. The three other studies indicate an absolute risk reduction of mortality in all age groups between 4% and 6%. In conclusion, therapy with ACE inhibitors is indicated in most patients for secondary prevention after myocar- dial infarction, in particular in patients with decreased left ventricular function.
Statins
In the Heart Protection Study, 20,536 people with a total cholesterol of>3.5mmol/L have been ran- domized to 40 mg simvastatin or placebo.42Sixty- five percent of these patients had coronary heart disease and 5860 patients were in the age group between 70 and 80 years at study entry. The risk reduction with statin therapy was 27% for coro- nary events and 25% for cardiovascular events.
The risk reduction was 22% in the age group
between 70 and 80 years. The risk reduction for a first coronary event was 20% in the age group between 70 and 80 years and 35% in the age group between 40 and 65 years. The PROSPER study included patients in the age group of 70 to 72 years with pre-existing cardiovascular disease and a total cholesterol between 4.9 and 9.0 mmol/L and triglycerides below 6.0 mmol/L.43 Patients have been randomized to 40 mg pravastatin daily or placebo. A total of 5804 patients in the age group between 70 and 80 years have been included and followed over 3 years. There was a reduction of 90% for coronary events under statin therapy but no reduction in overall cardiovascular events. This indicates that the advantages of statin therapy in patients older than 80 years are not evident. In conclusion, most men and women aged less than 80 years should receive statin therapy for sec- ondary prevention of coronary disease. However, the number needed to treat to prevent one car- diovascular event is 80 over a period of 5 years.
Cardiac Rehabilitation Programs
Data on exercise rehabilitation at elderly age are derived from one non-randomized controlled study and six observational studies, four of which compared older with younger coronary patients.
Patients up to age 82 were included, and the elderly patients included a significant proportion of women. Rates of entry into cardiac rehabilita- tion were substantially lower among elderly patients than among younger patients,44,45 and older women were even less likely to be referred for exercise rehabilitation than were older men.46 The non-randomized controlled trial also docu- mented statistically significant improvement in measures of exercise tolerance after exercise reha- bilitation, with no significant difference between older and younger patients. Patients older and younger than 70 years of age had comparable responses to exercise training, and women and men showed comparable improvements.
The six observational studies documented statistically significant improvements in exercise tolerance in both older and younger patients44–49 as well as comparable improvements in older men versus older women50and in patients aged 62–70 years versus patients older than 70 years. Elderly
patients were less fit after a coronary event, in part because of lesser fitness prior to the event; a lower peak exercise capacity was characteristic of elderly patients. Adherence to exercise was 90%,51 and significant reduction in coronary risk factors occurred in elderly patients who participated in multifactorial cardiac rehabilitation. No complica- tions or adverse outcomes of exercise training at elderly aged were described in any study. Elderly patients of both genders should therefore be strongly encouraged to participate in exercise- based cardiac rehabilitation.
The main goals of cardiac rehabilitation in elderly patients are summarized in Table 47-5. The main focus is somewhat different to that in younger patients.
The provision of cardiac rehabilitation services for elderly patients can be home based and nurse led,51,52community based,53,54or hospital based in the setting of a multidisciplinary cardiac rehabil- itation team. Elderly patients usually attend such cardiac rehabilitation programs two times a week and take advantage of the social integration in a group of patients of the same age. More treatment points should be given and should be repeated more often.
Physical Activity Programs
During physical activity more warnings of directional and step changes are necessary with emphasis on posture and technique. For endurance activities including gymnastics, walking and water gymnastics, 30 minutes of exercise two times a week seems appropriate and usually feasible. However, the older and frailer the participants, the greater the potential benefit from the inclusion of strengthening, stretching, balance and coordination activities and the greater the need for individually tailored exercise guidance from a trained specialist. As in younger patients, TABLE 47-5. Main goals of cardiac rehabilitation in elderly patients
– Preservation of mobility and independence – Preservation of mental function
– Prevention/treatment of anxiety and depression – Encouragement of social readaption and reintegration – Return to the same lifestyle as before the acute event
all sessions should start and finish gradually with a warm-up and cool-down. For frailer partici- pants, many of the activities should be related closely to daily life and maintaining indepen- dence. Techniques of lifting, walking, transferring (moving from sitting to standing, standing to lying), and even crawling should be specifically taught and discussed. Information about the specific benefits of particular exercises is greatly appreciated; for example, shoulder mobility for reaching zips; stamina for “energy” and less breathlessness during exhaustion; or quadriceps, hand grip and biceps strengthening for carrying shopping or using the bus.
Above all, fitness must be fun. Important factors can be variety, the use of appropriate equipment, games, music and opportunities for socializing. A home exercise program can usefully complement the organized session. Provision must be made for a wide range of initial levels of habitual physical activity and for a variety of disabilities. If water training and swimming is considered, one has to be aware that a considerable percentage of patients suffer from incontinence and should therefore not participate in this type of training.
A symptom-limited stress test using either a bicycle or a treadmill ergometer is mandatory before training in patients with cardiovascular disease. Although it is not a primary goal to train with a particular intensity, one should keep in mind that the most efficient and still safe endurance training is performed with a heart rate of 50–80% of the maximal heart rate which has been achieved during the stress test without signs of ischemia or rhythm disturbances. The use of the Borg scale to rate perceived exertion is also advised in elderly patients. A target of Borg 13/14 corresponds well with a heart rate of 60–85% of the maximal heart rate achieved during stress testing and therefore indicates an efficient but safe training intensity.
Educational Programs
Besides exercise training, elderly patients should also attend classes with information about car- diovascular disease, treatment options and medication, nutrition counseling, psychosocial support, and smoking cessation if necessary. Team members should be aware that the type of infor-
mation and the provision of the teaching is dif- ferent to that in groups with younger patients.
However, adherence to these teaching classes is high and the teaching atmosphere is usually pleas- ant and rewarding.
Benefits from Cardiac Rehabilitation Programs
A limited number of studies and publications are available in the field of exercise therapy and cardiac rehabilitation in elderly patients.44–51,55–62
The benefits of exercise training and risk factor intervention have been described earlier in this chapter. Comparing the effects of different service provision of cardiac rehabilitation, either home- based or as outpatient hospital-based programs, Marchionni and colleagues found similar short- term effects in regard to total work capacity and quality of life in each age group. However, patients with home-based cardiac rehabilitation had more prolonged positive effects at lower costs.63 The addition of cognitive behavior therapy may lead to greater improvements in self-reported physical function, particularly for patients with lower functioning at baseline.64 Improvement in cardiovascular fitness may also lead to improved cognitive performance, as healthy older adults completing an exercise program showed significant gains in multiple cognitive domains.65 Cardiac rehabilitation programs have been shown to effective in elderly patients after myocardial infarction.66There is also some indi- cation from a retrospective and non-randomized study that cardiac rehabilitation may improve outcome in elderly patients after percutaneous coronary intervention (PCI).67The authors found a lower incidence of major adverse cardiac events and restenosis when PCI patients are included in a cardiac rehabilitation program. Cardiac rehabil- itation programs can also successfully be used to optimize recovery outcomes of older individuals after aortocoronary bypass surgery.68
There is evidence from one randomized controlled trial that cardiac rehabilitation offers an effective model of care for older patients with heart failure.69 There were significant improvements in the NYHA classification and 6-minute walking distance at 24 weeks between the groups. Quality of life measured mainly by
the Minnesota Living with Heart Failure ques- tionnaire was improved with structured cardiac rehabilitation in elderly patients in several studies.63,70 Finally, there is one study indicating that early rehabilitation in patients >65 years of age reduces consumption of medical care during the first year after myocardial infarction and that therefore this type of intervention may be cost-effective.66
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