Transcript Cardiovascular and ____ in the Geriatric Patient

Cardiovascular and
Pulmonary Changes in
the Geriatric Patient
Tim Sauvage, MS, CRNA, ARNP
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Cardiovascular
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Increase in afterload
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Buildup of plaque = ↓ radius
Left ventricle works harder to
empty
Takes more time to empty the left
ventricle
Decrease in arterial compliance and
increased impedance to left
ventricular output
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Increases circulation time
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It takes longer for the blood to circulate
Onset of intravenous medication is delayed
Decrease/reduced myocardial pump function, reduced
cardial output
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All increase in the elderly:
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Conduction fibrosis
Incidence of dysrhythmia
SA node cell loss
Conduction system fibrosis and loss of SA nodal cells will
increase the incidence of dysrthythmias
SA nodal cells do not replicate as when they were young
Vagal tone – a decrease sensitivity of adrenergetic receptors
leads to decreases in heart rate.
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Increase in left ventricular wall tension
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Due to the chronic increase in afterload in the elderly
Remember: the left ventricle will pump against the
afterload
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Walls stay tense longer
 Stiff
 balloon
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Increase in systolic blood pressure
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Usually seen with increased arterial pulse pressure
caused by gradual increases in large artery stiffness
Arteries are less compliant – more like PVC pipe
As the SV leaves the L.V., it does so as one volume
and the energy is absorbed into the arterial wall by
dilation.
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Increase in cardiac workload
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A reduction in arterial compliance results in increases
in afterload, systolic pressure, and left ventricular
hypertrophy
Stiff vessels will increase after L hypertrophy – stretch
of muscle fibers
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Increase in peripheral vascular resistance
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The reduction in arterial compliance caused by
fibrosis of the tunica media layer of the vessel.
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Decrease in cardiac reserve
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Manifested as exaggerated drops in blood pressure
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Decrease in resting heart rate
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Due to an increase in vagal tone and normal aging loss
of one beat per minute for each year over 50 years.
Can the elderly compensate for decreases in BP
Decrease in heart rate?
What about Beta blockers?
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Decrease in stroke volume
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A decreased myocardial pump function leads to
decreased stroke volume and decreased cardial output.
Ask about BP, HR, and volume
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Decrease in left ventricular compliance
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Based on stiffer myocardial fibers and replacement of
these fibers with non-muscle connective tissue.
Stiff, not as flexible
Not as good a pump
Stiff seal in H2O pump
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Decrease in barorecpetor function
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Due to decreased sensitivity of stretch receptors
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Decrease perfusion to vital organs
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Organs with a major blood supply, atrophy as you age
and this results in less blood pumped to them.
There is a general loss of tissue mass in many organs
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Decrease in maximum cardiac output
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Due to increase in afterload (pressure)
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Decrease in arterial compliance
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Based on stiffening of the walls of the vessel
Less expandable
Like PVC pipe
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Geriatric Ventilation
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As we have completed the cardiac section, lets
look at aspects of the cardiac that may follow
through to respiratory.
The area I see is the carotid bodies decreased
sensitivity and the conduction fibrosis.
The replication of receptor (sensory, chemo,
pressure, stretch) are not nearly as functional or
selectively sensitive as they were years ago.
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Peripheral Chemo Receptors
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Are found in the carotid bodies and the aortic
bodies
They respond to decreased PaO2 (< 60 mmHg)
– most responsive
Increased hydrogen ion concentration
(decreased arterial blood pH)
Increased PaCO2
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Changes in the PAO2-PaO2 gradient
with age
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PAO2 – PaO2 = 0.21 x (age + 2.5)
Normal PAO2 – PaO2 gradient
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> 5-15 mmHg (breathing room air)
Based on the above formula:
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20 yr old = 4.4
30 yr old = 6.5
40 yr old = 8.5
50 yr old = 10.5
60 yr old = 12.5
70 yr old = 14.5
80 yr old = 16.5
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 These numbers tell us that as
we get older, our PAO2 – PaO2
gradient gets larger numerically
and falls out of range when you
reach 80 years old.
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Spirometry: Normal
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Flow Volume Loops
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Normal
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Flow-volume loops associated
with restrictive and obstructive
disease
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With restrictive lung disease, the
flow-volume loop still looks like
an upside-down “baby” ice
cream cone; however, lung
volumes are smaller – remember
that the lungs are restrictedsmaller volumes. With
obstructive lung disease, one side
of the upside down ice cream
cone appears caved in (the loop
looks like a baby carriage
without wheels); also, lung
volumes are greater
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Closing Volume
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As airways begin to close, the volume that can
be exhaled is the closing volume
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Closing Capacity
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This is the closing volume plus the residual
volume
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Point:
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As you age (60yrs), there is a constant change taking place. The
closing volume of the older patient increased from the younger person.
It increased enough to be part of the tidal volume.
Residual volume increased in the older person
Closing capacity increased in the older person
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CC = CV + RV; each increased
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…OR….
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Respiratory
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Increased risk of
pulmonary complications
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Aspiration pneumonia is
common and life threatening
due to a decrease in
protective laryngeal reflexes
with age
Also, the decreased ability to
cough adds to increased
pulmonary complications
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Increased risk of aspiration
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Due to vocal cord stimulation being elevated, thus
putting the patient at risk for aspiration
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Increased incidence of airway obstruction
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Decreased sensitivity of the need to clear secretions,
food, etc.
The decrease in laryngeal reflexes compunds the
problem
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Increase work of breathing
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Skeletal calcification and
increased airway resistance
increase the work of
breathing.
Predisposed to acute
postoperative ventilatory
failure
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Increased potential for hypoxia
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Decreased elasticity of lung tissue which reduces
alveolar surface area and decrease the efficieny of gas
exchange
Airway collapse and a decrease in normal oxygen
tension
V/Q mismatch, increase in pre-oxygenation time
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Increase in alveolar compliance
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Absorption of connective tissue
Loss of protective netting to limit the expansion of
alveoli
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Increase in FRC
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Failure to hold alveoli open (lungs)
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Increased closing capacity
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Caused by airway collapse and the distribution of tidal
volumes to areas of the lung that are less perfused
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Tissue elasticity decreases
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Some muscle is replaced with adipose tissue and less
elastic components
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Alveolar surface area decreases
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Alveolar wall tissue decreases
Loss of recoil
Less airway patency
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Chest wall compliance decreases
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Cartilage and connective tissue become stiffer
Increased stiffness of thoracic cage
Restricted chest expansion
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Response to hypoxia decreases
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Sensitivity of receptors is less
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Cervical spine mobility decreases
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Chest wall non-compliant
Arthritis
Decrease in muscle stretch and elasticity
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Lung recoil decreases
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Chest wall rigidity
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Ability to meet heavy loads decreases
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Ability to cough decreases
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Decreased muscle strength
Takes more stimulation to cough
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Questions?
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