1 Cardiovascular and Pulmonary Changes in the Geriatric Patient Tim Sauvage, MS, CRNA, ARNP

2 Cardiovascular Increase in afterload 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

3 Increases circulation time It takes longer for the blood to circulate Onset of intravenous medication is delayed Decrease/reduced myocardial pump function, reduced cardial output

4 All increase in the elderly: 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.

5 Increase in left ventricular wall tension Due to the chronic increase in afterload in the elderly Remember: the left ventricle will pump against the afterload Walls stay tense longer  Stiff  balloon

6 Increase in systolic blood pressure 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.

7 Increase in cardiac workload 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

8 Increase in peripheral vascular resistance The reduction in arterial compliance caused by fibrosis of the tunica media layer of the vessel.

9 Decrease in cardiac reserve Manifested as exaggerated drops in blood pressure

10 Decrease in resting heart rate 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?

11 Decrease in stroke volume A decreased myocardial pump function leads to decreased stroke volume and decreased cardial output. Ask about BP, HR, and volume

12 Decrease in left ventricular compliance 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 H 2 O pump

13 Decrease in barorecpetor function Due to decreased sensitivity of stretch receptors

14 Decrease perfusion to vital organs 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

15 Decrease in maximum cardiac output Due to increase in afterload (pressure)

16 Decrease in arterial compliance Based on stiffening of the walls of the vessel Less expandable Like PVC pipe

17 Geriatric Ventilation 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.

18 Peripheral Chemo Receptors Are found in the carotid bodies and the aortic bodies They respond to decreased PaO 2 (< 60 mmHg) – most responsive Increased hydrogen ion concentration (decreased arterial blood pH) Increased PaCO 2

19 Changes in the P A O 2 -PaO 2 gradient with age P A O 2 – PaO 2 = 0.21 x (age + 2.5) Normal P A O 2 – PaO 2 gradient > 5-15 mmHg (breathing room air) Based on the above formula: 20 yr old = yr old = yr old = yr old = yr old = yr old = yr old = 16.5  These numbers tell us that as we get older, our P A O 2 – PaO 2 gradient gets larger numerically and falls out of range when you reach 80 years old.

20 Spirometry: Normal

21 Flow Volume Loops Normal

22 Flow-volume loops associated with restrictive and obstructive disease 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 restricted- smaller 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

23 Closing Volume As airways begin to close, the volume that can be exhaled is the closing volume

24 Closing Capacity This is the closing volume plus the residual volume

25 Point: 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 CC = CV + RV; each increased

26 …OR….

27 Respiratory Increased risk of pulmonary complications 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

28 Increased risk of aspiration Due to vocal cord stimulation being elevated, thus putting the patient at risk for aspiration

29 Increased incidence of airway obstruction Decreased sensitivity of the need to clear secretions, food, etc. The decrease in laryngeal reflexes compunds the problem

30 Increase work of breathing Skeletal calcification and increased airway resistance increase the work of breathing. Predisposed to acute postoperative ventilatory failure

31 Increased potential for hypoxia 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

32 Increase in alveolar compliance Absorption of connective tissue Loss of protective netting to limit the expansion of alveoli

33 Increase in FRC Failure to hold alveoli open (lungs)

34 Increased closing capacity Caused by airway collapse and the distribution of tidal volumes to areas of the lung that are less perfused

35 Tissue elasticity decreases Some muscle is replaced with adipose tissue and less elastic components

36 Alveolar surface area decreases Alveolar wall tissue decreases Loss of recoil Less airway patency

37 Chest wall compliance decreases Cartilage and connective tissue become stiffer Increased stiffness of thoracic cage Restricted chest expansion

38 Response to hypoxia decreases Sensitivity of receptors is less

39 Cervical spine mobility decreases Chest wall non-compliant Arthritis Decrease in muscle stretch and elasticity

40 Lung recoil decreases Chest wall rigidity

41 Ability to meet heavy loads decreases

42 Ability to cough decreases Decreased muscle strength Takes more stimulation to cough

43 Questions?