Cardiovascular and Pulmonary Changes in the Geriatric Patient

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Cardiovascular and Pulmonary Changes in the
Geriatric Patient

• Tim Sauvage, MS, CRNA, ARNP

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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

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• 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

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• 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.

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• 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

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• 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.

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• 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

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

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

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• 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?

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• Decrease in stroke volume
• 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
• 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
• Due to decreased sensitivity of stretch receptors

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• 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

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

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

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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.

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Peripheral Chemo Receptors

• Are found in the carotid bodies and the aortic
  bodies
• They respond to decreased PaO2 (lt 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

• PAO2 PaO2 0.21 x (age 2.5)
• Normal PAO2 PaO2 gradient
• gt 5-15 mmHg (breathing room air)
• Based on the above formula
• 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

• ? 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

• Normal

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• 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

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Closing Volume

• As airways begin to close, the volume that can be
  exhaled is the closing volume

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Closing Capacity

• This is the closing volume plus the residual
  volume

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• 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

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OR.
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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

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

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• Increased incidence of airway obstruction
• 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
• 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
• 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
• Absorption of connective tissue
• Loss of protective netting to limit the expansion
  of alveoli

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

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• Increased closing capacity
• 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
• Some muscle is replaced with adipose tissue and
  less elastic components

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

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

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• Response to hypoxia decreases
• Sensitivity of receptors is less

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

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• Lung recoil decreases
• Chest wall rigidity

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• Ability to meet heavy loads decreases

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

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Questions?