Background Information

During the aging process, the body experiences gradual changes. Although many of these changes are inevitable, studies show that some of the changes are less pronounced in elders who do not have cardiovascular diseases and associated risk factors.² This is especially true for elders who have lifestyles that include regular physical activity. However, most elders experience age-related changes in their cardiovascular systems, including changes in the heart muscle and vessels, peripheral vascular disease, and an increase in systolic pressure, which makes the heart work harder.³ Most coronary diseases are related to lifestyle and family history, as well as age. Chronic cardiac conditions include hypertension, angina pectoris, congestive heart failure, and peripheral vascular disease. Heart disease often accompanies other illnesses or conditions such as diabetes or chronic obstructive pulmonary disease; therefore, the COTA should be aware of any additional precautions or contraindications associated with these diagnoses and cardiovascular disease.

Medical treatment varies according to the condition and other individual health factors. Thrombolytics are used to prevent muscle damage from heart attacks. Other common drugs are those used to treat hypertension, angina, heart failure, and dysrhythmias. The COTA should be aware of the medications that the patient is taking and the associated side effects. If conservative treatments involving medications are not effective, then surgical interventions may be necessary. Surgical treatments may include angioplasty or a bypass for damaged arteries. In rare cases, treatment may involve a heart transplant to replace heart muscle that is irreversibly damaged. Cardiac management may include electromechanical devices such as pacemakers to achieve a normal heart rate (HR) and rhythm.

Heart disease may begin with a loss of elasticity in the small vessels, causing the heart to work harder to maintain blood flow to organs. A change in the temperature in the extremities, cyanosis, or an increase in systolic blood pressure may indicate circulatory insufficiency.⁴ Atherosclerosis is a condition in which lipid deposits accumulate on the walls of large and medium vessels.⁵ This narrows the lumen of these vessels, which restricts blood flow. Atherosclerosis of coronary vessels can produce ischemia, which causes angina (chest pain), a myocardial infarction (MI), or both, which damages the heart muscle. Atherosclerosis of cerebral vessels can lead to a cerebrovascular accident, or stroke. A change in the structure of the heart valves, either from viral illness or aging, may result in heart failure, a condition in which the heart cannot deliver enough oxygen to peripheral tissues.

Valvular disease may be heard as a murmur during a routine examination. When the left side of the heart fails, fluid accumulates in the lungs, causing exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, dyspnea at rest, pulmonary edema, weakness, and fatigue.⁴ When the right side of the heart fails, blood backs up in the periphery, causing systemic venous congestion, dependent edema, upper right quadrant pain, anorexia, nausea, bloating, and fatigue.⁶ Many elders with cardiovascular disease lose the ability to perform physical activities and lose independence in their daily skills.²

Psychosocial Aspects of Cardiac Dysfunctions

Cardiac dysfunction can have profound psychosocial implications on elders and their significant others. All elders react differently to a cardiac event, experiencing a wide range of emotions, including anxiety, depression, denial, and helplessness,⁷ but most progress through many stages of adjustment. Initially, the anxiety produced by fear of death, discomfort, dependence, and disability can have a profound effect and produce overwhelming feelings. Some elders demonstrate this anxiety in behavioral changes and may act out or become agitated. This level of anxiety places a physiological demand on the cardiac system at a time when rest is important. Elders experiencing a rapid change in their care status may also have difficulty with anxiety; as a result, anti-anxiety medications are often used to assist them. However, anti-anxiety medications can have unwanted side effects and lead to additional stress. Elders should be encouraged to voice their feelings and work with the health care team to alleviate their fears about the course of events. Good communication and supportive staff members are the key elements in reducing elders’ anxiety levels.⁸ Fear of another cardiac event can impair functional levels, especially in the early rehabilitation phase. Education and therapeutic intervention can help alleviate these fears. Once stable, elders should be encouraged to begin ambulation and self-care activities following the guidelines established by the registered occupational therapist (OTR). This helps to eliminate the helplessness elders may feel after a cardiac event. The longer that these two elements are delayed, the more helpless elders may feel, which can reinforce the disability.^7,8 (Chapter 12 includes a discussion of ways to address the sexual concerns of elders with heart disease.)

As elders begin to regain some strength and control over their activity, the denial of risk related to the disease may become evident. Denial gives some elders the mechanism necessary to cope with the cardiac event. This particular phase may be more prevalent in elders with coronary disease because the symptoms and characteristics associated with this disease are vague. COTAs must not try to break through the denial phase too soon. Facing the realities of the situation may be overwhelming and may create stress-related physical and emotional complications. COTAs can help elders by instructing them to monitor their performance carefully, thus reducing the risk for another cardiac event.

Some elders become depressed after a cardiac event. Inactivity and anxiety may trigger depression. Depression and anxiety combined can have a long-term effect on the elder’s physical and emotional well-being. Patients with depression are less likely to resume normal activity and are at an increased risk for death.⁷

COTAs can play a strong role in addressing the psychosocial aspects of cardiac disease by educating elders about the expected outcomes after a cardiac event. Relaxation training and lifestyle education are key elements in achieving emotional well-being. Informing the family of risks and precautions can assist elders in the transition to the home environment and ensure that elders have the best chance to regain their status in the home and community.⁹

Evaluation of Elders with Cardiac Conditions

COTAs working with elders who have had cardiac events or who have chronic cardiac conditions should be able to monitor vital signs. It is important that COTAs accurately determine HR and take blood pressure (BP) during activities. Guidelines for HR and BP responses are typically written as treatment precautions. To determine the HR, COTAs should palpate the elder’s pulse at the wrist, count the number of beats felt for 15 seconds, and then multiply this number by 4. This will provide a baseline HR in beats per minute (bpm) before the elder engages in activity. Although HRs vary, a normal baseline HR ranges between 60 and 100 bpm.⁹ Maximum HR corresponds with performing maximal levels of exertion that involve large muscle groups in rhythmic activities, such as walking and cycling. One method of predicting maximum HR is by subtracting the elder’s age from 220. This figure is multiplied by 0.6 to predict the appropriate HR response for normal activity.¹⁰ For example, a 78-year-old woman’s predicted maximum HR would be 142 bpm (220 – 78 = 142). Her HR appropriate for activity would be 85 (0.6 × 142 = 85 bpm). Signs and symptoms, such as dyspnea, must be considered when using formulas to predict activity HR values. Elders should perform activities in a symptom-free range. Some medications (beta-blockers, verapamil, and diltiazem) blunt the usual HR in response to exercise, especially in elders; therefore, watching symptoms is especially important.¹¹ In the first phase of cardiac rehabilitation, patients are often on continuous pulse oximetry. The COTA should be careful to ensure that the patient is maintaining pulse and oxygen saturation levels within the range set by the physician.

Likewise, the BP should be taken if a physician has so ordered or if the elder has symptoms of distress such as shortness of breath, dizziness, weakness, or cyanosis. Elders with hypertension should be monitored for excessive increases in the BP or orthostatic hypotension, which may occur as a side effect of medications. BP values greater than 140/90 mm Hg indicate mild hypertension, and those greater than 160/100 mm Hg indicate moderate hypertension.¹² BP is considered hypotensive if the systolic BP is less than 90 mm Hg. Hypotension can be associated with dizziness and light-headedness or, in severe cases, circulatory inadequacy of the extremities.⁹ In the presence of a shunt for renal dialysis, the BP should be read on the opposite limb. Renal shunts are fragile and cannot withstand the pressure produced by the BP cuff (sphygmomanometer) during BP monitoring. For training, COTAs should practice monitoring HR and BP with an instructor before performing care.

The COTA/OTR team should be able to perform a basic bedside activities of daily living (ADL) evaluation as part of the initial evaluation. This might include having the elder perform oral care, grooming tasks, washing of the upper body, and dressing. COTAs working with elders who have decreased endurance and low activity tolerance caused by cardiac disease may use metabolic equivalents (METs) as a basis for estimating the energy expended when performing an activity. The MET table provided along with HR and BP responses can help COTAs determine the cardiovascular stress and amount of work performed for specific tasks (Table 23-1).^13,14,15 Further areas to be assessed are grip strength, muscle strength, and bed mobility. The OT should also assess the patient’s cognitive abilities to ensure that the patient will be able to comprehend the education and interventions that the COTA is teaching.

TABLE 23-1 Santa Clara Valley Medical Center’s Metabolic Equivalents After Myocardial Infarction and After Open Heart Surgery

ICU, intensive care unit; MET, metabolic equivalent.

Interventions, Goals, and Strategies

For interventions to be effective, COTAs must understand the functional levels that are used to classify elders with cardiac disease. There are four functional categories for cardiac disease (Table 23-2). Knowing the categories allows COTAs to make adjustments in elders’ rehabilitation programs. The four phases of cardiac rehabilitation describe where the elder is in the recovery process (Table 23-3).

TABLE 23-2 The Four Functional Categories of Cardiac Disease

From New York Heart Association. (1979). Nomenclature and Criteria for Diagnoses of Diseases of the Heart and Great Vessels, 8th ed. Boston: Little, Brown.

TABLE 23-3 The Three Phases of Cardiac Rehabilitation

COTAs need to be aware of activities that can be stressful to the heart. Such activities include isometric and upper extremity activities, especially if performed at a level above the heart. The stress on the heart is reflected by the elder’s HR and BP responses, as well as other signs and symptoms. Consequently, any activity that produces excessive increases in HR and BP may overstress the heart (Box 23-1).

The primary goal of any cardiac rehabilitation program is to return elders to their maximum functional capacities. The COTA/OTR team must design an individualized rehabilitation program for each elder. Although the phases of rehabilitation follow certain key steps, each elder’s progress will be different. Psychosocial aspects, family support, age, and medical status, as well as the desire to participate in the rehabilitation program, affect progression. A rehabilitation intervention plan for OT with MET allowances for specific activities is useful (see Table 23-1).

Energy Conservation, Work Simplification, and other Education

During OT, elders receive education on energy conservation, work simplification, and cardiac status monitoring.¹⁶ Energy conservation is not only important for the elder’s well-being, but also it is a safety monitor for routine tasks. In the acute portion of cardiac rehabilitation, this component allows elders to set the pace of their self-care routines. Energy conservation begins with basic task analysis, which includes identifying the main steps in the task, analyzing the way the task is performed, and determining the tools or skills needed to perform the task. Once analyzed, the next component of work simplification is added. Having elders perform basic grooming at the bedside is an example of ADL energy conservation. Using the bedside table, with arms propped for energy conservation, the elder can perform grooming with all of the supplies and a basin of water on the table (Figure 23-1). Elders may need to be educated to take rest breaks during the task if they experience dyspnea or an increase in HR beyond the established parameters. The task can be simplified with a complete setup of supplies, including the removal of all caps from grooming supplies and the provision of a lightweight electric razor, if appropriate. With the elder in the semi-reclined position in bed, this task can be accomplished with no more than 1.5 METs. Other ADL functions are analyzed in the same manner, with the therapist identifying ways to reduce the energy expenditure (energy conservation) and minimize steps to perform the task (work simplification). The addition of assistive devices may be an added benefit (Table 23-4). (See Chapter 12 to learn about addressing sexuality aspects of ADL with heart disease.)

FIGURE 23-1 Elders should perform oral care with arms propped on a table.

TABLE 23-4 Assistive Devices and Rationale for Use

Elders should be educated to pace themselves during activities to reduce fatigue. The work–rest–work principle is important for elders to maintain in the acute phase, especially when denial is an issue. Elders in denial about their cardiac disease may want to prove they are well by overworking or pushing themselves, placing unnecessary stress on their damaged hearts.

Intervention with Elders with Cardiac Conditions in Other Settings

The chapter has focused primarily on cardiac rehabilitation when cardiac disease is the primary diagnosis. However, COTAs may encounter elders who have cardiac problems, perhaps as one of many chronic conditions, in settings such as nursing homes, outpatient clinics, or at home. Elders with acute cardiac conditions eventually may be transferred from the cardiac rehabilitation setting to another setting for further rehabilitation. In these settings, COTAs who are not formally trained in cardiac rehabilitation need to be aware of treatment approaches and precautions. Elders with cardiac conditions in any setting need to be educated on work simplification and energy conservation. The optimal approach is to demonstrate work simplification and energy conservation during the performance of meaningful tasks.

The primary recommendation for all elders with cardiac conditions is to monitor responses to activity by measuring HR, BP, and respiratory rate at rest, during activity, and during recovery. Activities that elicit excessive increases in HR or BP or that elicit abnormal signs and symptoms should not be performed or should be modified to ensure appropriate responses. Elders who have had coronary artery bypass graft surgery are often given lifting restrictions. Recommendations vary by physician and often include not lifting more than 10 lb for at least 1 month after surgery. Lifting precautions may also be recommended for elders who have had a procedure involving catheterization of the femoral artery, such as angioplasty and stent placement. Lifting guidelines for these procedures, determined by the elder’s physician, are based on the elder’s lifestyle and physical status and the specific procedures performed.⁹

Recognition of distress signals is vital in any setting when working with elders with cardiac dysfunction. Primary signs and symptoms are chest pain, shortness of breath, cyanosis, sweating, fatigue, weakness, and confusion. Elders with cardiac dysfunction often complain of burning or pressure in the chest or of upper extremity, jaw, or cervical pain. These symptoms may occur with elders who have congestive heart failure, dysrhythmias, or a history of MI or angina.⁴ If elders demonstrate or report any of these symptoms, the COTA should monitor their BP, HR, and ECG readings for changes in medical status. Any abnormal sign or symptom should be documented and discussed with the OTR and other health care professionals.

Another key area is the type of medication that elders with cardiac or BP problems are taking. Anticoagulants are commonly used for elders who have hypertension or who have had a cerebrovascular accident or hip or knee replacement surgery. Nitroglycerin is a common medication for elders with angina pectoris. Table 23-5 lists commonly prescribed medications. Knowledge of which medications elders are taking and their side effects is important to any therapist, but especially to those who perform therapy services through a home health agency or in a community setting.

TABLE 23-5 Examples of Common Medications and Potential Side Effects

ACE, angiotensin-converting enzyme; CNS, central nervous system; GI, gastrointestinal; MI, myocardial infarction; SNS, sympathetic nervous system.

Case Study

Adelle, who is 79 years old, is receiving OT in an acute care hospital setting after a coronary bypass graft. Her medical history includes type II diabetes mellitus, hypertension, peripheral vascular disease, and iron deficiency anemia. Her occupational history includes interests in growing tomatoes and volunteering at her church, where she answers the telephone and sends welcome letters to new members. She lives alone in a home with three stairs. Some adaptations have been made in the home environment such as a tub/shower combination on the main level next to her bedroom. Adelle would like to remain independent with doing self-care and light homemaking tasks, managing her health, and gardening. Her son and daughter live nearby and drive her to appointments, shopping, and social activities. Her friends from her church visit weekly and they tend to her garden together. Adelle’s niece helps her with vacuuming and cleaning the bathroom.

Trina, the COTA, has been educating Adelle on energy conservation and work simplification techniques. They have practiced pacing self-care activities in bed and have discussed techniques for gardening and cooking simple meals when she returns home. Trina has also provided Adelle with handouts and a home program. Adelle will be receiving home health OT, and Trina will be communicating with the home health OTR to update her on Adelle’s progress and goals in the acute care hospital program.