An increasing number of cardiac patients are above the age of 65 years . They are susceptible to the adverse effect of bed rest . So early mobilization is especially important to return them to active and independent lifestyle. - Most of the patients with heart failure, are elderly patients, shooting up to 80% in both incidence and prevalence.This is due to improved and better survival after cardiac insults, such as myocardial infarction, especially in developed countries.(AHA,2013). -The safety and efficacy of cardiac rehabilitation have been demonstrated in the elderly (age >65 years) .(Pasquali ,et al.,2001) -CR has a class IA recommendation by the AHA and ACSM for secondary prevention after any coronary heart disease

1. CENTER FOR PHYSIOTHERAPYAND REHABILITATION SCIENCE
JAMIA MILLIA ISLAMIA
Topic: Special consideration in cardiac rehabilitation program for older
adults.
Shagufa Amber
MPT- 3rd Semester
Roll no.- 19MPC0006

2. CARDIAC REHABILITATION IN OLDER ADULTS
An increasing number of cardiac patients are above the age of 65 years . They are
susceptible to the adverse effect of bed rest . So early mobilization is especially important
to return them to active and independent lifestyle.
- Most of the patients with heart failure, are elderly patients, shooting up to 80% in both
incidence and prevalence.This is due to improved and better survival after cardiac insults,
such as myocardial infarction, especially in developed countries.(AHA,2013).
-The safety and efficacy of cardiac rehabilitation have been demonstrated in the elderly
(age >65 years) .(Pasquali ,et al.,2001)
-CR has a class IA recommendation by the AHA and ACSM for secondary prevention after
any coronary heart disease

3. Reasons for nonparticipation in Cardiac Rehabilitation:
1. Low rate of physician referral
2. Geographic maldistribution of programs
3.Systems-based barriers such as a poor degree of automation in hospital systems in
securing CR referrals.
4.Financial constraints.
5.Lack of awareness
-The elderly patient is often poorly fit and may suffer from significant muscle atrophy,
orthostatic intolerance, hypertension, diabetes Mellitus, , chronic obstructive lung disease,
mental depression, and degenerative bone disease in addition to CAD which may further
complicate the exercise prescription. The disability rates in older coronary patients is high

4. Specific to Older Cardiac Patients- Baseline Evaluation
Components
It extends beyond the standard clinical review, stress test, and risk factor review performed
in younger patients.
• Mental status
• Gait and balance
• Vision and hearing
• Physical function and home activity requirements
• Transportation requirements
• Psychosocial assessment: • Social isolation • Depression and anxiety
• Ability to physically navigate the rehabilitation facility
• Nutritional assessment
• Cognitive status assessment
Due to severe deconditioning, the older persons are often incapable of performing a standard
exercise tolerance test. Instead, other submaximal evaluations of the performance of specific
activities such as the 6-minute walk, timed stair climbing, or simulated activities of daily
living can also be used to evaluate the functional status of the older individual.

5. Points to consider during CR in Older Patients:
•Overall-There is decreased musculoskeletal function, decreased mobility, slower reflexes,
impaired senses, diminished short-term memory, limitations of balance and range of
motion, and co morbidities. Floor surfaces require slip prevention.
• Exercise –The equipment’s stability(avoiding tipping, loss of balance and injuries), use
of devices for mounting and dismounting, using cue cards, re-reading instructions ,and
focussing on ADL’s, recreational activities and functional independence.
•Education- It should take account of the impaired senses( hearing and vision).
In case of cognitive impairment, greater one-on-one supervision is needed. Keeping in
mind their timings, safety and identifying barriers to learning. The socialization counters
some of the deleterious effects of social isolation and mental depression.
Exercise duration and frequency should be advanced before exercise intensity,(as fitness
improves) based on target heart rate and ratings of perceived exertion.

6. Individualization of the exercise prescription is essential for elderly patient to minimize the
risk of cardiovascular and orthopaedic complications. The design should be to follow up the
principles described earlier. The goal of physical activity is to maintain functional capacity
for independent living.
Intensity
Exercise intensity is generally prescribed using the previously described
technique.(MET,HRR,RPE). However there may be an exception in the elderly .
It is generally accepted that the relative HRmax reserve corresponds to relative VO2 max .
Pantoo et al., have shown there the use of the HRmax reserve method in 60 to 80 year old
person result in an under prediction (5% to 10% of the true exercise intensity based on
patient VO2 Max). The elderly coronary patient generally starts with a lower intensity of
exercise because of limited functional capacity.
Exercise training at intensity as low as 30% to 40% of VO2 max improves
cardiorespiratory fitness in very low fit individuals.

7. Duration and Frequency
Interval training of 2 to 6 minutes with 1-min to 2-min rest in both the in-patient and early
outpatient phase.
When patient better tolerates then, progressed to 30 to 60 minutes of continuous exercise .
The frequency of exercise should be 2-3 times a day during the initial stage of the program
and progress up to 5 times per week when longer durations of exercise can be sustained.
Mode of training
The activities involves low impact of the feet and leg and make rhythmic use of large
muscle groups.
Walking, stationary cycling and combination of arm and leg work are excellent activities for
the elderly patients.It improves aerobic fitness and is the most basic home physical activity.
Swimming is beneficial to patients who also suffer from arthritis or other degenerative bone
disease.

8. Resistance training for older cardiac patients :
The need for resistance and flexibility exercises is indicated, as muscle atrophy and
weakness in the elderly have been linked to recurrent falls which is major cause of morbidity
and morality . The feasibility and efficiency of resistance training in the elderly has been
established.
The intensity is optimal performance of single-repetition maximal (1RM) in the CR, though
it can also be guided by perceived exertion using the Borg scale.
Resistance training includes the same activity as described for MI &CABG patients but is
typically performed with lighter weights and up to 15 or 20 repetitions .

9. Resistance Training Prescription in Older Coronary
Patients ( Williams et al. 2007)
INTENSITY 50% to 80% of 1RM
REPETITION 10 to 15, with appropriate body mechanics, avoiding breath
holding or straining, and not to failure
SETS One or two
FREQUENCY Two or three times per week
MODALITY Minimum of two from each of these groups
Lower body: leg extension (quadriceps) • Leg press (gluteals,
quadriceps) • Leg curls (hamstrings)
Upper body: bench press (pectoralis) • Shoulder press (deltoids,
triceps) • Arm curls (biceps) • Triceps extension (triceps) • Lateral
pull-down (latissimus)

10. Progression:
The progression in elderly is generally slower and the warm up and cool down periods
should be longer to allow the body more time to prepare for recovery from activity.
Exercise in hot environment should be avoided due to impaired mechanisms of heat
dissipation. During the early phase of cardiac rehabilitation, during ambulation
precaution shall be taken because of high incidence of orthostatic hypotension and
subsequent fall .

11. Secondary Prevention in Older Cardiac Patients.
(Fleg et al. 2002.)
Dyslipidemia • Dietary counselling (eliminate trans fats, decrease saturated fats,
increase soluble fiber and monounsaturated oils)
Weight reduction
Cardiovascular endurance exercise
Hypertension • Weight reduction • Limit sodium intake • Aerobic exercise
Type 2 diabetes, insulin
resistance, obesity
Weight reduction
Aerobic and resistance exercise
Physical inactivity Physical activity
Psychosocial
dysfunction
Group exercise programming
Psychological counselling
Tobacco use Nicotine replacement pharmacologic therapy
Group smoking cessation program

12. Author/Jo
urnal’s
name/Imp
act factor
Title Methodology Result Conclusion
Baldasseroni
et al., 2016
The
American
Geriatrics
Society
IF-3.4
Cardiac
Rehabilitation
in Very Old
Adults: Effect
of Baseline
Functional
Capacity on
Treatment
Effectiveness
Individuals aged 75 and older
were referred to an outpatient
CR unit after an acute coronary
event (unstable angina pectoris,
acute myocardial infarction) or
cardiac surgery (coronary artery
bypass grafting, heart valve
replacement or repair) (N =
160, mean age 80 ) Peak
oxygen consumption (VO2
peak, power) during a
symptom-limited
cardiopulmonary stress test,
distance walked in a 6-minute
walk test (6MWT, resistance),
and peak torque (strength)
using an isokinetic
dynamometer, were assessed at
baseline and at discharge from
a 4-week supervised training
program.
Index of physical
performance improved
from baseline to
discharge (VO2 peak,
10.9%; 6MWT, 11.0%;
peak torque, 11.5%).
Baseline performance
was independently
associated with changes
in all three indexes, with
higher baseline values
predicting less
improvement.
An exercise-based
CR program was
associated with
improvement in all
domains of physical
performance even in
older adults after an
acute coronary event
or cardiac surgical
intervention,
particularly in those
with poorer baseline
performance.

13. Author/J
ournal’s
name/Im
pact
factor
Title Methodology Result Conclusion
Chen et
al., 2018
Medicine
IF-2.1
Home-based
cardiac
rehabilitation
improves
quality of life,
aerobic
capacity, and
readmission
rates in patients
with chronic
heart failure
This study included HF patients with
LVEF of less than 50% . They
randomly assigned patients to the
control group (n=18) and the
interventional group (n=19). In the
interventional group, individualized
rehabilitation programs, including
home-based cardiac rehabilitation,
diet education, and management of
daily activity was done for 3-month
.Information such as general data,
laboratory data, Cardiopulmonary
Exercise Test (CPET) results, Six-
minute Walk Test (6MWT) results,
and the scores for the Minnesota
Living with Heart Failure
Questionnaire (MLHFQ) before and
after the intervention, was collected
from all patients in this study.
The home-based
cardiac rehabilitation
programs displayed
statistically significant
improvement . The
patients receiving
home-based cardiac
rehabilitation
experienced a 14.2%
increase in VO2 peak, a
37% increase in QOL
score, and an
improvement of 41m
on the 6MWD test. The
90-day readmission
rate for patients
reduced to 5% from
14% after receiving
cardiac rehabilitation.
Home-based
cardiac
rehabilitation
offered the most
improved results in
functional capacity,
QOL, and reduced
the rate of
readmission within
90 days.

14. Reference:
1.Chodzko-Zajko WJ, Proctor DN, Fiatarone-Singh M, et al. American College of Sports Medicine position stand. Exercise and physical
activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510–30.
2. . Pinsky JL, Jette AM, Branch LG, Kannel WB, Feinleib M. The Framingham Disability Study: relationship of various coronary heart
disease manifestations to disability in older persons living in the community. Am J Public Health. 1990;80:1363-1367
3. Suaya JA, Shepard DS, Normand SLT, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after
myocardial infarction or coronary bypass surgery. Circulation. 2007;116:1653-1662.
4. Ades PA, Waldmann ML, McCann W, Weaver SO. Predictors of cardiac rehabilitation participation in older coronary patients. Arch
Intern Med. 1992;152:1033-1035.
13. Curnier D, Savage PD, Ades PA. Geographic distribution of cardiac rehabilitation programs in the U.S. J Cardiopulm Rehabil.
2005;25:80-84.
5. Gurewich D, Prottas J, Bhalotra S, Suaya JA, Shepard DS. System-level factors and use of cardiac rehabilitation. J Cardiopulm Rehabil
Prev. 2008;28:380-385.
6. Ades PA, Savage PD, Brawner CA, et al. Aerobic capacity in patients entering cardiac rehabilitation. Circulation. 2006;113:2706-2712.
7. Ades PA, Savage PD, Tischler MD, Poehlman ET, Dee J, Niggel J. Determinants of disability in older coronary patients. Am Heart J.
2002;143:151-156.
8. Sanderson B, Bittner V. Practical interpretation of 6-minute walk data using healthy adult reference equations. J Cardiopulm Rehabil.
2006;26:167-171. 18. Ades PA, Savage PD, Cress ME, Brochu M, Lee NM, Poehlman ET. Resistance training improves performance of
daily activities in disabled older women with coronary heart disease. Med Sci Sports Exerc. 2003;35:1265-1270.
9. Williams MA, Haskell WL, Ades PA, et al. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a
scientific statement from the American Heart Association. Circulation. 2007;116:572-584.
10.American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia: Lippincott
Williams & Wilkins, 2009.
11.Ades PA, Maloney AE, Savage P, Carhart RL Jr. Determinants of physical function in coronary patients: response to cardiac
rehabilitation. Arch Intern Med. 1999;159:2357-2360.
12. Go AS, Mozaffarian D, Roger VL, et al. Executive summary: heart disease and stroke statistics–2013 update: a report from the
American Heart Association. Circulation. 2013;127:143–152.
13. Pasquali SK, Alexander KP, Peterson ED. Cardiac rehabilitation in the elderly. American heart journal. 2001 Nov 1;142(5):748-55.
14. Pollock, M. L., Franklin, B. A., Balady, G. J., Chaitman, B. L., Fleg, J. L., Fletcher, B., ... & Bazzarre, T. (2000). Resistance exercise in
individuals with and without cardiovascular disease: benefits, rationale, safety, and prescription an advisory from the committee on
exercise, rehabilitation, and prevention, council on clinical cardiology, American Heart Association. Circulation, 101(7), 828-833.

16. Thank you!