Geriatric Cardiac and Pulmonary Rehabilitation - #92
Take QuizBy assessing comorbidities, frailty and disease status in context of function and care goals, the appropriateness of cardiac or pulmonary rehabilitation for geriatric patients can be determined.
Cardiac and pulmonary rehabilitation (“cardiopulmonary rehab”) may benefit older adults with chronic obstructive pulmonary disease (COPD)1, congestive heart failure (CHF)2, or cardiovascular disease (CVD)3. Older patients are less likely to receive rehab referrals than age matched peers, making specialized rehab an underutilized intervention, despite evidence of benefit in frail and elderly populations.
Which patients may benefit?
- CHF with ejection fraction of 35% or less or NYHA symptoms II-IV4
- CAD with chronic stable angina, recent acute myocardial infarction, percutaneous intervention, or coronary artery bypass grafting5
- COPD at stage II or worse (FEV1 < 80%) with documented pulmonary function testing and functional limitations or symptom burden despite usual care6
What are potential contraindications to participation?
- Uncontrolled:
- cardiac disease (e.g., unstable angina, decompensated heart failure, ventricular arrythmia, pulmonary arterial hypertension with PASP >60 mmHg, symptomatic valvular disease)
- pulmonary disease (e.g., COPD exacerbations, exercise induced hypoxia)
- organ failure (e.g., hepatic or renal failure, uncontrolled infectious or inflammatory disease)
- Psychiatric disease or cognitive impairment with limited ability to follow instructions
- Musculoskeletal or functional limitations that leave a patient totally/nearly bed or chair bound
- Patient factors limiting participation (e.g.; travel distance or transport to rehabilitation location, depression, patient understanding of illness). Specialized rehab is not well studied in patients with a limited prognosis (<1 year).
What benefits may patients experience?
- Improved:
- quality of life, function, and symptoms7
- exercise tolerance and disease characteristics7
- strength, balance and gait
- care outcomes: decreased hospitalization and mortality in cardiac disease (Note: There is no evidence of mortality benefit for pulmonary rehab in COPD)8
How is effectiveness measured?
- Assess burden of disease on daily living including functional assessment and symptom burden including relieving and exacerbating factors. Functional assessment scales may be used, including:
- Activities of Daily Living – Barthel Scale (ADL)
- Instrumental Activities of Daily Living – Lawton Scale (IADL)
Older adults with cardiac or pulmonary disease experiencing reduced quality of life, function, or symptom control, or with recent or planned cardiopulmonary procedures.
Determine appropriateness of cardiac or pulmonary rehabilitation for geriatric patients by assessing comorbidities, frailty and disease status in context of function and care goals.
What is cardiac and pulmonary rehabilitation?
- Cardiac rehabilitation – 12-week program with up to 36 sessions including evaluation, modification of cardiac risk factors through nutrition and lifestyle changes, individual and group psychologic support and prescription of an exercise program.3
- Pulmonary rehabilitation – 4 to 12-week multidisciplinary program meeting multiple times a week. Sessions may include exercise training, breathing exercises, nutritional intervention, individual and group psychological support, and education.6
- List three components of cardiac and of pulmonary rehabilitation programs.
- List characteristics of patients who may benefit from cardiopulmonary rehabilitation.
- Identify three physiologic benefits of engaging in cardiac and pulmonary rehabilitation.
Review of Systems (ROS)
Geriatric Topics
ACGME Compentencies
Science Principles
- Li W, Pu Y, Meng A, Zhi X, Xu G. Effectiveness of pulmonary rehabilitation in elderly patients with COPD: A systematic review and meta‐analysis of randomized controlled trials. International journal of nursing practice. 2019;25(5):e12745.
- Austin J, Williams R, Ross L, Moseley L, Hutchison S. Randomised controlled trial of cardiac rehabilitation in elderly patients with heart failure. European Journal of Heart Failure. 2005;7(3):411-417.
- Lutz A, Delligatti A, Allsup K, Forman D. CAN CARDIAC REHABILITATION IMPROVE FRAILTY IN ADULTS WITH CARDIOVASCULAR DISEASE? Journal of the American College of Cardiology. 2019;73(9 Supplement 1):1730.
- Medicare Cf, Services M. Decision memo for cardiac rehabilitation (CR) programs—chronic heart failure (CAG-00437N). Medicare Coverage Database Baltimore, MD: CMS. 2014;
- Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. Journal of the American College of Cardiology. 2016;67(1):1-12.
- McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane database of systematic reviews. 2015;(2)
- Marchionni N, Fattirolli F, Fumagalli S, et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial. Circulation. 2003;107(17):2201-2206.
- Houchen-Wolloff L, Williams JE, Green RH, et al. Survival following pulmonary rehabilitation in patients with COPD: the effect of program completion and change in incremental shuttle walking test distance. International journal of chronic obstructive pulmonary disease. 2018;13:37.
- Keteyian SJ, Levine AB, Brawner CA, et al. Exercise training in patients with heart failure a randomized, controlled trial. Annals of internal medicine. 1996;124(12):1051-1057.
- Porszasz J, Emtner M, Goto S, Somfay A, Whipp BJ, Casaburi R. Exercise training decreases ventilatory requirements and exercise-induced hyperinflation at submaximal intensities in patients with COPD. Chest. 2005;128(4):2025-2034.