1. Cardiopulmonary Exercise in the Aging Adult
Matthew N. Bartels, MD, MPH
Professor and Chairman of Rehabilitation Medicine Albert Einstein College of Medicine
Chairman, Department of Rehabilitation Medicine Montefiore Medical Center

2. Declarations/Disclosures
Unfortunately no Conflicts of Interest
Working on that……
No off label uses of medications or devices

3. Objectives Effects of aging on cardiopulmonary exercise capacity
Review the basics of exercise physiology
Beneficial effects of aerobic and strengthening exercise on cardiovascular physiology in older individuals

4. Bad News and Good News with Aging
Capacity declines as you age
Good News
You can do something about it
Fatigue and immobility are not inevitable parts of aging
Fitness isn’t all that hard to achieve

5. The Bad News About Aerobic Exercise with Aging
Bad News 1: Muscle function changes with age
Strength decreases due to loss of muscle mass.
Fiber type switching to type II x
Increased fibrous tissue in muscle

6. Bad News 2: cardiovascular function change with age
Maximum heart rate decreases with age (MHR = 220 – age)
Resting cardiac output declines about 1%/year during adulthood
Coronary artery disease is more common
Blood flow during exercise is less
Maximum exercise declines gradually with age

7. Bad News 3: Pulmonary Function Changes with Age
Lung capacity declines
Chest wall is stiffer (less compliance)
Decreased oxygen absorbtion (lower DLCO)
Breathing becomes less efficient with age
Loss of lung with aging (1% per year)

8. Bad News 4: Aging Alters Body Composition
Increased Fatty Tissue
Decreased Lean Mass
Stature
We grow shorter as we get older by about one-half inch per decade after age 30.

9. Bad News 5: Multiple factors may explain the changes in functional capacities with age
True aging phenomena
Unrecognized disease processes
Disuse phenomena
Deconditioning
Medications

10. Assessment of Demands of Exercise Activities
Usually used for dynamic exercise
Typically described in terms of metabolic equivalents
1 MET = 3.5 ml O2/Kg weight/min
Use of standardized MET tables can help assess independence AND GOALS

11. Oxygen Consumption with Exercise

12. Relationship of Dynamic Exercise and Oxygen Uptake
Heart Disease

13. Limits on O2 Consumption
Stroke Volume
End Systolic Volume
End Diastolic Volume
Effected by position
Reduced in Cardiac Disease
Myocardial Infarction
Heart Failure
Muscle mass decreased
Neurologic dysfunction

14. Limits on O2 Consumption: Blood
Arterial Oxygen carrying capacity
Increased with exercise
Increased with increased Hemoglobin
Increased CaO2 - CvO2
Mostly due to decreased CvO2
Increased Peripheral extraction
Shunting of increased Output to active tissues
This is where blood doping in professional sports comes in!
Autotransfusion, Epo, etc.

15. Oxygen Carrying Capacity
Blood doped!

16. Tissue Blood Shunting with Exercise
Rest Blood Flow (mL)
% Blood Flow
Exercise Blood Flow (mL)
Muscle
1,000
20.0%
21,000
84.0%
Heart
200
4.0%
Liver
1,350
27.0%
500
2.0%
Kidneys
1,100
22.0%
250
1.0%
Brain
700
14.0%
900
3.6%
Skin
300
6.0%
600
2.4%
Other
350
7.0%
750
3.0%
Total Blood Flow
5,000
25,000

17. Effects of Dynamic Exercise on Blood Pressure
Minimal change in Diastolic BP
May actually drop a little
Marked Rise in a linear fashion in SBP
Does not usually rise above 200 mmHg
Moderate rise in Mean BP
BP increase due to increased CO, not increased peripheral resistance.
Effects are about 10% higher for arm exercise than leg exercise.

18. Effects of Dynamic Exercise on Blood Pressure

19. Response to Isometric Exercise
This is not safe type of exercise for Cardiac Patients!
Lower metabolic demand for a given activity
Marked increases in SBP, DBP, MBP
Can easily exceed 220/110 mmHg (SBP/DBP)
Marked heart rate increase
Out of proportion to the metabolic demand of the activity
SV lowered with activity, rebounds with relaxation
Cardiovascular steady state not achieved
Muscle blood flow decreased during >40% contraction, increased at <30% contraction

20. Blood Pressure Responses to Isometric Exercise

21. Effects of Inactivity on Exercise
Decreased VO2
Increased resting heart rate, blood pressure
Decreased stroke volume at rest and with exercise
Possibly due to decreased venous return
Have alterations in red blood cells, less red cells
Decreased responsiveness in muscle vascular beds – higher blood pressure!

22. Inactivity and Exercise Capacity

23. Good News 1: There are Benefits to Aerobic Exercise
Improved sense of well being
Weight control
Decreased fatigue
Improved immunity
Decreased bone/lean body mass loss
Decreased cardiac disease
Decreased decline in function

24. Good News 2: These benefits of exercise come about in many ways
Improved efficiency
Increased cardiac function
Improved circulation
Improved muscle function
Improved neural control of function
Increased lean body mass
Improved basal metabolic function

25. Good News 3: Improved Heart Function
Improved cardiac output
Increased stroke volume
Decreased resting heart rate
Decreased anginal symptoms
Decreased work of the heart
Decreased systemic blood pressure
Less resistance for cardiac work

26. Good News 4: Improved Circulation
Decreased arterial resistance
Decreased blood pressure
Improved capillary function
Decreased diastolic blood pressure
Improved delivery of oxygen to the peripheral tissues
Improved muscle tone in the blood vessel walls

27. Good News 5: Improved Muscle Function
Improved muscular circulation
Improved capacity to aerobically metabolize and perform work
Increased mitochondria (muscle power generation)
Increased muscle fiber density

28. Good News 6: Increased Lean Body Mass
Increase in muscle tissue
Decrease in fatty tissue
Improved metabolism
Increase use of fat
Decreased storage of fat
Helps with weight maintenance
Decreased appetite
Moderate exercise decreases appetite

29. SURPRISE! Aerobic Exercise is Reasonably Easy to Do
Even Moderate daily activities are helpful
Brisk walking
Gardening
Yard work
Housework
Climbing stairs
Active recreational pursuits

30. Principles of aerobic training for a healthy older adult
Mode:
Aerobic activity
Intensity:
An intensity of 55 to 90 percent of maximal heart rate or 40 to 85 percent of maximum heart rate reserve
Duration:
A duration of 20 to 60 minutes a session (or in 10-minute bouts accumulated throughout the day)
Frequency:
A frequency of three to five days per week

31. Estimation of Maximum Heart Rate
Usual Method: Max HR = 220-Age
Alternative method (for older ages):
Max HR = (Age) (conventional technique underestimates the peak HR for age.
Example for 40 and 60 year old people
Standard Way: = 180
= 160
Alternative Way: (40) = 180
(60) = 166

32. Karvonen Technique Calculate target heart rate based on intensity
HRtarget = HRrest + %(HRmax - HRrest)
Example: 30 year old woman to exercise at 80% of capacity after testing
Resting HR = 75 bpm, Max HR on CPET 185 bpm
HRtarget= (185-75) = 163 bpm
Estimate method: HRtarget= 0.80(220-30) = 152 bpm
Estimated HR targets usually lower and less accurate. But preserves safety in situation with no testing.

33. Caution 1: Recommendations for Developing and Maintaining Fitness
Use large muscle groups
Continuous, rhythmical, aerobic activities
Use heart rate guidelines
Use Warm-up and Cool-down
Assess cardiac risk
Simple history => family history
Unexplained dyspnea
Orthopedic risks

34. Types of Exercise Dynamic Aerobic - Cardiac Conditioning - Cardiac
Static
Anaerobic - Non Cardiac
Strengthening - Non Cardiac

35. Remember Basic Physiology!
Endurance activity requires more aerobic fibers
This is predominantly Type 1 fibers
Sustain activity for hours, but slow twitch speed and small fiber size
Short burst activity requires more anaerobic fibers
These are predominantly Type 2 fibers subdivided into:
2a moderately fast – long term anaerobic (<30 min)
2x fast – intermediate short term aerobic(<5 min)
2b very fast – short term aerobic (<1 min)

36. Basic Terminology Measurement of exercise capacity Aerobic Training
VO2 – defined as LO2/minute or mlO2/kg/min
MET – one metabolic equivalent mlO2/kg/min
Wattage – Resistance on an ergometer – this is power output
Heart rate – Used to determine the level of intensity once power at a given heart rate established
RPE – can guide exercise once power rates determined
Resistance Training
Maximum Voluntary contraction – one rep max

37. Basic Exercise for Health

38. Warm-up and Cool-down Guidelines
What constitutes an effective warm-up?
• Ideally the warm-up should involve low to
moderate intensity exercise that mimics the
physical activity to follow.
• Helps prevent musculoskeletal injuries
Benefits of cooling down after low to moderate activity
Helps to clear lactic acid from the blood
Prevents blood pooling in the lower extremities, which can cause dizziness/vasovagal syncope
Helps maintain increased muscle and connective tissue temperature, increasing flexibility

39. Conclusion
Moderate aerobic exercise is very beneficial and safe in most individuals
Even (especially) individuals with cardiac, pulmonary, or peripheral vascular disease will benefit.
After the age of 40, consider if there are risks prior to high intensity exercise, moderate is always safe
Qualified supervision in disease states
May benefit from specific programs