Medical History Mr. JW is a 76
Medical History
Mr. JW is a 76 yr old man with a history of obesity,hypertension, type 2 diabetes, heart failure with preservedejection fraction (HFpEF), and obstructive sleep apnea (OSA). Hismedications include furosemide 40 mg, Lisinopril 20 mg, metformin500 mg, and aspirin 81 mg daily. He has noticed progressiveexercise intolerance and associated dyspnea, especially whenwalking uphill or climbing stairs. He complains that “I can’t keepup with my grandchildren like I could last year.” Although he canstill perform all ADLs, he spends most of his time watchingtelevision or surfing the Internet. He sleeps well with hiscontinuous positive airway pressure (CPAP) device. His hemoglobinA1c is well controlled at 7.6%, and morning home blood pressureaverages in the low 140s/80s mmHg. He takes his medicationsregularly, eats a well-balanced diet, and sleeps well withCPAP.
Diagnosis
Mr. JW visits his internist about every 3 mo to monitor hishypertension, diabetes, HF, and OSA. An echocardiogram last yearshowed mild left atrial enlargement, normal LV size and functionwith moderate LV hypertrophy, and elevated Doppler E/e’, an indexof LV-filling pressure, indicating diastolic dysfunction. On hismost recent visit 1 mo ago, his physical examination wasunremarkable except for a BMI of 33 kg · m–2 and blood pressure of152/78 mmHg. A resting ECG showed left atrial abnormality and minorT wave flattening.
Objective and Laboratory Data
Exercise Test Results
To further investigate Mr. JW’s reported exercise intolerance,his internist administered a standard ECG treadmill exercise testusing a modified Bruce protocol. The patient walked 5 min (4.5METs), reaching a peak HR of 142 beats · min–1 and peak BP of196/72 mmHg, stopping due to breathlessness and fatigue. Occasionalpremature ventricular beats were seen near peak effort, but therewere no significant ST-segment changes.
Based on his examination and exercise test results, Mr. JW’sdoctor increased lisinopril to 30 mg daily and began spironolactone25 mg daily. He also referred him to a nutritionist for weightreduction counseling and suggested that he begin walking daily for30 min, which can be divided into 10 or 15 min segments ifneeded.
Assessment and Plan
A weight loss goal of 40 lb from his current weight of 220 lbwas set.
Exercise Prescription
This patient represents an all-too-common scenario in geriatricmedicine. Mr. JW has exercise intolerance, most likely related tothe combination of obesity, LV diastolic dysfunction, andinactivity-related deconditioning, superimposed on aging-associatedphysiologic changes that progressively reduce functional capacity.Unfortunately, this decrease in exercise tolerance often begets avicious cycle of reduced physical activity that causes furtherdeconditioning and exercise intolerance.
Mr. JW will likely benefit from an exercise program thatemphasizes walking and other lower-level aerobic activities whileincorporating resistance exercises and balance and flexibilitytraining. Weight reduction via moderate caloric restriction is animportant component of his treatment that will further increaseexercise tolerance as well as improving BP and glycemia control andobstructive sleep apnea (OSA).
A clinical exercise physiologist will need to be cognizant ofMr. JW’s multiple medical disorders and medications superimposed onage-associated physiological changes. Exercise must begin at lowlevels and progress in small increments to ensure that the regimenis well tolerated and that it addresses the spectrum of needsunderlying his functional limitations and health requirements.
Case Study Discussion Questions
- What motivational strategies can be used to enhance hisexercise adherence?
- What are the major risks of Mr. JW’s participation in anexercise program?
- What other tests might you perform on Mr. JW (diagnostic orfunctional)?
- What might be appropriate recommendations for advancing Mr. JWto walking for 30 min on a daily basis?
Answer:
●Some of the motivational strategies which can be applied forexercise adherence are
- Health educating the clients about the benefits of exercise andits major role in preventing complications
- Verbal rewards can be a better motivational strategy at thisage which give them a self confidence and psychological support atthis age
- Informing about the positive outcome to the client achieved outof exercise
- Self monitoring and goal setting can be used to motivate theclient
●The major risk present die to exercise are
- Risk for cardiovascular issue like myocardial infarction incase of strenuous exercise
- Risk for respiratory complications when deprived of oxygenwhich is consumed in excercises
●The following functional or diagnostic test can beperformed
- Leg or arm ergometry test to rule our any cardiovascularissues
- Resting heart rate to be assessed to rule out the aerobicexercise involvement.
- Lung function test to assess the respiratory function
●The appropriate recommendations for advancing walking for 30minutes on daily base are
- The patient should have a normal blood 0ressure
- Should have gradual decrease in dyspnea and improve lungfunction to increase walking time .
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