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Coronary heart disease.doc

  1. 1. Coronary Heart Disease 1Running head: OLDER ADULT AND CORONARY HEART DISEASE The Older Adult and Coronary Heart Disease Jillian Burke Saint Francis Xavier University
  2. 2. Coronary Heart Disease 2 AbstractCoronary heart disease, also known as coronary artery disease, is the most prevalent type ofcardiovascular disease. Coronary heart disease is an umbrella term that encloses angina pectorisand acute coronary syndrome. Acute coronary syndrome includes unstable angina and acutemyocardial infarction. The main cause of the formation of coronary heart disease isatherosclerosis, which is the formation of lipids and fibrous tissue that in result creates a block inthe vessel wall and therefore decreases the blood flow to the heart. Coronary heart disease is thenumber one killer for both men and women. Just as coronary heart disease fully impacts theindividual person, it impacts healthcare with increasing amounts of money spent on patients withthe disease. Some signs and symptoms of this disease include; pain, weakness or numbness, andanxiety. Although pain is felt in both younger and older adults, it is perceived uniquely in olderadults with coronary heart disease. Smoking is the number one risk factor for coronary heartdisease and in repeated studies, older adults who smoked were found to have increased rates ofcardiovascular mortality than older adults who did not participate in smoking. Coronary heartdisease like any other disease has an unlimited continuous impact on the person’s overallindependence and quality of life. Diabetes mellitus is commonly connected to cardiovasculardisease and it is found that people with diabetes that die, usually end up dyeing due to acardiovascular condition, such as coronary heart disease. There are many aspects of an olderadult’s life that can influence their ability to improve their lifestyle. These include; mobility,socioeconomic status, availability to transportation, access to good nutrition, and family suppot.
  3. 3. Coronary Heart Disease 3 Coronary Heart Disease The most widespread type of cardiovascular disease is coronary heart disease. Coronaryheart disease is a term that is used to describe insufficient blood supply to the heart ormyocardium. It consists of angina pectoris and acute coronary syndrome. Acute coronarysyndrome includes unstable angina and acute myocardial infarction. The goal for the care of aperson with coronary heart disease is to decrease the myocardial oxygen demand and increasethe myocardial oxygen supply, or both. The main cause of the formation of coronary heart disease is atherosclerosis. Thecoronary arteries anatomic structure makes them predominantly vulnerable to atheromadevelopment. The two points that are most susceptible to atheroma development are the branchpoints and bifurcations. Atherosclerosis is an abnormal accumulation of lipid and fibrous tissuewith a fibrous cap in the vessel wall which creates blockages that result in reduced blood flow tothe heart. The lesion that is created and therefore causes decreased blood flow to the heart iscalled an atheroma. Atheroma is also known as plaque and is referred to as plaque by manypeople. If the fibrous cap is ruptured and it hemorrhages into the plaque it creates a thrombuswhich results in blood flow obstruction. The obstruction of blood flow from a thrombuspotentially results in a myocardial infarction. Therefore coronary heart disease is a risk factor formyocardial infarction. Atherosclerosis is a disease that is progressive and that can be shortenedand even reversed in some instances. There are causes of coronary heart disease are; vasospasmof the coronary arteries, myocardial trauma from internal or external forces, congenitalabnormalities, decreased oxygen supply, increased demand for oxygen, and structural disease.(Day, Paul, Williams, Smeltzer, & Bare, 2007, p.717-718)
  4. 4. Coronary Heart Disease 4 There are risk factors for every illness and disease which increase a person’s probabilityof developing that particular disease or illness. Coronary heart disease has nonmodifiable andmodifiable risk factors associated with it. The nonmodifiable risk factors are risk factors thatpeople can not change no matter how healthy they live. The modifiable risk factors are areas thatthe person can help to control and maintain in their life. The nonmodifiable risk factors forcoronary heart disease are; family history of coronary heart disease, increasing age, male, andAfrican American. The modifiable risk factors include; high blood cholesterol, smoking andtobacco use, hypertension, diabetes mellitus, lack of estrogen in women, physical inactivity, andobesity. (Day, Paul, Williams, Smeltzer, & Bare, 2007,p.719) In the study by Vuori, 2007, it was established that people who are physically inactivehave a 30-50% increased risk of developing coronary heart disease compared with people whoare at least moderately active. As mentioned in this article study, the American Heart Associationrecommends that older people participate in moderately intensive activities such as aerobics for30 minutes at a time. Patient’s with coronary heart disease exhibit signs and symptoms that allow for thepatient and health care workers to diagnosis and treat the coronary heart disease. Some signs andsymptoms include; pain, weakness or numbness, and anxiety. The pain is typically described asheavy, pressuring, burning, choking, crushing, or a strangling sensation. Although signs andsymptoms do occur with coronary heart disease, symptoms do not occur in patients until thevessel is 75% occluded. These signs and symptoms mentioned are generally referred to foryounger adults and not the older adult population. Older adults often do not exhibit the same typical pain for coronary heart disease asyounger adults would exhibit. This is due to the decreased response of neurotransmitters in the
  5. 5. Coronary Heart Disease 5older adult. The most common symptom that older adults convey when they have coronary heartdisease is dyspnea. Older adults are also different than younger adults in that older adults usuallyhave symmetrical pain in both arms rather than only in the left arm as younger adults have. Theolder adult may exhibit coronary heart disease without any symptoms, known as silent CAD.This can cause difficulty in recognizing and diagnosing the disease. The change in symptoms ofcoronary heart disease should be educated to the older adult population especially those withknown cardiovascular problems or with high cardiovascular risk factors. Older adults should beencouraged to recognize their pain and symptoms so that they can take their prescribedmedications and not allow the pain or symptoms to progress. Diagnostic tests that are used tocommonly diagnose coronary heart disease, such as noninvasive stress testing, in younger adults,potentially may not be practical due to other conditions in the older adult. These other conditionscould contribute to the patient not being able to exercise. These conditions consist of peripheralvascular disease, foot problems, arthritis, physical disability, and degenerative disk disease.(Day, Paul, Williams, Smeltzer, & Bare, 2007, p.24) Normal aging changes that occur as a result of getting older make it difficult to detectsymptoms of disease such as coronary heart disease. These normal aging changes contribute tothe disease process and therefore make older adults exhibit their symptoms different from adultsthat are younger with coronary heart disease. Within the heart, there are particular changes thatoccur as adults become older. These changes include the thickening and stiffening of the heartvalves and the decreasing elasticity of the heart muscle and arteries. These normal aging changesallow the majority of older adults to continue living a life, but the heart is unable to react asefficiently to stress compared to when the heart was younger. Due to these changes within the
  6. 6. Coronary Heart Disease 6heart, older adults can show signs of fatigue with increasing activity and increasing fatigue whenstress rises. High blood cholesterol levels are associated with coronary heart disease. There are fourelement of fat metabolism; total cholesterol, low density lipoproteins, high density lipoproteins,and triglycerides. These four elements are primary factors that affect the development of heartdisease. Low density lipoproteins apply a harmful effect onto the arterial wall which acceleratesatherosclerosis. High levels of triglycerides, serum cholesterol, and low density lipoproteins canbe controlled usually by diet, exercise, weight reduction or weight maintenance, andmedications. Medications may be needed in some cases to control patient’s cholesterol levels.These medications are lipid lowering medications which can reduce coronary heart diseasemortality in patients. Medications to decrease cholesterol levels include; 3-Hydroxy-3-methylglutaryl coenzyme A, Nicotinic acids, Fibric acid or fibrates, and Bile acid sequestrants orresins. 3-Hydroxy-3-methylglutaryl coenzyme incorporate medications such as lovastatin,pravastatin, Fluvastatin, Atorvastatin, and simvastatin. Nicotinic acids incorporate Niacin andimmediate, extended, and sustained nicotinic acids. Fibric acids include Fenofibrate andClofibrate. Bile Acid Sequestrants include Cholestryramine, Colesevelam, and Colestipol HCL.(Day, Paul, Williams, Smeltzer, & Bare, 2007, p.719-720) Changing lifestyles is a complex process. Patients with coronary heart disease have toadapt to a new lifestyle in either one or several areas of their lives. Creating new lifestyle habitsneeds to result from behavior changes. These behavior changes tend to result from a threat of thebehavior, such as developing coronary heart disease and the belief that the change will result in aoutcome that is valued or positive. The ability to change behaviors is individual and usually pastexperience of changed behaviors help to predict whether or not the person potentially going to be
  7. 7. Coronary Heart Disease 7able to positively change their behaviors. Patients with coronary heart disease who join a cardiacrehabilitation program may find this beneficial in assisting them to change behaviors. Forexample, physical exercise is done in the presence of professionals and this encourages thepatients to being the behavioral change. (Karner, Tingstrom, Abrandt-Dahlgren, & Bergdahl, 2005) Older adults that are diagnosed with coronary heart disease may exhibit difficulty inadapting to a healthier lifestyle due to a decrease in mobility or loss of mobility. These patientstherefore may not be able to participate in exercise compared to older adults that do not have adecrease in mobility. This decline in mobility may result from another disease. Some causes ofdecreased mobility are; Multiple Sclerosis, paraplegic, weakness and fatigue as a result of ahealth condition. There is usually always some increase in activity that a patient can do. Forexample, if a patient with coronary heart disease is in a wheelchair they could do upper bodyexercises. Diseases that affect the cognitive functioning of some older adults, such as Alzheimer’sor dementia, may contribute to these patients not fully being able to incorporate particularchanges in their lifestyle if they develop coronary heart disease. These patients who have laterstages of the dementia or Alzheimer’s disease may also not be able to communicate symptoms ofthe disease due to lack of ability to fully communicate. The possible decrease in communicationand understanding of the disease can contribute to tough diagnosis and treatment of coronaryheart disease. After learning about coronary heart disease and also about dementia, I can imaginehow difficult it is to incorporate a healthy lifestyle into the patients with both coronary heartdisease and dementia, as these patients may not remember the conversation 5 minutes later. Fromexperience with my grandmother, I know how difficult it is to educate her on new ideas or her
  8. 8. Coronary Heart Disease 8health concerns as she is unable to recall the conversation altogether or she is only able to recallcertain areas of the conversation. Coronary heart disease is a key cause of death and illness in the elderly population.Exercise can improve functional capacity and prolong an active lifestyle in the elderlypopulation. Regular exercise therefore decreases the disability of the older adult. It expected thatpatients with cardiovascular disease are going to increase in the years to come. Increasing thenumber of patients with cardiovascular disease is going to also increase the amount of money ofthe healthcare system needing to be spent on these patients. Patients with coronary heart diseasehave restrictions in their every day lives with their physical bodies, their psychological and socialfunctioning. These restrictions potentially can lead to a decrease in their activities of daily livingand a decrease in independence. Other factors, such as, depression, negatively affect the recoverystage of cardiac rehabilitation patients. (Sandstrom & Stahle, 2005) Older adults who smoked were found to have increased rates of cardiovascular mortalitythan older adults who did not participate in smoking actions. Today, humans are living longerlives and therefore coronary heart disease is becoming a greater than before root of illness anddeath in the older adult population. When treating coronary heart disease there are primary andsecondary preventions used. These preventions include; ACE inhibitors, statins, treatment ofhypertension, use of antithrombotic agents, are B-adrenoceptor antagonists. Statins lower theLDL cholesterol and reduce the level of isoprenoids. Isoprenoids are molecules that assist in themetabolism of proteins. Statins also reduce platelet reactivity and decrease inflammation.(Andrawes, Bussy, & Belmin, 2005) As mentioned previously, cigarette smoking is a risk factor for coronary heart disease.Smoking can contribute to coronary heart disease in three different ways. First of all, people who
  9. 9. Coronary Heart Disease 9smoke have decreases oxygen and therefore, a heart with decreased oxygen can decrease theheart’s pumping ability. Second, nicotinic acid in tobacco raises the heart rate and bloodpressure. Finally, tobacco increases platelet adhesion and causes a detrimental vascular response,which leads to a higher probability of thrombus formation. Cigarette smoking cessation is greatlyencouraged throughout people with increased risks of coronary heart disease. Smoking cessationresults in a 30-50% risk reduction of heart disease in the first year after smoking cessationbegins. (Day, Paul, Williams, Smeltzer, & Bare, 2007, p.721) Cigarette smoking as a risk factor for coronary heart disease is reinforced by Andrawes,Bussy, & Belmin (2005), who found that older adults who smoked were found to have increasedrates of cardiovascular mortality. ACE inhibitors prevent coronary events in individuals who are considered high riskindividuals. Older adult women that use hormonal therapy were found in several studies to havea decreased occurrence of coronary heart disease. This finding was later disregarded afterlooking at women’s socioeconomic statuses. It was concluded that hormone replacement therapydid not benefit women and coronary heart disease. Additionally there were findings of increasingoccurrence of ischemic events. Hormone therapy is no longer used as a preventive measure forolder women in preventing cardiovascular events. (Andrawes, Bussy, & Belmin, 2005) There have been many studies conducted that found there was a relationship betweencoronary heart disease and socioeconomic status in the middle age person. This particular studyconducted by Sundquist, Jahansson, Qvist, & Sundquist, (2005), was aimed to study therelationship between coronary heart disease and socioeconomic status in the older adult.Smoking, Obesity, high cholesterol levels, hypertension, and physical inactivity were identifiedas main risk factors. It was found in this study that low socioeconomic status is linked to
  10. 10. Coronary Heart Disease 10coronary heart disease. Healthy behaviors such as smoking cessation and physical activity shouldbe introduced and encouraged in older adults among all socioeconomic statuses. Since coronaryheart disease is linked to socioeconomic status in both middle and older adults, it is important toassess the life path and history of the patient when caring for older adults.(Sundquist, Jahansson, Qvist, & Sundquist, 2005) Women can experience atypical symptoms or nonspecific symptoms in their chest pain.These labels can lead to a missed diagnosis or coronary heart disease. Women that had adiagnosis of nonspecific chest pain were found to have more of the risk factors of coronary heartdisease. Women that experienced nonspecific chest pain and resulted in coronary heart diseasewere found more in women over the age of 65. Although this particular study found that womenwho were diagnosed with nonspecific chest pain potentially are at an increased risk of coronaryheart disease, there still needs to be other studies conducted to support this and further researchthe relationship between nonspecific chest pain and an increased risk of coronary heart disease.(Robinson, et al., 2006) Coronary heart disease is the number one killer among women. Women are not referredto specialists for heart symptoms as often as men are. There is a myth around the public thatheart disease is a man’s disease. This causes women to delay seeking medical attention andtherefore believing that there is a heart problem. Today, the public is becoming more aware thatheart disease is both a male and female disease, but in previous years it was not known. This isrelevant to older adults in that in their previous years they were lead to believe that the diseasewas a man’s disease and therefore may still believe this. This could result in older women notreaching out for healthcare when they have early signs and symptoms of coronary heart disease
  11. 11. Coronary Heart Disease 11Coronary heart disease like any other disease has an unlimited continuous impact on the person’soverall independence and quality of life. Each person will cope with the disease individually,with some people coping adequately and others needing constant medical care. This diseaseimpacts the patient’s physical, emotional, and psychological aspects of their lives. Coronaryheart disease causes the patient to reintroduce their lifestyle such as diet. Patient’s that arediagnosed with coronary heart disease commonly need to change their diet, exercise, andpossibly other factors in their lives. An example of a diet change for coronary heart patientswould be to limit their salt intake. A reduction in sodium has been shown to help improvehypertension and therefore would benefit a person with a heart condition such as coronary heartdiseae. (Day, Paul, Williams, Smeltzer, & Bare, 2007, p. 199) Normal aging changes impact older adult’s lives completely and when a disease isinvolved on top of the aging changes, it becomes increasingly more stressful and may allow for adecreased ability of coping. Older adults greatly rely on their personal spiritual or religiousbeliefs to help them throughout their aging and disease processes. There are several dietsuggestions that should be followed by the older adult when dealing with normal aging changesand most importantly when there is a disease involved. The food that a person eats greatlyimpacts their health and therefore impacts there bodies ability to help combat a disease such ascoronary heart disease. Older adults fat consumption should remain between 20-25% of the totalamount of calories in an older adult’s diet. Carbohydrates should be about 55-60% of the olderadult’s caloric intake. The amount of protein that an older adult consumes should remain thesame as a younger adult. Particular food that should be encouraged in the older adult populationto assist with normal aging changes include; fruit, brown rice, whole grains, and potatoes. These
  12. 12. Coronary Heart Disease 12foods are full of minerals, vitamins, and fibre that help the body deal with normal aging changesand allow the body to be healthy to deal with disease such as coronary heart disease.(Day, Paul, Williams, Smeltzer, & Bare, 2007, p. 199) Just as coronary heart disease fully impacts the individual person, it impacts healthcarecosts. Cardiovascular disease is the most costly disease in Canada. Health Canada reiterates thefact that this impact of the costs of cardiovascular puts a burden on the Canadian healthcaresystem. Diabetes mellitus is commonly connected to cardiovascular disease. Diabetic patients thatdie usually die as a result of cardiovascular disease. Therefore, diabetic patients are seen ashaving the same risk of developing a cardiac event as patients with coronary heart disease. Bothdiabetic and coronary heart disease patients are at increased risk of a cardiac event with a tenyear span. (Day, Paul, Williams, Smeltzer, & Bare, 2007, p. 722-723) Nursing care for the older patient with coronary heart disease is very important. Whenassessing older adults it is important to remember that older adults over all well-being relies onphysical, mental, social, and environmental factors. Nurses are responsible to help in the care ofpatients with coronary heart diseases that have pain and signs and symptoms of the disease.Nurses collaborate with the patient to help treat the pain, reduce anxiety level, education of thedisease and the process of the disease, and education on early detection of coronary heartdisease. Nurses are responsible to help patients learn the importance of using their nitroglycerinand the when they should use it, if they have angina pectoris. Nurses assist the patient’s inmodifying their lifestyles to accommodate to their pain, anxiety, and signs and symptoms such asdyspnea. Nurses assess the patient’s lifestyle and discover if their pain or dyspnea appears withactivity and if so, how much activity it takes to initiate the pain or dyspnea is further assessed.
  13. 13. Coronary Heart Disease 13Once the nurse and patient determine the amount of activity it takes to initiate the pain ordyspnea, they alter the patient’s activities and incorporate rest periods as often as needed todecrease or elevate the pain and dyspnea. Nurses need to be extremely sensitive to the patient’soverall health and coping. Other disease process or illnesses affect greatly the person’s responseto treatment, their coping, and their overall health with coronary heart disease. The older patientwith coronary heart disease requires exceptional attention and specific attention to their signs andsymptoms as they appear different or in decrease than younger people with coronary heartdisease. (Day, Paul, Williams, Smeltzer, & Bare, 2007, p. 105, 727-728) It is essential that patient’s experiences are reviewed and understood in order to improvecoronary heart disease prevention and education in the future. Healthcare professionals perceivethat coronary heart disease is a male disease although recently females with coronary heartdisease have increased interest. Increasing information about the gendered character of coronaryheart disease helps nurses to stop stereotypical beliefs of coronary heart disease being a maledisease. (Emslie, 2005) In conclusion, it is unique to treat to an older adult with coronary heart disease as olderadults’ exhibit different signs and symptoms with coronary heart disease than do younger adults.There is no single solution to coping with coronary heart disease, as every individual hasdifferent coping styles and deals with the disease differently. Lifestyle factors greatly impact therisks of developing coronary heart disease and the progression of the disease.
  14. 14. Coronary Heart Disease 14 ReferencesAndrawes, W. F., Bussy, C., & Belmin, J. (2005). Prevention of Cardiovascular Events in Elderly people. Adis Date Information, 22 (10), 859-876.Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2007). Medical- Surgical Nursing: Lippincott Williams & Wilkins.Emslie, C. (2005). Women, men and coronary heart disease: a review of the qualitative literature. Journal of Advanced Nursing, 51(4), 382-395.Karner, A., Tingstrom, P., Abrandt-Dahlgren, M., & Bergdahl, B. (2005). Issues and Innovations in Nursing Practice. Incentives for lifestyle changes in the patients with coronary heart disease. Journal of Advanced Nursing, 51(3), 261-275.Nicklas, B. J., Cesari, M., Penninx, B. W., Kritchevsky, S. B., Ding, J., Newman, A., et al. (2006). Abdominal Obesity Is an Independent Risk Factor for Chronic Heart Failure in Older People. Journal Compilation, 54(3), 413-420.Robinson, J. G., Wallace, R., Limacher, M., Sato, M., Cochrane, B., Wassertheil- Smoller, S., etal. (2006). Elderly Women Diagnosed with Nonspecific Chest Pain May be an Increased Cardiovascular Risk. Journal of Women’s Health. 15(10), 1151-1160.Sandstrom, L., and Stahle, A. (2005). Rehabilitation of elderly with coronary heart disease- Improvement in quality of life at a low cost. Advances in Physiotherapy, 7, 60-66.Sundquist, K., Johansson, S. E., Qvist, J., & Sundquist, J. (2005). Does Occupational social class predict coronary heart disease after retirement? A 12-year follow up study in Sweden. Scadinavian Journal of Public Health, 33, 447-454.