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Cardiovascular System - Normal Aging

The cardiovascular system is composed of the heart, the blood and the vasculature. This system subserves many functions, most notably the delivery of oxygen throughout the body. The cardiovascular system also serves as a roadway for delivering:

  • 1. energy containing molecules like sugars and fats to needy tissues,

  • 2. amino acids and nucleic acids for the synthesis of new proteins and DNA,

  • 3. toxins and waste to the kidneys for elimination from the body,

  • 4. hormonal messages to distant target tissues,

  • 5. immune system cells to the site of foreign molecules,

  • 6. blood to and from the surface of the skin for regulating body temperature.

Each of these functions is minimally affected by age, but they can be severely altered by interactions that occur between aging and age-related diseases in the cardiovascular system.

Before we attempt to dissect out the physiological changes that can be accounted for by aging, we need to eliminate from the sample individuals experiencing varying degrees of disease. Human studies of cardiovascular aging are limited by the prevalence of occult coronary stenosis, with 60% of men over the age of 60 having a 75-100% block in at least one coronary artery. Through rigorous screening of coronary disease and elimination of those with coronary artery disease, it has been demonstrated that cardiovascular reserve capacity decreases with aging. These changes in cardiovascular function can be explained by changes in cardiac muscle, connective tissue, cardiac adrenoreceptors, and the compliance or distensibility of the vasculature. In addition, there are changes in kidney function which can alter fluid homeostasis and contribute to age-dependent reactions to therapies for cardiovascular conditions.

Cardiovascular System - Normal Aging The cardiovascular system is composed of the heart, the blood and

The Heart

The contractile muscle of the heart is made up of a special type of cell referred to as a cardiac myocyte. These highly contractile cells have an enormous appetite for oxygen and glucose. These cells never rest, from the day of fetal formation to the last day of your life. The cardiac myocyte is also unique in that it is electrically coupled to neighboring cardiac myocytes. This property facilitates the simultaneous contraction of all myocytes during either atrial or ventricular systole (systole is the contracted state of heart muscle). There are numerous arteries that go directly from the aorta (the first major blood vessel leaving the left ventricle) to the heart to ensure the rapid delivery of oxygen and glucose to working cardiac muscle. These blood vessels are called the coronary arteries. There is an intrinsic, self-sustaining mechanism (a pace maker) that sets the strength of each contraction and the number of heart beats per minute, but both of these can be modulated by hormones and neurotransmitters found within the body.

Aging in the Heart

With aging, a few functions are preserved. For example, the cardiac output (the amount of blood pumped per minute) is not changed. But the efficiency of pumping the blood does change. More blood is left in the heart after a contraction, the thickness of the major pump, the left ventricle is increased and the response to stimulation of the heart rate is diminished. As a result, the maximum heart rate decreases with aging. Therefore, when we exercise, the maximum heart rate decreases by 1 for each year of aging (i.e., maximum heart rate at 20 is 200 and at 70 is 150). Functionally, these "normal" age-related changes are unlikely to compromise everyday living, but they will reduce the maximal performance. This can occur due to the demands placed upon the cardiovascular system during competitive exercise are greater in old age.

The Vasculature

The aorta and much of the arterial tree function as an elastic buffering chamber that act to dissipate the pressure wave resulting from ventricular contraction (systole). During diastole (resting state of the heart), the large arteries supply the volume of blood to the periphery as a continuous peripheral blood flow. The diameter of the individual arteries steadily decreases as you move away from the heart. With each successive branching of the artery the diameter decreases, but the sum of the cross sectional areas of these branches gradually increases and, thus, the rate of blood flow and blood pressure diminishes as the blood approaches the capillaries. The arteries and veins are multi-layered cylinders, with each layer serving specific functions. The thickness of each layer is far greater in the arteries, however.

Blood

Pressure

for

Average,

Aged,

and

Diseased

Arteries

(on the average)

   

At

Maximum Animated

Rest Flow

Diagram

Comparison

 
 

Average

Aged

Diseased

80

110

140

180

Vascular Changes with Aging

With aging, there is a thickening of the artery walls. In hypertension, these normal age-related increases in the large arteries are enhanced. The generic term, arteriosclerosis, refers to a thickening and hardening of the arterial wall. Taken together, these age- related changes all contribute to an increase in systolic blood pressure, which makes age a risk factor for hypertension.

Normal Function

The respiratory system is a conduit for the exchange of gases between the external environment and our blood. When we think about respiration we focus our attention upon the need to replenish our bodies with oxygen, but another important function is the maintenance of blood carbon dioxide levels and the effect carbon dioxide homeostasis has an blood pH. The organ for gas exchange is the lung, located deep within our bodies. Gases travel through our mouth and nose into the tracheobronchial tree which divides into millions of minute branches terminating in structures known as alveoli. The alveoli are made-up of an incredibly delicate membrane that serves as a fragile barrier between the outside world and our blood. Fragile is the operative word, since life-style choices like smoking or anything that allows the entry of small particles into the lungs can severely damage the membrane and compromise the ability to exchange gases across the pulmonary membrane.

The trunk of the pulmonary tree is the trachea, which divides into two main branches referred to as bronchi. Each bronchi undergoes repeated branchings as bronchioles. The terminal bronchioles branch into alveolar ducts (2-11 ducts) which in turn terminate into alveolar sacs that have 2 or more alveoli. There are approximately 300 million alveoli in the adult lung. Each alveoli is intimately coated with capillaries specialized for the movement of gases into the bloodstream. The combined thickness of the alveolar epithelium and the capillary endothelium is less than 0.2 µm (10-6 meters). An incredibly thin layering of membranes that has evolved to maximize the diffusion of gases between the environment and the blood. The alveoli are the only site for gas exchange in the lung and a key component to maintaining their structure is the secretion of a thin coating of fat (phospholipids) along their outer surface. This coating is known as surfactant and it functions to oppose the natural tendency of bubbles like alveoli to collapse from the surface tension that exists between water and air.

The movement of air in and out of the lungs is voluntarily controlled by messages sent from the brain (medulla) to number of muscle groups, with the lungs acting passively like large rubber balloons. Enlargement of the chest (thorax) during inspiration is produced by a contraction of the diaphragm muscle, located below the lung, and a contraction of the intercostal and pectoral muscles which are attached to the rib cage. We exhale by simply allowing these muscles to relax and relying upon the numerous elastic fibers found within the lungs. This passive elasticity allows the lung to recoil to its smaller resting volume. The elastic recoil creates a net positive pressure within the lung to force a percentage of the lung air out. It is this elastic recoil that is most compromised in "successful aging" and as we will see later, it decreases the delivery of new oxygen and the removal of carbon dioxide.

Evaluation of the functional movements of the lung are performed by respiratory therapists. You will be asked to inhale from and exhale into a tube connected to a spirometer (or pneometer) that functions to measure the volumes of air moving in and out of the lung. The following definitions of lung volumes come from such spirometric examinations:

Tidal Air: the volume of air that enters and leaves the lungs during a resting breathing pattern.

Inspiratory Reserve Volume: the volume of air taken in by a maximal inspiration that is over and above the tidal volume.

Forced Vital Capacity: the sum of the tidal volume and the inspiratory reserve volume.

Expiratory Reserve Volume: the volume of air that can be expelled by the most powerful expiratory effort after the tidal volume has escaped naturally.

Forced Expiratory Volume: the sum of the tidal volume and the expiratory reserve volume.

Vital Capacity: the sum of the tidal air and the inspiratory and expiratory reserves (the volume of air expelled by the most vigorous expiratory effort after the deepest possible inspiration).

Residual Volume: the volume of air remaining in the lungs after the strongest possible expiration.

Total Lung Capacity: the sum of the vital capacity and the residual volume.

Functional Residual Capacity: the volume of air left in the lungs at the end of a normal resting, unforced expiration.

omparison of Normal and Aged Lung Function

Forced Vital Capacity: the sum of the tidal volume and the inspiratory reserve volume. Expiratory Reserve

The BLUE represents person.

the amount

of air inhaled

at

any

time by

a

The RED represents the Lungs.

The PINK (below the Lungs) represents the diaphram.

Aging and Respiration

Changes in pulmonary function with age are critical, since severe impairment is a direct risk for death. Aging not only affects ventilation and gas exchange within the lungs, but through compromise in another physiological system -the immune system, it also decreased the ability of the lungs to defend against infectious diseases and toxic insults. In the worst case scenario, the combined effect of age and chronic or acute insults can lead to airway obstruction which increases the risk for death due to:

Chronic obstructive pulmonary disease

Cardiovascular disease

Heart disease

Stroke

Diabetes mellitus

Lung cancer

Mechanical

Changes

Age-related changes in pulmonary function, independent of disease or a history of environmental insults, can be accounted for by 1) decreases in lung elasticity, 2) decreases in chest compliance (stiffening of chest wall) and 3) a decrease in the strength of the inspiratory muscles (diaphragm, intercostals, pectorals).

The decrease in lung elasticity is due to the generalized decrease in the turnover and function of the protein elastin throughout the body and the loss of elastic fiber attachments within the lungs. This change in the elastic recoil underlies the age-related increase in residual volume and the decrease in vital capacity. Which means: more stale air remains in the lungs and less fresh air is brought in with each breath.

The decrease in chest compliance is due to an ossification (calcification) of cartilage and rib articulations. The decrease in strength of respiratory muscles is due to a general age-related loss of skeletal muscles fibers with age (see musculoskeletal system in week 8). These later changes contribute significantly to the age-related change in forced expiratory volume.

All of the air flow measures reach a stable maximum between the ages of 20-25 in both sexes. Thereafter linear declines tend to occur, although changes due to attrition of respiratory system tissue are not accountable until age 40.

Diffusional Changes

Age-related decreases in alveolar surface area contribute to a decrease in blood oxygenation. This change is due to a partial collapse of the most distal (peripheral) airways entering the alveoli. These changes can result in a mismatch between the ventilation of the lung and the perfusion of the lung capillaries with blood. This mismatch decreases the diffusion of oxygen into the blood and the movement of carbon dioxide out of the blood. This change is further exacerbated by decreases in cardiac output, which together result in a lowered arterial oxygen content.

The control center for breathing lies deep in the brain in a structure called the medulla. The medullas receives information on blood oxygen and carbon dioxide content from specialized nerve cells known as chemoreceptors located peripherally in nodules known as the carotid and aortic bodies (located on the aorta and carotid artery). There is also evidence that neurons within the medulla react to changes in cerebral spinal fluid pH secondary to hypercapnia (elevated carbon dioxide content). Together, these chemodetectors generate a response which increases both heart and ventilatory rates. With age there is a decrease in these detectors or receptors and thus the response to hypoxia or hypercapnia is diminished as much as 50% in healthy older subjects (65-75 years).

Defense Mechanisms

We use mucus secretion to collect inhaled particulate matter and then we expel the mucus through the motion of ciliated cells found within the bronchioles. When the cilia are overloaded, we rely upon the cough mechanism to expel the mucus. With age, this clearance system is decreased leaving our lung vulnerable to damage associated with mucus obstructions. The cough reflex is further subdued by sedative use and neurologic disease, which are common in the elderly. Once our initial defense mechanism of mucus has been penetrated, we rely upon our immune system to eliminate foreign bodies. As discussed in the immune system section of the course, we have an impaired immune response as we get older that leaves the elderly easier targets to infectious disease in the lungs (i.e. pneumonia and tuberculosis).

Source:

Tabloski, P. (2006). Essentials of Gerontological nursing. Singapore: Pearson Education South Asia Pte Ltd.