APSEA Training

How to Measure Pulse

• Pulse and heart rate are used interchangeably: the pulse you feel is one heartbeat.
• Pulse is measured radially (at the wrist, just under the thumb)
• Use 2 fingers (palpation), never your thumb (your thumb has its own pulse that can be mistaken for the patient's)
• Measure for 30 seconds and multiply by 2, OR measure for a full 60 seconds

Heart Rate Ranges by Age

Adult Heart Rate Categories

If Bradycardia or Tachycardia

• Ask about symptoms: dizziness, fatigue, shortness of breath, chest pain, or palpitations
• Have the participant rest and recheck the pulse after 2–3 minutes
• If it remains abnormal, recommend home monitoring and follow-up with their PCP

Pulse Oximeter

• Fingertip pulse oximeter also measures SPO2 % (oxygen saturation)
• Normal SPO2: 95% – 100%

The Basics

• Systolic = pressure when the left ventricle contracts (top number)
• Diastolic = pressure when the left ventricle relaxes / fills with blood (bottom number)
• We estimate aortic BP by measuring at the brachial artery
• BP and heart rate are correlated but do NOT mirror each other

Causes of Hypertension

Blood Pressure Categories (AHA)

Low Blood Pressure (Hypotension)

• Low BP is generally < 90/60 mmHg
• Low BP without symptoms is often normal, especially in young, fit, or healthy people
• Low BP with symptoms (lightheadedness, dizziness, fainting, fatigue) warrants follow-up with a PCP

Sources of Measurement Error

• Inadequate rest: must rest 5 minutes
• Wrong arm position: should be at level of the right atrium (arm resting on a flat surface so the middle of the cuff is at heart level); 1 mmHg error per 1 cm change
• Unsupported arm / back / legs: back not against the chair, or feet not flat on the floor, adds ~6 mmHg
• Crossed legs: adds 2–8 mmHg
• Wrong cuff size: should be ≥ 80% of arm circumference
• Cuff over clothing: adds 5–50 mmHg
• Full bladder: adds ~10 mmHg
• Talking or engaging in conversation: adds ~10 mmHg

One Reading is NOT Enough

• A reading places a participant in a category / range; it is NOT a diagnosis
• Patient-measured BP is the gold standard due to the White Coat Effect
• Guidelines: 3 readings in the arm with the higher BP. Discard the 1st, average the last 2.

Factors That Affect BP

• Exercise: exertion causes BP to rise
• Cold → vessels constrict → BP increases
• Hot → vessels dilate → BP decreases
• Caffeine: within 30 min to 1 hr before screening
• Smoking: nicotine constricts blood vessels, raising BP

Proper Setup for Blood Pressure Measurement

1. 5-minute rest prior to measurement
2. Legs uncrossed, feet on floor
3. Arm supported (resting on table)
4. Correct cuff size, placed on bare arm
5. Cuff positioned 1–2 inches above elbow crease
6. Cuff tight enough for 1–2 fingers only
7. Line up artery mark (medial, over brachial artery)
8. Patient should NOT talk, use phone, or read

First-Line HTN Medications

A participant on BP medication may mention one of these classes:

• Thiazide diuretics, e.g., hydrochlorothiazide (HCTZ)
• Calcium channel blockers, e.g., amlodipine
• ACE inhibitors / ARBs, e.g., lisinopril (especially for diabetes, CKD)

Hypertensive Crisis Response

If a participant's reading is in the crisis range, respond as follows:

• Ask if they are on medication & if they took it today
• Re-take blood pressure
• Check for: chest pain, shortness of breath, headache, nausea, vomiting, dizziness
• Confirm with the doctor on call before advising the participant on next steps

Missed Doses & Medication Questions

• If a participant hasn't taken today's dose (or asks "should I take it now?"), don't decide it yourself, in either direction
• Bring it to the screening supervisor, who can contact the doctor on call. Sometimes the answer genuinely is "yes, take it now"
• Note the missed dose either way; it's key context for interpreting the reading
• Never advise starting, stopping, doubling, or borrowing medication, and never take a pill prescribed for someone else

What is Orthostatic Blood Pressure?

• Measurement of blood pressure changes in response to postural changes
• Specifically the lowering of BP when a person stands up from a sitting or supine (lying down) position
• Due to screening location limitations, APSEA measures with sitting and standing positions only

Orthostatic Hypotension (OH)

• OH = drop of systolic BP ≥ 20 mmHg OR diastolic BP ≥ 10 mmHg within 3 minutes of standing
• When standing, gravity causes blood to pool in the legs and belly, so BP drops because less blood returns to the heart
• Normally, special cells tell the heart to beat faster, pump more blood, and narrow blood vessels to restore BP
• OH is often comorbid with Hypertension in adults (per the AHA)

Prevalence & Clinical Significance

• Affects about 10% of adults aged 60–65
• Increases to 15–30% in adults over age 65
• Great screening tool for early signs of neurodegenerative diseases, heart issues, and measuring fall risk
• Elderly with OH are more likely to be physically frail with decreased functional capacity

How to Measure Orthostatic BP

1. Participant should sit for at least 2–5 minutes
2. Measure their Sitting BP and pulse (heart rate) and record them (on paper or phone)
3. Have participant stand for 3 minutes
   • A single reading at 3 minutes is the most feasible approach; taking one at 1 minute and another at 3 minutes is too much standing for the participant and too much time for us
4. Measure their Standing BP and pulse (heart rate) and record them
   • Arm can be down at their side OR rested on your arm at heart level

Calculations & OH Criteria

• (Systolic Sitting BP) − (Systolic Standing BP)
• (Diastolic Sitting BP) − (Diastolic Standing BP)
• (Standing Heart Rate) − (Sitting Heart Rate)

Counseling: Orthostatic Hypotension

1. Explain what orthostatic hypotension is
   • "Orthostatic hypotension happens when your blood pressure drops when you move from sitting or lying down to standing. This can cause symptoms like lightheadedness, fatigue, or fainting."
2. Ask the participant if they feel any symptoms: lightheadedness, fatigue, dizziness, fainting

Type 1 vs. Type 2 vs. Gestational

These are general patterns with exceptions: Type 2 increasingly occurs in young adults, and Type 1 can occur at any body weight.

Diagnostic Criteria

Controlled Ranges (On Medication)

What to Do with a High BG

• Ask: "Are you on medication? Have you taken it today?" If today's dose was missed, route the "should I take it now?" question to the screening supervisor / doctor on call; never advise it yourself
• Ask: "How often do you check your BG? What is it normally? Do you know your A1c?"
• Not under control → recommend checking once or twice a day
• Under control → recommend checking a few times a week
• A severely high / clearly uncontrolled reading (or any concerning symptoms) warrants advising prompt medical follow-up, not just checking more often
• Encourage lifestyle changes and direct to APSEA Lifestyle Program

BMI Basics

• Does NOT differentiate between fat, muscle, or bone
• BMI overestimates body fat in muscular people (e.g., bodybuilders) and may underestimate it in the elderly
• Always measure weight via the scale rather than relying on verbal report (height comes from intake, not measured by volunteers)

BMI Ranges

Waist Circumference

BMI ignores fat distribution; central (visceral) fat carries independent risk, so waist circumference adds information BMI misses.

Thresholds reflect risk of cardiovascular & metabolic disease.

Waist-to-Hip Ratio

An apple (central) shape carries higher cardiometabolic risk than a pear shape; waist-to-hip ratio captures where fat is stored.

Visceral Fat

• Found within the abdominal cavity, lining organs
• Much higher risk than subcutaneous fat, with higher risk of type 2 diabetes, heart disease, and metabolic syndrome
• The level is a device index (a unitless rating), not centimeters or other units
• Reducible through diet and exercise

Bioimpedance Device

Measures: Weight, BMI, Body Fat %, Muscle %, Basal Metabolic Rate, Body Age, and Visceral Fat. It passes a small electrical current through the body to estimate composition.

• Enter all participant info first (age, sex, height)
• Have the participant step on only when the display reads 0
• Body Age and BMR are not emphasized in our screenings

Body Fat %

Source: Gallagher et al., Am. J. Clinical Nutrition (2000); NIH/WHO.

Skeletal Muscle %

Source: Omron Healthcare.

Grip Strength

• Reflects overall muscle strength and declines with age (sarcopenia, the loss of lean muscle)
• Low grip strength correlates with higher all-cause mortality
• Method: measured once on each arm using a standard grip-strength dynamometer

Purpose

• Very useful for older adults (65+) to assess fall risk as a form of early intervention
• Fall risk rises with age-related loss of skeletal muscle (sarcopenia) and declining bone density
• Prevents potential injuries; falling becomes increasingly dangerous with age
• Helps uncover underlying dizziness or instability, allowing for targeted physical therapy
• Can enhance overall mobility

TUG Test (Timed Up and Go)

• Time how long it takes someone to stand up from a chair, walk 3 meters, turn, walk back, and sit down
• Under 10 seconds = good mobility
• Over 15 seconds = increased fall risk, requires further evaluation by a professional (especially if balance issues are observed)

Proprioception Test (One-Leg Stand)

• Stand on one foot for up to 45 seconds with both eyes closed
• Record the time in seconds for both the left and right legs
• Goal: hold for at least 10–30 seconds depending on age; 45 seconds indicates excellent balance (typical of younger adults)

TWT (Tragus to Wall Test)

• Measures the horizontal distance from the ear's tragus to a wall to check for forward head posture (FHP)
• Common assessment in conditions like Parkinson's or ankylosing spondylitis
• Assesses cervical spine extension and overall upper body alignment
• Setup: patient stands with heels/buttocks against the wall, tucks chin, and the clinician measures the gap
• A larger distance (e.g., over 10 cm) indicates worse posture, and is used to track treatment progress

Functional Reach Test (FRT)

• Measures how far someone can reach forward without stepping or bending the knees
• Measure the distance from the starting point to the fingertip's end position
• Setup: stand next to a wall, feet shoulder-width apart, arm at 90°, fist closed, next to a ruler
• Patient reaches forward as far as possible without moving their feet or losing balance

Counseling: Balance Training

Counseling: Flexibility Training

• Use stretching, yoga, and pilates
• Hold each stretch for 10–30 seconds and repeat 3–5 times
• Reach further as you get comfortable in each stretch
• Keep joints slightly bent and NOT locked
• Examples: shoulder rolls, chest stretch, inner thigh stretch, wall push, palm touch, calf stretch, hip flexor stretches, hamstring stretch

Counseling: Desk Exercises

• If the job requires long periods of sitting, move around regularly to offset health risks
• Examples: desk push-ups, chair dips, spinal twists, leg raises, lunges, standing up, walking around
• Yoga improves balance, strength, and flexibility
• Many lower body exercises improve strength and balance

Blood Pressure: 2 Mandatory Questions

1. "Have you been diagnosed with high blood pressure?"
   • If YES → "Are you currently taking any medications for blood pressure?"
   •    If YES → "Have you taken them today?"
   •    If NO → "Have you been prescribed any medications by your doctor?"
2. "Have you consumed caffeine, exercised, or smoked in the past 30 minutes to an hour?"
   • If YES → have them return once 30 min–1 hr has passed since the caffeine, workout, or smoking.
   • If NO → proceed with the reading.

Blood Glucose: 2 Mandatory Questions

1. "Have you been diagnosed with diabetes/pre-diabetes?"
   • If YES → "Are you currently taking any medications?"
   •    If YES → "Have you taken them today?"
   •    If NO → "Have you been prescribed any medications by your doctor?"
2. "Have you had anything to eat in the last eight hours?"
   • If YES → do NOT take a blood sugar reading. Recommend they return fasting at our next screening (nothing but water for ~8 hours).
   • If NO → take a fasting blood sugar reading.

Lifestyle Assessment (7 Categories)

Conducted after the vitals are taken.

The "MMMMMM" Mnemonic

• Medications: Do you take medications? Did you take them today?
• Monitoring: When did you last check your BP? Do you have a machine at home?
• Meals: How is your diet? Go over preventive strategies.
• Metabolism: Do you exercise? What type? Trying to lose weight?
• Motivation: Set SMART goals. Give specific advice.
• Medical History: Any other relevant issues?

Bedside Manner

• Always ask for consent before taking measurements (especially blood sugar)
• Ask for consent to record data
• Be human: ask how their day is; make it pleasant
• Keep patient information private

Preventive Strategies

SMART Goals

Specific, Measurable, Achievable, Relevant, Time-bound.

• "Pack lunch on Mondays and Wednesdays for the next 2 weeks"
• "Take a 10-minute walk during lunch break 3 days this week"
• "Replace one cup of coffee with water or herbal tea"