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Medical Conditions and Medications Impacting on Falls, Injury and Capacity to Exercise

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Title: Medical Conditions and Medications Impacting on Falls, Injury and Capacity to Exercise


1
Medical Conditions and Medications Impacting on
Falls, Injury and Capacity to Exercise With
thanks to Dr Rob Morris
2
Introduction
Why bother with this? Medical conditions
(diseases and disorders), and the medications
used to treat them, both have potential influence
on postural stability and the capacity to
exercise effectively Older People More
diseases/conditions accumulated deficits More
susceptible to drug toxicity (side
effects) More disease More drugs More
types of drugs Greater potential for falling
3
Question
  • Identify any condition common among older people
  • Consider
  • Does it increase risk of falls and why
  • Does it limit exercise capacity
  • Risks and Benefits of Exercise

4
Contents
Part 1 Medical Conditions
  • Cardiovascular disease
  • Ischaemic heart disease
  • Peripheral vascular disease
  • Cerebrovascular disease - Stroke
  • Hypertension
  • Arrhythmias
  • Heart Failure
  • Respiratory disease
  • Asthma
  • Chronic Obstructive Pulmonary Disease
  • Brain disease
  • Parkinsonism and Parkinsons disease
  • Depression
  • Dementia

5
  • Musculoskeletal Disorders
  • Osteoarthritis
  • Rheumatoid arthritis
  • Endocrine and Metabolic Disorders
  • Diabetes
  • Osteoporosis
  • Sensory system abnormalities Nervous System
    Integration
  • Cataracts
  • Glaucoma
  • Age-related macular degeneration
  • Ménières disease

6
Part 2 Medications (drugs)
  • Drugs for high blood pressure (Antihypertensives)
  • Drugs used in angina
  • Drugs used to reduce clots (Antiplatelet drugs
    anticoagulants)
  • Drugs for abnormal heart rhythms (Antiarrhythmic
    drugs)
  • Drugs used in respiratory disease
  • Drugs for Parkinsons disease
  • Drugs acting on the brain (Psychotropic drugs)
  • Drugs for arthritis and connective tissue
    disorders
  • Drugs for diabetes

7
Cardiovascular Disease
8
Ischaemic Heart Disease
  • Definition
  • Impairment of blood flow to heart muscle caused
    by narrowing of coronary arteries
  • Symptoms
  • Chest pain/tightness on exertion and relieved by
    rest angina (pectoris)
  • Concern
  • Can ultimately lead to heart attack myocardial
    infarction
  • Management
  • Medication or invasive procedures, including
    angioplasty (balloon dilatation), stent
    coronary artery bypass grafting (CABG)
  • Relevance for exercise
  • Should always consult with GP prior to exercise
    program

9
Angioplasty
10
Coronary Artery Bypass Surgery
11
Peripheral Vascular Disease
  • Definition
  • Impairment of blood flow to the peripheries (legs
    mainly) caused by narrowing of blood vessels
  • Symptoms
  • Cramp like pain in legs on exertion, relieved by
    rest
  • Concern
  • May deter people from exercising. Often
    co-existent with ischaemic heart disease (which
    may be silent)
  • Management
  • Angioplasty (balloon dilatation) or stent, if
    narrowing is in larger blood vessels, or bypass
    surgery
  • Relevance for exercise
  • Will limit exercise capacity.
  • Need to encourage to work into, but not through,
    pain (which may lead to opening of collateral
    vessels)

12
Stroke
  • Definition
  • Damage to part of the brain from either blockage
    to a blood vessel or bleeding from a blood
    vessel (15)
  • Symptoms
  • Depends on area damaged in brain - Face, Arm,
    Leg, Speech, Vision
  • Concern
  • Increased risk of falls may also affect
    comprehension or speech
  • Management
  • Thrombolysis, rehabilitation, and address risk
    factors for recurrent stroke. Occasionally
    carotid artery angioplasty
  • Relevance for exercise
  • Increased risk of falls due to weakness, impaired
    co-ordination of movement, loss of visual field,
    sensory neglect or confusion.
  • Nonetheless have potential to benefit from
    exercise.
  • Need to be aware of language, memory or sensory
    problems.

13
Stroke CT Scan
14
Carotid Artery Angioplasty
Before
After
15
Hypertension
  • Definition
  • High blood pressure
  • Systolic pressure gt 140 and/or Diastolic pressure
    gt 80mmHg
  • Symptoms
  • Usually no symptoms
  • Concern
  • Increased risk of stroke or heart attack
  • Management
  • Usually controlled on medication long term, also
    diet and exercise
  • Relevance for exercise
  • Not an exclusion for exercise.
  • Some studies have shown that exercise lowers BP
    (Tai Chi).
  • Client responsibility to ensure BP is checked
    regularly and liaise with GP

16
Arrhythmias
  • Definition
  • Abnormalities of the heart rhythm
  • Symptoms
  • Palpitations, dizzy spells (rare), collapse. May
    be asymptomatic.
  • Determined by site in heart where disturbance
    originates.
  • Concern
  • Risk of exercise inducing abnormal rhythm
  • Management
  • Once type of rhythm disturbance is identified,
    then medication is usual treatment
  • Relevance for exercise
  • Be aware of any precipitating factors
  • Client responsibility to liaise with GP

17
Heart Failure
Definition A complex syndrome that can result
from any structural or functional cardiac
disorder that impairs the ability of the heart to
function as a pump to support a physiological
circulation Symptoms Severe tiredness,
breathlessness or swelling of the ankles and feet
Concern Development of heart failure is
associated with poor prognosis but careful
exercise can improve heart function and
symptoms Management Dependent upon cause. Drugs
form the mainstay of management in most
cases. Relevance for exercise Depending on
severity may limit exercise capacity significantly
18
Pacemakers and Defibrillators
Definition Pacemakers are electrical implants
used to treat certain disorders of cardiac
rhythm, usually where the heart goes too
slowly. Defibrillators are implanted to treat
more serious rhythm disorders, particularly
paroxysmal ventricular tachycardia or
fibrillation. Symptoms Usually the presence of a
pacemaker or defibrillator is asymptomatic Concer
n Patients with exercise-induced arrhythmias may
find that their defibrillator is triggered.
Pacemakers should not be a concern. Relevance
for exercise Pacemakers should not preclude
exercise, though clients should check with their
GP or pacing clinic. Should not exercise within 6
weeks of a new pacemaker. Clients with
defibrillators must check with their specialist
clinic and should avoid exercising to maximum
heart rate. More sustained, lower intensity
exercise is preferable.
19
Respiratory Diseases
20
Asthma
  • Definition
  • Reversible airflow limitation due to constriction
    of airways
  • Symptoms
  • Shortness of breath, wheeze, cough
  • Concern
  • Can be induced by exercise or limit exercise
    capacity
  • Management
  • Inhaled medication for the majority
  • Some will take oral medications
  • Relevance for exercise
  • Not a contra-indication to exercise but may limit
    exercise capacity.
  • Clients should bring inhalers with them and use
    at beginning of session

21
Airways in Asthma
22
COPD/Emphysema
  • Definition
  • Irreversible airflow limitation usually caused by
    smoking
  • Symptoms
  • Shortness of breath on exertion
  • Concern
  • Reduced exercise capacity
  • Management
  • Similar to that of asthma although less
    responsive
  • Relevance for exercise
  • Can limit exercise capacity, but exercise may
    improve this.

23
Case Study 1
  • 74 year old male with history of COPD and a
    myocardial infarction 6 months ago
  • What is the likely causal link between the two
    conditions?
  • What are the benefits of physical activity for
    this patient?
  • What may limit his activity?

24
Brain Diseases
25
Parkinsons Disease
  • Definition
  • Deficiency of neurotransmitter dopamine in the
    brain
  • Symptoms
  • Resting tremor, bradykinesia (slowness of
    movement), rigidity, postural instability,
    shuffling gait and reduced facial expression
  • Concern
  • Increased risk of falls
  • Management
  • Managed with drugs. Rarely surgery
  • Relevance for exercise
  • Likely to be slow to initiate movement and
    exhibit postural instability
  • May be embarrassed
  • No specific exercise programme has proven benefit

26
Depression
  • Definition
  • Low mood
  • Symptoms
  • Sad, low self-esteem, loss of appetite, weight
    loss, concentration and memory problems, sleep
    problems, anxiety, somatic symptoms etc.
  • Concern
  • Increased risk of falls, may be increased fear of
    falling
  • Management
  • Medication or psychology
  • Relevance for exercise
  • Postural instability, due to deconditioning or
    drugs
  • Participation may be poor and will need
    encouragement etc.

27
Dementia
  • Definition
  • Progressive decline in cognitive ability and
    other brain functions. Alzheimers disease is
    commonest cause, followed by vascular disease
  • Symptoms
  • Impairment in short term memory, alteration in
    ability to sequence tasks, disorientation,
    reduced risk-awareness, ?impaired balance
  • Concern
  • Increased risk of falls
  • Management
  • Depends on cause but largely supportive, drugs of
    limited benefit
  • Relevance for exercise
  • May have difficulty following commands
  • May get agitated or disorientated
  • Some can benefit from supervised exercise
  • May be better to have carer present

28
Osteoarthritis
  • Definition
  • Degeneration of joints with loss of cartilage.
    Affects most commonly used joints - knees, hips,
    lower back, shoulders and hands
  • Symptoms
  • Pain, stiffness and swelling of joints.
    Instability of knees. Reduced mobility.
  • Concern
  • Pain in joints may be worsened by exercise.
    Unstable knees can give way.
  • Management
  • Analgesia is mainstay of management.
    Consideration of joint replacement. Strength
    training has proven benefit - may protect joint
    from excess wear.
  • Relevance for exercise
  • Will limit exercise tolerance through affected
    joint. This may be helped by taking analgesia
    prior to exercising.

29
Rheumatoid Arthritis
  • Definition
  • Inflammatory disorder of joint lining and tendon
    sheath lining
  • Symptoms
  • May be similar to OA, but different joints
    affected - hands, wrists, neck
  • Inflammatory changes and swelling more common,
    especially in the morning
  • Concern
  • As with OA. Joints need protection when acutely
    inflamed
  • Management
  • Usually controlled with variety of analgesic
    agents and disease modifying drugs. Sometimes
    joint replacement.
  • Relevance for exercise
  • Ensure adequate analgesia, may be less stiff in
    afternoon

30
Joints in Rheumatoid Arthritis
31
Diabetes
  • Definition
  • Impaired production of, or reduced sensitivity
    to, insulin causing high blood sugar. Associated
    with abnormal lipids, high BP, obesity.
  • Symptoms
  • Weight loss, thirst, passing a lot of urine,
    blurred vision
  • Concern
  • Hypoglycaemia if prolonged fast or excessive
    exercise (only if treated with tablets or
    insulin)
  • Management
  • Can be managed with diet, oral tablets and/or
    insulin
  • Relevance for exercise
  • Peripheral neuropathy causes impaired foot
    sensation, altering balance
  • Should carry dextrose tablets for classes
  • Exercise training has proven benefit in reducing
    blood sugar

32
Osteoporosis
  • Definition
  • Progressive loss of bone (all bones) and
    disruption of bone architecture leading to a weak
    fragile skeleton that is prone to fractures -
    particularly spine, hip wrist.
  • Symptoms
  • Low trauma fractures
  • Concern
  • Risk of injury from fall. Pain
  • Management
  • Usually treated with drugs, including calcium and
    vitamin D
  • Relevance for exercise
  • Increased risk of fracture in the event of a fall
  • Weight-bearing exercise may increase bone density
  • Might be a group to consider for hip protectors???

33
Nervous System Integration
34
Nervous System Integration
35
Nervous System Integration
36
Nervous System Integration
Diseases affecting sensory input
Vision Age-related refractive error (long sight) Age-related macular degeneration Glaucoma Cataracts Stroke causing visual field defect
Proprioception Diabetic neuropathy Vitamin B12 deficiency (uncommon) Syphilis (very rare) Degenerative joint disease, especially of neck and ankles
Vestibular Age-related middle and inner ear changes Chronic ear infections Perforated ear drum? Labyrinthitis Benign paroxysmal positional vertigo
37
Nervous System Integration
Diseases affecting central processing
Cerebrum Cerebrovascular disease (stroke, small vessel disease) Dementia Brain tumour (benign malignant)
Cerebellum Cerebrovascular disease (stroke) Long term alcohol misuse
Basal ganglia Cerebrovascular disease (stroke) Parkinsons disease and related conditions
Brain stem Cerebrovascular disease (stroke) Atherosclerosis (narrowing of blood vessels supplying the brain) Postural hypotension
38
Nervous System Integration
Diseases affecting Effector response
Spinal cord and nerves Any condition causing narrowing of spinal cord Neuropathy Motor neurone disease Multiple sclerosis Foot drop (common peroneal nerve palsy)
Muscles Cerebrovascular disease (stroke) Motor neurone disease Muscular dystrophy (unlikely in older adults) Multiple sclerosis Polymyalgia rheumatica Polymyositis Hypothyroidism Vitamin D deficiency (osteomalacia) Diabetes (diabetic amyotrophy) Muscle disuse following fracture, injury or prolonged immobility
Joints Osteoarthritis Rheumatoid arthritis
Other Foot deformities Poor fitting shoes
39
Case Study 2
  • 75 year old woman
  • 20 year history of diabetes poorly controlled by
    diet.
  • High blood pressure and angina.
  • Hip osteoarthritis
  • Smokes 20/day
  • What are the potential medical problems which may
    limit exercise ability/capacity?

40
Medications
  • 4/5 aged 75 or over prescribed at least one
    medication
  • Over one third on four or more
  • One drug may have a number of indications
  • Potential Impact on
  • Risk of falls
  • Exercise Capacity

41
For all Medication
  • Consider
  • Indications
  • Main effects
  • Side-effects including falls and exercise
    ability/capacity
  • Idiosyncratic adverse effects
  • Contra-indications
  • Interactions with other drugs
  • Compliance
  • Eg Atenolol

42
Common Indications
  • Cardiovascular Drugs
  • High blood pressure (Antihypertensives)
  • Angina
  • Abnormal Heart rhythms (Antiarrhythmic drugs
  • Drugs used to reduce clots (Antiplatelet/Anticoagu
    lant drugs)
  • Drugs for diabetes
  • Drugs used in respiratory disease
  • Drugs for Parkinsons Disease
  • Drugs acting on the brain (Psychotropic drugs)
  • Drugs for arthritis and connective tissue
    disorders
  • Drugs for osteoporosis

43
Drugs for high blood pressure
  • ß Blockers (atenolol, metoprolol etc)
  • Diuretics (Thiazide)
  • Calcium Channel Blockers (Nifedipine, Verapamil
    etc)
  • ACE Inhibitors ( Angiotensin receptor blockers)
    (Captopri, Enalarpril etc)
  • Often in combination
  • Not contraindicated for exercise

44
Drugs used in angina
  • ß Blockers
  • Nitrates (GTN and long acting)
  • Calcium Channel Blockers
  • Potassium Channel Openers (Nicorandil)
  • Often used in combination and statins
    (cholesterol lowering) also prescribed
  • If patient has GTN, they should keep it with them
    when exercising and may consider using it prior
    to exercise.
  • If patient forgets their GTN, recommend gentle
    exercise only

45
Drugs used in heart failure
  • Diuretics
  • ACE-Inhibitors
  • ß Blockers
  • Vasodilators
  • Patients may have reduced exercise tolerance
  • Patients may omit diuretics if going out, which
    may further reduce their exercise capacity - they
    should be advised to continue all medications

46
Antiplatelet drugs
  • After heart attacks, strokes, or when risk of
    clots
  • Antiplatelet
  • -Aspirin (Acetyl Salicylic Acid ASA)
  • -Dipyridamole (Persantin)
  • -Clopidogrel (Plavix)
  • Anticoagulant
  • -Warfarin
  • Not a contraindication to exercise, but may
    increase risk of bleeding in the event of a fall,
    particularly if on both Aspirin and Clopidogrel

47
Anticoagulants
  • Warfarin
  • (Phenindione - rare)
  • Not a contraindication for exercise, but will
    increase risk of bleeding if patient falls

48
Antiarrhythmic drugs
  • ß Blockers
  • Atenolol, Bisoprolol, Sotalol
  • Calcium Antagonists
  • Verapamil, Diltiazem
  • Digoxin
  • Amiodarone
  • Drugs for ventricular arrhythmias
  • Quinidine, Flecainide, Mexiletine, Disopyramide
  • Patients on Digoxin or Amiodarone should be able
    to exercise
  • Patients treated for Ventricular arrhythmias
    should only exercise with medical advice

49
Drugs used in respiratory disease
  • Inhaled therapy
  • ß2 Agonists Salbutamol (Ventolin), Terbutaline
    (Bricanyl)
  • Long acting Salmeterol (Serevent, Seretide),
    Formoterol
  • Anticholinergics Ipratropium Bromide (Atrovent),
    Tiotropium (Spiriva)
  • Steroids Beclometasone (Becotide, Becloforte)
  • Budesonide (Pulmicort), Fluticasone
    (Flixotide)
  • Patients should have short-acting ß2 Agonists
    with them when exercising
  • Oral Therapy
  • ß2 Agonists Salbutamol (Ventolin) - rarely used
  • Theophyllines Uniphyllin, Phyllocontin
  • Steroids Prednisolone
  • Immunomodulator Monteleukast, Zafirlukast -
    rarely used in older adults

50
Drugs used in Parkinsons disease
L-Dopa Co-careldopa - Sinemet Co-beneldopa -
Madopar Dopamine agonists Ergot-based -
Pergolide, Cabergoline Bromocriptine - rarely
used Non-Ergot - Pramipexole, Ropinirole COMT
inhibitors Entacapone Other drugs MAO(B)-inhibit
or - Selegiline Amantadine Anticholinergics
- Trihexyphenidyl, Procyclidine Apomorphine
injection - used in late disease Ability to
exercise will depend on stage of disease and time
of day Drug regimes can be complex - should not
miss doses
51
Psychotropic drugs
Anti-depressants Tricyclic - Amitriptyline,
Dosulepin, Lofepramine SSRIs - Citalopram,
Sertraline, Fluoxetine SNRI -
Venlafaxine Sedatives Benzodiazepines -
Temazepam, Nitrazepam, Diazepam Z drugs -
Zopiclone, Zolpidem Phenothiazines Nausea -
Prochlorperazine, Metoclopramide Agitation
(usually acute) - Haloperidol New agents -
Risperidone, Quetiapine All can cause sedation
or confusion and increase falls
risk Anti-dementia Donepezil (Aricept),
Rivastigmine, Galantamine Despite modestly
improving cognitive function, do not reduce falls
risk
52
Drugs for arthritis and connective tissue
disorders
Analgesics Paracetamol, Codeine,
Tramadol Combination analgesics Co-codamol,
Co-dydramol Co-proxamol has been
withdrawn Anti-inflammatory drugs Aspirin (only
over the counter) NSAIDs - ibuprofen,
diclofenac Disease-modifying drugs Immunosuppress
ants Steroids (e.g. Prednisolone) Azathiop
rine, Methotrexate, etc. Ensure patient has
taken pain relief, or has it with them for after
exercise Avoid exercise during acute flare-ups
53
Drugs for diabetes
Oral hypoglycaemic agents Biguanides -
Metformin Sulphonylureas - Gliclazide,
Tolbutamide Glitazones - Pioglitazone,
Rosiglitazone Insulin Human (recombinant,
analogue) Beef or Pork (rarely used
now) Long-acting - Insulatard, Glargine,
Detamir Intermediate Acting - Mixtard,
Novomix Short-acting - Actrapid,
Humalog Glucose Dextrose
tablets Glucogel (Hypostop)
54
Drugs for osteoporosis
Calcium Vitamin D Adcal D3, Calcichew D3
Forte, Cacit D3 Vitamin D insufficiency is
common in older people Causes reduced bone and
muscle strength Treatment reduces fractures by
about one third in housebound or
institutionalised older women, may also reduce
falls
Bisphosphonates Alendronic acid (Fosamax),
Risedronate Build bones by slowing
resorption. Robust evidence of fracture reduction
(approx 50) Other drugs Strontium ranelate,
Teriparatide, Raloxifene HRT no longer
recommended for osteoporosis due to adverse
effects. Slows post-menopausal bone loss. Effect
lost once withdrawn. Some concerns over
increased risk of breast cancer.
55
Case Study 1 - Mrs A (age 75 years)
History Two falls Hypertension Type 2
diabetes Angina Sleep problems Glaucoma
Medications Zopiclone GTN spray Gliclazide Aspir
in Atenolol Adcal D3
  • Questions
  • Why is she on each medication?
  • Which medications may be contributing to her
    falls?
  • Are there any exercise considerations with these
    medications?

56
Case Study 2 - Mr. B (age 80years)
Medications Aricept Becotide Captopril Citalopram
Co-dydramol Furosemide Salbutamol
  • Questions
  • What medical conditions might he have?
  • Could any of these medications be contributing to
    his falls?
  • Are there any exercise considerations of the
    medications?

57
If someone is prescribed the following drug(s),
what conditions are they likely to have?
  • Alendronic acid
  • Diltiazem
  • Pergolide and Co-careldopa (Sinemet)
  • Mixtard

58
Useful Information Sources
  • www.prodigy.nhs.uk (patient and professional)
  • www.bnf.org.uk (need to register)
  • www.merck.com/mmpe (professional)
  • www.merck.com/mmhe (patient)
  • www.besttreatments.co.uk (patient)

59
Thank you
  • Enjoy the rest of the course
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