Transcript 2-MedicalConditions_Medications_2009

Medical Conditions and Medications
Impacting on Falls, Injury and Capacity
to Exercise
With thanks to Dr Rob Morris
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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 Parkinson’s disease
Depression
Dementia
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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 Parkinson’s disease
•
Drugs acting on the brain (Psychotropic drugs)
•
Drugs for arthritis and connective tissue disorders
•
Drugs for diabetes
•
Drugs for osteoporosis
Specialist PSI Exercise Module
Cardiovascular Disease
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
Angioplasty
Specialist PSI Exercise Module
Coronary Artery Bypass Surgery
Specialist PSI Exercise Module
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)
Specialist PSI Exercise Module
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.
Specialist PSI Exercise Module
Stroke – CT Scan
Specialist PSI Exercise Module
Carotid Artery Angioplasty
Before
After
Specialist
PSI Exercise Module
Hypertension
Definition
High blood pressure
Systolic pressure > 140 and/or Diastolic pressure > 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
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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
Concern
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.
Specialist PSI Exercise Module
Respiratory Diseases
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
Airways in Asthma
Specialist PSI Exercise Module
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.
Specialist PSI Exercise Module
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?
Specialist PSI Exercise Module
Brain Diseases
Specialist PSI Exercise Module
Parkinson’s 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
Specialist PSI Exercise Module
Definition
Low mood
Depression
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.
Specialist PSI Exercise Module
Dementia
Definition
Progressive decline in cognitive ability and other brain functions.
Alzheimer’s 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
Specialist PSI Exercise Module
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.
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
Joints in Rheumatoid Arthritis
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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???
Specialist PSI Exercise Module
Nervous System Integration
Specialist PSI Exercise Module
Nervous System Integration
Vestibular system
Balance
Brain stem
Basal Ganglia
Movement control
Spinal cord
Relay of signals
Cerebrum
Cerebellum
Coordination
Autonomic
Nervous System
Pulse, BP control
Peripheral nerves
Motor - muscles
Sensory - skin sensation
- proprioception
Specialist PSI Exercise Module
Nervous System Integration
Vision
Vestibular
Pain/Temperature
Proprioception/Vibration
Pressure
Light touch
Motor
Autonomic
Blood pressure
Heart rate
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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)
Parkinson’s disease and related conditions
Brain stem
Cerebrovascular disease (stroke)
Atherosclerosis (narrowing of blood vessels supplying the brain)
Postural hypotension
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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?
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
Common Indications
•
Cardiovascular Drugs
•High blood pressure (Antihypertensives)
•Angina
•Abnormal Heart rhythms (Antiarrhythmic drugs
•Drugs used to reduce clots (Antiplatelet/Anticoagulant drugs)
•
Drugs for diabetes
•
Drugs used in respiratory disease
•
Drugs for Parkinson’s Disease
•
Drugs acting on the brain (Psychotropic drugs)
•
Drugs for arthritis and connective tissue disorders
•
Drugs for osteoporosis
Specialist PSI Exercise Module
Drugs for high blood pressure
•
β – 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
Specialist PSI Exercise Module
Drugs used in angina
•
β – 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
Specialist PSI Exercise Module
Drugs used in heart failure
•
Diuretics
•
ACE-Inhibitors
•
β – 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
Specialist PSI Exercise Module
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
Specialist PSI Exercise Module
Anticoagulants
•
Warfarin
•
(Phenindione - rare)
•
Not a contraindication for exercise, but will increase
risk of bleeding if patient falls
Specialist PSI Exercise Module
Antiarrhythmic drugs
•
•
β – 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
•
Specialist PSI Exercise Module
Drugs used in respiratory disease
Inhaled therapy
β2 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 β2 Agonists with them when exercising
Oral Therapy
β2 Agonists Salbutamol (Ventolin) - rarely used
Theophyllines
Uniphyllin, Phyllocontin
Steroids
Immunomodulator
Prednisolone
Monteleukast, Zafirlukast - rarely used in older adults
If on a course of steroids for acute exacerbation, not advisable to exercise
Specialist PSI Exercise Module
Drugs used in Parkinson’s 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)-inhibitor - 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
Specialist PSI Exercise Module
Psychotropic drugs
Anti-depressants Tricyclic - Amitriptyline, Dosulepin, Lofepramine
SSRI’s - 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
Specialist PSI Exercise Module
Drugs for arthritis and connective tissue disorders
Analgesics
Combination analgesics
Paracetamol, Codeine, Tramadol
Co-codamol, Co-dydramol
Co-proxamol has been withdrawn
Anti-inflammatory drugs
Aspirin (only over the counter)
NSAID’s - ibuprofen, diclofenac
Disease-modifying drugs
Immunosuppressants
Steroids (e.g. Prednisolone)
Azathioprine, Methotrexate, etc.
Ensure patient has taken pain relief, or has it with them for after exercise
Avoid exercise during acute flare-ups
Specialist PSI Exercise Module
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)
Specialist PSI Exercise Module
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.
Specialist PSI Exercise Module
Case Study 1 - Mrs A (age 75 years)
History:
Two falls
Hypertension
Type 2 diabetes
Angina
Sleep problems
Glaucoma
Medications:
Zopiclone
GTN spray
Gliclazide
Aspirin
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?
Specialist PSI Exercise Module
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?
Specialist PSI Exercise Module
If someone is prescribed the following drug(s),
what conditions are they likely to have?
a) Alendronic acid
b) Diltiazem
c) Pergolide and Co-careldopa (Sinemet)
d) Mixtard
Specialist PSI Exercise Module
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)
Specialist PSI Exercise Module
Thank you
Enjoy the rest of the course
Specialist PSI Exercise Module