Medical Diagnoses, Medications, and their importance in the community setting

1. Medical Diagnoses, Medications,and their importance in the community setting Laura Morris, P.T. University of Pittsburgh Medical Center

2. Session Objectives • Be able to describe the signs and symptoms associated with common medical conditions • Be able to modify activities that are contraindicated or likely to exacerbate certain medical conditions • Identify categories of medications that produce side effects likely to adversely affect balance and/or mobility.

3. Why is it important? • Prevalence of medical diagnoses in community elders • Challenge of finding a happy medium between challenge and safety for ALL participants in a community-based class

4. Commonly Observed Medical Diagnoses • Stroke* • Arthritis • Cardiovascular Disease* • Osteoporosis • Parkinson’s Disease • Diabetes Mellitus • Total Joint Replacement • Vestibular Dysfunction*

5. Medical Diagnoses • Important to be aware of related signs and symptoms when planning activities. • Eliminate contraindicated exercises • Adapt/modify balance exercises • Ensure safety during class sessions • Know when to refer to the medical model

6. Jerry • Weakness on right side • Difficulty speaking, especially when excited or stressed • Tends to move quickly and impulsively • If he is walking through a doorway, often runs into it on right side

7. Stroke • Characterized by weakness on one side, although not universal • Can involve cognition such as impulsivity or lack of insight into deficits, impaired memory • Glean information from others who know client • Visual neglect: Inability to centrally process visual sensory input from one side of body • not just lack of attention to the environment

8. Cognitive Impairment • Memory loss, command following • Difficulty filling out Health/Activity Information • Difficulty following class activities, verbal instructions • Progress may be slower

9. Judy • Rests in class as she gets short of breath from time to time • bruises on arms, complains about fragile skin • occasionally complains of lightheadedness or headache if the class is challenging

10. Cardiac Disease • fatigue • shortness of breath: Congestive Heart Failure (CHF) • Hypertension (HTN)/ unstable blood pressure (BP) • headaches due to HTN • Anticoagulant therapy (blood thinning)

11. Gabriel • Reports that he occasionally has numb feet • Won’t eat the cookies that Ed’s wife brought for the group • Has difficulty with reading if the light isn’t bright • Skin appears frail

12. Diabetes Mellitus • Can be well controlled or “brittle” • Need to find out from client how well condition is managed • Keep a keen eye for client having a “bad day”

13. Alice • Walks with a slight limp on the left • Difficulty getting up and down from a low chair • Lacks agility of movement • Grumbles about the rain we’re about to have the day before it comes

14. Arthritis • Hallmark signs/symptoms: joint pain and instability • Rheumatoid Arthritis: more swelling although intermittent • Exercise not a contraindication for either Osteo- or Rheumatoid • May look to you as an instructor for guidance in exercise

15. Total Joint Replacement • Total Hip Precautions • for at least 6 weeks after surgery • No flexion past 90 degrees • No adduction past neutral- “Sit like a man” • No internal rotation • Some physicians recommend following precautions forever • Longstanding hip abductor/extensor weakness • Clients should not be attending class until at least 6 weeks after surgery

16. Total Joint Replacement • Total Knee Replacement • Difficulty with adequate flexion or extension range of motion (ROM) • May not feel comfortable kneeling • May have decreased stability on surgical leg

17. Perry • Sweet, soft spoken type • Stoops over, especially by the end of class • Hesitates in doorways as if he’s shy about entering the room • Hates mingling in crowds or turning activities in class

18. Parkinson’s Disease • Increasing rigidity of trunk and limbs over time • Shuffling gait w/ difficulty in turning, changing surfaces or obstacle negotiation • Difficulty with “freezing”, especially if nervous or tired • Hand tremors at rest • Reduced arm swing

19. Parkinson’s Disease • Loss of voice production and swallowing • Progression:  trunk and hip flexion • Need stretching of flexors, strengthening of extensors (good for homework) • Sensitive to timing of medications • Visual/auditory cues helpful

20. Patsy • Walks stiffly with little trunk or head movement • Looks positively Greenon a bad day • Hates going to Cosco or the mall • Goes early to the movie while the lights are still on

21. Vestibular Dysfunction • Symptoms vary significantly • Defining dizziness: spinning, lightheadedness, off balance • Complex visual environments can be exacerbating

22. Vestibular Dysfunction • Nausea may or may not be present • To sit down and rest with all dizziness is not helpful • better to use pacing and sit only if symptoms get severe • Can use a 10-point scale to get a sense of how bad the dizziness is • Only allow dizziness to get to a 4 or 5/10

23. Vestibular Dysfunction • What to do with the undiagnosed dizzy client? • Encourage them to seek an answer from their primary physician • Educate them about resources for information about dizziness • Vestibular Disorders Association (VEDA) • www.vestibular.org

24. Joanna • Terrified of falling • Looks at her feet all of the time • Shoulders severely “humped” • Limits community activity unless someone with her

25. Osteoporosis • Posture: flexed upper thoracic trunk with bony changes • Much higher risk of fracture with fall • Compression fractures of spine more common with less impact • Extension exercises for trunk and hips beneficial (homework)

26. Medications • The market changes daily • Your client’s medications are changing often as well • Impossible to keep up with brand and generic names • Tinetti and others: Four meds or more= Fall risk!

27. Moral of the story: • Know where to look them up!! • Good references/sites to use: • www.Micromedex.com - go to “health content for clinicians” • www.nlm.nih.gov/medlineplus • www.askthedoctor.com

28. What meds are of concern? • Leipzig et al (1999) and others performed systematic reviews of drugs and their affects on falls in elders • Analyzed many meds and studies to get the “big picture” • Medication impact studies difficult due to dosage, duration, etc. • Measured falls, not necessarily symptoms of dizziness, etc.

29. Anticoagulants (blood thinners) • Used to decrease risk of thrombotic stroke • Studies found that there is no significant  risk of falls • No increased risk of subdural hematoma (SDH) from use • Bruise easily in extremities

30. Anti-Hypertensives (blood pressure) • NO significant risk for falls according to Leipzig et al • Common side effect is dizziness, esp. if BP not regulated well • NO correlation between Orthostatic Hypotension (OH) and falls/serious injury • Common meds that cause OH: alpha adrenergic blockers • Cardura, Minipres, Hytrin, Flomax

31. Pain Medications & Narcotics • Non-steroidal anti-inflammatories, aspirin, non-narcotic analgesics, etc. NO increased risk • Narcotics = NO significant risk for falls in the studies • HOWEVER, common side effects are sedative, confusion, slow reaction time

32. So What DOES cause falls?! • Antidepressants: Double edged sword • Any Central Nervous System Suppressant: • Anti-seizure • Sleepers (Campbell ‘99- 66% decrease risk w/withdrawl + home program, 45% drop out) • Sedatives • Meclazine/Antivert • Question about indication vs. drug itself

33. AND… Cardiac meds • Loosely correlated with falls • Diuretics: Thiazide > loop diuretic (Lasix) • Digoxin: used to regulate HR, control atrial fibrillation • Type 1a antiarrhythmic agents • Common examples: Quinidine, Procanamide, Diisopuramide

34. Reminder... • ASK participants regularly how they are feeling, any changes in symptoms • Participants should inform you of any medication change • Participants need a new release form after having any change in medical status