Medical Diagnoses, Medical Diagnoses, Medications,Medications,

and their importance in the community and their importance in the community

settingsetting

Laura Morris, P.T.University of Pittsburgh Medical Center

Session ObjectivesSession 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.

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

Commonly Observed Medical Commonly Observed Medical DiagnosesDiagnoses

Stroke*ArthritisCardiovascular Disease*OsteoporosisParkinson’s DiseaseDiabetes MellitusTotal Joint ReplacementVestibular Dysfunction*

Medical Medical DiagnosesDiagnoses

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

JerryJerry

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

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

Cognitive ImpairmentCognitive Impairment

Memory loss, command following• Difficulty filling out Health/Activity

Information• Difficulty following class activities, verbal

instructions• Progress may be slower

JudyJudy

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

Cardiac DiseaseCardiac Disease

fatiguefatigue shortness of breath: Congestive Heart Failure shortness of breath: Congestive Heart Failure

(CHF)(CHF) Hypertension (HTN)/ unstable blood pressure (BP) Hypertension (HTN)/ unstable blood pressure (BP) headaches due to HTNheadaches due to HTN Anticoagulant therapy (blood thinning)Anticoagulant therapy (blood thinning)

Gabriel 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

Diabetes MellitusDiabetes 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”

AliceAlice

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

ArthritisArthritis 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

Total Joint ReplacementTotal Joint Replacement Total Hip Precautions

• for at least 6 weeks after surgeryNo flexion past 90 degreesNo 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

Total Joint ReplacementTotal 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

PerryPerry

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

Parkinson’s DiseaseParkinson’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

Parkinson’s DiseaseParkinson’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

PatsyPatsy

Walks stiffly with little trunk or head movement

Looks positively Green on a bad day Hates going to Cosco or the mall Goes early to the movie while the lights

are still on

Vestibular DysfunctionVestibular Dysfunction

Symptoms vary significantly Defining dizziness: spinning,

lightheadedness, off balance Complex visual environments can be

exacerbating

Vestibular DysfunctionVestibular 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

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

JoannaJoanna

Terrified of falling Looks at her feet all of the time Shoulders severely “humped” Limits community activity unless

someone with her

OsteoporosisOsteoporosis 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)

MedicationsMedications

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!

Moral of the story: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

What meds are of concern?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.

Anticoagulants (blood thinners)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

Anti-Hypertensives Anti-Hypertensives (blood pressure)(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

blockersCardura, Minipres, Hytrin, Flomax

Pain Medications & NarcoticsPain 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

So What So What DOES DOES cause falls?!cause falls?! Antidepressants: Double edged swordAntidepressants: Double edged sword Any Central Nervous System Suppressant:Any Central Nervous System Suppressant:

• Anti-seizureAnti-seizure• Sleepers (Campbell ‘99- 66% decrease risk Sleepers (Campbell ‘99- 66% decrease risk

w/withdrawl + home program, 45% drop out)w/withdrawl + home program, 45% drop out)• SedativesSedatives• Meclazine/AntivertMeclazine/Antivert

Question about indication vs. drug itselfQuestion about indication vs. drug itself

AND… Cardiac medsAND… 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

Reminder...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