Specialist PSI Exercise Module
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
Cardiovascular diseaseIschaemic heart diseasePeripheral vascular diseaseCerebrovascular disease - StrokeHypertensionArrhythmiasHeart Failure
Respiratory diseaseAsthmaChronic Obstructive Pulmonary Disease
Brain diseaseParkinsonism and Parkinson’s diseaseDepressionDementia
Part 1 – Medical Conditions
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
• 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
Part 2 – Medications (drugs)
Specialist PSI Exercise Module
Ischaemic Heart Disease
DefinitionImpairment of blood flow to heart muscle caused by narrowing of coronary arteries
SymptomsChest pain/tightness on exertion and relieved by rest – angina (pectoris)
ConcernCan ultimately lead to heart attack – myocardial infarction
ManagementMedication or invasive procedures, including angioplasty (balloon dilatation), stent & coronary artery bypass grafting (CABG)
Relevance for exerciseShould always consult with GP prior to exercise program
Specialist PSI Exercise Module
Peripheral Vascular DiseaseDefinitionImpairment of blood flow to the peripheries (legs mainly) caused by narrowing of blood vessels
SymptomsCramp like pain in legs on exertion, relieved by rest
ConcernMay deter people from exercising. Often co-existent with ischaemic heart disease (which may be silent)
ManagementAngioplasty (balloon dilatation) or stent, if narrowing is in larger blood vessels, or bypass surgery
Relevance for exerciseWill 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
StrokeDefinitionDamage to part of the brain from either blockage to a blood vessel or bleeding from a blood vessel (15%)
SymptomsDepends on area damaged in brain - Face, Arm, Leg, Speech, Vision
ConcernIncreased risk of falls: may also affect comprehension or speech
ManagementThrombolysis, rehabilitation, and address risk factors for recurrent stroke. Occasionally carotid artery angioplasty
Relevance for exerciseIncreased 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
HypertensionDefinitionHigh blood pressureSystolic pressure > 140 and/or Diastolic pressure > 80mmHg
SymptomsUsually no symptoms
ConcernIncreased risk of stroke or heart attack
ManagementUsually controlled on medication long term, also diet and exercise
Relevance for exerciseNot 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
ArrhythmiasDefinitionAbnormalities of the heart rhythm
SymptomsPalpitations, dizzy spells (rare), collapse. May be asymptomatic.Determined by site in heart where disturbance originates.
ConcernRisk of exercise inducing abnormal rhythm
ManagementOnce type of rhythm disturbance is identified, then medication is usual treatment
Relevance for exerciseBe aware of any precipitating factorsClient responsibility to liaise with GP
Specialist PSI Exercise Module
Heart FailureDefinitionA 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
SymptomsSevere tiredness, breathlessness or swelling of the ankles and feet
ConcernDevelopment of heart failure is associated with poor prognosis but careful exercise can improve heart function and symptoms
ManagementDependent upon cause. Drugs form the mainstay of management in most cases.
Relevance for exerciseDepending on severity may limit exercise capacity significantly
Specialist PSI Exercise Module
Pacemakers and DefibrillatorsDefinitionPacemakers 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.
SymptomsUsually the presence of a pacemaker or defibrillator is asymptomatic
ConcernPatients with exercise-induced arrhythmias may find that their defibrillator is triggered. Pacemakers should not be a concern.
Relevance for exercisePacemakers 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
AsthmaDefinitionReversible airflow limitation due to constriction of airways
SymptomsShortness of breath, wheeze, cough
ConcernCan be induced by exercise or limit exercise capacity
ManagementInhaled medication for the majoritySome will take oral medications
Relevance for exerciseNot 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
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
Parkinson’s DiseaseDefinitionDeficiency of neurotransmitter dopamine in the brain
SymptomsResting tremor, bradykinesia (slowness of movement), rigidity, postural instability, shuffling gait and reduced facial expression
ConcernIncreased risk of falls
ManagementManaged with drugs. Rarely surgery
Relevance for exerciseLikely to be slow to initiate movement and exhibit postural instabilityMay be embarrassedNo specific exercise programme has proven benefit
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DepressionDefinitionLow mood
SymptomsSad, low self-esteem, loss of appetite, weight loss, concentration and memory problems, sleep problems, anxiety, somatic symptoms etc.
ConcernIncreased risk of falls, may be increased fear of falling
ManagementMedication or psychology
Relevance for exercisePostural instability, due to deconditioning or drugsParticipation may be poor and will need encouragement etc.
Specialist PSI Exercise Module
DementiaDefinitionProgressive decline in cognitive ability and other brain functions. Alzheimer’s disease is commonest cause, followed by vascular disease
SymptomsImpairment in short term memory, alteration in ability to sequence tasks, disorientation, reduced risk-awareness, ?impaired balance
ConcernIncreased risk of falls
ManagementDepends on cause but largely supportive, drugs of limited benefit
Relevance for exerciseMay have difficulty following commandsMay get agitated or disorientatedSome can benefit from supervised exerciseMay be better to have carer present
Specialist PSI Exercise Module
OsteoarthritisDefinitionDegeneration of joints with loss of cartilage. Affects most commonly used joints - knees, hips, lower back, shoulders and hands
SymptomsPain, stiffness and swelling of joints. Instability of knees. Reduced mobility.
ConcernPain in joints may be worsened by exercise. Unstable knees can give way.
ManagementAnalgesia is mainstay of management. Consideration of joint replacement. Strength training has proven benefit - may protect joint from excess wear.
Relevance for exerciseWill limit exercise tolerance through affected joint. This may be helped by taking analgesia prior to exercising.
Specialist PSI Exercise Module
Rheumatoid ArthritisDefinitionInflammatory disorder of joint lining and tendon sheath lining
SymptomsMay be similar to OA, but different joints affected - hands, wrists, neckInflammatory changes and swelling more common, especially in the morning
ConcernAs with OA. Joints need protection when acutely inflamed
ManagementUsually controlled with variety of analgesic agents and disease modifying drugs. Sometimes joint replacement.
Relevance for exerciseEnsure adequate analgesia, may be less stiff in afternoon
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DiabetesDefinitionImpaired production of, or reduced sensitivity to, insulin causing high blood sugar. Associated with abnormal lipids, high BP, obesity.
SymptomsWeight loss, thirst, passing a lot of urine, blurred vision
ConcernHypoglycaemia if prolonged fast or excessive exercise (only if treated with tablets or insulin)
ManagementCan be managed with diet, oral tablets and/or insulin
Relevance for exercisePeripheral neuropathy causes impaired foot sensation, altering balanceShould carry dextrose tablets for classesExercise training has proven benefit in reducing blood sugar
Specialist PSI Exercise Module
OsteoporosisDefinitionProgressive 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.
SymptomsLow trauma fractures
ConcernRisk of injury from fall. Pain
ManagementUsually treated with drugs, including calcium and vitamin D
Relevance for exerciseIncreased risk of fracture in the event of a fallWeight-bearing exercise may increase bone densityMight be a group to consider for hip protectors???
Specialist PSI Exercise Module
Nervous System Integration
Cerebrum
CerebellumCoordination
Brain stemBasal GangliaMovement control
Spinal cordRelay of signals
Peripheral nervesMotor - musclesSensory - skin sensation
- proprioception
Autonomic Nervous SystemPulse, BP control
Vestibular systemBalance
Specialist PSI Exercise Module
Pain/TemperatureProprioception/VibrationPressureLight touch
Vision
VestibularMotor
AutonomicBlood pressureHeart rate
Nervous System Integration
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Nervous System Integration
Diseases affecting sensory input
Vision Age-related refractive error (long sight)Age-related macular degenerationGlaucomaCataractsStroke causing visual field defect
Proprioception Diabetic neuropathyVitamin B12 deficiency (uncommon)Syphilis (very rare)Degenerative joint disease, especially of neck and ankles
Vestibular Age-related middle and inner ear changesChronic ear infectionsPerforated ear drum?LabyrinthitisBenign paroxysmal positional vertigo
Specialist PSI Exercise Module
Nervous System Integration
Diseases affecting central processing
Cerebrum Cerebrovascular disease (stroke, small vessel disease)DementiaBrain 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 IntegrationDiseases affecting Effector response
Spinal cord and nerves
Any condition causing narrowing of spinal cordNeuropathyMotor neurone diseaseMultiple sclerosisFoot drop (common peroneal nerve palsy)
Muscles Cerebrovascular disease (stroke)Motor neurone diseaseMuscular dystrophy (unlikely in older adults)Multiple sclerosisPolymyalgia rheumaticaPolymyositisHypothyroidismVitamin D deficiency (osteomalacia)Diabetes (diabetic amyotrophy)Muscle disuse following fracture, injury or prolonged immobility
Joints OsteoarthritisRheumatoid arthritis
Other Foot deformitiesPoor 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
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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 therapyβ2 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 Therapyβ2 Agonists Salbutamol (Ventolin) - rarely used
Theophyllines Uniphyllin, Phyllocontin
Steroids PrednisoloneImmunomodulator 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 - SinemetCo-beneldopa - Madopar
Dopamine agonists Ergot-based - Pergolide, CabergolineBromocriptine - rarely usedNon-Ergot - Pramipexole, Ropinirole
COMT inhibitors Entacapone
Other drugs MAO(B)-inhibitor - SelegilineAmantadineAnticholinergics - Trihexyphenidyl,
Procyclidine Apomorphine injection - used in late disease
Ability to exercise will depend on stage of disease and time of dayDrug regimes can be complex - should not miss doses
Specialist PSI Exercise Module
Psychotropic drugs
Anti-depressants Tricyclic - Amitriptyline, Dosulepin, LofepramineSSRI’s - Citalopram, Sertraline, FluoxetineSNRI - Venlafaxine
Sedatives Benzodiazepines - Temazepam, Nitrazepam, Diazepam
‘Z drugs’ - Zopiclone, Zolpidem
Phenothiazines Nausea - Prochlorperazine, MetoclopramideAgitation (usually acute) - HaloperidolNew 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 Paracetamol, Codeine, TramadolCombination analgesics Co-codamol, Co-dydramol
Co-proxamol has been withdrawn
Anti-inflammatory drugs Aspirin (only over the counter)NSAID’s - ibuprofen, diclofenac
Disease-modifying drugs ImmunosuppressantsSteroids (e.g. Prednisolone)Azathioprine, Methotrexate, etc.
Ensure patient has taken pain relief, or has it with them for after exerciseAvoid exercise during acute flare-ups
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Drugs for diabetes
Oral hypoglycaemic agents Biguanides - MetforminSulphonylureas - Gliclazide, TolbutamideGlitazones - Pioglitazone, Rosiglitazone
Insulin Human (recombinant, analogue)Beef or Pork (rarely used now)Long-acting - Insulatard, Glargine, DetamirIntermediate Acting - Mixtard, NovomixShort-acting - Actrapid, Humalog
Glucose Dextrose tabletsGlucogel (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 peopleCauses reduced bone and muscle strengthTreatment 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
Questions:
• Why is she on each medication?• Which medications may be contributing to her falls?• Are there any exercise considerations with these medications?
History: Two fallsHypertensionType 2 diabetesAnginaSleep problemsGlaucoma
Medications:ZopicloneGTN sprayGliclazideAspirinAtenololAdcal D3
Case Study 1 - Mrs A (age 75 years)
Specialist PSI Exercise Module
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?
Case Study 2 - Mr. B (age 80years)
Medications:AriceptBecotideCaptoprilCitalopramCo-dydramolFurosemideSalbutamol
Specialist PSI Exercise Module
a) Alendronic acid
b) Diltiazem
c) Pergolide and Co-careldopa (Sinemet)
d) Mixtard
If someone is prescribed the following drug(s), what conditions are they likely to have?
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)