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

Medical Conditions and Medications Impacting on Falls, Injury and Capacity

to Exercise

With thanks to Dr Rob Morris


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


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


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


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


• 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)


Cardiovascular Disease


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


Angioplasty


Coronary Artery Bypass Surgery


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)


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.


Stroke – CT Scan


Before After

Carotid Artery Angioplasty


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


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


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


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.


Respiratory Diseases


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


Airways in Asthma


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.


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?


Brain Diseases


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


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.


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


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.


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


Joints in Rheumatoid Arthritis


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


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???


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


Pain/TemperatureProprioception/VibrationPressureLight touch

Vision

VestibularMotor

AutonomicBlood pressureHeart rate




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



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


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


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?


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


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


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


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


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


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


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


Anticoagulants

• Warfarin

• (Phenindione - rare)

• Not a contraindication for exercise, but will increase risk of bleeding if patient falls


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


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


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


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


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


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)


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.


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)


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


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?


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)


Thank you

Enjoy the rest of the course

Documents

Specialist PSI Exercise Module Medical Conditions and Medications Impacting on Falls, Injury and Capacity to Exercise With thanks to Dr Rob Morris