FOXcast OT: Medication Management In The Older Adult

This is the clinical countdown from FOX Rehabilitation.

One topic, five takeaways, in 10 minutes or less. The clinical countdown from FOX Rehabilitation.

Jimmy McKay, PT, DPT: Welcome to FOXcast. I’m your host physical therapist Jimmy McKay. On the program this afternoon is FOX PT Connie Lewis. Connie welcome to the program.

Constance Lewis, PT, DPT: Thanks for having me.

Jimmy: All right today we’re going to do a different type of episode. We’re trying a different format. We’re going to look at one topic polypharmacy in older adults, with five takeaway points for you and we’ll do it in just 10 minutes. Connie you think you’re up to the task? I’m ready. Get your stopwatch is out because we know you’re busy. So want to get right to something that’s really important in paying attention to polypharmacy with older adults. I’m gonna synchronize my swatch not sure anybody says that anymore.

Constance: I don’t think so.

Jimmy: So when we’re talking about polypharmacy with older adults, medication management where does your head go first what’s our first takeaway point today? Number one.

Constance: Polypharmacy itself just talking about the sheer number of medications that somebody is taking has been known to increase the risk of poor outcomes in older adults. Looking at that medlist how many meds is somebody on? Should they be on all of those meds and what are the interactions and the risks or those adverse drug reactions? Age related physiological changes they can literally increase the risk of adverse drug reactions especially in somebody who has renal compromise and it’s filtering or clearing them meds at a different rate. I don’t expect any clinician to remember what each drug does or even what each drug’s name is. You got a generic names and brand names, it can get really confusing but no your resources. You can go to a website Drugs.com That anyone can use and there is a drug interactions checker where you can plug in every single medication that a client is taking. And we’ll look at those interactions and then take a look at where there are multiple physicians prescribing. Are they talking to each other? Sometimes where the common denominator between various scopes of medical practitioners who are prescribing these meds. The American Geriatrics Society just updated the beer’s criteria for anyone who doesn’t know this provides an explicit list of medications that should be avoided and older adults evidence based provides the rationale for use of these drugs along with the greatest strength of evidence supporting the recommendation.

Jimmy: So the first thing is pay attention. And then if you see something go in check that really really easy to do Drugs.com as you mentioned. So poorly pharmacy and adverse drug reactions you might be the difference maker the one that spots it first as a PT as an OT as an SLP.

Constance: Correct.

Jimmy: Where we going next?

Constance: Medications that actually do increase the risk of fall. Not only is it just the sheer number of minutes that somebody is on can increase that risk but then there’s certain drug classes and certain medications that are actually going to increase the risk of falls in our older adult. First one being drug with anticholinergic properties that are commonly prescribed. These are drugs that block the effects of acetylcholine on the body. So antihistamines antiparkinsonian meds. Muscle relaxants, antidepressants antipsychotics. There are so many and the elderly could be taking it for anything from muscle spasms to overactive bladder, insomnia, anxiety, vertigo, seasonal allergies, even a common cold. But here’s the problem so many drugs have these anticholinergic properties that it can result in a fancy term called a high anticholinergic burden. Which is really the cumulative effect of using multiple medications with these properties. Research is showing that this cumulative effect can be associated with everything from falls to impulsive behaviors, poor physical performance, loss of independence, dementia, delirium, even brain atrophy. Really important to take a look at what meds they’re taking. Other classes of meds that can increase risk of falls for a variety of reasons include benzodiazepines, nonbenzo hypnotics, narcotics, NSAID’s, antihypertensives. Benozo’s are pretty common as a prescribed psychotropic for use of anxiety. Also to help prevent insomnia agitation delirium but here are the negatives, benzo’s have been associated with cognitive decline, impaired driving, falls, fall related injuries such as hip fractures in older adults. Now the recommendation is to try and avoid using them as a first line treatment for anxiety. Antipsychotics are sometimes used to treat for dementia and they’ve been associated with not only a risk of falls and fall related fractures but also acute kidney injury and as well as over sedation and worsening of cognitive function. Big things to take a look at.

Jimmy: This just sounds like more communication and paying attention to what medications your older adult clients are on.

Number three.

Jimmy: All right. Number three where we go.

Constance: All right. I want to talk about statin’s!

Jimmy: Let’s talk about statins.

Constance: This is an interesting one and recently was discussing this with a physician who referred clients to our practice and he really got on a soapbox about it. And for other clinicians it’s really a good thing that people are taking a look at them. The statins are a class of drugs known for helping to lower blood cholesterol levels. Thereby decreasing risk of heart attack or chest pain, common brand names usually end in o-r. So Lipitor, Crestor, Zocor are a few of the big ones. Here’s the problem. Research is showing that in older adults these drugs should really not be used as a primary prevention for cardiovascular disease. Why do we care? Myopathy is a common adverse effect of statins. And as we know my myopathy is a disease in the muscle where the muscle fibers aren’t functioning properly and resulting in muscular weakness. So statin’s should be used as a secondary preventative tool in older adults and is really questionable as primary prevention. And that’s a good discussion to have with some of our referring physicians.

Jimmy: I’m seeing a theme here it’s communication and paying attention. To the symptoms and the things you’re seeing as a clinician.

Constance: Exactly.

Number four.

Jimmy: Number four it’s about timing.

Constance: Timing the timing of meds related activity. When working with anyone who receives a breathing treatment such as albuterol you really want them to receive the treatment prior to their therapy for optimal pulmonary performance. Same thing with Parkinson’s meds. Levadopa, carbodopa commonly combined as Sinemet. Know the on off times for your client. And know that if they’re not performing optimally one day or they appear to have a regression maybe it’s related to the timing of their meds that day. And you can proactively optimize their performance by knowing those on times. Another one opioids. Obviously a big push lately to help get people off of opioids due to the dependency and negative side effects such as constipation, sedation, orthostatic hypertension. But know that older adults are also more susceptible to opioid induced psychotropic reactions. Such as confusion, anxiety, hallucinations and dysphoria. A lot of people will turn to NSAIDs for pain relief. Aspirin ibuprofen. But then you have to watch for anyone who has a compromised hepatic or renal function.

Number five.

Jimmy: Wrapping up with number five. It’s about safety.

Constance: Safety education beta blockers. We obviously know that if anyone is on a beta blocker we should not be monitoring their heart rate as an indicator of exercise intensity. So we’re just taking a look at what they’re on but you can monitor their exercise performance. We know we need to use the RPE scale in that case. With the borg or modified borg scale. Anyone on a blood thinner. If somebody falls or told you they had a fall and you start to ask those red flag questions. Well did you set your head could you put your head and not remembered it. That’s an automatic trip to the emergency room to rule out a brain bleed and something that somebody might not think to do. Meds that cause orthostatic hypertension. There’s a lot of em’. Opioids antipsychotics antihypertensives. To be able to identify A, what is true orthohypertension or that 20 mm mercury drop in systolic and 10mm of mercury drop in diastolic bp within three minutes of a position change. And then A, do they really need to be on that medication that might be causing this? Another communication factor with the physician. B, if they do and they’re experiencing this educating the client on how to decrease their risk of falls and after sitting, after they sit up sit and wait a few minutes. Until that doing it passes. Same with standing. Don’t try to go too fast. The other one is diuretics. A fair a number of older adults are treated for hypertension by using diuretics. This is fairly safe and well tolerated but then we got to think of their safety. How often are they getting up in the middle of the night? Is the pathway to the bathroom clear? Are there obstacles? Is it clearly lit? These are things that can pose a fall risk for a different reason. So kind of thinking outside the box there and then clients with diabetes making sure that they’re regularly checking their glucose levels and they’re aware of the signs and symptoms of hypo or hyperglycemia especially type 1 diabetic or anyone on insulin timing of their meals and medications. With exercise can be really really important. And in an emergency you know that it’s OK to give some type of juice or sugar to boost their glucose levels. As long as that person can still swallow obviously. We can really bring them down that dangerous zone and they’ll pay that little bit of extra isn’t going to hurt them. That’s all I’ve got on that.

As we check the clock we came in just under 10 minutes perfect.

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