Elderly And Falls

Question 0

What is an adverse drug reaction?

Answer 0

Undesirable effect of a drug beyond its anticipated therapeutic effects occurring during clinical use

Question 1

Why is looking at drug use in the elderly important?

Answer 1

4 in 5 over 65s take at least one medication
36% take ≥4 medicines (polypharmacy)
3 times more likely to suffer ADRs
ADRs account for 5-12% of elderly hospital admissions
Up to 50% of older patients do not take their prescribed medicines

Question 2

What 3 things can ADRs relate to?

Answer 2

Dose
Time-course
Susceptibility
DoTS classification

Question 3

Describe dose related adverse drug reactions

Answer 3

Above therapeutic range: toxic reaction eg bleeding following too high dose of warfarin. Treat by reducing dose, Prevent by using minimal effective dose
Within therapeutic range: collateral reaction eg drowsiness with antihistamine. May be unavoidable, May not be reduced even by reducing dose (without also reducing desired therapeutic effect)
Below therapeutic range: hypersusceptibility reaction eg penicillin allergy. Avoid by using foreknowledge of patient susceptibility, Permanent avoidance of drug

Question 4

Describe time course related adverse drug reactions

Answer 4

First dose reactions: eg hypotension after first dose of ACEi. Advice / special precautions may be needed eg take first dose at night while lying down to reduce risk of collapse
Early reactions: eg nitrate-induced headache. Patients become tolerant to these reactions and can continue with treatment, ADR wears off
Intermediate reactions: eg neutropenia due to carbimazole. Reaction occurs within a specific time frame. No reaction has occurred after this time, vigilance can be relaxed
Late reactions: eg bruising due to corticosteroids. Risk of ADR increases with continued or repeated exposure. Need for long-term monitoring and prevention
Withdrawal reactions: eg SSRI antidepressant discontinuation. Slow withdrawal or reduction of dose needed
Delayed reactions: eg carcinogenesis, teratogenesis. Avoid use of drug in patients who are susceptible

Question 5

Describe susceptibility adverse drug reactions

Answer 5

Genetic susceptibility
Age
Sex
Specific physiological states – e.g. pregnancy
Diseases – e.g. hepatic / renal impairment
Exogenous factors – drugs interactions, diet

Question 6

What is ageing? And what influences it?

Answer 6

Gradual loss of function of cells and organs with eventual outcome of death
Influenced by genetics, psychology, lifestyle, socioeconomic, environment

Question 7

Why should we be concerned about ageing and treatment of elderly people?

Answer 7

We’re all getting older so will be caring for lots of older people
Aim to improve quality of life (as well as longevity)
Resource issues for NHS: 65% of benefit expenditure on over 65y
NHS spending on patients >65y nearly double younger households
Average cost of providing hospital and community health services for a person aged ≥85y is around three times greater than for a person aged 65-74y

Question 8

What are the stages of old age?

Answer 8

65 – 75yrs - retired
75 – 85yrs - lots of emerging conditions and preventative techniques
85y+ - lots of comorbitidies, polypharmacy

Question 9

What are normal cardiovascular changes seen in ageing?

Answer 9

Cardiac enlargement / left ventricular hypertrophy
Decreased cardiac output (reduced exercise capacity)
Decreased response of heart rate to exercise
Systolic hypertension
Left ventricular failure

Question 10

What are normal respiratory changes with ageing?

Answer 10

Decreased FEV1/FVC and increased residual volume
Increaed susceptibility to infection
Increased susceptibility to aspiration

Question 11

What are normal endocrine changes with ageing?

Answer 11

Decreased insulin sensitivity

Decreased thyroid hormone production

Question 12

What are normal GI changes with ageing?

Answer 12

Increased gastric acid production

Constipation due to decreased motility

Question 13

What are normal skin and hair changes with ageing?

Answer 13

Dry skin, wrinkles, increased bruising, slower healing (ulcers/sores), Greying hair

Question 14

What are normal Genito urinary changes with ageing?

Answer 14

Decreased glomerular filtration rate
Benign prostatic enlargement (prostatism)
Deceased sexual function, erectile dysfunction
Vaginal dryness, increased susceptibility UTI

Question 15

What are normal musculoskeletal changes with ageing?

Answer 15

Sarcopenia – decreased muscle strength/power
Decreased mobility
Increased likelihood of falls
Increased susceptibility to fractures (osteoporosis)

Question 16

What are normal nervous system changes with ageing?

Answer 16

Slower thought processes/reactions
Vision deteriorates (presbyopia, cataracts)
High-frequency hearing loss (presbyacusis)
Inner ear dysfunction, balance problems

Question 17

What are normal immune changes that occur with ageing?

Answer 17

Atrophy of thymus

Decreased immune function - increaed infections, increased cancer, reactivation of latent infections (TB, shingles)

Question 18

What factors are affected which exacerbate decline when ageing and disease are present together?

Answer 18

Functional capacity
Quality of life
Independence
Wellbeing
Care needs
Mobility

Question 19

What physiological changes may lead to increased adverse drug reactions in the elderly?

Answer 19

Receptor responses – e.g. Decreased ß-adrenoceptor sensitivity 
Altered coagulation factor synthesis 
CNS becomes more sensitive to psychotropics /hypnotics
Baroreceptor response less sensitive 
Renal clearance reduced 
Thirst response blunted 
Thermoregulation blunted 
Altered immune response 
Slower gastric emptying 
Reduced plasma albumin 
Increased ratio of adipose to lean tissue 
Altered liver metabolism

Question 20

What factors may lead to increased adverse drug reactions in the elderly?

Answer 20

Decreased organ function: altered pharmacodynamics, pharmacokinetics and homeostatic functions
Multi disease morbidities
Polypharmacy
Decreased compliance

Question 21

What ageing changes in pharmacokinetics may be present in elderly?

Answer 21

Absorption: Swallowing, Gastric emptying, Intestinal motility, Blood flow, Surface area
Distribution: Tissue perfusion & blood flow, Plasma protein binding
Volume of distribution (water vs lipid solubility)
Metabolism: Hepatic mass, Hepatic blood flow, Thyroid function, Genetics
Excretion: Renal drug excretion relies on Renal blood flow, Glomerular filtration rate (GFR), Older patients take longer to eliminate renally excreted drugs, Assume that elderly have at least mild renal impairment, most important & predictable change

Question 22

What ageing changes in pharmacodynamics occur in elderly?

Answer 22

Changes in receptor sensitivity e.g. Decreased ß-adrenoceptor sensitivity with age
Changes in receptor number – never static
Changes in hormones levels – e.g. menopause
Actions of medicines affecting the CNS and the CVS are frequently altered – e.g. hypnotics, psychotropics

Question 23

Name some drugs with a narrow therapeutic range

Answer 23

ACE inhibitor, diazepam, digoxin, NSAIDs, opiates, oral hypoglycaemics (older people have less awareness of a hypo), warfarin (CYP450 interactions)

Question 24

Describe ageing changes in homeostasis in elderly

Answer 24

Decreased baroreceptor reflex with blunting of reflex tachycardia - orthostatic hypotension
Decreased postural control
Decreased thermoregulation
Decreased reserve of cognitive function
Decreased immune response – prone to infection

Question 25

What impact does multi morbidity have on the likelihood of adverse drug reactions in the elderly?

Answer 25

More drugs needed, so more chance for drug-drug interactions
More chance of drug-disease interactions, e.g Anticholinergics for prostatic hypertrophy precipitate urinary retention, Benzodiazepines may precipitate delirium in patient with dementia

Question 26

What is polypharmacy?

Answer 26

Taking 4 or medications

Question 27

What are pitfalls in prescribing for the elderly?

Answer 27

Concordance / compliance issues: Can they take it? Do they want to take it? Are they taking it as intended?
Cognitive & visual impairment
Over-the-counter drugs
Communication between care providers
Prescribing cascade: need to give a continuum of drugs to treat side effects of others

Question 28

How can the prescribing cascade relating to NSAIDs as painkillers be reduced?

Answer 28

Prescribe analgesia less likely to cause serious side effects
Advise the patient to stop taking the tablets if notice any worsening heartburn or abdominal discomfort
Minimise duration
If a NSAID is absolutely necessary: Use ibuprofen instead of diclofenac (fewer upper GI side effects), Co-prescribe a proton-pump inhibitor

Question 29

What are strategies to improve concordance in drug taking in the elderly?

Answer 29

Simplify: Use once-daily dosing! prescribe medicines to be taken at same time of day, use medications with dual indications, Consider daily dose reminder system (e.g. Dosette box)
Educate: Explain reasons for medication & how to take it, Warn of predictable side effects, Enlist support of family & carers in monitoring
Monitor: Check tablet boxes & use of medications, Monitor requests for prescriptions, Serum monitoring if needed

Question 30

How often should medication reviews be done?

Answer 30

All patients aged >75 years annual review of their repeat medication
Those taking ≥ 4 medicines should be reviewed every 6 months
May be completed by any suitably qualified health professional

Question 31

What are strategies to minimize adverse drug reactions?

Answer 31

Take a good drug history (incl. OTC)
Prescribe sensibly: Do they need it? Can they take it? Do they want to take it?
Consider drug-drug and drug-disease interactions
Minimize use of high-risk drugs e.g. warfarin, macrolides
For every new problem, consider whether medication could be the cause (avoid prescribing cascade)
Start low, and go slow (dosing)
Extreme caution when care is transferred
Record allergies & intolerances

Question 32

What is a fall?

Answer 32

Unintentionally coming to rest at a lower level

Question 33

What is syncope?

Answer 33

A sudden, transient loss of consciousness due to reduced cerebral perfusion
Patient unresponsive, with a loss of postural control (slumps or falls)
Spontaneous recovery

Question 34

How many people fall each year?

Answer 34

30% of over-65s fall each year

50% of over-80s fall each year

Question 35

What are consequences of falls?

Answer 35

Bio - fractures, head injury, soft tissue injury, burns, pressure sores, rhabdomyolysis, hypothemia, hypostatic pneumonia, 50% of those lying for over 1 hour, dead within 6 months
Psycho - depression, anxiety, fear of further falls
Social - loss of independence, institutionalisation, impact on others - carers

Question 36

When do most falls occur?

Answer 36

Most falls occur in mid afternoon due to shifting body weight, trip, hit, loss of support, collapse, slip

Question 37

What are intrinsic causes of falls?

Answer 37

Syncope / transient LOC
Dizziness, vertigo, Seizures 
Peripheral neuropathy 
Stroke 
Visual impairment 
Parkinson’s disease 
Cognitive impairment - affects assessment of risk
Side effects of drugs or alcohol 
Age-related frailty

Question 38

What are causes of syncope?

Answer 38

Situational hypotension – posture, coughing, eating, orthostatic
Vasovagal – vagal stimulation (pain, fear, emotion)
Carotid sinus syndrome
Cardiac arrhythmia or ischaemia
Outflow obstruction – aortic stenosis
Pulmonary embolism

Question 39

What are extrinsic causes of falls?

Answer 39

Poor lighting - steps/stairs
Clutter around the home
Inappropriate footwear - open-backed slippers, high heels
Incorrect use of walking aids
Pets or children
Trailing cables
Slippery floors or pavements
Rugs & carpet folds
Bath / toilet problems - too low, slippery, lack of handles
Unfamiliar environment - hospital, care home

Question 40

What are common causes of falls?

Answer 40

DAME, Multifactorial
Drugs: polypharmacy, alcohol
Age-related changes: gait, balance, sarcopenia, sensory impairment
Medical: syncope, Parkinson’s disease, stroke
Environmental: obstacles, trailing wires, lighting

Question 41

What aspects of the history are particularly important when understanding a fall?

Answer 41

SPLATT!
Symptoms: dizziness, faint, chest pain, palpitations, LOC, tongue biting
Previous falls: is this the first fall? Or one of many?
Location: where did the fall happen?
Activity: what were you doing when you fell?
Time: was it soon after taking tablets, after meal, associated with coughing / straining?
Trauma sustained? Any injuries that need attention?
Drug History

Question 42

What aspects are important on examination of someone who has fallen?

Answer 42

General appearance
Gait & balance
Pulse rate & rhythm, Postural BP
Consider carotid sinus massage (expert only!)
Listen for murmurs – esp. aortic stenosis
Neurological examination, Parkinson’s disease, peripheral neuropathy
Check vision & hearing
Examine neck & head movements
Consider screening for cognitive impairment

Question 43

What investigations can be used to evaluate falls?

Answer 43

Bloods: FBC (infection, anaemia), U&Es, creatinine, Thyroid (TSH), BM, B12, folate, Calcium, phosphate 
ECG, 24h ECG, Echocardiography
Tilt table (simulate postural changes)
CT head 
EEG (seizures)

Question 44

What is orthostatic hypotension? And what can cause it?

Answer 44

> 20 mmHg fall in systolic BP and a >10 mmHg fall in diastolic BP in 3 minutes of standing with symptoms
Causes: drugs, chronic hypertension, volume depletion, autonomic failure (Parkinson’s, diabetes), prolonged bed rest, adrenal insufficiency
Treat the cause. Consider fludrocortisone or desmopressin

Question 45

What is post-prandial hypotension? And how can it be reduced?

Answer 45

A fall of >20 mmHg in systolic blood pressure after the ingestion of a meal. Can have effect for up to 90 minutes
Alter timing of antihypertensives, Lie down / sit down after meals
Caffeine, fludrocortisone, NSAIDs

Question 46

How can visual impairment affect the risk of falls?

Answer 46

Common with increased age
Bifocals increase the risk of falling
Glaucoma, Macular degeneration, Retinopathy, Cataracts
More likely to trip over if poor vision

Question 47

How can cognitive impairment affect risk of falls? And what can be done about it?

Answer 47

Increased risk of falls
Distinguish delirium (acute) vs dementia (chronic)
Use a cognitive assessment tool (e.g. MMSE or GPCOG)
Consider medical causes for reduced cognitive function, eg hypothyroidism, hyponatraemia, hypoglycaemia, vitamin deficiency, drugs, alcohol
Refer to specialist for formal diagnosis and treatment

Question 48

What is a Multifactorial risk assessment of falls?

Answer 48

Falls history, gait and balance assessment, mobility, muscle weakness, osteoperosis, percieved functional ability, fear of falling, visual impairment, cognitive impairment, urinary incontinence, home hazards, CV exam and medication review

Question 49

What are Multifactorial interventions for falls?

Answer 49

Medication review, treat underlying causes, individualised strength and balance training, exercise in extended care settings, home hazards and safety intervention, vision assesment and referral