Falls
Presentation
- Often not the main problem but an important link with multi-factorial aetiology
- Fear of further falls
- Injuries
- Acute hospitalisations
- Admission into residential aged care facilities
- Fall may have resulted in long lie, with dehydration and rhabdomyolysis secondary to pressure induced muscle necrosis, note 50% 6 month mortality for lie > 1hr
- Clarify circumstances surrounding fall - lots of people will say they 'just tripped', be specific. Note periods of LOC, can they remember the episodes, episodes of palpitations preceding, vertigo, dizziness, fading vision etc.
- Vision testing
- Timed up and go test - walk 3m after starting sitting in a chair, turn and return to seat, >10s discriminates fallers from non-fallers
- Functional reach test
- Bloods - infective cause, electrolytes as cause of dysrythmia, CK, hypothyroidism as a cause of proximal myopathy, diabetes and loss of proprioception
- ECG, X-ray and imaging of injured regions
- Drugs - benzodiazepines, psychotropics (highest OR), anti-arrhythmics
- Musculo-skeletal (decreased muscle strength), neurological, CVS, vascular, arthritis, peripheral neuropathy
- Poor vision, esp depth perception, cataracts and decreased glare sensitivity
- PD - 60% fall/ yr
- Cognition and cognitive impairment - impairs judgement, eg dual tasking of talking and walking may be difficult
- Enroll patient in multidisciplinary and multi-factorial falls prevention program (only if there is no dementia so patient can participate)
- Physiotherapy incorporates balance training, resistance training, endurance training, with successful programs having multiple components
- Gait aids: improve stability, can off load weight bearing leg, and therefore decrease arthritis related pain
- Glasses: require optometrist review as prescriptions are often old. NOTE that ulti-focal/ bifocal glasses impair clear vision of the ground and contrast sensitivity on rough ground or steps
- Footwear: risk of falling if heel height >5cm, or narrow heel, loose fitting shoes, poor fastening of shoes. NOTE that 10 degree heel level has least slip in testing, firm fitting around heel
- Occupational therapy: OT home assessments have been shown to decrease falls in the community, leads to hazards reduction and provision of aids
- Personal alarms --> decreases time on ground
- Injuries, long lie, increased mortality, decreased independence, increases probability of admission to residential aged care facility
Urinary Incontinence
History
- Aim to determine what type of urinary incontinence that patient suffers from
- urge incontinence
- stress incontinence
- overflow incontinence
- neuropathic bladder
- Symptoms
- Hesitancy
- Urgency
- slow flow
- triggered by coughing
- leak
- vaginal dryness/ soreness or prolapse
- Delineate risk factors
- post-menopausal females
- age
- recurrent urinary tract infections
- prostatomegaly
- Determine impact on function
- significant psychosocial impact with threatened independence
- Investigations
- Urine MCS for infection
- PR for prostate
- Bladder scan
- Renal tract US if retention and worry about hydronephrosis
- Urodynamic studies
- Management Aust Prescr 2014;37:10-3
- Non-pharmacological
- continence pads
- perfumes for odour
- physiotherapy with bladder training exercises for overactive bladder
- lifestyle modification - lose weight, avoid bladder irritants such as caffeine and nicotine, regular exercise
- modify fluid intake
- postponement and distraction techniques
- pelvic floor muscle exercises
- continence nurse specialist if present
- The Continence Foundation of Australia also provides brochures
- Pharmacological
- Medically manage prostatomegaly with 5-alpha reductase inhibitors (SE fatigue, loss of libido and ejaculatory and/or erectile dysfunction) and alpha blockers
- non-selective muscarinic blockade (M2/ M3)
- oxybutynin - oral and transdermal patch formulations, can cross BBB - adverse effects such as dizzyness and confusion
- selective (mainly M3)
- solifenacin - lower rate of dry mouth and constipation than with nonselective antimuscarinic drugs, solifenacin reduced the daily mean number of voids compared to placebo (2.2 vs 1.2 episodes), reduction in the number of urgency episodes is 2.8 with 5 mg solifenacin, and 1.4 with placebo
- solifenacin - lower rate of dry mouth and constipation than with nonselective antimuscarinic drugs, solifenacin reduced the daily mean number of voids compared to placebo (2.2 vs 1.2 episodes), reduction in the number of urgency episodes is 2.8 with 5 mg solifenacin, and 1.4 with placebo
- most recent randomised trial (2013 SENIOR trial) reports that both oxybutynin and solifenacin are well-tolerated in the elderly, but oxybutynin is associated with a reduction in attention compared to placebo
- botulinum toxin
- effective in both drug-refractory non-neurogenic and neurogenic overactive bladder syndrome
- inhibits the release of acetylcholine into the neuromuscular junction, thus dampening detrusor contractility
- main potential adverse effects are temporary urinary retention that may require catheterisation, and urinary tract infection
- Australia botulinum toxin A is approved by the Therapeutic Goods Administration for both neurogenic and non-neurogenic overactive bladder, with the neurogenic indication now listed on the Pharmaceutical Benefits Scheme
- effective in both drug-refractory non-neurogenic and neurogenic overactive bladder syndrome
- Surgical
- Especially for stress incontinence if pelvic floor training fails
- synthetic mid-urethral sling and autologous fascial slings in women, and the transobturator bulbo-urethral sling in men
- Especially for stress incontinence if pelvic floor training fails
- Non-pharmacological
Medication rationalisation
General
- In the elderly patient, polypharmacy is always a significant issue. Older patients are more prone to type A adverse drug events (dose effect, predictable)
- " I would use a harm minimisation approach in order to rationalise Mrs RA's extensive medications list"
- Note that elderly patients are particularly susceptible to adverse drug effects due to altered drug handling in a patient with poor physiological reserve
- Note that elderly patients will have atypical responses to adverse drug reactions - including delirium, falls, incontinence and immobility
- To caution - there is reduced renal blood flow and glomerular filtration in older patients, therefore reduce dose/ frequency of renally excreted drugs, especially those with a narrow therapeutic index such as digoxin, lithium, vancomycin and gentamicin
- To caution - CNS acting drugs increase the risk of confusion and falls. Never prescribe haloperidol in patients with parkinsonism
- There is reduced liver mass and reduced hepatic blood flow - avoid long acting benzodiazepines
- Avoid drugs with a significant anticholinergic effect as it may exacerbate confusion
- Always think that a new symptom is drug related
- Make sure that one medicine is not prescribed to deal with another medicine
- Pharmacokinetic/ pharmacodynamic changes
- increased V(d) therefore increased t(1/2) of lipid soluble drugs due to increased total body lipid content - for lipid soluble drugs such as amiodarone and benzodiazepines
- reduced albumin levels hence reduced protein binding and increased free fraction for given dose. Problematic for phenytoin
- reduced first pass metabolism therefore higher bioavailability of drugs such as morphine
- hepatic conjugation is not as affected as hepatic biotransformation via CYP system. Drugs that are eliminated via phase 2 metabolism through conjugation include oxazepam, temazepam, lorazepam - these should be used.
- increased V(d) therefore increased t(1/2) of lipid soluble drugs due to increased total body lipid content - for lipid soluble drugs such as amiodarone and benzodiazepines
- before prescribing for a condition ask if the symptom is related to an adverse effect of another medication
- are there multiple medications of the same class eg sedatives?
- is there a safer and more effective option?
- can a non-pharmacological approach be used to manage this patient?
- cease medicines for conditions that have resolved
- cease medicines that patient is not taking
- medicine should be reduced sequentially and over a period of months
