Geriatric Medications

As a reminder, what is the difference b/w pharmacokinetics and pharmacodynamics?

Pharmacokinetics = what WE do to the drugs (i.e., absorption, distribution, metabolism, excretion) vs. pharmacodynamics = what the DRUG does to us (mechanism of action, dose-response relationship, agonist vs. antagonist, potency vs. efficacy)

________: range where therapeutic effect vs. toxic effect occurs

Therapeutic index/range

How does absorption of a drug change as we age?

Altered GI function due to decreased gastric acid, absorbing area, stomach emptying, and motility

How does distribution of a drug change as we age?

Altered distribution due to decreased body H2O, lean body mass, plasma proteins & increased body fat

How does hepatic metabolism change as we age?

Altered metabolism due to decreased liver mass, liver blood flow, and enzyme activity

How does renal excretion change as we age?

Altered renal excretion due to decreased kidney mass, kidney blood flow, and tubular function in nephron

________: excessive or inappropriate use of multiple drugs

Polypharmacy

What is something WE should do as PTs to limit the negative effects of polypharmacy in older adults?

Comprehensive medication reconciliation (ID duplicates, adverse reactions/effects, drug-food interactions)

List risk factors for adverse drug reactions.

Comorbidities, lack of proper drug testing/regulations, lack of patient education, lack of patient adherence, use of inappropriate meds, other facts (diet, OTC, drugs & alcohol, caffeine, certain foods)

Which list is CRITICAL to have access to when determining whether a patient is taking appropriate drugs for the older adult?

Beer's Criteria List

List key medications from Beer's criteria list 2023.

Aspirin (NSAID), baclofen (anti-spasticity), clonazepam (anti-anxiety), ciprofloxacin (anti-biotic), digoxin (BP), diclofenac (NSAID), diuretics (BP), gabapentin (neuropathic pain), fluoxetine (anti-depressant), esomeprazole (GERD), insulin (anti-diabetic), meclizine (nausea), lorazepam (anti-anxiety), tramadol (opioid), warfarin (anti-coagulant)

Define "FRIDs."

Fall Risk Increasing Drugs

List Fall Risk Increasing Drugs (FRIDs).

Antipsychotics, antidepressants (higher risk from SSRIs), antiepileptics, hypnotics (benzos), opioids, cardiovascular meds, insulin, antihistamines, anticholinergics and overactive bladder

Suffix: typical antipsychotics

-azine (ex: chlorpromazine (Thorazine))

Function: typical antipsychotics

Block dopamine receptors and (+) symptoms of psychosis (hallucinations, delusions, paranoia)

Side effects: typical antipsychotics

Dry mouth, blurred vision, constipation, urinary retention, tachycardia, orthostatic hypotension, dizziness, sedation, weight gain

Extrapyramidal side effects: abnormal movement patterns, tardive dyskinesia

Suffix: atypical antipsychotics

-apine (ex: clozapine (Clozaril))

Function: atypical antipsychotics

Address the (-) symptoms (inability to experience pleasure and limited speech)

Side effects: atypical antipsychotics

Cardiovascular in nature

Suffix: tricyclics (antidepressant)

-itriptyline, -ipramine (ex: amitriptyline (Elavil))

Function: tricycylics (antidepressant)

Prolong and enhance effect of norepi and serotonin

Side effects: tricyclics (antidepressant)

Result of effects on ACh, histamine, and adrenergic receptors -- NARROW THERAPEUTIC INDEX

Suffix: MAOIs (antidepressant)

None (ex: isocarboxazid (Marplan), phenelzine (Nardil))

Function: MAOIs (antidepressant)

Prevent breakdown of monoamine NT norepi, dopamine, serotonin

Side effects: MAOIs (antidepressant)

Food-drug interactions --> CNS excitation, restlessness, irritability, sleep loss... MAO also breaks down tyramine --> $ release of large amount of norepi --> violent HA, severe HTN, possible CVA

Suffix: SSRIs (antidepressant)

-italopram, -oxetine (ex: citalopram (Celexa), fluoxetine (Prozac))

Function: SSRIs (antidepressant)

Block normal reuptake of free serotonin by nerve cells

Side effects: SSRIs (antidepressant)

Higher risk for falls -- but no effect on ACh, histamine, and adrenergic receptors like tricylclics or MAOIs

Suffix: SNRIs (antidepressant)

None (ex: venlafaxine (Effexor), duloxetine (Cymbalta))

Function: SNRIs (antidepressant)

Block reuptake of serotonin at low doses and norepi at higher doses

Side effects: SNRIs

Similar to SSRIs w/ addition of possible increase in BP

List types of antiepileptics.

Phenytoin (Dilantin) (primary drug for all seizures except absence), carbamazepine (Tegretol) (effective for all partial seizures), phenobarbital (Luminal) (schedule IV controlled substance for tonic-clonic & partial seizures), valproate (Depakene), ethosuximide (Zarontin)

Function: antiepileptics

Blocks Na+ current (phenytoin & carbamazepine), increases threshold for neuronal firing & enhances GABA, blocks Ca2+ channels in the thalamus thought to be involved w/ absence seizures (ethosuximide (Zarontin))

Side effects: antiepileptics (that would increase the risk of falls)

CNS depression (drowsiness, fatigue, vertigo, ataxia, diplopia)/ sedation (except phenytoin (Dilantin)), hypotension, dizziness

Suffix: benzodiazepines (aka hypnotics or anti-anxiety meds)

-azepam, -azolam (ex: diazepam (Valium), lorazepam (Ativan))

Function: benzodiazepines (aka hypnotics or anti-anxiety meds)

Bind to inhibitory GABA sites in the brain to provide sedation

Side effects: benzodiazepines (aka hypnotics or anti-anxiety meds)

Sedation, dizziness, ataxia, difficulty w/ speed and accuracy

List types of opioids.

Codeine, fentanyl, hydromorphone, meperidine, methadone, morphine sulfate, oxycodone

Function: opioids

Relieve pain by binding w/ opiate receptor sites in the brain

Side effects: opioids

Respiratory depression, sedation, dizziness, orthostatic hypotension

Why would cardiovascular meds (including loop diuretics) increase the risk of falls in the older adult population?

Orthostatic hypotension, dizziness, lightheadedness, dehydration

Why would insulin increase the risk of falls in the older adult population?

HYPO-glycemia --> dizziness

Why would antihistamines increase the risk of falls in the older adult population?

Drowsiness & dizziness

Why would anticholinergics and overactive bladder drugs increase the risk of falls in the older adult population?

Blurred vision, drowsiness, dizziness

Suffix: anticholinergics

None (ex: benztropine (Cogentin), trihexyphenidyl (Artane))

Function: anticholinergics

Inhibit ACh in the brain to restore balance w/ ACh and dopamine

Side effects: anticholinergics

Dry mouth/skin, tachycardia, dilated pupils, slowed GI/GU motility

Clinical implications: anticholinergics (and other meds associated w/ Parkinson's)

Patients w/ PD are already at risk for low BP, and these meds at to that; be away of the on-off phenomenon; understand pts may develop a tolerance and require a larger dose

What are the PT implications -- in terms of pharmacology for the geriatric population?

FALLS RISK, distinguishing s/s vs. side effects, scheduling PT visits, education on meds, education on compliance of drug regimens, advocating and coordinating care w/ provider

What are ways to monitor a patient's response to medication and care in PT?

Vitals, pain, glucose levels, SOB, O2 sats, RPE, dyspnea, circumferential measurements, weight, mood, PHQ-9, s/s of anxiety, seizure rate

Case 1: Acute Care (Hospital- Post-Surgical)

Patient: Mr. Johnson, 78 y/o male, admitted for hip fracture repair (ORIF).

PMH: Hypertension, Type II Diabetes, Atrial Fibrillation.

Medications: Metoprolol, Warfarin, Metformin, Oxycodone (post-op pain), Lorazepam (PRN for sleep)

Scenario: On post op day 2, during PT, Mr. Johnson reports dizziness and near-syncope when standing. His HR is 54 bpm and BP drops from 132/76mmHg supine to 98/60mmHg standing.

Which medications may be contributing to orthostatic hypotension and dizziness?

Metoprolol (bradycardia/ hypotension), Oxycodone (CNS depression/ dizziness/ OH), Lorazepam (sedation/ dizziness)

Case 1: Acute Care (Hospital- Post-Surgical)

Patient: Mr. Johnson, 78 y/o male, admitted for hip fracture repair (ORIF).

PMH: Hypertension, Type II Diabetes, Atrial Fibrillation.

Medications: Metoprolol, Warfarin, Metformin, Oxycodone (post-op pain), Lorazepam (PRN for sleep)

Scenario: On post op day 2, during PT, Mr. Johnson reports dizziness and near-syncope when standing. His HR is 54 bpm and BP drops from 132/76 mmHg supine to 98/60 mmHg standing.

What PT precautions are necessary given his Warfarin use?

Increased bleeding/ bruising risk so have to watch intensity, monitor for signs of bleeding, careful if increased fall risk, ensure safe transfers

Case 1: Acute Care (Hospital- Post-Surgical)

Patient: Mr. Johnson, 78 y/o male, admitted for hip fracture repair (ORIF).

PMH: Hypertension, Type II Diabetes, Atrial Fibrillation.

Medications: Metoprolol, Warfarin, Metformin, Oxycodone (post-op pain), Lorazepam (PRN for sleep)

Scenario: On post op day 2, during PT, Mr. Johnson reports dizziness and near-syncope when standing. His HR is 54 bpm and BP drops from 132/76 mmHg supine to 98/60 mmHg standing.

How would you modify your PT session and education?

Complete supine or seated activities, more gradual increase to standing, lower the intensity of exercise, increased rest breaks, education on: impact of medication, fall prevention, slow transitions, ankle pumps or leg movements before rising, increased guarding for safety

Case 1: Acute Care (Hospital- Post-Surgical)

Patient: Mr. Johnson, 78 y/o male, admitted for hip fracture repair (ORIF).

PMH: Hypertension, Type II Diabetes, Atrial Fibrillation.

Medications: Metoprolol, Warfarin, Metformin, Oxycodone (post-op pain), Lorazepam (PRN for sleep)

Scenario: On post op day 2, during PT, Mr. Johnson reports dizziness and near-syncope when standing. His HR is 54 bpm and BP drops from 132/76 mmHg supine to 98/60 mmHg standing.

How could you communicate your concerns to the medical team?

Discuss w/ nurses if this has happened before, document vitals, reach out to PCP, give a heads-up to OT or other professionals coming afterwards, report symptomatic OH, bradycardia, and/or sedation

Case 1: Acute Care (Hospital- Post-Surgical)

Patient: Mr. Johnson, 78 y/o male, admitted for hip fracture repair (ORIF).

PMH: Hypertension, Type II Diabetes, Atrial Fibrillation.

Medications: Metoprolol, Warfarin, Metformin, Oxycodone (post-op pain), Lorazepam (PRN for sleep)

Scenario: On post op day 2, during PT, Mr. Johnson reports dizziness and near-syncope when standing. His HR is 54 bpm and BP drops from 132/76 mmHg supine to 98/60 mmHg standing.

If this patient refuses to participate in PT session due to dizziness, how would you balance risk vs. benefit in your PT goals?

Complete more seated activities to get some movement and blood clot prevention in, see if the patient wants to complete some type of mobility (going to the bathroom, switching to a chair, etc.), educe on early mobility, prioritize safety but emphasize early mobility and exercise to prevent deconditioning. Adjust intensity/duration, modify exercises into supine/sitting for patient comfort.

Case 1: Acute Care (Hospital- Post-Surgical)

Patient: Mr. Johnson, 78 y/o male, admitted for hip fracture repair (ORIF).

PMH: Hypertension, Type II Diabetes, Atrial Fibrillation.

Medications: Metoprolol, Warfarin, Metformin, Oxycodone (post-op pain), Lorazepam (PRN for sleep)

Scenario: On post op day 2, during PT, Mr. Johnson reports dizziness and near-syncope when standing. His HR is 54 bpm and BP drops from 132/76 mmHg supine to 98/60 mmHg standing.

How might you use monitoring to guide safe progression?

Keep monitoring HR and BP, subjective report of how dizzy the patient is, use of RPE scale, progress gradually as tolerance increases

Case 1: Acute Care (Hospital- Post-Surgical)

Patient: Mr. Johnson, 78 y/o male, admitted for hip fracture repair (ORIF).

PMH: Hypertension, Type II Diabetes, Atrial Fibrillation.

Medications: Metoprolol, Warfarin, Metformin, Oxycodone (post-op pain), Lorazepam (PRN for sleep)

Scenario: On post op day 2, during PT, Mr. Johnson reports dizziness and near-syncope when standing. His HR is 54 bpm and BP drops from 132/76 mmHg supine to 98/60 mmHg standing.

What could happen if the PT overlooks the impact of his medications on fall risk?

More medications could be prescribed to address dizziness (polypharmacy cycle), unnecessary tests and measures causing additional medical costs, increase overall risk for the patient - falls, fractures, internal bleeding

Case 1: Acute Care (Hospital- Post-Surgical)

Patient: Mr. Johnson, 78 y/o male, admitted for hip fracture repair (ORIF).

PMH: Hypertension, Type II Diabetes, Atrial Fibrillation.

Medications: Metoprolol, Warfarin, Metformin, Oxycodone (post-op pain), Lorazepam (PRN for sleep)

Scenario: On post op day 2, during PT, Mr. Johnson reports dizziness and near-syncope when standing. His HR is 54 bpm and BP drops from 132/76 mmHg supine to 98/60 mmHg standing.

How would your discharge recommendations (home vs. rehab vs. SNF) change based on his medication-related risks?

If there is no one at home and patient continues to have severe medication response, it would be unsafe to send them home. If the patient continues to not be able to tolerate exercise, they would likely have to be discharged to SNF due to inability to tolerate 3 hours of IPR.

Case 2: Outpatient (Orthopedic)

Patient: Mrs. Lee, 72 y/o female, attending PT for chronic low back pain.

PMH: Depression, Osteoarthritis, Hyperlipidemia.

Medications: Fluoxetine, Atorvastatin, Ibuprofen PRN

Scenario: She reports increased fatigue, imbalance, and a recent fall. She feels "foggy" during your session.

Which of her medications are considered FRIDs?

Fluoxetine (anti-anxiety --> dizziness/sedation), Atorvastatin (can cause myopathy which can increase fall risk)

Case 2: Outpatient (Orthopedic)

Patient: Mrs. Lee, 72 y/o female, attending PT for chronic low back pain.

PMH: Depression, Osteoarthritis, Hyperlipidemia.

Medications: Fluoxetine, Atorvastatin, Ibuprofen PRN

Scenario: She reports increased fatigue, imbalance, and a recent fall. She feels "foggy" during your session.

What education would you provide regarding falls risk and safe exercise?

Intentional with transfers- slow sit <> stand, make sure feeling okay before walking; do HEP in a non-cluttered environment & prevent tripping (home safety assessment); have countertop or support nearby to hold on to for balance as needed; encourage patient to have a conversation w/ PCP about increased fatigue; education on medication side effects and awareness of side effects

Case 2: Outpatient (Orthopedic)

Patient: Mrs. Lee, 72 y/o female, attending PT for chronic low back pain.

PMH: Depression, Osteoarthritis, Hyperlipidemia.

Medications: Fluoxetine, Atorvastatin, Ibuprofen PRN

Scenario: She reports increased fatigue, imbalance, and a recent fall. She feels "foggy" during your session.

How/what would you coordinate w/ her primary provider?

Send a secure chat/ phone/ email to contact about medication, esp. if it's new or a change in dosage; share info on fall history and any side effects noted (fogginess, increased fatigue)

Case 2: Outpatient (Orthopedic)

Patient: Mrs. Lee, 72 y/o female, attending PT for chronic low back pain.

PMH: Depression, Osteoarthritis, Hyperlipidemia.

Medications: Fluoxetine, Atorvastatin, Ibuprofen PRN

Scenario: She reports increased fatigue, imbalance, and a recent fall. She feels "foggy" during your session.

If she reports another fall, how would that alter your plan of care?

Balance intervention, add in a new balance outcome measure based on circumstances surrounding fall, progress note, reach out to PCP (if not done already)

Case 2: Outpatient (Orthopedic)

Patient: Mrs. Lee, 72 y/o female, attending PT for chronic low back pain.

PMH: Depression, Osteoarthritis, Hyperlipidemia.

Medications: Fluoxetine, Atorvastatin, Ibuprofen PRN

Scenario: She reports increased fatigue, imbalance, and a recent fall. She feels "foggy" during your session.

How can you decide whether her fatigue is due to depression, medication, or deconditioning?

Subjective interviewing, subjective PROMs, outcome measure scores, depression screen, medication consolidation form, timing of medications

Case 2: Outpatient (Orthopedic)

Patient: Mrs. Lee, 72 y/o female, attending PT for chronic low back pain.

PMH: Depression, Osteoarthritis, Hyperlipidemia.

Medications: Fluoxetine, Atorvastatin, Ibuprofen PRN

Scenario: She reports increased fatigue, imbalance, and a recent fall. She feels "foggy" during your session.

What community or interdisciplinary referrals might be appropriate?

Skilled nursing referral, psychiatrist, pharmacist, support groups, ADRC, any exercise programming available for geriatric "folks," falls prevention programs in community

Case 2: Outpatient (Orthopedic)

Patient: Mrs. Lee, 72 y/o female, attending PT for chronic low back pain.

PMH: Depression, Osteoarthritis, Hyperlipidemia.

Medications: Fluoxetine, Atorvastatin, Ibuprofen PRN

Scenario: She reports increased fatigue, imbalance, and a recent fall. She feels "foggy" during your session.

If she is reluctant to discuss medication effects w/ her provider, how can you frame the conversation to empower her?

Discuss side effects, ask if patient wants PT to reach out or if patient wants to do it themselves (team approach); education - resources for self-research before talking to provider; emphasize safety and functional independence (bring it back to her personal goals and "why" for PT)

Case 2: Outpatient (Orthopedic)

Patient: Mrs. Lee, 72 y/o female, attending PT for chronic low back pain.

PMH: Depression, Osteoarthritis, Hyperlipidemia.

Medications: Fluoxetine, Atorvastatin, Ibuprofen PRN

Scenario: She reports increased fatigue, imbalance, and a recent fall. She feels "foggy" during your session.

If her provider decides to change her antidepressant, what PT observations would be important to track before and after the adjustment?

PHQ9; monitor mood, engagement, motivation, alertness each session; change in fall frequency and/or fatigue symptoms; assess for changes in pain perception and functional performance (as mood/energy can affect activity tolerance); note any new or worsening side effects (dizziness, GI upset, orthostatic s/s); communicate objective findings (TUG, gait speed, fall reports) to the provider to support medical mgmt. decisions

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

Which medication is most likely contributing to his weakness and hypokalemia?

Atorvastatin (can cause muscle cramps and weakness but NOT potassium loss), Furosemide (can cause potassium loss which can cause cramps, weakness, arrhythmias)

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

How might polypharmacy affect his rehab participation?

Sedation, dizziness, fatigue, drug-drug interactions, decreased tolerance

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

What red flags should PTs recognize that may require nursing/ medical follow-up?

Some examples of red flags to be aware of would be: unusual bleeding (rare but can cause bleeding bc Sertraline blocks reuptake of serotonin and in turn also blocks serotonin reuptake in platelets --> impairing platelets ability to form a clot), irregular HB, hypoglycemia, unusual changes to urine, seizures, hypokalemia (weakness, cramps, arrhythmia), excessive fatigue, hypotension

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

What education could you provide to prevent falls and promote adherence?

Importance of medication adherence, hydration, symptom monitoring, transitions, fall precautions

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

If his electrolyte imbalance worsens, what are the potential life-threatening consequences, and how would you recognize them?

Low potassium --> heart issues (HF, cardiac arrest, cardiac arrhythmias); low sodium --> seizures or cerebral edema; unusual cramping, mental confusion, seizures, N/V

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

What PT-specific precautions should you take knowing he is on Clopidogrel (Plavix)?

Need to be aware that this medication can cause bleeding --> regularly perform checks to observe for any bleeding, avoid any activities that could increase risk for falls, may need to modify approach w/ MT techniques

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

How do you balance intensity of rehab w/ the risks of medication side effects?

Monitor vitals closely, adjust intensity, coordinate sessions w/ nursing for med timing

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

How might his polypharmacy interact w/ fatigue, cognition, and motivation in therapy?

Might fatigue quicker than normal, experience several side effects that could also increase fatigue (e.g., N/T, pain, HA, N/V, etc.), altered cognition due to his meds (confusion, issues w/ vision and speech, feelings of irritation and aggressiveness), motivation might be lower

Patient: Mr. Hernandez, 80 y/o male, 3 weeks post ischemic stroke, admitted for rehab.

PMH: CHF, Hypertension, Seizure disorder.

Medications: Atorvastatin (new since CVA), Clopidogrel (new since CVA), Furosemide, Lisinopril, Levetiracetam, Sertraline

Scenario: During gait training, Mr. Hernandez becomes weak and unsteady. He reports leg cramps and lightheadedness. Labs later show hypokalemia.

If his labs hadn't been drawn yet, how would you justify to nursing/MD that something went wrong?

Report clinical changes (weakness, cramps, lightheadedness, hypotension, unsteadiness), link to medications (likely diuretics), suggest labs

Case 4: Skilled Nursing Facility (SNF)

Patient: Ms. Baker, 84 y/o female, admitted after pneumonia hospitalization.

PMH: Dementia, Overactive bladder, Hypertension.

Medications: Oxybutynin, Amlodipine, Acetaminophen PRN

Scenario: Nursing reports increased confusion and agitation. During PT, she is drowsy, has difficulty following commands, and is at high risk of falls.

Which medication is MOST concerning for cognitive side effects in older adults?

Oxybutynin - anticholinergic, causes confusion and delirium

Case 4: Skilled Nursing Facility (SNF)

Patient: Ms. Baker, 84 y/o female, admitted after pneumonia hospitalization.

PMH: Dementia, Overactive bladder, Hypertension.

Medications: Oxybutynin, Amlodipine, Acetaminophen PRN

Scenario: Nursing reports increased confusion and agitation. During PT, she is drowsy, has difficulty following commands, and is at high risk of falls.

How can PTs adapt interventions when cognition is impacted by meds?

Speak with short and clear instructions (simplify instructions and reps). Adapt communication style to be verbal, visual, or tactile. Utilize family if available for encouragement. Modify to shorter sessions to maintain engagement.

Case 4: Skilled Nursing Facility (SNF)

Patient: Ms. Baker, 84 y/o female, admitted after pneumonia hospitalization.

PMH: Dementia, Overactive bladder, Hypertension.

Medications: Oxybutynin, Amlodipine, Acetaminophen PRN

Scenario: Nursing reports increased confusion and agitation. During PT, she is drowsy, has difficulty following commands, and is at high risk of falls.

What environmental or scheduling strategies can reduce fall risk?

For the environment, consider safe transfer setup and positioning of equipment, have lights turned on, have AD nearby/chosen correctly, and use nonslip footwear. Reduce distractions. Schedule for when patient is most alert. Keep the schedule consistent. Incorporate frequent resk breaks.

Case 4: Skilled Nursing Facility (SNF)

Patient: Ms. Baker, 84 y/o female, admitted after pneumonia hospitalization.

PMH: Dementia, Overactive bladder, Hypertension.

Medications: Oxybutynin, Amlodipine, Acetaminophen PRN

Scenario: Nursing reports increased confusion and agitation. During PT, she is drowsy, has difficulty following commands, and is at high risk of falls.

How would you advocate for reviewing her medication list?

Document and communicate w/ the healthcare team about symptoms and ask for adjustments based on observed behavior patterns or changes in cognitive status. Communicate w/ coworkers about what happens in therapy.

Case 4: Skilled Nursing Facility (SNF)

Patient: Ms. Baker, 84 y/o female, admitted after pneumonia hospitalization.

PMH: Dementia, Overactive bladder, Hypertension.

Medications: Oxybutynin, Amlodipine, Acetaminophen PRN

Scenario: Nursing reports increased confusion and agitation. During PT, she is drowsy, has difficulty following commands, and is at high risk of falls.

How can you differentiate b/w disease progression (dementia) vs. drug-induced confusion?

Consider the symptom progression overtime

Case 4: Skilled Nursing Facility (SNF)

Patient: Ms. Baker, 84 y/o female, admitted after pneumonia hospitalization.

PMH: Dementia, Overactive bladder, Hypertension.

Medications: Oxybutynin, Amlodipine, Acetaminophen PRN

Scenario: Nursing reports increased confusion and agitation. During PT, she is drowsy, has difficulty following commands, and is at high risk of falls.

If her agitation increases, what strategies can PT use to safely engage her in mobility?

Do things they enjoy or were compliant with in the past. Have a safe environment set up or extra help as needed. Use simple instructions, try to de-escalate by changing to familiar environments, people, etc. Make sessions meaningful. Use a calm voice and redirection as needed, incorporate family/ caregivers/ friends/ familiar staff if able.

Case 4: Skilled Nursing Facility (SNF)

Patient: Ms. Baker, 84 y/o female, admitted after pneumonia hospitalization.

PMH: Dementia, Overactive bladder, Hypertension.

Medications: Oxybutynin, Amlodipine, Acetaminophen PRN

Scenario: Nursing reports increased confusion and agitation. During PT, she is drowsy, has difficulty following commands, and is at high risk of falls.

How would her medication side effects impact caregiver training for mobility and transfers?

Educate caregivers on side effects, alternative strategies for mobility or transfers that are safe/successful in PT. Educate how the caregiver can adjust for cognition changes, educate on what's worked in PT, and problem-solve how they can have carryover in a home setting. Keep in mind routines to prevent confusion and agitation.

Case 4: Skilled Nursing Facility (SNF)

Patient: Ms. Baker, 84 y/o female, admitted after pneumonia hospitalization.

PMH: Dementia, Overactive bladder, Hypertension.

Medications: Oxybutynin, Amlodipine, Acetaminophen PRN

Scenario: Nursing reports increased confusion and agitation. During PT, she is drowsy, has difficulty following commands, and is at high risk of falls.

If you suspected a medication was inappropriate for her age, how would you present that to the team w/o overstepping your scope of practice?

Beer's Criteria, document and communicate findings w/ objective data to support claims (but use language that is framed in a way that is not diagnosing or directing)

Case 5:

Patient: Mr. Williams, 89 y/o male, receiving HH PT for deconditioning after CHF exacerbation.

PMH: CHF, Osteoarthritis, Insomnia.

Medications: Digoxin, Furosemide, Hydrocodone-acetaminophen (PRN), Ibuprofen (PRN), Lisinopril, Zolpidem (for sleep)

Scenario: On arrival, you find him drowsy, with slowed responses and impaired balance. He reports frequent nighttime urination and occasional dizziness.

What are your main concerns based on his current status upon your arrival? What would you assess/screen while building your hypothesis?

My concern is whether the patient's current status is a re-exacerbation of his CHF vs. a side-effect of his medication(s) vs. an entirely new condition. I would conduct a vital assessment (to include weight and edema), formal balance/ gait/ mobility tests, and measures to build our hypothesis.

Case 5:

Patient: Mr. Williams, 89 y/o male, receiving HH PT for deconditioning after CHF exacerbation.

PMH: CHF, Osteoarthritis, Insomnia.

Medications: Digoxin, Furosemide, Hydrocodone-acetaminophen (PRN), Ibuprofen (PRN), Lisinopril, Zolpidem (for sleep)

Scenario: On arrival, you find him drowsy, with slowed responses and impaired balance. He reports frequent nighttime urination and occasional dizziness.

Which meds place him at high risk of falls?

ALL OF THEM - digoxin (bradycardia/ syncope/ dizziness/ vision changes), furosemide (dehydration/ hypotension/ nocturia), lisinopril (OH/ dizziness/ lightheadedness), zolpidem (sedation), hydrocodone-acetaminophen (sedation/ dizziness/ OH)

Case 5:

Patient: Mr. Williams, 89 y/o male, receiving HH PT for deconditioning after CHF exacerbation.

PMH: CHF, Osteoarthritis, Insomnia.

Medications: Digoxin, Furosemide, Hydrocodone-acetaminophen (PRN), Ibuprofen (PRN), Lisinopril, Zolpidem (for sleep)

Scenario: On arrival, you find him drowsy, with slowed responses and impaired balance. He reports frequent nighttime urination and occasional dizziness.

How would you schedule PT visits considering diuretic use?

Morning, in b/w voiding schedules (try to avoid right after taking furosemide)

Case 5:

Patient: Mr. Williams, 89 y/o male, receiving HH PT for deconditioning after CHF exacerbation.

PMH: CHF, Osteoarthritis, Insomnia.

Medications: Digoxin, Furosemide, Hydrocodone-acetaminophen (PRN), Ibuprofen (PRN), Lisinopril, Zolpidem (for sleep)

Scenario: On arrival, you find him drowsy, with slowed responses and impaired balance. He reports frequent nighttime urination and occasional dizziness.

How might the timing of diuretic doses change your exercise prescription and safety planning?

You want to make sure the patient's diuretic doses are timed appropriately - i.e., we don't want to take them too close to the appointment and too far away from the appointment. May need to increase rest breaks if fatigued from bathroom runs.

Case 5:

Patient: Mr. Williams, 89 y/o male, receiving HH PT for deconditioning after CHF exacerbation.

PMH: CHF, Osteoarthritis, Insomnia.

Medications: Digoxin, Furosemide, Hydrocodone-acetaminophen (PRN), Ibuprofen (PRN), Lisinopril, Zolpidem (for sleep)

Scenario: On arrival, you find him drowsy, with slowed responses and impaired balance. He reports frequent nighttime urination and occasional dizziness.

What home safety recommendations would you prioritize?

Modify the home environment to optimize safety and balance. Bathroom safety w/ grad bars and high-rise toilet if necessary and discuss use of easy to manage clothing.

Case 5:

Patient: Mr. Williams, 89 y/o male, receiving HH PT for deconditioning after CHF exacerbation.

PMH: CHF, Osteoarthritis, Insomnia.

Medications: Digoxin, Furosemide, Hydrocodone-acetaminophen (PRN), Ibuprofen (PRN), Lisinopril, Zolpidem (for sleep)

Scenario: On arrival, you find him drowsy, with slowed responses and impaired balance. He reports frequent nighttime urination and occasional dizziness.

How would you engage the caregiver in both education and monitoring for red flags related to his medications?

Make sure the caregiver is aware of what adverse effects/red flags to watch out for (specific to their meds and condition/ diagnoses). Educate the patient and the caregiver at the same time to make sure everyone is on the same page and can engage in the conversation.

Case 5:

Patient: Mr. Williams, 89 y/o male, receiving HH PT for deconditioning after CHF exacerbation.

PMH: CHF, Osteoarthritis, Insomnia.

Medications: Digoxin, Furosemide, Hydrocodone-acetaminophen (PRN), Ibuprofen (PRN), Lisinopril, Zolpidem (for sleep)

Scenario: On arrival, you find him drowsy, with slowed responses and impaired balance. He reports frequent nighttime urination and occasional dizziness.

If you find him drowsy at the start of a session, how would you decide whether to proceed, modify, or reschedule therapy?

Assess vitals and ability to perform low-level tasks. If the patient is stable, consider modifying their activities for the day. If the patient is unstable, consider rescheduling. Also assess cognition.

Case 5:

Patient: Mr. Williams, 89 y/o male, receiving HH PT for deconditioning after CHF exacerbation.

PMH: CHF, Osteoarthritis, Insomnia.

Medications: Digoxin, Furosemide, Hydrocodone-acetaminophen (PRN), Ibuprofen (PRN), Lisinopril, Zolpidem (for sleep)

Scenario: On arrival, you find him drowsy, with slowed responses and impaired balance. He reports frequent nighttime urination and occasional dizziness.

What could be the long-term functional consequences of repeated medication related falls?

Limited ability to complete ADLs, decreased functional capacity, recurrent hospital visits, broken bones/ injuries, TBI, death