Helping older patients to be physically and socially active

The recent disruptions to daily social and physical activities during COVID-19 restrictions may have had unintended but serious flow-on effects for some people.¹ The challenges of physical distancing are exacerbated by people losing their everyday functional support systems, being more sedentary, having reduced cognitive stimulation, being unfamiliar with telehealth and feeling stressed to leave the house.¹ Older people often lack the reserve to compensate when changes occur and are more vulnerable to a decline in mental and physical health, and daily functioning.^2, 3

Explore with your older patients actions they can take to rebuild social connections and physical activities safely as COVID-19 restrictions change.

Now is the time to assess your older patient’s functional capacity

There are several ways you can do this:

• Gait speed is a reliable measure of functional capacity.⁴ Older people with a slow gait speed are at a higher risk of falls, physical and cognitive functional decline, hospitalisation and poor quality of life.⁵ Gait speed can be quickly and easily measured in the clinical setting by you or your practice nurse.^4, 6

You can assess your patient’s gait speed by:

• observing their gait, stride length, postural stability and sway as they walk.⁷ Ask your patient or their partner/carer if they have noticed any changes in their mobility,⁷ in particular, following COVID-19 restrictions and associated disruptions to their social and physical activity routines.
• using one of the falls tests listed in the Royal Australian College of General Practitioners’ (RACGP) Silver Book, Part A, at: www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgpguidelines/silver-book/part-a/falls

for example, the:

• ‘timed up and go’ test which measures the time it takes for a person to stand from a chair, walk three metres, turn around, return to the chair and sit down again, and how they manage this task. Normally this can be done comfortably within 10 seconds.⁷

• As falls and frailty overlap with gait speed, consider using the ‘Rapid geriatric assessment’ which assesses for frailty, muscle loss, appetite and food intake, and cognitive decline. You or your practice nurse can conduct this test in about five minutes.⁸ Obtain the test at: www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/rapid-geriatric-assessment.pdf or go to the RACGP’s Silver Book, Part A, Frailty section to find an appropriate test, at: www.racgp.org.au/clinicalresources/clinical-guidelines/keyracgp-guidelines/view-all-racgpguidelines/silver-book/part-a/frailty
• A ‘Health assessment for people aged 75 years and older’, under MBS items 701, 703, 705 or 707, is useful to identify factors that may be influencing your patient’s physical, psychological or social functioning. Further information about the assessment is available at: mbsonline.gov.au

Talk to patients displaying a decline in mobility and functional capacity about:

being more physically active

Explain that:

• exercise programs are safe for older people; the risk of inactivity poses a greater health risk than exercise⁹
• even small amounts of physical activity can delay or prevent falls and frailty, and maintain or improve mobility^10, 11
• increasing the amount of moderate intensity activity per week, even by a small amount, is beneficial⁹
• a mixture of resistance, aerobic, strength and balancing exercises provides the best health outcomes⁹
• adding a social element to physical activities often adds to the enjoyment.⁹

If patients feel anxious about re-joining individual or group physical activities outside the home, direct them to Safe Exercise at Home, Information on physical activity and exercise for older people at: www.safeexerciseathome.org.au

If patients are having trouble getting motivated, the Physical Activities tool on DVA’s High Res website may help them to get started and commit to staying active, available at: https://highres.dva.gov.au/highres/#!/tools/physical-activity

For patients who don’t feel confident to exercise at home or have not been active for some time, refer them to an exercise physiologist or physiotherapist for a tailored activity plan that meets their needs without the need for costly gym equipment, and in appropriate cases, an occupational therapist or a psychologist if required.⁹

To find:

• a physiotherapist or an exercise physiologist in your area, go to the Australian Physiotherapy Association at: https://choose.physio/find-aphysio or Exercise & Sports Science Australia at: www.essa.org.au/find-aep
• an occupational therapist at healthdirect, go to: www.healthdirect.gov.au/
• a psychologist at the Australian Psychological Society, go to: www.psychology.org.au/Find-a-Psychologist or phone Open Arms – Veterans & Families Counselling on 1800 011 046 for referral advice.

hearing, eyesight, appetite and food intake, and alcohol consumption

Explain that:

• improved hearing and vision can help make everyday life and being socially and physically active more enjoyable and safer,^1, 12

• ask your patients when they last had their hearing and vision checked and encourage them to wear hearing aids or glasses if they have them.

• the adverse effects of some medicines can cause dry mouth, and a loss of appetite, taste and sense of smell,^13-15 which can interfere with oral health and enjoyment of food, leading to undernutrition and loss of energy,^10, 15

• ask your patients about their appetite, their sense of smell and taste and whether they ever feel they have a dry mouth, especially if there have been recent changes to their medicines
• encourage your patients to have a dental check-up at least once a year, even if they have dentures.¹⁶

For further information, go to the MATES topic, Reducing the impact of medicine-induced dry mouth, at: www.veteransmates.net.au/topic-53-therapeutic-brief

• limiting alcohol consumption to no more than two standard drinks per day is recommended to reduce health-related risks from drinking alcohol,¹⁷

• where appropriate, ask your patients about their alcohol consumption and advise them there is help available if alcohol use is becoming a problem.

Consider that medicines might be contributing to a decline in mobility and functional capacity

Exposure to medicines with sedative effects, including medicines with anticholinergic properties and medicines for pain, can impair older peoples’ ability to be mobile, and socially and physically active.^15, 18 The use of these medicines can cause the sedative load to unintentionally build up over time.^13, 19

An Australian study showed that older people who were users of sedative or anticholinergic medicines, compared to non-users, had overall poorer physical strength and function, including poorer grip strength, slower walking speed and a decreased ability to carry out daily activities.¹⁵ Compared to non-users, people who used sedative or anticholinergic medicines were also three times more likely to be frail.¹⁵

Analysis of the DVA veteran population over 65 years dispensed medicines with sedative effects (antipsychotics, hypnotics and sedatives, antidepressants, opioids, anti-epileptics, anti-Parkinson medicines and medicines for migraine), found that using three or four of these medicines concurrently was associated with double the risk of falling resulting in hospitalisation, and five or more used concurrently, was associated with triple the risk (see Figure 1).²⁰

Adverse medicine effects often masquerade as symptoms of ageing, including urinary incontinence or retention, fatigue or sleepiness, cognitive and functional decline, blurred vision, loss of appetite and constipation.^15, 21, 22 These adverse effects can contribute to frailty in older people.¹⁵ Frailty is associated with an increased risk of adverse health outcomes, including falls, fractures, confusion, dependence, hospitalisation and death (see Figure 2).^23-25

Not recognising a symptom as an adverse medicine effect can trigger a prescribing cascade, which may cause further decline in health and functional ability (see Figure 3).^21, 26

Reassess the role of medicines with sedative side effects

Consider whether a high sedative load may be contributing to your older patient’s mobility or functional decline, especially if there has been an increase in the number of medicines or a change in the dose of medicines with sedative effects over this period.

Note that individual variability, dosages, interactions, non-prescription medicines with sedative side effects, and co-morbidities may also influence the severity of adverse effects and overall sedative load.¹³

It may be possible to taper the dose or cease some medicines, in particular those that no longer have a clear benefit, may cause harm, are being used for an indication that is no longer present or no longer fit with your older patient’s current goals of care.⁷

Review the following list of medicines to see if any are suitable for tapering or ceasing:

Benzodiazepines

Benzodiazepines can cause oversedation, ataxia, confusion and memory impairment in older people.^13, 29 As many as one-third of residents in aged-care facilities are dispensed a benzodiazepine and more than half of these residents use the medicine for longer than the recommended duration.³⁰

When an older person takes a benzodiazepine for sleep the chance of an adverse effect is more than double that of improved sleep.³¹

Zopiclone and zolpidem

Zopiclone and zolpidem can cause protracted daytime drowsiness and ataxia, especially in older people.²⁹

For further information, go to the MATES topic Helping veterans learn to sleep well at: www.veteransmates.net.au/topic-55-therapeutic-brief

Antipsychotics

Adverse effects that can affect mobility and physical function include sedation, orthostatic hypotension, acute extrapyramidal side effects and anticholinergic effects, including confusion.¹³

One-fifth of residents in aged-care facilities in Australia take an antipsychotic; more than half of these residents use the medicine for longer than the recommended maximum duration of 12 weeks.³⁰

To better understand options available to manage behavioural and psychological symptoms in dementia (BPSD), including tapering antipsychotic medicines prescribed for BPSD, go to NPS MedicineWise at: www.nps.org.au/person-centreddementia-care

Antidepressants

Common sedating side effects of many antidepressants include dizziness, drowsiness and weakness.¹³

To access the MATES topic Achieving best outcomes for depression, go to: www.veteransmates.net.au/topic-49-therapeutic-brief

Medicines for Parkinson’s disease

Medicines for Parkinson’s disease can cause drowsiness, weakness, fatigue, sudden sleep onset and delirium, especially in older people.¹³ Dopamine agonists can cause orthostatic hypotension, dizziness and neuropsychiatric symptoms, including confusion.¹³

Antihistamines, including those purchased over-the-counter

Antihistamines can cause sedation, psychomotor impairment and dizziness because of their anticholinergic effects. ‘Non-sedating’ antihistamines can also cause sedation and dizziness.¹³

Opioids, tapentadol and tramadol

Opioids can cause drowsiness, sedation, weakness, cognitive impairment and orthostatic hypotension, particularly in older patients.¹³ Use of tramadol is not recommended in patients older than 75 years.¹³ Tapentadol can cause dizziness, somnolence and fatigue.³²

Almost half of residents in aged-care facilities using an opioid take the medicine for longer than the recommended maximum duration of no longer than 90 days.³⁰

For further information on opioid use in chronic non-cancer pain, go to NPS, Opioids, chronic pain and the bigger picture, at: www.nps.org.au/professionals/opioids-chronic-pain

Anti-epileptics

Anti-epileptics can cause sedation, confusion, cognitive impairment and hypotension.¹³

Gabapentinoids

Gabapentinoids, pregabalin and gabapentin, can cause sleepiness, dizziness, ataxia, confusion and memory impairment.¹³

Medicines for migraine

Medicines for migraine, for example triptans, can cause sedation, dizziness, weakness and fatigue.¹³

Tap into DVA support services

DVA provides support to veterans and their families through a range of services.

• Day Club programs, operated nationally by DVA and ex-service organisations, provide opportunities for older DVA patients to develop and maintain social contacts outside the home by being involved in sports, fitness, information sessions, and arts and crafts. To find a Day Club program in your area and to check whether they have resumed as COVID-19 restrictions change, go to: www.dva.gov.au/healthand-treatment/work-and-social-lifeprograms/day-club-programs
• Support organisations and groups provide opportunities for DVA patients to connect with people and to rebuild social networks, including the War Widows Guild, Partners of Veterans Association, Vietnam Veterans groups, RSL, Legacy, Team Rubicon, Men’s Shed, Cooking for One or Two and Mates4Mates. For further information, go to the Open Arms – Veterans & Families Counselling website at: www.openarms.gov.au/living-well/be-social or call 1800 011 046
• Rehabilitation Appliances Program (RAP) National schedule of Equipment provides a range of equipment, including mobility and functional support aids, medical grade footwear and low vision aids to support DVA patients living at home or in an aged-care facility.³⁵ To access the list of equipment available, go to: www.dva.gov.au/providers/rehabilitation-appliances-program-rap
• Choose Health: Be Active: A physical activity guide for older Australians, developed by DVA and the Australian Government Department of Health in association with Sports Medicine Australia, aims to help people understand the importance of being physically active and how to become or stay more physically active as they get older.³⁶ The brochure is available at: www1.health.gov.au/internet/main/publishing.nsf/Content/3244D38BBBEBD284CA257BF0001FA1A7/$File/choosehealth-brochure.pdf

RACF Care Staff Guide: Identifying the effects of an increasing sedative load

Sedation and confusion can contribute to an older person’s overall functional decline and frailty²⁰

A frail older person typically has several chronic health issues and uses multiple medicines.^37, 38 The sedative load can unintentionally build up over time with the use of many of these medicines.¹⁵ For a frail older person, even a minor event, such as taking an ‘as required’ (pro re nata [PRN]) medicine or starting a new medicine, can trigger a disproportionate change in their health; tipping the balance from being mobile to immobile, from being steady on their feet to falling, or from being independent to dependent.³⁸

Once the balance is tipped, an older frail person is often unable to recover to their previous health status, and may begin a downward spiral into immobility, functional decline, falls, delirium, incontinence, admission to hospital, and death.³⁸ As frailty increases, so too does the need for extra care.³⁸ See diagram.

References

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