Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2720_Библиотеки_им_академика_М_И_Перельмана
.pdf
184
https://t.me/med1917
184
CHAPTER8 Chronic disease and elderlycare
Pain- relievingdrugs
Paracetamol As eective a painkiller as ibuprofen. No anti- inammatory
eect but potent antipyretic. Drug of choice in OA where inammation
is absent. Side eects are rare. Overdose (>4g/ 24 h) can be fatal causing
hepatic damage sometimes not apparent for 4– 6d. Inadvertent overdose is
easy due to presence of paracetamol in most OTC cold preparations— if
suspected, refer immediately to A&E.
Non- steroidal anti- inammatories (NSAIDs) (Table 8.1) Anti-
inammatory, analgesic, antipyretic. Start at the lowest recommended dose
and do not use >1 NSAID concurrently. 60% respond to any NSAID—
for those who don’t, another may work. Selective inhibitors of cyclooxygenase- 2 (COX2) have lower GI side eects, but should not be given to
any patient with pre- existing, or high risk of, CVD.
Table8.1 Commonly used NSAIDs
Drug Dosage Features
Ibuprofen 1.2– 1.8g/ d in 3– 4
Naproxen 0.5– 1g/ d in 1– 2
Diclofenac 75– 150mg/ d in 1–
divided doses
divided doses
2 divided doses
Fewer side eects than other NSAIDs. Antiinammatory properties are weaker. Do not
use if inammation is prominent, e.g. gout.
Higher doses (>1.2g/ d) are associated with
irisk of thrombotic events and MI
Good ecacy with a low incidence of side
eects. Associated with lower thrombotic risk
than other NSAIDs
Good ecacy with a low incidence of side
eects. Associated with i thrombotic risk
and i liver reactions (drug- induced hepatitis)
compared to other NSAIDs
Common sideeects
• GI Associated with intestinal ulceration ± GI bleeding. GI side eects
are more common in the elderly, people with liver disease or who
have high alcohol intake, and those taking continuous low- dose aspirin,
steroids, or SSRIs— avoid if possible. Warn all patients about the risk
of GI side eects when taking NSAIDs and advise them to always take
NSAIDs after food. If at high risk, >50y, or taking long- term NSAIDs,
always co- prescribe stomach protection, e.g. with a PPI. NSAIDs may
also cause exacerbation of pre- existing Crohn’s disease or UC
• Sodium and water retention This can lead to deterioration in renal
function ± renal failure. Avoid NSAIDs if possible in patients with renal
impairment, liver disease or high alcohol consumption, hypertension,
and/ or heart failure. Where prescribing is unavoidable, monitor renal
function while taking NSAIDs
• Impairment of ♀ fertility Avoid in women trying to conceive
Topical NSAIDs Of proven benet for acute and chronic conditions and can
be as eective as oral preparations. They have lower incidence of GI and
other side eects, although these still can occur.
https://t.me/med1917
PAIN-RELIEVINGDRUGS
Use of opioids Useful for management of acute pain (e.g. following acute
injury) and cancer pain, especially at the end of life. Little evidence they are
helpful for long- term pain. In the UK, 8– 12% of long- term prescribed opioid
users meet criteria for current or past opioid use disorder.
General rules forinitiating opioidtherapy
• Explain that opioids are most eective for the treatment of acute pain;
for the majority (>70%) opioids are not eective for long- term pain
which requires other strategies
• Stress the aim of treatment is not complete abolition of pain, but d in
pain to allow the patient to use other strategies for symptom relief
• Warn about adverse eects including eects on driving
• Prescribe initially for a trial period only (1– 2wk) and set dened outcomes
in terms of pain, functional ability, and sleep (if impaired by pain)
• Set rules for stopping the drug— e.g. if outcomes are not achieved in
1– 2wk, if the underlying condition resolves, if there are intolerable side
eects, or if the patient is found to have abused the medication
• Explain that no further prescriptions will be issued if the patient does
not come for review following the opioid trial
Management of prescription opioid misuse E p. 167
Weak opioids Commonly used in primary care include codeine,
dihydrocodeine, and tramadol.
Codeine and dihydrocodeine The most commonly used weak opioids in the
UK. Standard adult dose is 30– 60mg every 4h to a maximum of 240mg/ 24h.
Analgesic eect is i by regular ingestion. 10mg of codeine/ dihydrocodeine
equipotent to ~1mg of morphine. Eects of codeine/ dihydrocodeine are
reduced by concurrent use of antipsychotics (e.g. chlorpromazine, haloperidol), tricyclic antidepressants (e.g. amitriptyline), and metoclopramide.
5– 10% of Caucasians have CYP2D6 genotype and lack a hepatic enzyme
needed to convert codeine to morphine. They gain less analgesic eect codeine/ dihydrocodeine.
Tramadol Asynthetic analogue of codeine. Standard adult dose is up to
400mg/ 24h. It produces analgesia by 2 mechanisms:an opioid eect, and
an enhancement of serotonergic and adrenergic pathways. Compared to
codeine/ dihydrocodeine, oral tramadol is absorbed faster giving analgesia
in <1h with peak action in 1– 2h. Tramadol is also metabolized in the liver,
so safer for the elderly and those with renal impairment, as associated with
fewer opioid side eects (notably less respiratory depression and constipation). However, nausea and vomiting can be a problem and rarely tramadol
can trigger psychiatric reactions.
0 Always consider co- prescribing a laxative to any patient taking opioids.
Opioid side eects E p. 186
Morphine and other strong opioids E p. 186
Further information
Faculty of Pain Medicine Opioids Aware. M www.rcoa.ac.uk/ faculty- of-
pain- medicine/ opioids- aware
Livewell with Pain M https:// livewellwithpain.co.uk/
185
ALGRAWANY
186
https://t.me/med1917
186
CHAPTER8 Chronic disease and elderlycare
Morphine and other strongopioids
Morphine is the strong opioid of rst choice for moderate to severe pain in
both malignant and non- malignant conditions.
General rules for initiating opioid therapy E p. 185
Starting oral morphine Start with 4- hourly immediate release mor-
phine. Give clear instructions. Initial dosage:
• Adults not pain- controlled with regular weak opioids, 5– 10mg every 4h
• Elderly or cachectic patients, or those not taking regular weak opioids
5mg every 4h (2.5mg if very elderly/ frail)
Titration of dose i dose as needed by 25– 50%/ d until pain is controlled, or the
patient experiences unacceptable side eects, to a maximum of 120mg/ d.
•Risk of harm increases substantially at doses >120mg/ d with no i benet.
0 Never attempt dose titration for unstable pain using a fentanyl patch—
convert from oral morphine once a stable dose is attained.
Maintenance Once pain is controlled, consider a long- acting preparation
of equivalent dose (e.g. MST® bd, MXL® od). Calculate total daily dose of
morphine by adding together the 4- hourly doses.
Increasing dose If further increase in dose is necessary, use a 25– 50% dose
increment to a maximum of 120mg/ d. i dose rather than frequency of
administration— slow- release tablets are designed for od/ bd dosing.
Breakthrough pain Pain of rapid onset, and moderate/ severe intensity
despite background analgesia. Management:
• Prescribe immediate release morphine for breakthrough pain— give the
equivalent 4- hourly dose as an additional dose
• If pain starts to occur regularly before the next dose of analgesia is due,
consider i the regular background dose
Common side eects of opioid drugs Warn patients:
• Nausea/ vomiting— aects >1 in 3 patients for the rst 2wk of use.
Prescribe a regular antiemetic for 2wk, e.g. cyclizine 50mg tds. If
nausea/ vomiting continues, consider an alternative opioid
• Constipation— consider prescribing prophylactic laxatives, e.g. bisacodyl
1– 2 tab nocte. Fentanyl causes less constipation than morphine
• Drowsiness/ cognitive impairment— usually improves within the rst
week. Advise patients not to drive, perform other skilled tasks, or work
with dangerous machinery if aected. If not improving, consider an
alternative opioid, or refer for specialist advice
Conversions to other preparations See Table 8.2
Reasons tochoose/ switch toan alternative strongopioid
• Unacceptable side eects
• Renal failure— fentanyl is licensed for patients with renal failure;
oxycodone is safe in mild/ moderate renal failure
• Unable to take oral medication regularly— consider fentanyl or
buprenorphine patch, or syringe driver
Controlled drug prescriptions E p. 125
Syringe drivers E p. 1030
https://t.me/med1917
MORPHINE AND OTHER STRONGOPIOIDS
Table8.2 Quick conversions oforal morphine
From To Conversion Example
Oral morphine
(total dose)
e.g. 10mg
morphine 4
hourly=60mg
oral morphine
in 24h
0 If total 24h dose is equi valent to 120mg morphine or more— get specialist advice.
sc
diamorphine
sc morphine ÷ by 2 60 ÷ 2=30mg morphine by
po oxycodone ÷ by 2 60 ÷ 2=30mg oral oxycodone
÷ by 3 60 ÷ 3=20mg diamorphine by
syringe driver over 24h
syringe driver over 24h
in divided doses over 24h
Opioid toxicity Intentional or unintentional overdose produces:
• Drowsiness or coma
• Pinpoint pupils
• Vomiting
• Hypotension
• Confusion— including auditory and/ or visual hallucinations
• Respiratory depression:
• If respiratory rate ≥ 8/ min + the patient is easily rousable and not
cyanosed— adopt a policy of ‘wait and see’; consider d or omitting
the next regular dose of opioid. Stop syringe drivers temporarily to
allow plasma levels to d, then restart at lower dose
• If respiratory rate <8/ min, and/ or the patient is barely rousable/
unconscious and/ or cyanosed— dilute naloxone 400mcg to 10mL
with sodium chloride 0.9%. Administer 0.5– 1mL IV every minute
until respiratory status is satisfactory. If respiratory function still
does not improve, question diagnosis. Further doses may be needed
later as naloxone is shorter acting than morphine
• Muscle rigidity/ myoclonus— consider renal failure (can produce
myoclonus alone). Treat with rehydration. Consider stopping other
medication which may exacerbate myoclonus, switching opioid, or
treating with clonazepam 2– 4mg/ 24h depending on circumstances
Subacute overdosage Slowly progressive somnolence and respiratory
depression— common in patients with renal failure. Withhold morphine
for 1– 2 doses then reintroduce at 25% lower dose.
Opioid toxicity may be i by
• Renal failure
• Other change in disease status
e.g. hepatic function, weight loss
• Dehydration
• Other analgesics e.g. NSAIDs
• Co- administration of amitriptyline
187
Management of drugs misuse E p. 166
Further information
BNF M https:// bnf.nice.org.uk/
Faculty of Pain Medicine Opioids Aware. M www.rcoa.ac.uk/ faculty- of-
pain- medicine/ opioids- aware
Livewell with Pain M https:// livewellwithpain.co.uk/
Online converter for fentanyl patches M www.globalrph.com/ fentconv.htm
ALGRAWANY
188
https://t.me/med1917
188
CHAPTER8 Chronic disease and elderlycare
Neuropathicpain
Neuropathic pain occurs as a result of damage to neural tissue. Examples include post- herpetic neuralgia, complex regional pain syndrome (reex sympathetic dystrophy), peripheral neuropathy (e.g. due to DM), compression
neuropathy, and phantom limb pain.
Pain typically occurs in association with altered sensation, e.g. burning,
stabbing, or numbness. Pain may also be provoked by non- noxious stimuli
(allodynia), e.g. gentle heat or cold.
Diabetic neuropathy E p. 330
Post- herpetic neuralgia Persistent neuropathic pain in a dermatome
aected by shingles (E p. 628). May be severe.
Treatment ofneuropathicpain
Trigeminal neuralgiaN (E p. 531). The drug of choice for treatment of tri-
geminal neuralgia pain is carbamazepine (unlicensed indication). Often
poorly tolerated. Oxcarbazepine is an alternative. If no response in <8wk,
refer early for specialist assessment and advice on pain control.
Other neuropathic painN Where possible, treat the underlying cause of the
pain. If that is not possible, consider treatment with one of:
• Amitriptyline • Gabapentin
• Duloxetine • Pregabalin
For all these drugs, start at low dose and titrate the dose up according to
response. Consider capsaicin cream if localized pain and the patient wishes
to avoid, or cannot tolerate oral medication.
0 Consider tramadol only if an acute rescue therapy is needed.
Review
After starting/ changing medication Perform an early review after 1– 2wk to
check dosage titration, tolerability, and adverse eects.
Once established on medication Review regularly every 4– 8wk to assess and
monitor eectiveness of treatment. Ask about:
• Overall perception of improvement • Adverse eects
• d in pain (pain diaries may help) • Sleep
• Ability to do everyday activities, e.g. work, driving
• Mood— depression/ anxiety screening questionnaires may be helpful
If improvement is sustained over ≥6mo, consider gradual d dose of medi-
cation over time.
Refer To a specialist pain clinic or other appropriate specialist service if:
• Severe pain or pain signicantly limits activities
• Underlying health condition has deteriorated
• Inadequate response to rst- line (trigeminal neuralgia) or second/ third-
line medication (all other neuropathic pain)
Antidepressants
Amitriptyline Proven treatment for neuropathic pain (unlicensed indication).
Start at a dose of 25mg at 5– 7p.m.— 10mg if elderly. i dose by 10– 25mg
https://t.me/med1917
NEUROPATHICPAIN
every 5– 7d to a maximum of 75mg in a single dose as needed (higher
doses under specialist supervision). Some patients do not derive benet
for 4– 6wk.
Alternatives to amitriptyline include nortriptyline and imipramine. Both are
given at an initial dose of 10– 25mg in the evening; dose can be titrated up to
75mg as needed. May have fewer side eects than amitriptyline.
Duloxetine Eective treatment for neuropathic pain. Currently only licensed
for the treatment of diabetic neuropathy. Usually less sedating than amitriptyline. Start with 60mg once daily, increasing to 60mg bd after 2– 3wk if
inadequate response.
Anticonvulsants
Carbamazepine Only recommended for treatment of trigeminal neuralgia.
Start with 100– 200mg 1– 2×/ d (less if elderly or frail). Build up dose slowly
to the usual dose of 0.8– 1.2 g daily in di vided doses. Often poorly tolerated.
Pregabalin Licensed for treatment of neuropathic pain. Initially 150 mg/ d in
2 divided doses, i if necessary after 3– 7d to 150mg bd, and again if needed
after a further 7d to 300mg bd.
Gabapentin Eective for neuropathic pain but less clinically and costeective than pregabalin. Start with 300mg tds, increasing in steps of 300mg
every 2– 3d as needed to a maximum of 3.6g/ d. Slower titration is advisable
for the elderly or frail.
0 Both gabapentin and pregabalin are drugs of abuse; monitor frequency
of repeat prescriptions; be careful when issuing to temporary patients.
NSAIDs Sometimes eective for neuropathic pain— either because there
is mixed nociceptive pain or because they d inammatory sensitization of
nerves. There is considerable variation in individual patient tolerance and
response (E p. 184).
Opioids Neuropathic pain often responds only partially to opioid anal-
gesics. Of the opioids, oxycodone, tramadol and methadone are probably
the most eective. Do not start regular treatment with opioids for neuropathic pain in primary care.
Capsaicin Active ingredient in chilli peppers. Licensed for treatment of
neuropathic pain and applied locally as a cream 3– 4×/ d. Advise patients to
apply the cream sparingly in a well- ventilated room and wash their hands
after use. Side eects include intense burning at the site of application, and
more rarely eye symptoms or sneezing. The cream should not be applied
after a hot shower/ bath as this intensies the burning sensation.
Topical lidocaine Plasters impregnated with lidocaine 5% (Versatis
Licensed for post- herpetic neuralgia. Apply daily for up to 12h, followed
by a 12h plaster- free period; discontinue if no response after 4wk. Up to 3
plasters may be used to cover large areas; plasters may be cut.
®
).
Further information
BNF M https:// bnf.nice.org.uk/
NICE (2013, updated 2018)Neuropathic pain. M www.nice.org.uk/ guid-
ance/ cg173
189
ALGRAWANY
190
https://t.me/med1917
190
CHAPTER8 Chronic disease and elderlycare
Normalageing
Of the UK’s 65.6million people, 18% are aged ≥65y, and 2.4% ≥80y. Life
expectancy is i. Over the past 30y, the population aged >65y has grown by
23% with largest percentage growth among those >85y.
What is ageing? Ageing is a gradual series of changes over time that lead
to loss of function of organs and cells, with the eventual outcome of death.
Normal changes of ageing (Table 8.3). Individuals vary greatly in the rate at
which they age. Several factors seem to inuence this:
• Genetic makeup • Socioeconomic factors
• Psychological health • Environment
• Lifestyle— diet, physical exercise, smoking
Diculties assessing theelderly
• Communication problems— hearing, cognition, speech
• Multiplicity of cause— 1 symptom may be caused by dierent,
concurrent processes, e.g. breathlessness as a result of COPD + heart
failure
• Non- specic symptoms/ signs— confusion, falls, or ‘o legs’ may be the
only overt sign of underlying disease, e.g. UTI, MI, stroke
• Symptoms may be absent despite disease, and signs harder to elicit
• Polypharmacy (E p. 194) may result in side eects and interactions
• Laboratory tests may be unreliable— especially white cell counts and
ESR (always check CRP)
Disease The ageing process is compounded by overt disease. This may
aect functional capacity, quality of life, and independence, cause frailty, d
well- being and independence, and result in i care and mobility needs.
Multiple morbidity E p. 174. Older people are more likely to have
several ongoing chronic illnesses that can act in combination to cause disability greater than either illness alone and/ or result in:
• Direction of care at some problems with relative neglect of others
• Polypharmacy— E p. 194
• Involvement of multiple specialist teams which can cause inconvenience
to the patient and family, and result in conicting advice, and opposing
opinions on cause/ eect of symptoms
Frailty Elderly people are described as ‘frail’, as term used to describe
individuals who are physically weak and fragile. Frailty can occur on a background of natural ageing or be precipitated by disease. It is not a disease/
disability, but an inability to withstand physical/ psychological stressors.
Common features include:
• Feeling of exhaustion • Slow walking speed
• Unintentional weight loss (>5kg in a year)
• Weakness— measured by grip strength
• Low levels of physical activity
Detecting frailty can enable support (E p. 198) to be put in place earlier,
to enable frail people to remain well at home, and avoid crisis situations.
https://t.me/med1917
NORMALAGEING
Table8.3 Normal changes ofageing
System Clinical/ functional eects
Cardiovascular Cardiac enlargement/ left ventricular hypertrophy
Respiratory d FEV1/ FVC and i residual volume
Endocrine d insulin sensitivity l impaired glucose regulation
Gastrointestinal i in gastric acid production
Genitourinary d glomerular ltration rate not reected by i creatinine
Musculoskeletal Sarcopenia— d muscle strength/ power, d lean body mass
Nervous Slower thought processes/ reaction times
Vision Presbyopia (diculty focusing on near objects); d visual acuity;
Hearing High- frequency hearing loss/ presbycusis— deafness aects 80%
Immune Atrophy of the thymus
Skin/ hair Dry skin, wrinkles, tendency to bruise easily, and slower healing
d cardiac output l d exercise capacity
d response of heart rate to exercise
Systolic hypertension
Left ventricular failure
i susceptibility to infection
i susceptibility to aspiration
d thyroid hormone production
Constipation
Benign enlargement of the prostate (25– 50% of men >65y)
lprostatism (♂)
Slowing of sexual f unction (♂ and ♀); erectile dysfunction (♂)
Dry vagina and i susceptibility to urinary infections (♀)
(30– 40%), i fat body mass
d mobility; i likelihood of f alls
i osteoporosis/ susceptibility to fractures
General decline in performance
0 Dementia is not a normal change of ageing
cataract; impaired dark adaptation
of 80y- olds
Degenerative changes in the inner ear leading to impairment of
balance causing falls
Reduced immune function resulting in i infectious disease,
reactivation of latent disease (e.g. TB, shingles), i cancer, and
iautoimmune disease
Greying of the hair
d sweating, heat generation, and heat conservation l heat
stroke; hypothermia
d sensitivity to touch, pain, and temperature discrimination l
burns and pressure sores
191
Further information
NHS England (2017) Toolkit for general practice in supporting
older people living with frailty. M www.england.nhs.uk/ publication/
toolkit- for- general- practice- in- supporting- older- people- living- with- frailty
ALGRAWANY
192
https://t.me/med1917
192
CHAPTER8 Chronic disease and elderlycare
Falls intheelderly
Falls are a major cause of disability and the leading cause of mortality due
to injury in people aged >75y. Tendency to fall i with age. Assessment of a
patient who has fallen is a common primary care emergency.
Risk factors for falls Recurrence i with number of risk factors:
• ♀:♂82:1 in the over 75s
• i age
• Multiple previous falls
• Disorders of gait or balance
• Visual impairment
• Cognitive impairment
• Low morale/ depression
• High level of dependence
• d mobility
Assessment Deal with the injuries rst— ask about pain, loss of func-
tion, headache. Ask carers about behaviour. Check for bruising, d function,
confusion, BP, pulse, neurology, and fundi. Consider hypothermia if on the
oor any duration.
Investigate the cause of the fall Consider:
• Physical problems Neurological problems (e.g. stroke); visual loss;
cardiac abnormalities (e.g. arrhythmia, postural hypotension); muscular
abnormalities (e.g. steroid- induced myopathy); skeletal problems (e.g.
OA); infection (pneumonia, UTI)
• Environmental problems Climbing ladders to do routine maintenance;
loose/ holed carpets; slippery oor/ bath; chair or bed too low
Management
• Treat any acute injury (20%). Exclude fracture (mainly Colles’/ neck of
femur). 0 Subdural haematoma may take days/ weeks to reveal itself
• Even if uninjured, older people might not be able to get up o the oor
without help. The result may be a prolonged period of lying on the oor
until help arrives. Apart from the indignity/ helplessness this causes,
2° problems (e.g. pneumonia, pressure sores, hypothermia, UTI, and
dehydration) may follow
• Perform/ refer to a specialist falls service for a falls assessment
• Undertake measures to d risk of falls or damage from falling
Furtheractions
• Refer to A&E— if signicant head injury (E p. 1094); any suspicion of
fracture; any other signicant injury, e.g. lacerations
• Admit to the acute medical or elderly care team— if the cause of the
fall was an acute medical problem, e.g. stroke
• Refer to the intermediate care (rapid response) team— if the patient
is unable to cope at home or the patient/ carer is worried about the
possibility of further falls
• Refer to the specialist elderly care team or falls clinic— if the cause of
recurrent falls remains unclear
Osteoporosis and prevention of fractures E p. 482
• Foot problems
• Lower limb weakness or arthritis
• History of stroke or PD
• Use of psychotropic drugs, sedatives,
diuretics or β- blockers
• Alcohol
• Environmental factors, e.g. loose rugs,
poor lighting, ice, high winds
• Infection, e.g. pneumonia, UTI
https://t.me/med1917
FALLS INTHEELDERLY
Prevention of falls Falls are one of the biggest risk factors for fracture.
All elderly people should have risk of falls assessed regularly. 0 Any fall
may seriously undermine an elderly person’s condence and cause worry
about the possibility of recurrence. As a result, there may be restriction of
activities l d tness and i dependency on others.
Is a falls assessment needed? Ask if patients fall— they may not vol-
unteer the information spontaneously.
The timed get- up- and- go test 0 May use usual walking aid.
• Start with the patient sitting in a straight- backed chair of comfortable
height with arms
• Ask the patient to rise from the chair, walk to a line 10 feet (3m) away,
turn around, return to the chair, and sit down again
• Start timing while the patient is sitting; end timing when the patient has
sat down again
• Atime of ≥13sec predicts i falls risk
Falls assessment If available, refer to a specialist falls service. Record:
• Frequency and history of circumstances around any previous falls
• Drug therapy:polypharmacy, hypnotics, sedatives, diuretics,
antihypertensives may all cause falls
• Assessment of gait and balance, including abnormalities due to foot
problems or arthritis, and motor disorders, e.g. stroke, PD
• Examination of basic neurological function, including vision, mental
status (impaired cognition and depression), muscle strength, lower
extremity peripheral nerves, proprioception, and reexes
• Assessment of basic cardiovascular status including BP (exclude postural
hypotension), heart rate, and rhythm
• Assessment of environmental risk factors, e.g. poor lighting particularly
on the stairs, loose carpets or rugs, badly tting footwear or clothing,
lack of safety equipment such as grab rails, steep stairs, slippery oors,
or inaccessible lights or windows
Measures tod risk offalls and damage fromfalling
• Correct vision, if possible
• Correct postural hypotension— alter medication; consider compression
stockings— but many elderly people cannot apply stockings tight enough
to be of any use themselves
• Treat other medical conditions, e.g. refer to cardiology if arrhythmia
• Review medication and discontinue/ alter inappropriate medication
• Remove environmental hazards— arrange bath at a day centre, refer to
OT to identify/ correct hazards in the home, e.g. remove loose carpets,
wheeled trolley for use indoors, commode/ urine bottle at night, etc.
• Liaise with other members of the PHCT and social services to provide
additional support if needed; refer to local council for ‘carephone’ or
alarm system to call for help if any further falls
• Refer to rehabilitation/ physiotherapy to improve condence after falls
and for weight- bearing exercise (focusing on strength and exibility) and
balance training (d risk of falls). Use of hip protectors d fracture risk in
patients at high risk but compliance is a problem
193
ALGRAWANY
Соседние файлы в папке Библиотека им академика М.И. Перельмана