practice partner a target of 140-150 / 90 would have been recommended by the evidence and expert guidelines; her blood pressure in the months following her admission to the retirement home was significantly lower than this target.
It cannot be determined from this review if the attending physician was aware of the woman’ s low blood pressure readings and if the readings were being monitored, why there was not a change in prescribing. It also cannot be determined if orthostatic blood pressures were measured and if consideration had been given to reducing the hypertensive medications in order to prevent dizziness and falls.
• Oral hypoglycemic therapy: Hypoglycemia is a much greater danger to the frail elderly than hyperglycemia. There is no evidence of benefit from tight glycemic control( i. e., fasting glucose 4-7 mmol / L), and hypoglycemia can lead to poor balance and falls. Target HbA1c should be 0.08- 0.12 in a patient such as the deceased.
It cannot be determined from this review if consideration was given to reducing or stopping the administration of metformin to the patient. The Canadian Diabetes Association guidelines regarding management of diabetes in the frail elderly is an excellent reference( guidelines. diabetes. ca), as is the Dalhousie PATH Program website( Dalhousie University, pathclinic. ca).
• Other medications: Sertraline is an SSRI anti-depressant. SSRI medications increase the risk of falls in the elderly, even at low doses. The indication for this medication with this patient was not clear as there was no history of depression documented, nor any responsive behaviours for which this medication may have been used.
• Physiotherapy assessment: It is unclear whether walking and mobility had been formally assessed and optimized by a physiotherapist, including an assessment of her feet and footwear, and her walking aid.
• Discussion with substitute decisionmaker( SDM): A discussion held with the substitute decision maker regarding the ongoing risk of falls, and the risks vs. benefits of various parts of the plan of care, including medication therapy, were not documented.
As part of its report, the GLTCRC reminded physicians who provide care to the frail elderly to be familiar with the most recent evidence regarding treatment of common, chronic conditions in frail elders, including hypertension and diabetes.“ The evidence suggests that treatment targets should be different than in younger adults,” stated the Committee. In reviewing another fall-related death, the GLTCRC reminds physicians working in inpatient psychiatric units to do a careful assessment, management, and documentation of patient falls. The patient in this case had a progressive neurodegenerative illness( i. e., mixed dementia-Alzheimer’ s and Vascular) which led to a gradual loss of cognitive function, increasingly disinhibited and inappropriate aggressive and sexual behaviours. Over the last year of his life, he also experienced increased fall frequency. In this particular case, the Committee found that the patient’ s psychotropic medication management was adjusted carefully in an ongoing way and there was clear documentation of risks and benefits to medication choices. Psychotropic medication side effects were discovered in a timely fashion with clear end points for medication use identified. The use of the medication was reasonable and within the standard of care. In general, psychiatric medication use in the elderly carries the risk of falls and sedation. Although the patient’ s behaviour was well documented while in the psychiatry unit, the
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Dialogue Issue 1, 2017