Mr. P is a 76-year-old male living in assisted living. He moved into the facility because his care needs exceeded his family’s capacity to care for him at home. He has multiple medical comorbidities, including a history of falls, and he requires complex medical management. He uses a walker to assist with ambulation. Over the past few weeks, he has been falling frequently and is experiencing a functional decline, which necessitates staff assistance with transfers and ambulation. He expresses feelings of dizziness when sitting up; his blood pressure in a prone position is 200/84, and it drops to 110/70 with dizziness when he stands. There is no change in his blood pressure when he remains sitting. His heart rate is 74 and regular whether he is lying, standing, or sitting.
His past medical history includes hypertension, type 2 diabetes, Parkinson’s disease, urinary incontinence due to benign prostatic hypertrophy, neuropathy, and depression. His cognition is intact. He sees multiple specialists — a cardiologist, endocrinologist, urologist, and neurologist — for these problems.
His current medications include aspirin, 81 mg by mouth daily; atorvastatin, 40 mg by mouth daily; famotidine, 40 mg by mouth daily; metformin, 1,000 mg by mouth twice a day; selegiline, 5 mg by mouth twice a day; tamsulosin, 0.4 mg, two tablets at bedtime; extended release mirabegron (Myrbetriq), 50 mg by mouth daily; carbidopa, 25 mg/levodopa, 100 mg, four tablets by mouth three times, and a dose of extended release carbidopa 50/200 at bedtime; sertraline, 150 mg by mouth daily; carvedilol, 12.5 mg by mouth twice a day; and amlodipine, 5 mg by mouth daily.
The immediate laboratory tests were a comprehensive metabolic panel and a complete blood count, which were all within normal limits. Given his change in condition, the staff are concerned that Mr. P may require a higher level of care, so a care plan meeting is scheduled. The resident and his wife are actively involved.
Michelle Bellantoni, MD, CMD
Dr. Bellantoni is an associate professor in the Department of Medicine at the Johns Hopkins University School of Medicine. She is also the clinical director of the Division of Geriatric Medicine and Gerontology, and medical director of the Specialty Hospital Programs at Johns Hopkins Bayview Medical Center.
Orthostatic hypotension, which is present in about 30% of Parkinson’s disease patients, is exacerbated by levodopa medications. Nonpharmacologic interventions offer modest effects, including adequate fluid intake (2 to 2.5 liters per day), salt intake of 9–12 g/day, compression stockings and an abdominal binder, and physical counter maneuvers such as leg crossing, tilting forward, and squatting before standing. Frequent small meals with low carbohydrate content may reduce the postprandial contributions to hypotension. Dose increases in medications containing levodopa may cause orthostasis, which will improve with time.
Combination drug therapies may exacerbate the orthostasis. The benefit of combination therapies on movement and function must be weighed against the risk of orthostasis and falls.
Diane Mockbee, BS, AC-BC
Ms. Mockbee is an Activity Consultant/Educator – Board Certified through the National Association of Activity Professionals Credentialing Center. She had worked as an activity director and dementia trainer in long-term care for over 28 years until retiring in 2018. She currently consults and speaks in a variety of settings.
Music and movement can help address Mr. P’s depression and the effects of his Parkinson’s disease. Music helps support the rhythm of walking, balance, and strengthening and has potential mental health and well-being benefits. The rhythm of music has shown great benefit to those with Parkinson’s patients: their gait is more fluid and there is less freezing.
Begin from a seated position and monitor Mr. P’s blood pressure. Then transition into a standing position with a four-wheeled walker. With someone by his side using a gait belt, have Mr. P walk to the rhythm of music. While he is seated, have him incorporate upper and lower body exercises in time to the music to increase his strength and safety while using the walker.
Also consider incorporating chair yoga to enhance his strength and flexibility as well as his walking, gait, speed, and balance. Yoga can decrease anxiety, depression, and expressions of distress. The sequencing used in yoga also can promote mindfulness and an inner feeling of peace and accomplishment. Mr. P’s wife could be invited to participate in the program so that they have a positive shared experience together.
Karen Evans, BSN
Ms. Evans is nurse manager for Residential Care Roland Park Place.
While Mr. P’s medications are being adjusted, monitor his lying and standing blood pressures a few times per day. Ideally, the goal is to resolve the orthostatic hypotension and maintain his function so he can remain in the assisted living setting.
As much as he is willing, encourage Mr. P to spend time out of his room so he is around other people and staff who can assist him quickly. Offer Mr. P many opportunities throughout the day for supervised ambulation to maintain his strength and optimal function.
Finally, have nursing work with Mr. P to spread his meals out during the day to be six smaller meals versus three larger ones. The staff should encourage protein and vegetables versus higher carbohydrate types of foods.
Ms. Hector is a social work expert and a coeditor of this column.
As a social worker, I would explore the possibility that Mr. P could be experiencing emotional and psychological trauma given his potentially stressful life events – his recent transition into supportive living, complex medical diagnoses, dizziness and increasing falls, and depression. Key indicators of this type of trauma include feelings of helpless and of being overwhelmed and isolated, all of which impact one’s sense of security.
Screen Mr. P for trauma symptoms using the Primary Care (PC) PTSD-5. Additionally, create a sense of safety for Mr. P to share his feelings and help identify what he needs. He may need to grieve the losses he has already experienced as well as the anticipation of pending loss and more change, and the impact of these losses on the relationship with his wife. If it has not already been done, I would complete a depression screening such as the PHQ-9 (which will also be helpful as a baseline if Mr. P moves into a nursing home). Also consider the quality of Mr. P’s sleep hygiene and whether any interventions may impact his well-being.
I would advocate for Mr. P to the extent necessary and ensure that his values and preferences are at the center of the plan of care and decision-making process. Collaborate with colleagues to ensure that all perspectives are considered and interventions integrated across disciplines. It may be necessary to explore financial considerations if a transition into long-term care is in the future. Facilitate advance care planning conversations and ensure that Mr. P’s advance directives are in place. If the decision is reached that Mr. P should move into a nursing home, assist with his education about the new setting, how it is different from assisted living, and what his family can expect.
Nicole Brandt, Pharm D, MBA
Dr. Brandt is a professor and the executive director of the Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy.
From a medication-related perspective, the primary concerns are drug-drug interactions, particularly the interaction of selegiline for Parkinson’s disease and sertraline, which is a selective serotonin reuptake inhibitor (SSRI). Concomitant use of selegiline and SSRIs should be avoided and requires a washout period of at least two weeks after discontinuing selegiline and starting the SSRI, and at least 5 weeks after discontinuing fluoxetine and starting selegiline. If an SSRI is used, its dosage should be on the lower side to prevent the patient experiencing a serotonin syndrome.
Orthostatic hypotension is another concern, and it is likely Mr. P has neurogenic orthostatic hypotension. Baroreflex dysfunction may cause hypertension when he is supine, which can last for several hours during sleep. It may be helpful to continue to modify his antihypertensives by stopping the amlodipine and giving losartan at bedtime instead. Other behavioral measures that might help include avoiding having him supine during the day.
If Mr. P needs a pressor agent to control the orthostatic hypotension during the day, short-acting drugs such as midodrine or droxidopa are preferable to long-acting ones such as fludrocortisone, with the final administration scheduled before 4:00 p.m. Drugs that can cause an increase in blood pressure should be avoided such as nonsteroidal anti-inflammatory medications (NSAIDs).
Finally, with regard to Mr. P’s medications, it is not clear why he is on a high-dose famotidine. At minimum, the dose should be reduced to 20 mg daily.
Ms. Haynes holds a master’s degree from Thomas Jefferson University and has 24 years of experience as a physical therapist working with the geriatric population. She is the director of rehabilitation at Mountain View Care Center in Tucson, AZ.
The physical therapist (PT) would contribute to a comprehensive fall assessment to identify causation, location, and patterns that indicate how the staff can modify Mr. P’s environment to minimize occurrence and potential injury. Objective testing like the Timed Up and Go (TUG) test, which measures functional mobility, and the Berg Balance Test may provide valuable assessment information for the development of a therapy treatment plan.
Mr. P has an assistive device, but we will evaluate him to determine whether there is a more appropriate device to optimize his function, particularly with transfers and ambulation. He should be monitored closely for symptoms of dizziness, and his blood pressure measurement should be obtained only when he is symptomatic.
The PT can provide staff training to optimize Mr. P’s transfers and ambulation as well as recommend strengthening and balance exercises (e.g., sit to stands) to incorporate into his daily interactions. The PT would also contribute to the discussion about the most appropriate living arrangement.
Guey-Fang (Christine) Jih, PhD, MHE,OTR/L
Dr. Jih has worked in skilled nursing facilities, home health, acute care, and the academic setting for over 28 years.
An environmental assessment and caregiver training are necessary to allow Mr. P to function safely and comfortably. Mr. P’s shuffling gait and tremors are persistent risk factors for a fall, so both the use of assistive devices and a safe environmental setting/layout will assist in overall safety and fall prevention strategies.
The layout of Mr. P’s bedroom and living room should be as similar as possible to a typical home setting, which may help him more safely maneuver within the space. Because Mr. P has a history of multiple falls at home, he must be taught how to use a call button to call for assistance and how to use a walker appropriately for support. The instruction and education should emphasize how to break and recover from a fall, which will minimize his fall-related injuries. Mr. P and his caregivers should be educated on the signs and symptoms of dizziness and orthostatic hypotension, as well as their causes — such as avoiding ascending or changing a position too quickly.
Based on Mr. P’s functional assessment results, the occupational therapist (OT) will recommend and provide adaptive equipment and assistive devices to facilitate his independence in feeding, grooming/hygiene, dressing, toileting, and safe bathing. If swallowing difficulty is an issue, the OT can reinforce the importance of upright sitting and safe swallowing strategies.
The OT will also provide education and training on exercise to Mr. P and his caregivers. For example, facilitating elbow/wrist extension/arm swinging and minimizing any forward tilt of the trunk, stooped posture, or rigidity. Hand exercise programs can focus on his bilateral hand coordinative activity, such as buttoning/unbuttoning or shoe lacing. Mr. P should ensure he is well-rested before exercise/activity.
Dr. Resnick is the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore. She is also a member of the Editorial Advisory Board for Caring for the Ages.
Ms. Hector is an author, speaker, and educator specializing in clinical operations for the interdisciplinary team, process improvement and statistical theory, risk management and end-of-life care, and palliative care, among other topics. She is associate editor and a member of the Editorial Advisory Board for Caring for the Ages.
Is The interdisciplinary approach was critical in this very complicated case, which required communication and coordination. All team members were focused on optimizing Mr. P’s safety and function to help him remain in the assisted living community.
Changes in medications would be followed with assessment.
Physical activity would be modified with the goal of slowly decreasing Mr. P’s orthostatic hypotension while maintaining his blood pressure at a reasonable level and optimizing his function with strengthening and balance exercises.
Activities would incorporate strategies to increase his strength, including movement with music and chair yoga, with Mrs. P encouraged to participate to provide a shared experience.
Social work would explore the impact of recent life events on Mr. P’s emotional well-being using the PC-PTSD-5 and the PHQ-9, while advocating for his values and preferences and supporting the family as they explore alternate living arrangements if indicated. Social work would also facilitate advance care planning discussions.