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