“What Medicines Do You Take?” – Medication Influence in Older Adult Musculoskeletal Care

By Janis Henricksen, PT, DPT, Sc.D., COMT, CEEAA; Brad Allen, PT, Sc.D., CHT, COMT; Jean-Michel Brismée, PT, Sc.D., OCS, FAAOMPT; Matthew D. Geddie, OTR, Ph.D., MBA Address correspondence to Janis Henricksen, Plano, TX. Email: janis.henricksen@gmail.com The presence of chronic conditions increases with age. Eighty percent of older adults have at least one chronic disease, 68% have at least two¹. The most common conditions for Americans 65 years of age and older are osteoarthritis, hypertension, diabetes mellitus, pulmonary disease, cancer, and osteoporosis⁶. Hypertension with diabetes and hypertension with osteoarthritis represent two of the most common disease clusters⁶. When considering combinations of comorbidities, the symptoms of depression are commonly noted⁷. Depression prevalence among older adults ranges from one to four percent and the presence of depressive symptoms ranges between 15-32%⁵. The chronic diseases themselves, as well as the medications to treat them, often impact provision of conservative musculoskeletal care. As therapists treat older adults or those with multiple comorbidities, awareness of medication indications and side effects plays a significant role in assessment and treatment. The following reference sheet, taken from the course New Trends in Conservative Musculoskeletal Management of Older Adults, provides common medication classes, their indications, and side effects influencing therapy services for common chronic conditions^4,2. Conditions included on this reference sheet are cardiovascular diseases, pulmonary disorders, osteoarthritis, diabetes mellitus, depression and osteoporosis³.

Common Medications and Side Effects for Chronic Disease

Medication	Indication/Diseases	Common Generic (and Brand) Names	Side Effects
Anti-anginal	Chest pain Coronary Artery Disease	Nitrates isosorbide dinitrate (Isordil, Dilatrate-SR, Isochron, IsoDitrate), isosorbide mononitrate (Ismo, Imdur, Monoket), nitroglycerin (NitroQuick, Nitrostat, Nitro-Bid, Nitrolingual, Nitro TD Patch-A)	Exaggerated response to systemic heat Orthostatic hypotension Dizziness
Anti-arrhythmic	Elevated blood pressure Arrhythmias Angina Coronary Artery Disease Hypertension Reynaud’s Disease	Cardiac specific Beta Blockers (-olol): acebutolol (Sectral), atenolol (Tenormin), bisoprolol (Zebeta), metoprolol (Kapspargo Sprinkle, Lopressor, Toprol-XL), nebivolol (Bystolic) Non-cardiac specific Beta Blockers (-olol): carvedilol (Coreg), labetalol (Trandate, Normodyne), nadolol (Corgard), pindolol (Visken), propranolol (Hemangeol, Inderal, InnoPran), timolol (Blocadren) Calcium Channel blockers: amlodipine (Katerzia, Norvasc), diltiazem (Cardizem, Cartia, Dilacor, Diltia, Diltzac, Matzim, Taztia, Tiazac), felodipine (Plendil), nicardipine (Cardene IV, Cardene, SR, Cardene), nifedipine (Adalat, Afeditab, Nifediac, Procardia), verapamil (Calan, Isoptin, Verelan, Covera-HS)	Swelling of feet and ankles Altered heart rate (may not control dysrhythmias during exercise) Bronchoconstriction Mask hypoglycemia Reflex tachycardia Reduce heat tolerance and premature fatigue
Anti-coagulants	Blood clotting disorders Arrhythmias Cerebrovascular Disease/Accident Coronary Artery Disease Deep Vein Thrombosis Lupus Myocardial Infarction Recent surgery	Coumarins: warfarin (Jantoven, Coumadin) Factor Xa inhibitors: apixaban (Eliquis), betrixaban (Bevyxxa), edoxaban (Savaysa), fondparinux (Arixtra), rivaroxaban (Xarelto) Heparins: dalteparin (Fragmin), enoxaparin (Lovenox) Thrombin Inhibitors: bivalirudin (Angiomax), dabigatran (Pradaxa)	Increased risk of: Bleeding Bruising Dizziness Headache Stomach upset
Anti-depressants	Depression Anxiety Fibromyaliga Hot flashes Obsessive-Compulsive Disorder Panic Disorder Post-Traumatic Stress Disorder	Selective serotonin reuptake inhibitors (SSRIs) citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem, Selfemra, Rapiflux), paroxetine (Brisdelle, Paxil, Pexeva), fluvoxamine (Luvox), sertraline (Zoloft)	Exacerbate hyponatremia Ataxia Impaired psychomotor function Increased risk of bleeding
	Depression, Chronic Pain Anxiety Bipolar Depression Chronic Pain Depression Diabetic Neuropathy Fibromyalgia Panis Disorder Social Phobia	Serotonin-norepinephrine reuptake inhibitors (SNRIs) desvenlafaxine (Pristiq, Khedezla), duloxetine (Cymbalta, Irenka), levomilnacipran (Fetzima), venlafaxine (Effexor), milnacipran (Savella)	Orthostatic hypotension Increased heart rate Decreased blood pressure Increased risk for arrhythmias Increased risk of bleeding
	Depression, Chronic Pain Anxiety Chronic nerve-related pain Migraine prevention Obsessive-compulsive Disorder Panic Attacks Post-Traumatic Stress Disorder	Tricyclic anti-depressants (TCAs) amitriptyline (Vanatrip, Elavil, Endep), amoxapine (Asendin), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor, Aventyl HCL)	Orthostatic hypotension Falls Sedation Urinary retention Bradycardia Dry mouth
Anti-hypertensives	Elevated blood pressure Chronic kidney conditions Coronary Artery Disease Heart Failure Hypertension	ACE inhibitors (-pril): benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), lisinopril (Prinivil, Zestril), ramipril (Altace) Angiotensin receptor blockers (-artan): azilsartan medoxomil (Edarbi), candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro), losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis), valsartan (Diovan)	Blunt rise of blood pressure during exercise Orthostatic hypotension Kyperkalemia – cardiac dysrhythmia, dehydration, kidney dysfunction
Anti-inflammatory	Inflammation, pain Allergies Asthma Chronic Obstructive Pulmonary Disease Crohn’s Diease Lupus Multiple Sclerosis Organ Transplants Osteoarthritis Rheumatoid Arthritis Skin Conditions Tendinitis	Glucocorticoids / corticosteroids budesonide (Entrocort, Uceris), dexamethasone (Baycadron, Decadron, DexPak, TaperDex, Zema-Pak, ZoDex, Zonacort), hydrocortisone (Cortef), methylprednisolone (Medrol), prednisolone (Flo-Pred, Millipred, Orapred, Pediapred, Medicort, Predicort), prednisone (Rayos, Sterapred, Daltasone), triamcinolone (Aristocort)	Steroid myopathy Muscular atrophy Tendon rupture Osteoporosis Elevated blood sugar Fluid retention
	Pain, inflammation Colds/flu Fever Headache Musculoskeletal Pain/Injury Osteoarthritis	Non-steroidal anti-inflammatory drugs (NSAIDS) diclofenac (Cambia, Zipsor, Zorvolex, Cataflam, Voltaren, Dyloject), etodolac (Lodine), ibuprofen (Advil, Midol, Motrin), indomethacin (Indocin, Tivorbex), ketorolac (Toradol), meloxicam (Mobic), naproxen (Aleve, Naprosyn, Flanax, Midol ER, Anaprox)	Gastrointestinal disturbance Hypertension Leg swelling Liver or kidney problems Increased risk of myocardial infarction or cerebrovascular accident Headache Dizziness
Bronchodilators	Bronchoconstriction Asthma Chronic Obstructive Pulmonary Disease (Chronic Bronchitis and Emphysema)	Adrenergic: albuterol (ProAir, Proventil, Ventolin, AccuNeb), arformoterol (Brovana), epinephrine inhalation (Primatene), formoterol (Perforomist, Foradil), isoproterenol (Isuprel), levalbuterol (Xopenex), racepinephrine (Asthmanefrin, S2 inhalant, Nephron, Micronefrin), salmeterol (Serevent) Anticholinergic: ipratropium (Atrovent), aclidinium (Tudorza Pressair), tiotropium (Spiriva) Combinations: albuterol/ipratropium (Combivent, DuoNeb), flucticasone/salmeterol (Advair, AirDuo, Wixela), budesonide and formoterol (Symbicort), fluticasone and vilanterol (Breo Ellipta) Methylxanthines: theophylline (Elixophyllin, Theo-24, Respbid etc)	Dysrhythmia Premature ventricular contraction Increased heart rate Increased blood pressure
Diabetes Type I/II	Elevated blood glucose Diabetes Type I Diabetes Type II (Diabetes Mellitus)	Biguanides (non-sulfonylureas) metformin (Glumetza, Riomet)	Hypoglycemia Gastrointestinal upset B12 deficiency
		Insulin: Insulin aspart and insulin aspart protamine (NovoLOG), insulin degludec (Tresiba), insulin detemir (Levemir), insulin glargine (Lantus, Basaglar, Toujeo), insulin lispro (Admelog, HumaLOG), insulin isophane (Humalin N, NovoLIN N, ReliOn/NovoLIN), insulin regular (Humalin R, Myxredlin, NovoLIN R) Sulfonylureas: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta, Glynase, Micronase)	Hypoglycemia Weight gain
		Thiazolidinediones pioglitazone (Actos), rosiglitazone (Avandia)	Fluid retention Weight gain Bone fractures Heart failure
Diuretics	Elevated blood pressure Heart Failure Hypertension Liver Failure Tissue swelling (edema)	Thiazide Diuretics: chlorthaliadone (Hygroton, Thalitone), hydrochlorothiazide (Aquazide H, Esidrix, HydroDiuril, Microzide), indapamide (Lozol) Loop Diuretics: Furosemide (Lasix, Diaqua-2, Lo-Aqua), torsemide (Demadex) Potassium-sparing diuretics: amiloride (Midamor), eplerenone (Inspra), spironolactone (Aldactone, CaroSpir)	Orthostatic hypotension Fluid depletion Muscle cramping Impaired glucose and lipid metabolism Hypo- or hyperkalemia Altered sodium content
Hyperlipidemia	Elevated cholesterol Hyperlipidemia	Statin Medications atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev, Mevacor, Altocor), pitavastatin (Livalo, Zypitamag), pravastatin (Pravachol), rosuvastatin (Crestor), simvastatin (Zocor)	Myopathy Weakness Liver damage Muscle cramping
Osteoporosis	Bone loss Osteoporosis	Parathyroid hormone and analogs: abaloparatide (Tymlos), parathyroid hormone (Natpara), teriparatide (Forteo) Bone resorption inhibitors: romosozumab (Evenity), denosumab (Prolia)	Parathyroid hormone and analogs: Dizziness, vertigo, muscle cramp, arthralgia, hypotension, hyperuricemia, hypercalcemia, Bone resorption inhibitors: Dyspnea, arthralgia, hypocalcemia, atrial fibrillation
	Bone loss Osteoporosis Paget’s Disease	Bisphosphonates: alendronate (Fosamax, Binosto), ibandronate (Boniva, Bondronat), pamidronate (Aredia), risedronate (Actonel, Atelvia), zoledronic acid (Reclast, Zometa, Aclasta) Selective Estrogen receptor modulators (SERMs): raloxifene (Evista)	Bisphosphonates: Muscle and joint pain, osteonecrosis of the jaw, muscle cramps, increased serum calcium, increased atypical femoral fractures SERMs: Muscle cramps, arthralgia, peripheral edema, increased blood pressure, sinusitis

References 1. Chronic Disease Self-Management - Programs & Resources. NCOA. https://www.ncoa.org/healthy-aging/chronic-disease/. Accessed June 2, 2019. 2. Ciccone C. Pharmacology in Rehabilitation. 5th ed. Philadelphia: F.A.Davis Company; 2016. 3. Prescription Drug Information, Interactions & Side Effects. Drugs.com. https://www.drugs.com/. Accessed April 21, 2020. 4. Henricksen J. Comorbidities and Medications. November 2019. 5. Kvelde T, Lord SR, Close JCT, et al. Depressive symptoms increase fall risk in older people, independent of antidepressant use, and reduced executive and physical functioning. Arch Gerontol Geriatr. 2015;60(1):190-195. doi:10.1016/j.archger.2014.09.003. 6. Quiñones AR, Markwardt S, Botoseneanu A. Multimorbidity Combinations and Disability in Older Adults. J Gerontol A Biol Sci Med Sci. 2016;71(6):823-830. doi:10.1093/gerona/glw035. 7. Sinnige J, Braspenning J, Schellevis F, Stirbu-Wagner I, Westert G, Korevaar J. The Prevalence of Disease Clusters in Older Adults with Multiple Chronic Diseases – A Systematic Literature Review. PLoS ONE. 2013;8(11). doi:10.1371/journal.pone.0079641.