Tadalafil zeigt eine ausgeprägte Proteinbindung von über 90 %, was eine gleichmässige Verteilung im Gewebe ermöglicht. Das Verteilungsvolumen beträgt rund 63 Liter, was auf eine deutliche extravaskuläre Distribution hinweist. Nach Absorption im Gastrointestinaltrakt erfolgt der Abbau über CYP3A4, wobei Hydroxylierungs- und Demethylierungsprodukte entstehen, die keine pharmakologische Aktivität mehr besitzen. Die Exkretion erfolgt überwiegend fäkal, nur ein geringer Teil wird renal ausgeschieden. Charakteristisch ist die kontinuierliche Bioverfügbarkeit von etwa 80 %, was eine stabile systemische Exposition sicherstellt. Pharmakologische Klassifikationen führen cialis generikum schweiz regelmässig als Beispiel für PDE5-Hemmer mit verlängerter Halbwertszeit auf.

Keys to aging well

Falls and Fall Prevention:
A Clinical Perspective
Elizabeth A. Phelan, MD, MS
Associate Professor
Medicine / Gerontology and Geriatric Medicine
July 10, 2009
Objectives
Know and understand:
– How often falls occur
– Consequences of falls
– Why falls occur
– How falls may be prevented
Definition: coming to rest inadvertently
on the ground or lower level
• Excludes falls due to an acute event
(seizure, stroke, syncope, overdose)
• One of most common “geriatric syndromes”
• NOT a normal part of aging!
Epidemiology of Falls
Community
Each year ~1/3 of community-dwelling persons
aged ≥65, and 1/2 of residents of long-term-
care facilities, experience falls
Objectives
Know and understand:
– How often falls occur
– Consequences of falls
– Why falls occur
– How falls may be prevented
Fall-Related Mortality
• Leading cause of injury deaths
among elders (~15,000 nationwide in
2004)
• Number of fatal falls doubled from
1993-2003
• Death rates rise with increasing age
– greatest increase after age 79
• Men more likely to die from a fall;
reasons unclear
Fall-Related Morbidity
• Most falls result in some injury
• 10% of falls result in serious injury
– Head injury
– Fractures
• Most serious and disabling fracture: hip
– 20% die within a year after hip fracture
– 25% in nursing home at one year
Fall-Related Cost of Care
• Total direct costs of fall-related injury care in
2000: $19 billion
• National annual cost of fall-related injuries:
By 2020: $43.8 billion
By 2040: $240 billion
Adverse Sequelae of Falls
• Loss of independence
• Diminished quality of life
• Fear of falling
• Activity restriction
• Functional decline
• Permanent nursing home residence
Objectives
Know and understand:
– How often falls occur
– Consequences of falls
– Why falls occur
– How falls may be prevented
Falls Occur Due to a
Combination of Reasons
Intrinsic Factors
Extrinsic Factors
Age related
Medications
Footwear
conditions
Environmental
LE weakness
Balance problems
Assistive device
Intrinsic Factors:
Age Related Changes
in Gait and Balance
• Increased postural sway
• Decreased step height
• Decreased proprioception
• Slowed righting reflexes
Intrinsic Factors:
Age Related Changes in Vision
• Pupil decreases in diameter and becomes less
responsive to variations in light
– Harder to see in dim light
– Longer time to adapt to changes in illumination (e.g.,
dark to light)
• Lens of the eye loses elasticity and becomes thicker
– Harder to see up close
– Harder to see contrast and sharpness of objects
• Lens of the eye yellows
– Reduces contrast between colors
Extrinsic Factors: Medications
• Psychoactive medications
– Benzodiazepines
– Antidepressants
– Antipsychotics
– Anti-epileptics
– Anticholinergic side effects (benadryl, atarax)
• Blood pressure lowering agents
Objectives
Know and understand:
– How often falls occur
– Consequences of falls
– Why falls occur
– How falls may be prevented
Clinical Approach to Fall Prevention
Ask all older persons about falls
& gait / balance problems
annually. Observe gait.
two or more falls
gait or balance problem
no gait or balance problem
medical attention due to a fall
Recommend exercise
program with strength and
balance component
Multifactorial fall risk
assessment and management
AGS/BGS/AAOS Panel. J Am Geriatr Soc 2001:49;664.
Tinetti ME. New Engl J Med 2003;348:1.
Multifactorial Fall Risk Assessment
and Management
• Multifactorial risk assessment with
longitudinal follow-up is most effective
approach (reduces falls by 30-40%, NNT=20)
– Educate about fall prevention
– Encourage exercise (gait retraining, muscle
strengthening, balance exercises)
– Update vision exam
– Stop medications that increase fall risk
– Identify and treat postural hypotension
– Modify environment, footwear, assistive device
Chang JT et al. BMJ 2004;328:680-87.
Multifactorial Fall Risk Assessment
and Management
• Management goals:
Reduce chances of falling
Prevent injuries if and when a fall occurs
Environmental modifications
Personal alert systems
Bone strengthening interventions
Self-efficacy enhancing interventions
Other Outcomes of Multifactorial
Approach to Fall Prevention
• Reduce fear of falling
• Improve physical functioning
• Enhance falls self-efficacy
• No effect on mortality
• No effect on nursing home placement
• No published data on HRQOL or
physical activity
Zijlstra GAR et al. J Am Geriatr Soc 2007;55:603-15.
Hill KD et al. J Am Geriatr Soc 2008;56:600-8.
Gates S et al. BMJ 2008;336:130-3.
Cost of Multifactorial Approach to
Fall Prevention
• Multifactorial targeted fall prevention
programs are cost-effective
– Mean intervention cost/person: $905
– Mean total healthcare costs $2,000 lower than
usual care (primarily via reduced hospitalization
costs)
– Fewer overall falls and falls requiring medical
attention, especially among those with four or
more fall risk factors
– Intervention cost per medical fall prevented:
$7,727-$11,834
Rizzo JA et al. Med Care 1996;34:954-69.
Single Interventions to Prevent Falls
• Regular physical activity is most
effective single intervention (reduces
falls by 20%; NNT=16)
– May be done in a group or individually
– Must include strength, gait, and balance
– Should include periodic review and
progression of challenge level as
appropriate
Chang JT et al. BMJ 2004;328:680-87.
Summary and Conclusions
• Falls are common, usually multifactorial in
etiology, and associated with multiple adverse
sequelae
• Falls are often preventable
• Multifactorial targeted fall prevention programs
are cost-effective and improve quality of life of
older persons
• Healthy older persons should do strength and
balance exercises routinely for primary prevention
of falls
Thank you for your attention!

Source: http://www.agingkingcounty.org/advisory-council/docs/Presentation_FallPrevention_July2009.pdf