Elder Drugs » Nutrition

Is poor balance the cause of falls or is it the medications? Or is it both?

Alan Lukazewski — Mon, 17 Oct 2011 18:15:51 +0000

I heard someone say the other day that “Drugs are clearly not the cause of falls but it is poor balance that is the cause.” I found it interesting since that was said by a physical therapist and sounded a lot like a bias, not unlike a pharmacist I know who is focused on drugs as the cause of falls. However, what I understand to be true about falls is that their cause is usually multi-factorial, involving more than one risk factor, albeit drugs can cause poor balance, altered gait, cognitive impairment, blurred vision, dizziness, leg weakness, and other factors that are validated to contribute to or cause falls in numerous studies. But I must set the record straight that I am the last person to focus just on drugs. In fact, when I am engaging a client while reviewing their medications I also use that discussion as an opportunity to teach them what they can do to reduce their risk for falling. Case in point: A client commented on how the information I provided, that timolol eye drops was a leading risk factors for falls when improperly administered, helped her in regaining balance and stamina, thereby allowing her to stop using her walker. I then cautioned her that her new found confidence could produce a fall since issues could still exist with balance, weakness or gait. I advised that she seek the advice of a physical therapist for a comprehensive assessment.

As a result of hearing this PT’s comment I searched the literature again and looked at falls through a different lens, the one that views the null hypothesis of drugs not causing falls. In an article published in 2003 in Pharmacy & Therapeutics, the authors stated: “Beta- blockers do not contribute to falls”. Perhaps they needed to know about the systemic effects of beta blocker eye drops because Australian data have proven timolol eye drops to be the number one risk factor for falls in patients with glaucoma. (One must also understand that any drug that can cause bradycardia or hypotension can cause a fall.) The authors also stated that “Chronic therapy with blood pressure lowering medications rarely cause falls.” They referred to older studies and meta-analyses from the 1990′s, clearly older evidence that conflicts with more recent data. I found other references that state medications are key contributors to falls, and that is also backed by years of professional experience where changes in antihypertensive medications eliminated dizziness and reduced the incidence of falls. Dr. James Cooper, PharmD, has shown that medications play a key role in causing falls, as reviewed in Medication Interventions for fall prevention in the older adult, Pharmacy Today, 2009 where he referred to his research in reducing the incidence of falls in nursing home residents by 70%. The literature is replete with references showing that alterations in medications reduces the incidence of falls in older adults, and I could fill a few pages with those validated studies.

I am fascinated by the conflicting “evidence” in the literature, and it is now beginning to amuse me. It also shows me that years of reviewing the literature, combined with clinical experience, helps paint a clearer picture that precludes any conclusions from a meta-analysis or retrospective database review that implies cause and effect after “adjusting for confounding factors”. If I followed the advice in some of the literature over the last couple of years I would: Adhere to a complex medication regimen that causes me to be cognitively impaired, dizzy and to fall down the stairs breaking a hip, all because someone said non-adherence causes falls. I would have also stopped taking my calcium, because it is associated with higher risk of death, for which I then might be at greater risk of fracture. I would also have stopped taking a multivitamin with iron and become anemic, thereby further contributing to my risk of falling by causing weakness, and last but not least, I would be typing this post from my nursing home room.

If you don’t know where to look then you won’t know where to find the truth. It’s also wise to work as a team addressing all the identifiable risk factors for falls.

Falls, incontinence and memory loss: Is that normal aging or can something be done to help me?

Alan Lukazewski — Tue, 29 Mar 2011 02:35:30 +0000

Falls, urinary incontinence, and memory loss are just a few of what are classified as geriatric syndromes. A geriatric syndrome is a condition that is not a disease entity itself but is known to increase our risk of losing independence by affecting function and quality of life. When talking with someone who is experiencing one or more of these syndromes, I first need to know if this person is ageist. You see, many people, even older adults, are ageist and assume that these syndromes are a normal part of aging and accept them without a challenge, thereby living a poorer quality of life. But let’s get past that and come to understand that we can alter the course of aging and improve our function and quality of life.

Falls, for example, can be caused by a number of risk factors such as medications, leg weakness, protein malnutrition, vitamin D deficiency and urinary incontinence, all of which can be altered with a little knowledge and effort. If we are protein malnourished we can always eat more protein, and that combined with the proper exercise regimen can improve our leg strength. We can also do balance exercises that help reduce our risk of falling, along with altering some of those medications known to cause falls, such as blood pressure medications, medications for insomnia among many others. Incontinence can be managed with behavioral modifications thereby avoiding medications that can affect our memory and cause falls. Vitamin D deficiency, known to be associated with poor balance, falls, and memory loss in some, can be corrected with the right replenishment of vitamin D. All of these are easy to identify when screened for and easily altered to improve function and quality of life. We all know our body’s organ systems decline with aging but we can slow down that decline and alter the trajectory with these interventions.

What I recommend is to go to the National Institute of Aging web site at: www.nihseniorhealth.gov or www.nia.nih.gov, and go to the Publications section, Age Pages, and search for the condition that affects you or your loved one. The brochures can be printed in PDF format or can be read on line with altering text size for those with low vision. It’s a great way to continue your life-long learning and age well. One other point is that medications themselves can cause geriatric syndromes which are assumed to be a normal part of aging. A medication review with an experienced pharmacist can help identify medications associated with geriatric syndromes and help you age in place. Don’t subscribe to the stereotype that falls, urinary incontinence and memory loss are always a normal part of aging. They may not be in your case!

FDA warns that Prilosec-like drugs cause low magnesium levels

Alan Lukazewski — Thu, 03 Mar 2011 13:54:44 +0000

Prilosec-like drugs, also called proton pump inhibitors, or PPIs, are associated with low serum magnesium levels when used for long periods of time, usually over one year. The significance is that low serum magnesium can cause, muscle spasms, irregular heart beats, and seizures, in severe cases. Low serum magnesium can also increase the risk of toxicity from Lanoxin (digoxin), which can be fatal if undetected and left untreated. The risk of low serum magnesium from PPIs can be further increased with certain diuretics. FDA advises that health care providers obtain magnesium levels in people who are going to be on any of these drugs for a long period of time. Low magnesium can increase the risk of toxicity of antiarrhythmic drugs such as digoxin. That also leads to the question, should most people be on these drugs for extended periods of time? In certain instances, yes, but in many instances these drugs become “legacy drugs” that just continue to be taken without a valid indication. But when some people try to stop these drugs a rebound hyperacidity syndrome occurs which results in worsening symptoms, thereby giving the impression that the drug is needed. Practitioners and patients should work together to do a thoughtful, slow taper, if indeed it is determined that a PPI may not be needed for an extended period of time.

Prescription PPIs include Nexium (esomeprazole magnesium), Dexilant (dexlansoprazole), Prilosec (omeprazole), Zegerid (omeprazole and sodium bicarbonate), Prevacid (lansoprazole), Protonix (pantoprazole sodium), and AcipHex (rabeprazole sodium). Vimovo is a prescription combination drug product that contains a PPI (esomeprazole magnesium and naproxen). Over-the-counter (OTC) PPIs include Prilosec OTC (omeprazole), Zegerid OTC (omeprazole and sodium bicarbonate), and Prevacid 24HR (lansoprazole)

The link to the FDA notice is as follows: http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm

This new information can be put into the category of drug-nutrient interactions in which a drug can alter the absorption or disposition of vital nutrients the body needs. PPIs are also known to reduce calcium and vitamin B-12 absorption. Other PPI-nutrient interactions and information on supplements older adults need can be found at my link: http://elderdrugs.com/category/wellness/supplements-wellness/

Institute of Medicine (IOM) Report on Vitamin D and Calcium: Too much?

Alan Lukazewski — Fri, 03 Dec 2010 02:57:33 +0000

The Institute of Medicine (IOM) released its long awaited report on vitamin D and calcium intake recommendations on November 30th. Articles in the New York Times and Wall Street Journal would have you believe that we are all taking too much vitamin D and calcium, and that supplementing with either of these two is dangerous. Here is a slightly different interpretation of that report.

All older adults (>65y/o) should have their vitamin D blood level checked by their physician. If it’s low, <30, they should be treated in order to get that blood level up to about 40. Supplements may be needed to maintain that blood level over time. Vitamin D is an essential nutrient and many of us do not make enough due to inadequate sun exposure, along with the fact that this mechanism doesn’t work well as we get older. (NOTE: The IOM INCREASED the recommended daily amount of vitamin D to 800 units for older adults, a very conservative number, and set the upper limit at 4000units a day.) We recommend that older adults consider achieving daily intakes between 1000 and 2000 units if there are no reasons why they should not. Keep in mind, more processed foods are now supplemented with vitamin D so you need to count how much you normally take in each day, and don’t forget most multiple vitamins contain about 400 units. In summary, if you are an older adult who has had a low level, continue with what your doctor told you. Most older adults are safe with taking a daily supplement. An excellent review of the benefits of vitamin D can be found at the Linus Pauling Institute at Oregon State University. Here’s the link: http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/index.html

Regarding calcium, the daily recommended intake for older adults is set in the report summary between 1200mg and 1500mg daily, which is what we normally recommend. There’s really no big deal into this report and you should appreciate the benefits to getting enough calcium and vitamin D each day as they are essential nutrients. The IOM report in brief is in PDF format in the link below.

http://www.iom.edu/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Vitamin%20D%20and%20Calcium%202010%20Report%20Brief.pdf

Now for some guidance when it comes to health information in the news. Watch out! This is the worst source of information, the general news media. We have a link to the National Institute of Aging web site that provides you with a publication on how to interpret what’s in the news and other health research findings. Take a look at the link below. It will help you stay on track and not get so confused when you hear conflicting information.

http://www.nia.nih.gov/NR/rdonlyres/43F218DA-2188-40BC-90CE-7B740E8FA701/10421/Understanding_RiskWhat_Do_Those_Headlines_Really_M.pdf