http://www.merckmedicus.com/medical-news/f5c48af5aa2c0c74dc31be6b301f604e?WT.mc_id=MM_POC_WKL_US_en_23&e=alan.lukazewski@oakwoodvillage.net

It is common for people with diabetes, and without who have high blood glucose readings while in the hospital, to be put on a “sliding-scale” insulin regimen. This regimen is not safe and is tantamount to “chasing blood sugars”. The reason is that treating a high blood sugar with a dose of insulin is treating the blood sugar at that time and not at the time when factors, such as carbohydrate intake, were responsible for that rise in blood sugar, which was most likely hours ago. This then leads to the roller coaster effect of low blood sugars followed by high blood sugars, and more frequent hypoglycemia. The use of sliding scale insulin is considered by theAmerican Geriatrics Societyas one of the Updated Beers Criteria of inappropriate treatments in older adults. This practice in hospitals then carries over into nursing homes for those discharged from the hospital to the nursing home and is wrought with danger. It is best to set reasonable goals or targets, such as a blood glucose range between 140 and 200mg/dl, and use insulin in an anticipatory manner, not reactive.

• Statins are known to cause peripheral neuropathy, to the extent that it was estimated in one study that it may be more of a public health problem than myopathy. Meaning, it may occur more frequently than myopathy and often go undetected and possibly misdiagnosed as a disease, or from another disease such as diabetes. And since these drugs are so widely used this may affect a large number of people.
• Statins are known to cause memory loss or amnesia in a very small population. This is relevant when memory loss is assumed to be age-related, such as mild cognitive impairment or dementia, such as Alzheimer’s disease. Some people have had the diagnosis of Alzheimer’s disease removed from their medical record when it was found the statin was the cause. Others are not so lucky.
• Tendinous disorders, including tendon ruptures. This is rare but fairly well correlated with the use of statins. There is a proposed mechanism as to why it may occur from use of a statin, which supports the premise that statins can cause this disorder.
• Muscle weakness is also a side-effect of statins. One study showed that statins can cause muscle weakness without reducing muscle mass, and a more recent study showed that statins can reduce exercise ability and tolerance. Some athletes can’t run as fast or as far while on a statin.
• Statins are correlated with an increased risk of falls, probably due to the effects on weakening of the large muscles in the legs.

If you stand to benefit from a statin, keep taking it but be wary of possible life-altering side-effects and work with your physician to monitor for the side-effects. Intervening sooner than later can prevent a side-effect from causing serious harm.

The elderly were shown to be at higher risk and also to experience low serum calcium in association with low magnesium. Other electrolyte imbalances, such as hypokalemia, were found in association with hypomagnesemia from PPI use. One-percent as an overall incidence, along with widespread PPI use in the elderly (20-25%) make this adverse drug event a serious concern. Since many older adults are taking PPIs needlessly it behooves everyone and their practitioner to review if continued use is essential to their safety and health. If not deemed essential, a slow taper of the drug to prevent rebound hyperacidity is recommended.

The authors studied older adults, average age 78, who were treated with statins to measure the beneficial effects in stroke prevention, survival and functional outcomes. The results showed that statins did not decrease stroke severity and did not improve 30-day survival. However, use of statins after that first stroke did improve survival at 12 months, along with improving the function at the 12 month interval. The authors stated a limitation of their study, one being that the use of statins may have been a marker of disease severity hence outcomes were poorer. Also found in this study was that people with poorly controlled diabetes treated with statins had more long term benefits. Lastly, statin use did not influence the rate of recurrent stroke during the first year of follow-up.

These findings suggest that statin use after the first stroke may be beneficial in the long term, but the question remains as to whether preventing that first stroke with the use of statins has strong enough evidence to make general recommendations. Regardless, in all cases, the patient and the physician should make an informed decision as to whether the addition of a statin to other interventions, whether they be dietary, exercise, blood pressure treatment, etc., would be beneficial in preventing the effects from one of the most disabling events an older adult can experience.

If you’re interested in one of the leading causes of death by disease, Adverse Drug Events, here’s a list of web sites that may be useful to you.

http://www.drugcite.com/

http://www.fdable.com/aers/fda_adverse_events?gclid=COmq1qf8wqwCFQrHKgodIn3hpg

http://www.drugwatch.com/

https://www.medmarx.com/

http://www.tga.gov.au/DAEN/daen-entry.aspx

http://www.psip-project.eu/

http://treato.com/

https://www.rxisk.org/Default.aspx

http://www.adverseevents.com/

http://www.drugalert.org/

http://www.ismp.org

http://www.ismp-canada.org

http://www.ncbi.nlm.nih.gov/pubmed/23121724

Other links related to statins and peripheral neuropathy:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103035/

http://www.jfponline.com/Pages.asp?AID=9452

http://www.sciencedaily.com/releases/2002/05/020514075710.htm

Vitamin D: Dr. Oz said “Because it’s difficult to get enough from food, I recommend taking 1000units in supplement form daily, with a healthy fat to improve absorption”. CRoH was painting a different picture in the article “Do you really need more vitamin D?”. Comments in their article were: “But many of the claims about vitamin D may be wishful thinking”, and “There’s no need for a test of your vitamin D levels unless your doctor finds you at risk for deficiency”.

My understanding is that many older adults, perhaps over 50%, have low or less than ideal levels of vitamin D in their blood. And evidence suggests that older adults are at higher risk for falls, fractures, poor memory health, and muscle weakness, if their levels are low. Also, by taking a supplement and not having your level checked, specifically 25-hydroxy vitamin D, less than 50% will get their levels to where geriatricians would target. The best advice for older adults is to have their level checked and work with their physician to treat to get their vitamin D level to above 30 or higher. There is no harm by doing this and many older adults, in a large population, benefit from higher levels of vitamin D.  By the way, in one study, just taking a supplement as recommended did not get levels to where they needed to be in over 50% of the participants.

Blood Pressure: Both Dr. Oz and CRoH made statements about blood pressure, which were not age specific. “Dr. Oz says “The systolic pressure-the top number-should never be over 120″, and CRoH said “The ideal systolic pressure, or top number, is below 120…”. If you go to my recent post, http://elderdrugs.com/2013/04/blood-pressure-lowering-for-older-adults-what-is-a-safe-target/, you will find more recent evidence that says lower is not better for most older adults. This evidence started to emerge over 5 years ago in studies in male veterans which showed that treating to below 120/80 was wrought with more harm than good. Other studies have since emerged that suggest a higher target, say for example 150/95, may be safer and as effective at lowering risk of stroke. The newer target is suggested at 130/90. My recommendation is to discuss blood pressure goals with your physician since not everyone should follow general recommendations, as is implied in these general health news reports.

In conclusion, general health information in the media is concerning in that it may be inaccurate, and at best not specific to your health care needs. Try not to react to health information in the news and have more meaningful discussions with more than one health professional and search for current guidelines. Use this information to work with your physician to come up with a plan that is more specific to your needs.

There are many studies, the first that came out several years ago and based in an elderly, male Veteran’s population, showed that lowering blood pressure too low is actually wrought with more harm than good. We also now have evidence from other studies that going far below 130/90 doesn’t necessarily produce any further risk lowering benefit, and may actually cause harm. This newer evidence, which actually isn’t that new but just coming to the surface in review committees who make consensus recommendations, is especially strong for people with diabetes. Studies such as the ACCORD trial, INVEST, ABCD, and HOT were well-designed studies and proper interpretation of these studies shows that aggressive lowering of blood pressure is not always aligned with good outcomes.

So what is a good target blood pressure? Any target blood pressure goal should be individualized, to consider life-expectancy, fall risk, and risk for adverse medication effects. What’s the point of lowering blood pressure in a 92 year old to 110/70 if the person is lethargic and dizzy all the time and, as an outcome, falls, breaks a hip and then experiences the negative sequelae thereafter, eg. pneumonia, immobility, chronic pain and fear of falling. Blood pressure goals in the older adult should be about 130/90, in general, but also individualized, as mentioned above. In general, going far below 130/90 is not associated with strong evidence to suggest any further benefit.

In their study, “People with Alzheimer’s who were more physically active weren’t cured, but they had less deterioration in their brain matter volume, compared with the sedentary individuals”. The study used MRI scans from 876 individuals, along with clinical data, over a 20 year period. Measurements of cognition were not mentioned in the results of this study. Linking increased gray matter volume to better performance of memory and learning would strengthen the results of this study.