Posts tagged Featured Articles
Dizziness from Blood Pressure Medications
Aug 8th
JH was frequently dizzy when he stood up and had several falls as a result. We identified terazosin as a high-risk drug that frequently causes dizziness upon standing. His terazosin 10mg daily was changed to lisinopril and his dizziness and falls resolved.
What is described above is called orthostatic hypotension. It is best described as dizziness upon standing up from a seated or lying down position which can compromise blood flow to the brain thereby causing dizziness. This is a leading cause of falling in older adults but can be easily remedied. When blood pressure is affected by medications used to treat a cardiovascular condition such as high blood pressure there is an increased risk of experiencing this syndrome. Although many medications can cause dizziness by different mechanisms, we will focus on those that affect blood pressure.
Any blood pressure medication can cause a drop in blood pressure and isn’t this what we’re looking for? However, sometimes the medication dose is too high or perhaps another medication was added that interacted with the blood pressure medication thereby increasing its effect and risk of side-effects. In any event, whenever dizziness appears in someone who is taking a blood pressure medication orthostatic hypotension needs to be ruled out. Keep in mind that there are other non-drug causes of orthostatic hypotension in older adults and that’s why you should consult your physician. However, here’s a little information on how to determine if you are experiencing orthostatic hypotension.
Orthostatic hypotension can be measured by the nurse, physician or other trained health care professional. It is defined as follows:
Systolic (upper number) blood pressure decrease >20mmHg after standing for 2 minutes as compared to blood pressure when sitting,
AND/OR
Diastolic (lower number) blood pressure decrease >10mmHg after standing for 2 minutes as compared to blood pressure when sitting,
AND/OR
Increase in pulse >20 beats per minute,
AND
having symptoms of dizziness.
In general, if your blood pressure is LESS than 120/80 while on medications OR if you experience dizziness upon standing up, you should talk with your physician and have your medications reviewed for possible dose reductions or other medication changes in order to prevent a fall from dangerously low blood pressure.
Statin-Associated Memory Loss
May 9th
MJ was encouraged to take a statin for his high cholesterol since he has diabetes which adds to the risk of cardiovascular disease, such as stroke or heart attack. But while taking two different statins, Lipitor and Zocor, he developed memory loss and a “goofy, loopy feeling”. Soon after we found the evidence that supports the claim that some people develop memory health issues while on a statin.
A study in Pharmacotherapy, Vol. 29, Number 7, 2009, confirmed that 128 users of statins suffered memory loss as a result of taking the drug. This was a select population of 143 statin users who had complained of memory loss so the actual incidence of memory loss from statins in the general population is quite low, probably less than 1%. However, this study showed that several study participants had the diagnosis of Alzhemier’s disease removed from their medical record after having confirmed the memory loss was caused by taking the drug.
Other findings from the study are that 128 out of 143, or 90%, who stopped taking the statin reported improvement in cognitive problems, some in as little as a few days. The average time to improvement was 2 & 1/2 weeks. In 19 who re-challenged, by re-starting a statin after it was stopped, memory loss reappeared. Lastly, the higher the potency of the statin showed a higher correlation with developing memory loss.
In summary, statins are very useful drugs that should be used when the benefits clearly outweigh the risks. These drugs are known to reduce the incidence of cardiovascular events so they are valuable tools in the arsenal in the fight against stroke and heart attack. However, some people react adversely to these drugs and it is recommended that users of statins be aware of the possibility of developing memory loss (cognitive impairment) from the use of these drugs. We do not recommend anyone stop taking their medication but should first consult with their physician.
Marcella A. Evans, B.S., and Beatrice A. Golomb, M.D., Ph.D., Pharmacotherapy, Vol. 29, Num. 7, 2009
Eye Drops: Systemic Side-Effects
May 6th
The use of timolol eye drops in people with glaucoma is the leading risk factor for falling. PB had her timolol changed to another drug and her balance improved within 3 days and she stopped using a walker after 7 days.
Adverse Medication Events: The significance of eye drops causing side-effects in older adults
Adverse drug events (ADE’s), also called side-effects, are responsible for 2.2 million hospital visits and 106,000 deaths each year! If ADE’s were a disease by itself, it would be the 5th leading cause of death by disease. This becomes more likely as we age since we are more sensitive to the effects of most medications and we tend to take more medications.
The most recent information we have is in relation to systemic side-effects from eye drops. One might assume that the effects of a topically applied eye drop would be limited to the area of the eye. However, the transit of medication through the tear duct into the body make many eye medications as potent as an intravenous (injected) dose of medication. Here are a couple ways to put this into perspective:
**One (1) drop of Timolol 0.5% Opthalmic Solution is as strong as one (1) 10 mg oral tablet used for treatment of hypertension or angina.
**The leading risk for falls in patients with glaucoma is the topical administration of (Timoptic) timolol eye drops.
Here are some examples of documented side-effects found in the literature:
1) Bronchospasm and congestive heart failure (Timolol)
2) Depression (Timolol & other beta blockers)
3) Low blood pressure (Timolol & Pilocarpine)
4) Headache or “brow ache” (Pilocarpine)
5) Urinary frequency (Pilocarpine)
6) Asthenia (Alphagan) Asthenia is defined as physical weakness and loss of strength
This is only mentioning side-effects from one drug at a time. Many older adults take up to four eye drops at the same time for their glaucoma. That being said, we need to pay closer attention to what’s going on. Here’s what we recommend:
1) One way to reduce the drug from being absorbed into the body is to follow a particular technique. This procedure is called the “double DOT” procedure” which stands for “Don’t open eyes technique and Digital Occlusion of the Tear Duct” This involves closing the eye and applying pressure over the lacrimal duct (tear duct) for 1-2 minutes after application of the eye drop. This technique reduces systemic absorption by two-thirds.
2) Describe what you might think are side-effects from the list mentioned above.
3) Report those to the prescriber of those medications and/or consult your pharmacist. You may also consult Elder Drugs if you have concerns relating to your eye drops.
High Blood Pressure and Stroke Risk
Jan 31st
Irene had a blood pressure with the upper number over 190. This type of blood pressure, isolated systolic hypertension, is the strongest predictor of stroke. We helped verify she had a problem and then worked to get a blood pressure medication started.
Stroke is a leading cause of death among all American’s and the most disabling event for an older adult. Of those that have a stroke, 10% make a full recovery with rehabilitation, 40% have some mild to moderate loss of function, another 40% have significant functional loss and the remaining 10% are likely to need long term care in a nursing home. But if you modify certain risk factors for stroke then perhaps you can significantly reduce your risk of having a stroke. Important to understand is that high blood pressure is the single most significant risk factor for stroke in older adults.
About 2/3 of first strokes are attributable to hypertension so treating hypertension significantly reduces your risk of a stroke. But many older adults may be traveling with the assumption that the lower number, called diastolic blood pressure, is the most important. However, when we age that number usually stabilizes and then the higher number, the systolic blood pressure, tends to rise. The elevation of systolic blood pressure in the absence of high diastolic blood pressure is called “isolated systolic hypertension”. OK, I know that’s a lot, but if you can appreciate that the upper number is just as important as we age, if not more important, then you can monitor your blood pressure and manage your risk. Risk factors for hypertension are: smoking, high salt intake, lack of exercise, high body weight, diabetes, high cholesterol and aging itself.
Below is a table that classifies blood pressure in terms of severity by stage. The higher the numbers the greater the risk.
| Class | Systolic # (upper) |
Diastolic # (lower) |
|
| Normal | <120 | And | <80 |
| Prehypertension | 120-139 | Or | 80-89 |
| Stage I Hypertension | 140-159 | Or | 90-99 |
| Stage II Hypertension | > or = 160 | Or | > = 100 |
Appreciate the following: In a wellness group I helped design, I found it revealing that in about 12% of participants, they had previously undetected and untreated isolated systolic hypertension.
Reducing Your Risk
What is encouraging is that you can greatly reduce your risk of a disabling stroke by first finding out your blood pressure and then treating it with medication to lower that upper number. When the upper number is high, medication is usually needed. There are many medications that can be used to treat high blood pressure and the use of these medications should be individualized. Not everybody should use the same medication but selection should be driven by several factors such as co-morbid conditions, like diabetes, which may warrant an antihypertensive agent that also protects the kidneys. Or perhaps you are allergic to thiazide diuretics and use a different medication. Regardless, if you know your blood pressure is high, work with your physician to get it down!
Drugs to be Cautious of
Some medications in older adults are associated with significant side-effects that can affect function or increase risk in other areas, such as causing sedation and low blood pressure thereby increasing fall risk. Drug selection is important as we age since we don’t want to add another complicating factor into our lives. Drugs used for hypertension can generally be well tolerated in older adults but some drugs, such as clonidine and some beta blockers, like atenolol and metoprolol, can cause drowsiness, fatigue and dry mouth which affects function and quality of life. Alpha blockers, drugs like doxazosin and terazosin are notorious for causing dizziness upon standing and may be a significant risk factor for falling in older adults. We generally recommend staying away from this class of drugs, if at all possible.
One drug that is a useful first-line agent in treating hypertension is hydrochlorothiazide (HCTZ). But the dose of HCTZ in most older adults should be no more than 25mg daily and most will respond to a dose of 12.5mg daily. The concern with higher doses is that dehydration can occur or, the loss of potassium which has other implications. HCTZ at higher doses can also have lingering effects on bladder function since diuresis can continue into the nighttime hours thereby making managing incontinence a challenge.
There are other ways to modify risk such as aerobic exercise, moderate weight loss, quitting smoking, and coping with stress. These approaches can work but many people do not find it easy to incorporate change into their daily routines, nor do people see the benefit in changing if they are over 70 years old thinking it’s too late. However, there are many older adults that do make changes in their lives, well into their 80′s, that benefit from those changes. By learning more about how you can improve your likelihood of successful aging through small changes in lifestyle, you are then more likely to make a beneficial change.
BEWARE! Drugs That May Cause Harm
Jan 31st
Not all medications that are commonly used are ideal for older adults. In fact, there is a list of medications that may actually pose as hazardous for use in older adults. This list, called the Beer’s List, has several medications that can send older adults to the hospital or cause cognitive or functional impairment. This article reviews a few of those drugs while adding a few more we know to be of concern when used in older adults. If you would like any references that support our findings, please write us and we can forward those to you.
NITROFURANTOIN
This drug is commonly used to either treat or prevent urinary tract infections. The problem with this drug is three-fold: 1) In many older adults it does not get into the bladder due to reduced kidney function, which is common in aging, so it may be ineffective, 2) use can cause peripheral neuropathy, or damage to the nerves, and 3) it can lead to hypersensitivity reactions of the lungs, called pulmonary fibrosis.
To determine if this drug is appropriate for an older adult, a consulting pharmacisst can estimate your kidney function. If it is below a threshold then your physician may need to be made aware that alternative approaches may be best. Although this medication can work for some individuals it’s use should be monitored closely.
DIGOXIN
This medication can be very useful in those with abnormal heart rhythms, especially atrial fibrillation, although newer therapies now are preferred as first-line choices. Due to reduced kidney function in older adults, this drug can accumulate and lead to toxicity which can be fatal. We don’t intend to scare you because your physician should be monitoring for potential toxicity and monitoring its use greatly reduces the risk of this adverse effect, but one should always be aware of the potential risks of its use. A factor that contributes to toxicity is low serum potassium, which your physician should also monitor while on this drug. Digoxin is one of the top three drugs that causes serious adverse effects that lead to hospitalization.
AMIODARONE
This is another medication that can be quite useful in controlling atrial fibrillation but can be toxic. It can cause hypothyroidism, lead to vision loss and perhaps pulmonary fibrosis. There have been several case reports of amiodarone-induced confusion. We advise you are aware of the potential adverse effects of this drug and work with your physician to ensure you have a monitoring plan. Amiodarone can also interact with warfarin (Coumadin) and enhance the effects of warfarin. Your physician should also have a monitoring plan to guard against any adverse effect from combination therapy.
METFORMIN
Although quite safe in a large number of older adults, this drug can accumulate in those with reduced kidney function. The rate at which this leads to serious adverse effects is quite low, but when it does it can be very serious. As mentioned above, your kidney function can be estimated and, along with your total daily dose and age, we can give guidance as to whether you are at high risk for adverse effects from this drug. What can happen, although rare, is a condition can develop called lactic acidosis, which can be fatal.
PROPOXYPHENE
This narcotic analgesic has no better effect than acetaminophen (Tylenol) at maximum dose yet comes with all the narcotic-related side-effects, such as sedation, impaired cognition, constipation which can worsen urinary incontinence, among others. If you are finding this drug relieves pain and you are functioning well, then perhaps this is not an issue. However, if you still experience pain or think the drug may be causing side-effects, you may want to learn more about how to effectively and safely manage your pain. NOTE: Propoxyphene was withdrawn from the U.S. market in 2010 by the FDA and is no longer available.
DIPHENHYDRAMINE (BENADRYL, TYLENOL PM)
This drug is widely used in older adults primarily because it’s available without a prescription. It comes in many over-the-counter (OTC) formulations so one must read labels carefully and not go by the marketing of the product that may imply the drug is safe. This drug can cause cognitive impairment and lead to falls. It is known to affect function and increase the length of hospital stays. Clearly, it is not a drug older adults should rely on. If you have problems sleeping we suggest you learn more about how to sleep better and not rely upon this medication since it’s effects are short lived yet it’s toxicity lingers. This drug is commonly used in OTC sleep aids.
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS- Commonly used drugs for joint pain, headache and body aches that are even available without a prescription include Motrin (ibuprofen), Aleve (naproxen) and aspirin among others. These drugs are not necessarily safe just because you can buy them Over-The-Counter. In fact, indiscriminate use of NSAIDS is a leading cause of hospitalization and death from gastrointestinal bleeding and one of the top adverse drug events (ADE’s) that we focus on preventing. It is now understood that older adults are at higher risk for a GI bleed because of certain risk factors but also because of certain medications they take on top of the NSAID’s. Drugs like warfarin and ibuprofen in combination greatly increase the risk of a GI bleed in an older adult. Now that we understand how high this risk is it is recommended to approach pain management in older adults much differently. If pain is chronic and disabling, the use of low-dose opiates is now recommended by the American Geriatrics Society in order to reduce the risk of a serious ADE from an NSAID. There are other side-effects from this class of drugs that are beyond the scope of this article. If you have a specific question feel free to use the Ask A Pharmacist feature on this web site.
CIMETIDINE
This medication, brand name Tagamet, is available over-the-counter and used for heartburn. It was originally available as a prescription for the treatment of stomach ulcers. It has the ability to cause cognitive impairment and, in certain circumstances it can cause delirium. Drugs that are more favorable but accomplish the same task are Pepcid and Zantac.
METOCLOPRAMIDE
This medication is used to promote gastrointestinal motility. It is used in people with diabetes and other conditions in which the nervous system does not function well and the stomach does not empty it’s contents soon enough thereby leading to nausea. The problem with this drug is that it can cause movement disorders just like Parkinsonism, which is manifest by tremors and slowed movement. Long term use is associated with a possibly irreversible movement disorder called tardive dyskinesia. This condition is manifest by by uncontrollable movements of the face and limbs which can impair one’s ability to function. If this medication is absolutely needed it should be used at the lowest dose possible and the user should be screened for tardive dyskinesia at least annually.
DETROL & DITROPAN (BLADDER HEALTH DRUGS)
Urinary incontinence is a prevalent condition in many American’s but what many people don’t know is that non-drug methods can be very effective at managing the condition. That would be good to now since these medications are shown to cause older adults to function more slowly and impair cognition. One study showed that participants taking one of these drugs functioned as if they were 78 or 79 years old and not as if they were 75 years old as in the control group. The management of incontinence should include comprehensive evaluation first, then only medications when non-drug methods have not achieved the goal.
AMITRIPTYLINE & IMIPRAMINE (TCA’S)
These older antidepressants are still used for neuropathic pain but can cause significant anticholinergic side-effects, such as dry mouth, constipation , dizziness, sedation and memory impairment. Newer antidepressants are by far preferred as first line agents in the treatment of depression in older adults.
DIAZEPAM & FLUAZEPAM (BENZODIAZEPINE’S)
These drugs are so well documented to cause falls and fractures that Medicare refuses to pay for them under Part D! Now that’s strong evidence to re-think taking a drug such as diazepam, lorazepan or alprazolam, and others that are related. They are also responsible for causing confusion and delirium. If one of these drugs is needed it should be used at the lowest dose for the shortest period of time.
Medication Adherence: Simple Solutions to Improve Your Life
Jan 31st
Edi was not taking her Aricept and we were asked to help find a solution. We worked one-on-one with Edi to find a weekly exchange system that she would accept and she is now taking her Aricept and doing much better.
Not adhering to a well-designed drug regimen can cost you your health and independence. It is proven that people with congestive heart failure experience more hospital admissions when they don’t adhere to there medication regimen. People with Parkinson’s disease also experience declining function when not adhering to their medication regimen. Not adhering to medications when you have high blood pressure will increase your risk of stroke and not adhering to your antidepressant medication will increase your risk of decline. All of the above examples are evidence-based and improving adherence will greatly increase your chances of staying at home and remaining independent. But what can you do to adhere to your medication regimen especially when your regimen is complex?
Develop a routine- Simply by developing a routine that has triggers to remind you to take your medication can be a big help. Taking your once daily medications with breakfast is a good start. Unless, of course, you need to take a medication on an empty stomach first thing in the morning. Then perhaps it’s best to start your routine with that medication in your med-box in plain view as you head for the coffee pot. Another trick is to place certain medications in key spots that you frequent at certain times of the day. For example, say I take my asthma inhaler first thing in the morning because it’s right where I have my shoes to put on before going out to get the paper. What I can do to remember to take it twice a day is to leave it there where all my change and wallet get dropped on my in from work. Simple! Lastly, buying an alarm wrist-watch is a simple way to have triggers in place throughout the day. After all, some people have to take medications up to 6 times a day!
Med-Box- A simple medication box can help by providing structure and the visual triggers to take your medications at certain times of day. However, it may not be that simple since we can be quite active and if that box is out of sight, it’s out of mind. It is not uncommon to have lower adherence when taking medications more than once a day. We also don’t want our medications to run our lives! We want then to help us and not tie up our time. After all, if I’m retired I don’t want a part-time job managing my medications! So what else can I do?
Technology- Argggh! The dreaded “T” word- Technology! Don’t sweat it because technology can be transparent, out of your way, and quite useful. It’s worth a try. There are several ways that technology can assist you in adhering to your medications yet not become invasive of your life. You can subscribe to several Internet reminder services that can send text messages to your cell phone, call you with an automated voice response that reminds you to take your medication, or go as far as to deliver your medications in an automated pill box. The choices are numerous and can be confusing. But we can help sort all that out.
Links: Here are some links related to each category of assistance.
Reminders:
1) http://www.lifelinesys.com/content/medication-dispensing-service/index.jsp
2) http://www.medication-reminders.com/
3) https://www.pillphone.com/PillLogin.htm
4) http://www.lifelinesys.com/content/lifeline-products/carepartner-reminders.jsp
Automated Boxes:
1) http://www.lifelinesys.com/content/medication-dispensing-service/index.jsp
2) http://www.medreadyinc.com/
3) http://www.autopills.com/
Other options: Keep in mind, complex regimens can be simplified and one best way to do that is to work with a pharmacist to eliminate unnecessary medications and supplements, consolidate doses into long-acting forms, and change some times of the day you take medications. We have had good experience with eliminating several medications for each client while still attaining their goals and maintaining their health. It takes an expert to provide this service and we caution you to not go it alone.
Bladder Control Without Drugs
Jan 30th
Many older adults live with the ageism that loss of bladder control is a normal part of aging thereby living more restrictive lives and becoming socially isolated.This leads to a higher risk of depression and falling. With evidence-based knowledge, and some action on your part, you can improve the quality of your life and perhaps manage this condition without medications.
FIRST THINGS FIRST
I’ll be bold and say that most practitioners don’t do a thorough examination and thoughtful interview when someone complains of incontinence. It’s usually a brief conversation and then the prescription is written for Detrol, Ditropan or Flomax. However, if there’s one thing I’ve learned in order to get this right it’s to have a thorough pelvic examination by someone who is experienced in bladder health along with a thoughtful interview. Anatomical changes seen with aging, especially in women, can cause incontinence and knowing specifically what changes have occurred then leads to accurate decisions for effective management. Is it exercises, or is it a topical estrogen cream or a pessary? If the diagnosis is correct, then the least invasive and most effective therapy can be prescribed.
TYPES OF INCONTINENCE
There are several types of incontinence but it should be understood that people can frequently have more than one. The approach to managing each type can differ so it’s important to understand the differences.
STRESS INCONTINENCE
This form is most common in women and is associated with the post-menopausal decline in the body’s estrogen which leads to atrophy of supportive tissue around the urethra. It usually results in a small amount of urine leakage when coughing, laughing, exercising, sneezing or lifting heavy objects. Stress incontinence should first be managed with exercises that help control the muscles that surround the urethra. These exercises are called Kegel exercises. If you can change your daily routine and add these simple and short exercises into your routine you can take control of urine leakage caused by stress incontinence. In some instances the use of topical estrogen creams helps enhance the integrity of the tissue that surrounds the urethra thereby giving more support so urine doesn’t leak out. This low-dose estrogen can also be delivered by having a bladder health specialist or your physician insert an estrogen-ring that stays in for 3 months. Every 3 months it is replaced thereby delivering the medication constantly over three months and eliminating the need to administer medication routinely. Medication should always be combined with bladder health exercises since medication alone is not as beneficial.
URGE INCONTINENCE
This form can be described by a sudden urge to go to the bathroom. If you do not make it in time then a larger loss of urine usually occurs. Urge incontinence is more common in co-morbid conditions like diabetes, Parkinson’s disease, MS, Alzheimer’s disease and others. In addition to pelvic floor exercises, timed or prompted-voiding is known to greatly reduce the number of incontinence episodes in those with urge incontinence. The idea is to develop the bladder muscles by trying to hold in urine longer each time you have the urge. The urge can frequently dissipate and each time you hold urine in longer you extend the time between episodes. Literature states that you can reduce the number of episodes by up to 50%. Medications added to that, like Detrol, Ditropan, and others only enhance the reduction to 60 or 70%. Our recommendation is to ALWAYS try to manage this condition without medication first because these medications are known to cause memory health problems in older adults and are expensive. If a bladder health medication is needed we suggest you consider those that have the lowest likelihood of causing side-effects such as Oxytrol patch which is placed on the skin twice a week. Go to www.rxlist.com to learn more about Oxytrol.
Other factors that contribute to urge incontinence which you can alter are caffeine intake, nicotine, alcohol, and managing constipation. Don’t always assume there is one approach to managing incontinence. Success is usually based on several factors. Seeing a bladder health specialist can help tremendously. You can also get very useful information at the National Institutes of Aging web site. This Age Page publication is an unbiased brochure on how to manage incontinence and gives specifics on the exercises and other approaches mentioned above.
OVERFLOW INCONTINENCE
This form of incontinence is more common in men with prostate enlargement. Treatment can involve medications that are usually well tolerated such as Flomax, which relaxes the urethra so urine can flow more easily. If the prostate is enlarged then other medications such as finasteride can shrink the prostate over several months. This medication is most useful in managing the condition when combined with a drug like Flomax. Another contributing factor to this form of incontinence is constipation. Managing constipation will help with improving urine flow. Again, it’s a multi-factorial approach that usually works best.
FUNCTIONAL INCONTINENCE
This form of incontinence is associated with the inability to get to the bathroom in time due to slow mobility or severe disability. Consulting a bladder health specialist will help with useful coping mechanisms to assist with reducing the number of episodes.
ABSORBENT PRODUCTS
These come in all sizes and are usually packaged by the amount of absorbent product in each pad which correlates with the amount of urine loss that usually occurs. Stress incontinence usually requires a small pad or panty liner whereas urge incontinence usually requires a brief or “pull-up”. These products are useful in preventing unexpected loss of urine but we encourage people to seek out the cause of incontinence and manage it as suggested above so these products are kept to a minimum. Over-reliance upon these products can lead to skin breakdown, rash and fungal infections.
We hope this information at least directs you to more options to successfully manage your bladder health. Please keep in mind that if you can incorporate some small changes in daily routine you can better manage this condition and do so without medications.
