Diseases
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.
Bone Health Drugs: More harm than good?
May 6th
Bone health drugs such as Fosamax, Boniva, Actonel and Reclast are proven to reduce the risk of hip fractures, one of the most life-altering events an older adult can experience. However, these drugs may produce serious side-effects and in the last couple of years these drugs have spent more time in the press than a college student on the beach in Florida over spring break!
The first and most concerning side-effect reported is osetonecrosis of the jaw or (ONJ). This side-effect, however, was seen almost exclusively in those who were using injectable (intravenous) forms of the drugs and/or were being actively treated for cancer. Also worth noting is that most of the rare cases of ONJ, when the oral form of the drug was used, were in those with who had major dental surgery such as a tooth extraction.
These variables are a far cry from the typical user of an oral Fosamax (alendronate) or Actonel in the older adult population. Nevertheless, some people were immediately frightened and stopped taking their medication. Stopping a medication based on information read in the newspaper or found in the lay press is not a safe thing to do.
Osteonecrosis of the jaw is rare in users who take the oral form of these drugs and practicing good oral hygiene reduces the risk of developing this rare side-effect. The chances of developing ONJ are about 1 in 100,000 for each year of use. However, if you are going to have a major dental procedure performed, then you should talk with your doctor and dentist to review what are the next appropriate steps.
More recently the side-effect of atrial fibrillation from Fosamax-like drugs was in the newspaper. We received an update from the Food and Drug Administration, and all conclusions show that the risk of this heart rhythm disturbance is very, very small. In fact, the conclusion of these findings is such that we can say, in general, the benefits of the use of these drugs in older adults in preventing fractures greatly outweighs the risk of developing atrial fibrillation. Nevertheless, general statements don’t always represent all older adults. If you have a history of atrial fibrillation or are at high risk for the condition, it may be prudent to discuss the benefits and the risks with your physician. We have the references on file for you or your physician to view.
Last but not least, there has been some discussion about stopping these bone health drugs if you have been on one for at least 5 years. In the original study in which Fosamax was proven to reduce hip fractures, it was suggested that after 5 years there was no further reduction in hip fractures when compared to placebo. There can be several flaws in drawing a firm conclusion from that limited evidence. First, one study does not form a consensus opinion and more studies would be needed to support such a claim.
Second, bone density did go down in the placebo group, yet they didn’t fracture at a higher rate which can not be explained. Also, we don’t know if after a long period the behaviors changed in study participants and they actually fell less because they were working at fitness and overall fracture prevention, like they should be! Falling wasn’t measured in the Fracture Intervention Trial, or at least it wasn’t reported, but fractures were the measured outcome. Lastly, everyone is different in where they are at with their bone health. These general findings are not always relevant to one self.
For me, if I had osteoporosis, I would take a bone health drug BUT I would also work very hard at fall prevention and risk factor reduction such as minimizing caffeine intake, eating foods rich in calcium and taking vitamin D. In fact, vitamin D deficiency is common in older adults and is shown to correlate with increased falls and fractures. Talk to your doctor about having your vitamin D level checked.
In closing, fracture prevention is not just about taking a prescription medication but the medication can be extremely important in preventing that disabling hip fracture.
Diabetes and Neuroaging
May 6th
November is National Diabetes Awareness Month and marks an important time in the lives of older adults since the risk and incidence of diabetes increases with age. Diabetes is more than just high blood sugar and can result in complications such as loss of eye sight, lower extremity amputations, neuropathy and an increase in cardiovascular disease such as heart attack and stroke. Yet there is another concern regarding diabetes as we age and that is our memory health.
Scientists have documented in several recent studies that poorly managed diabetes and/or “metabolic syndrome” speeds up the process of “neuroaging”. What this means is that our brains may decline faster than if we didn’t have this condition. This puts us at increased risk of memory loss.
“Metabolic Syndrome” is a set of risk factors that includes: abdominal obesity, a decreased ability to process glucose (increased blood glucose and/or insulin resistance), dyslipidemia, and hypertension.
The proof- A recent study presented at the International Conference of Alzheimer’s by Dr. Roriz-Cruz showed that those with metabolic syndrome showed more rapid decline in cognitive function as compared to age-matched controls WITHOUT metabolic syndrome, 47% vs. 13%. Dr. Roriz-Cruz concluded his presentation by saying that “People with metabolic syndrome age faster, not only in terms of vascular aging (as is already known) but also in terms of “neuroaging”.
So what to do? Learn more about the successful management of diabetes outlined in the AADE 7- the 7 healthy habits to successfully manage diabetes, and they are: Healthy Eating, Being Active, Monitoring, Taking Medication, Problem Solving, Reducing Risks and Healthy Coping. AADE stands for American Association of Diabetes Educators.
Taking inventory of the AADE 7. Rate yourself in each area on how you have been functioning the last several weeks in order to learn where you can do a little bit more to stay healthy and function independently longer. Consider writing down HOW you perform specific tasks in each of these areas, for example: “I eat smaller portions at each meal and have cut out 250 calories each day and lost 7 lbs.”
Healthy Eating- (write down how you think you are doing)
A= I aced the test! B= I’m doing fairly well
C= OK. More work to do D= Time to re-evaluate
Being Active- (write down how you think you are doing)
A= I aced the test! B= I’m doing fairly well
C= OK. More work to do D= Time to re-evaluate
Monitoring- (write down how you think you are doing)
A= I aced the test! B= I’m doing fairly well
C= OK. More work to do D= Time to re-evaluate
Taking Medication- (write down how you think you are doing)
A= I aced the test! B= I’m doing fairly well
C= OK. More work to do D= Time to re-evaluate
Problem Solving- (write down how you think you are doing)
A= I aced the test! B= I’m doing fairly well
C= OK. More work to do D= Time to re-evaluate
Reducing Risks- (write down how you think you are doing)
A= I aced the test! B= I’m doing fairly well
C= OK. More work to do D= Time to re-evaluate
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. Another 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 better managing stress. These approaches can work but many people do not find it easy to incorporate change into their daily routine nor do people see the benefit in changing if they are over 70 years old. Well guess what? You can change and making that change will help you live a better life and perhaps not in a nursing home. Elder Drugs’ wellness program, Windmere, is designed to assist people with making those small changes that can lead to big results. You are welcome to learn more about Windmere on our wellness page or, at the least, we encourage you to seek out just a little more information on reducing your stroke risk and keep it on your mind so you are more likely to do something about it.
