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.

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

1) Always learn more about the condition in which the drug is being prescribed BEFORE you start taking it. In many cases there are non-drug methods to manage the condition.

2) Always ask your doctor and pharmacist about possible drug interactions as they are frequently the cause of hospital admissions due to adverse effects.

3) Ask if there is a generic drug in the class of medications the doctor is prescribing. For example, Lipitor can sometimes be changed to simvastatin to successfully lower cholesterol at a much lower cost.

4) Consider having the doctor write a prescription for twice the dose and cut the tablets in half. For example, 80mg of simvastatin can be cut in half to get a 40mg dose, at almost half the cost! Note: Some medications can NOT be cut in half because they may be sustained release and cutting them could affect absorption. Always consult your pharmacist first.

5) Always have your physician and pharmacist review your medications on an annual basis in order to determine if all of them are still needed. Circumstances may have changed that could suggest discontinuing a drug or two.

In summary, medications are the most affordable and efficient form of healthcare at only 10% of all health care costs. However, when mismanaged they can cause harm and increase your costs. Consult with an expert today if you take more than four medications as this is a risk factor for falls, memory impairment or other serious adverse drug events.

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.

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

Calcium

Over 50% of the American population is deficient in calcium, a vital nutrient needed to help maintain bone health and reduce our risk of a life-altering fracture. As we age our bones become less dense and this predisposes us to a fracture. Calcium intake, when high enough, has been shown to reduce our risk of a fracture but it must be maintained throughout the life-cycle.

If our bones become less dense to the point of developing osteoporosis, we may need a bone health drug like Fosamax, Actonel or Bonvia, in order to maintain or build back our bone density. Calcium is needed to help these drugs work properly. In fact, taking a bone health drug without sufficient calcium may even be dangerous in some people.

How much calcium do I take? The recommended amount of calcium, measured or expressed as the elemental amount of calcium, is between 1200 and 2000mg per day for an older adult. Setting a target of 1500mg is a good start. But can’t I get calcium from foods? The answer is yes but have you ever done a “calcium count” to see how much calcium you ingest each day? Each glass of milk has 300mg of calcium. Many orange juice and yogurt products are fortified with calcium. So it is possible to get enough calcium each day from your diet, which is preferred, but if you count your calcium intake each day for three days, you’ll be surprised that you may not be reaching the required amount. To find a list of foods with their calcium content, search our articles section under nutrition and look for calcium-rich foods.

So if I am not getting enough calcium in my diet, is a supplement a good idea? Yes, a supplement is just that, a supplement to add to your diet when your aren’t getting enough calcium from foods. Most supplements express the amount of calcium as elemental calcium so if you see a supplement that says Calcium 500mg, then you can take one of these to add to a diet that may contain 1000mg of calcium to reach 1500mg per day.

But what about all the different forms of calcium? Now it can get confusing! Calcium comes in many forms or salt forms. The most common is calcium carbonate, which is readily available and cheap. However, calcium carbonate is poorly absorbed and can be even more poorly absorbed if you are taking drugs like Nexium, Prilosec, Aciphex and Protonix, drugs which cut the production of acid in your stomach. Because of this these drugs were shown to increase the risk of fractures. It is thought that this happens since acid is needed to absorb calcium carbonate and these drugs eliminate the much needed acid. One alternative is to take your calcium supplement with food, always. Food aids in the absorption of calcium. However, one sure-fire way of making sure you get all the calcium absorbed is to take another form of calcium, called calcium citrate. This form is absorbed even without acid in the stomach and can be taken without food.

Vitamin D – The ‘Sunshine Vitamin’

Isn’t vitamin D needed to absorb calcium? Yes, and many older adults are also deficient in vitamin D. Vitamin D is actually a potent hormone just misnamed as a vitamin. It’s also called “the sunshine vitamin” but that is misleading since most older adults don’t make vitamin D from sun exposure and many of us use sunscreen that blocks the conversion to active vitamin D in the skin. So what I’m getting at is, yes, you need to take additional vitamin D.

Vitamin D is shown to also reduce fall risk and reduce the risk of fractures. What is also interesting is that vitamin D may improve cognition or memory in those who are deficient. The amount of vitamin D recommended for older adults is 1000 to 2000 units each day. You can take it once daily whereas calcium must be taken no more than 600mg at a time which may require more than once daily dosing. If you are an older adult you should have your vitamin D level checked by your doctor since supplementation doesn’t always get your blood level up to where it should be. That’s when the doctor may prescribe a “whopping dose” of vitamin D for a short period of time to get your blood level up into the healthy range. Then you can take supplements to help keep it there. Otherwise, most people who are not deficient can take the above recommended amount.

Vitamin B-12

Vitamin B-12 is an important vitamin for older adults. In fact, vitamin B-12 deficiency can lead to serious anemia but also irreversible nerve damage or even memory loss. And this is another vitamin that is affected by low acid levels in the stomach and was also shown to be poorly absorbed in those taking the acid suppressing drugs mentioned above. As we get older we can also lose the ability to absorb vitamin B-12 efficiently so it is recommended to take higher doses to ensure you get enough absorbed. You can take up to 1000 micrograms each day and it would be safe. Vitamin B-12 tablets are available over the counter and are inexpensive.

Multiple Vitamin

Another supplement that is recommended  is a multiple vitamin. We can’t possibly get all the vitamins we need from food and other “B-vitamins”, such as vitamin B-6, are needed to prevent anemia from developing that are more common in old age. Taking a multiple vitamin can’t hurt and can only help. However, if you eat 3-5 servings of vegetables each day, perhaps you can do without a multiple vitamin.

There you have it, your “pot pourri” of supplements and here’s the list to summarize.

1) Calcium 12000-2000mg each day

2) Vitamin D 1000- 2000 units each day

3) Vitamin B-12 up to 1000mcg each day

4) Multiple vitamin  One each day

A fall is a sign that something else is going on and it may be more than stumbling on the throw rug. For this reason alone, if you have fallen within the last year you need to take it seriously as it is a strong indicator that you may fall again. Up to 50% of falls result in injury and about 10% require hospitalization, of which hip fractures are not uncommon. Of those that fracture a hip, 23% die within the first year and 50% go on to suffer from chronic pain, disability and fear of falling. Fear of falling can lead to a loss of physical condition which is needed to prevent future falls. Fear of falling is also associated with anxiety and a higher risk of depression.

HOW CAN I TELL IF I’M AT RISK OF FALLING?

The most significant risk factors that are associated with falling are:

• Lower extremity weakness
• Gait disturbance
• Balance disturbance
• History of recent falls
• Recent hospitalization
• Poor vision
• Using more than 4 medications
• Cognitive impairment or dementia
• Use of an assistive device

The good news is that you can alter your risk of falling. For example, if you have developed lower extremity weakness or balance problems, you can take action with specific exercises to improve leg strength and balance.

SO IF I EXERCISE I’LL BE ALRIGHT?

It’s good that you are motivated to exercise since exercise is well proven to aid in maintaining independence as we age, not just for preventing falls but also helping in maintaining cardiovascular fitness and reducing risk of memory loss. It’s never too late to start exercising! But if you have trouble staying with an exercise regiment we recommend joining a senior exercise group at a local senior center or health club, since that commitment always makes a difference and you’ll more than likely benefit from the socialization. But keep in mind, as we age there can be several reasons for falling so it is wise to address them all. For example, you can experience lower extremity weakness, poor balance, poor eye sight and take medications that can contribute to a fall. So it is wise to learn about the multiple risk factors for falling and work with someone who can help you address those areas of risk. Exercise alone can’t alter all the areas of fall risk.

Other contributing factors can be malnutrition due to low protein intake which causes loss of muscle mass. It’s important to maintain adequate nutrition as we age. Malnutrition can also lead to anemia which can cause weakness and contribute to a fall. Another contributing factor is vitamin D deficiency. Many older adults lack vitamin D in the blood at a sufficient level and taking more vitamin D is shown to reduce fall and fracture risk. To learn about vitamin D check out our article on supplements older adults should take .

Other considerations are using medications that can cause dizziness, such as blood pressure meds or meds that cause drowsiness. Using more than 4 or more medications is a risk factor in itself and it is wise to have someone who knows about falls to review your medications.

BUT IF A TAKE FOSAMAX I WON’T BREAK A HIP, RIGHT?

Keep in mind that over 95% of fractures are from trauma, or falling, and that taking a drug like Fosamax, although of benefit in the long run, does not quickly impact on reducing your risk of a life-altering fracture. Our concern is that we see too many people believe that by taking a drug like this will prevent a fracture when, in fact, 100  people have to take this drug for 5 years to prevent one hip fracture! Those are not exactly great odds. So,  it’s important to understand that if you have osteoporosis, a drug like Fosamax is appropriate but it should not be relied upon and the best way to quickly reduce your risk of a fracture is to reduce your risk of falling. Other drugs that work like Fosamax are Actonel and Boniva, which are oral forms, and there is the once yearly injectable drug Reclast.  For more on these medications check our article titled Bone Health Drugs: More Harm Than Good?

Other data show that your risk of an adverse drug event is 50% if you take between 5 and 8 medications but rises to 100% if you take more than 8 medications! Simply put, more is NOT merrier! There is a strong correlation of the number of medications you take with  your risk of a serious, potentially life-threatening adverse drug event. The most serious events involve insulin, Lanoxin (digoxin) and Coumadin (warfarin).

Insulin- When we use insulin and perhaps miss a meal or perhaps start a medication that can cause loss of appetite or enhance insulin’s effect, we can have a life-threatening lowering of our blood sugar. Since insulin is vital in managing our diabetes which can affect our ability to function later in life, we must learn about how to constantly juggle what we eat with our activity level and monitor our blood sugar frequently. Otherwise we can become too distant from managing our condition and be surprised with severe low blood sugar.

Lanoxin (digoxin)- As we age our kidneys slowly lose function, actually starting in our 40’s. By the time we get to 70 or 80 our doctor must watch our level of Lanoxin in body more closely since it is eliminated by the kidneys. In other words, as we age our kidneys close like the gates on a dam and the Lanoxin is the water that accumulates behind the dam until too much causes toxicity. There are also numerous medications that can alter our potassium level which can also encourage Lanoxin toxicity, which can be fatal.

Coumadin (warfarin)- This drug is a life-saver but can also kill. Coumadin prevents blood from clotting which can be essential in many older adults with cardiac rhythm disturbances. It prevents clots from forming in the lungs or the legs. However, Coumadin interacts with numerous medications and also vitamin K-rich foods. Whenever you have a new medication added your doctor and pharmacist should work together to ensure there are no significant interactions with Coumadin (warfarin). You should also develop a healthful diet that is balanced and does not very much in vitamin K-content foods each day. Drastically reducing vitamin K or increasing it can alter the effect of Coumdain.>

Falls & Delirium- I can go on for hours talking about this subject but I’ll talk about a couple more areas of adverse drug events that are frequently known to cause admission to a hospital in older adults. The two areas that are closely related to the number of medications you taker are falls and delirium (a loss of knowing oneself or like having dementia).

There is a strong correlation with excessive or inappropriate medication use in older adults and falls. There are many risk factors for falling and medications can worsen those areas of risk. For example lower leg weakness, gait and balance disturbances, poor vision, and cognition. In fact, one element of a falls screening program is to screen someone’s medication if they take more than four, yep that’s it, only four or more medications is a risk factor for falling. Again, more is NOT merrier!

Another area of concern is how medications, not necessarily just one, but a combination of medications can have additive toxic effects and cause cognitive impairment or, put another way, anti-memory effects. Sometimes when we are challenged by an acute episode such as upper respiratory infection with dehydration, these medications can take hold in a negative way and cause delirium. Delirium presents itself as if the person had dementia of the Alzheimer’s type, and rather advanced. Someone with delirium is combative, can hallucinate and not be oriented to their surroundings thereby presenting as a danger to themselves. In fact, cognitive impairment and especially delirium are risks factors for falling. So, if you take more than four medications and are concerned with your mental sharpness or have a history of falls or, if you think something is just not right, please consider having an expert look into your medications.

Stay well and stay upright