Taking BP Medications at Night More Efficacious Than in the Morning

The European Heart Journal published the Hygia Chronotherapy Trial which followed hypertensive patients in Spain for a decade between 2008 and 2018. There were 19,000 participants of whom 10,600 were men, all older than 18 and all being treated for high blood pressure.  The group was randomly selected to either take their blood pressure medications at bedtime or in the morning.  They were followed with frequent blood pressure checkups plus 48-hour ambulatory blood pressure monitoring to assess their sleep time blood pressures.

The study was performed only on Caucasian participants who went to sleep on what would be considered a normal day/night schedule.  The results were significant and important.

Those who took their blood pressure medications at bedtime saw the risk of dying from a heart or blood vessel related problem drop by two-thirds compared to those who took their meds in the morning.  Night time administration of blood pressure medications resulted in a 44% drop in heart attack risk, a 40% drop in the need for coronary artery revascularization, a 42% drop in the risk for heart failure and a 49% drop in stroke risk.  The overall reduction in risk for cardiovascular death was 45%.

This is a significant study which must now be performed in patients of color who tend to have higher night time blood pressures.  While these studies are in progress, it appears that taking your blood pressure medication before bed is the correct choice.

Healthy Aging – Adjustments for Living & Reality

For several years now my wife has been complaining that I do not hear her when she talks.  I have gone for regular ENT checkups with audiology testing and while there is clearly a drop in hearing certain frequencies, my word discrimination and comprehension put me in a position of delaying using hearing aids for another year.

I was aware I had trouble hearing my middle adult daughter’s voice frequency.  I was missing words on TV especially when foreign accents were present leading to the purchase of TV Ears which solved the problem.  Still I knew that without auditory stimulation your brain deteriorates at a faster rate.

Last year the ENT doctor sent me home with a pair of hearing aids to try.  “Your wife called and said that if you don’t try them she may find me and kill me in my sleep.”  I was so angry with my wife for interfering that I made a point of pretending not to hear her every time she addressed me and I had the hearing aides in.  Those hearing aids were returned within the 30-day trial period because I could not use my stethoscope with them in.

One year later I was back again and this time my hearing test showed some drop in my word discrimination. They suggested trying a blue tooth compatible pair of hearing aids and even took out a stethoscope to show me how my hearing was enhanced using the stethoscope thus eliminating my favorite argument.   I wore them home and frankly they are wonderful.

The next day I had an appointment for my six-month eye exam. My acuity was off and I suspected my visual field in one eye had diminished based on driving and athletic pursuits.  The test confirmed my suspicions with my ophthalmologist diagnosing “normal pressure glaucoma” in my right eye.  “We need to lower the pressure by 3% with the drops I am prescribing and if the pressure doesn’t decrease we will recommend a laser surgery procedure in three weeks.  You are not going blind, but we want to preserve your visual field.”

The look on my face advertised my disappointment.  “It’s not so bad, you have sent me hundreds of patients with this situation and we helped them all. Why are you so troubled over this?  Looking at your med sheet and problem list at least you aren’t complaining about ED.”    When I didn’t answer her there was a long pause and she said, “Oh, I am sorry if I brought up a difficult topic.”   The best I could mutter was that in geometry what was once an acute angle is now an obtuse one.”

I tried to sell the fact that my dermatologist had me on a short-term course of prednisone which was raising the ocular pressure, but she wasn’t buying that argument.  New glasses, nightly eye drops and hearing aides all in a 72-hour period.

Instead of being grateful and thankful that I had minor correctable issues, and I could afford to spend the $6000 plus dollars for hearing aides and new trifocal lenses, I was moaning and groaning about the trials and tribulations of healthy aging. It was like running into the ocean surf on a hot day preparing to dive in to the surf and cool off and an unexpected wave smacks you down and stuns you before you can dive below its crest and avoid the strong impact.  I was devastated.

It took about 72 hours to adjust.  At my regular Friday night dinner with friends my buddy said, “Steve you seem to be hearing much better tonight. We did not have to repeat anything. What are you doing?”   I told him I was wearing new hearing aids which he had not noticed.  I hear better through my stethoscope than I did before.  When I walk my dogs or take my daily walk I hear the birds chirping, the children playing, the sprinklers initiating their watering cycle. These are all sounds I had forgotten about.  At lectures and movies I am hearing clearer. The blue tooth connection to my cellphone makes calls easier to complete.  My new trifocals allow me to read up close far more easily and see distance much better.

As a physician and geriatrician, I stress eye exams, hearing tests and evaluations to determine our ability to stay independent and functional. I cannot explain why I was so resistant to applying the same principles to my own health.

My day-to-day life has improved markedly with the hearing enhancement and new glasses. I hope my patients and students will look at my stubbornness and reluctance to accept healthy age-related changes as an example of how hard we cling to our independence and how reluctant we are to give up pieces of it even when we know it is for the best.

Restorative Dental Surgery, the Elderly and Shared Decision Making

A wise professor of medicine always told me as a young physician, “Eighty-year olds are to be revered and not messed with.”   This is especially true for those 90 or older.  Here in South Florida there is always some senior citizen telling us today’s 80 is yesterday’s 60 and today’s 70 is yesterday’s 50.  It just isn’t so.  I see this erroneous belief of the elderly having the healing power of younger individuals   highlighted in the area of cosmetic and restorative surgery and dentistry in my affluent youth-seeking community.

We all want to look our best. In many cases this requires pulling teeth, placing implants and covering those implanted posts with crowns to produce that young smile and maintain a chewing surface. Most times it’s better to do less.

Pulling rotten teeth, obtaining dentures or using a bridge and practicing meticulous hygiene on the gums may be the better course.  Don’t tell this to 91 year old Hal who is mildly cognitively impaired, and his loving caring daughter who sent him for extensive dental surgery.   This gentleman had an artificial aortic valve placed by the less invasive TAVR method a few years back. He was required to take antibiotics before the procedure to prevent a heart valve infection as per the guidelines of the American Heart Association, American College of Infectious Disease and American Dental Society.

His former physician taught infectious diseases in a major academic center and felt he needed a longer course of antibiotics than the guidelines recommended.  Several weeks later he had intractable back pain and severe diarrhea. He was diagnosed with antibiotic related colitis and treated appropriately with oral vancomycin. The back pain was more problematic.  His daughter self-referred him to a physical therapist who could not find a way to obtain relief.

He came to me as a new patient with severe back pain and, after hospitalizing him for pain relief and with the assistance of an infectious disease expert, we were able to document an infection of the heart valve and an infection of the back disc space causing the excruciating pain. The infection originated with the disturbance of his gums and teeth during the dental work. He received 10 weeks of intravenous antibiotics and four months of physical therapy at a skilled nursing facility before he was able to return to his home with help.

At that point he and his family were advised to limit the dental work, follow antibiotic guidelines for the work being done and clear the work and antibiotic regimen with his internist and local infectious disease physician prior to undergoing non-life-threatening non-emergency procedures. It was no surprise however when I received a phone call from his aide saying he had diarrhea after a dental procedure and the daughter chose to use the prolonged antibiotic protocol that the former doctor had recommended years ago.  One of the aides had given the patient immodium several days prior to the call to me to slow down the diarrhea so now the body’s natural clearing response to a pathogen had been delayed by a medication choice.

He was examined and found to have a mildly tender abdomen. A digital rectal exam identified microscopic blood in his loose stools.   A stool evaluation identified clostridia difficile as the causative agent of his antibiotic related colitis. He is now back on medications for this entity and hopefully it will control the disease while we keep him hydrated and out of the hospital again.  More is not always better. The frail elderly need to be revered and not messed with. Palliative rather than aggressive therapy may be best in this patient population.

Mrs. Sommerville is another example. A beautiful mid-eighties woman, she looked years younger. She signed up for pulling all her teeth on her lower jaw and recreating her smile with implants. She was given an opioid medication for pain control. Post-surgery she ran a fever for several days.  After taking the opioid for pain relief she fell and hit her head. She was referred to a hospital ER where she was noted to have a subdural hematoma from the fall (blood on the brain) and positive blood cultures from the oral bacteria which seeded the bloodstream during her dental procedure.  I suggested transferring her to a facility that had the neurosurgical capabilities to treat the complications of a subdural hematoma. The patient did not want to be transferred and, in the era of shared decision making, the consulting neurologist was comfortable obtaining serial MRI scans to observe the brain bleed and follow its course.  The MRI’s didn’t get done on a timely fashion because the patient had just had hair extensions placed by her hair stylist and the metal clips were not permitted in the magnetic range of the MRI machine. The patient refused to allow anyone but her hair stylist to remove the extensions and his schedule didn’t permit his visit to the hospital for 48 hours.

Both situations exemplify the zest for life and vitality human beings exhibit. In both cases, less would have been preferential.

I suggest that as we get older before considering cosmetic procedures, we discuss it with our medical doctors and review the pros and cons and alternatives. I am not accusing the dentists of being too aggressive but maybe too accommodating with no real geriatric training to help them in their clinical decision making.

Hypertension Guidelines Versus Life Experiences

One of the advantages of practicing clinical medicine, and seeing patients daily for many years, is you develop your own long-term study regarding certain medical health issues. In the area of hypertension, I have been taught by the best since my internship with pioneers such as Eliseo Perez Stable and Barry Materson at the University of Miami affiliated hospitals, Jackson Memorial Program, ensuring that their trainees were up to the task.

The goals and guidelines have changed. Lifestyle changes including salt restriction (sodium chloride), weight reduction, smoking cessation, reducing alcohol intake and regular exercise will always be mainstays of non-pharmacologic treatments.  We used to be taught to keep the systolic blood pressure at less than 140 and the diastolic blood pressure at less than 85.  These numbers have changed over the years, having been lowered, with everyone over 120 systolic now being classified as having some degree of increased risk of cardiac, cerebrovascular or vascular disease and hypertension.

We originally were taught to start with a diuretic and keep raising the dosage until the blood pressure was controlled or the patient developed adverse effects. We learned that when we used one medication, pushing it to its limit inducing adverse effects along the way, patients just stopped taking their medications. This resulted in a change in strategy to using several medicines each with another pathway to controlling blood pressure but all at a lower dosage which did not produce any ill feeling adverse effects.  The downside of more medications was additional costs and more pills to remember to take.  As hypertension experts pushed us to lower systolic blood pressure to 120 or less in our geriatric population I was concerned that lowering the pressure that much would again create adverse effects which were as or more troublesome than the risk  of having a BP between 120 and 140 systolic.  An article in JAMA Internal Medicine looked at this issue. They looked at patients over 65 years of age who were hospitalized for non-cardiac related problems and whose blood pressure was over 120. They studied these patients at Veterans Administration hospitals over two year period. Patients with elevated blood pressure above 120 were given more medications and higher dosages to bring their pressure down to meet the more stringent guidelines. The result was that there were no fewer cardiac events than anticipated and no better blood pressure control at a year.  In addition, these patients suffered from an increased number of re-admissions to the hospital and “serious“ adverse events within 30 days.

The new guidelines for blood pressure control may be applicable in a younger healthier population.  In the geriatric population we may need to readjust our goals to account for the physiologic changes that occur in men and women who age in a healthy manner. More specific data on why there were more re-admissions and what serious adverse effects occurred needs to be made public to determine if the effort to tightly control blood pressure is to blame.

The Trouble with Using the Local Hospital

I have been fortunate in that I have not had to hospitalize any patients the past four weeks.  This means I have an extra 60 minutes or more to prepare for the workday in my office. The streak ended this weekend when my associate, taking his rotation of being on call, hospitalized one of my patients with pneumonia.

In many cases pneumonia is treated as an outpatient. You receive an antibiotic and cough medicine and stay at home, rest, hydrate and recuperate.  In this case, the patient has had multiple lung surgeries to save her life from cancer and she is left with much less pulmonary reserve than most.  She was coughing with a productive cough for several days as she moved from one home to her future residence while her husband, who usually watches after her, was away. By Sunday morning it hurt to breathe and she was exhausted. She called and spoke to my associate who suggested she meet him in the hospital emergency room.

Being an anxious and nervous individual, she called her cardiologist next, repeated the story and he wholeheartedly concurred with the decision.  In the ER her x-ray showed multiple areas of pneumonia and her elevated white blood cell count and temperature (which she was not aware of) confirmed the problem.  Blood and sputum cultures were obtained; antibiotics guided by an infectious disease specialist were begun.  Surprisingly and fortunately she was not wheezing, her lungs sounded better than on many visits and she did not feel particularly ill compared to past encounters of this nature

She was moved to a private isolation room where hospital routines and protocols took over and created nothing but anxiety and concern.  She had been on a low dose of corticosteroids as an outpatient and because her body was stressed she needed a higher stress dosage short term.  It was ordered on the computer system to be given all at once after a meal, but the pharmacy protocol called for multiple dosages and this conflict resulted in her getting half the dosage ordered.

When the patient noticed the difference in administration, she complained to her nurse.  However, no one had been notified.  The infectious disease specialist ordered an extra dosage of intravenous antibiotics for the evening of her arrival. The pharmacist noted that a dosage of this long acting medication had been administered earlier in the day and cancelled the order for the evening dosage without anyone calling the ID doctor or me as the attending physician. The patient objected but was overruled by nursing.

The patient was receiving a respiratory treatment with a medication that speeds up her heart rate greatly.  She normally takes a drug to prevent rapid heartbeats called a beta blocker. This was ordered for her but not given because the patient’s blood pressure was considered “too low.”  The problem is that the patient is a small thin woman and her blood pressure is always this low. She has taken this medication for years at this dosage with no ill effects.

When the covering physician placed the order for these medications the parameters for withholding the drug due to slow pulse or low blood pressure were not presented for his consideration. Once again, a medication was held, the patient was aware of it and no one called her attending physician or cardiologist to discuss it. This made the patient even more anxious and upset.

Since early spring 2019 the physicians’ parking lot has been closed while the facility builds a new parking lot. They have the doctors parking in a much more distant location about 2500 steps away from the main entrance.  It takes an extra 10 minutes to reach the entrance in and 10 minutes leaving now to get to your car and then leave. On a hot humid South Florida summer-like day you need to shower by the time you reach the air-conditioned main entrance.

Upon entering the building with our new corporate ID cards it takes another five minutes or longer to reach the patient floor if the elevator is free. From there you walk to the nursing station and try and find an open and functioning computer terminal.  In past years, when I entered the nursing and administrative section of the patient floors, the nurses and aides would say good morning and greet me by name. The patient’s paper chart was handed to me and a nurse would accompany me to the bedside to discuss the day’s plan, review the patient’s progress and reconcile the medications.

In today’s hospital no one looks up from their screen, rarely does someone say hello and I would not be surprised if I showed up in a Halloween Costume of Freddy Kruger if anyone would even notice.

Every item of information is now on the computer. Once you obtain an open workstation it takes several minutes to log in using multiple security rituals to finally find the patient’s chart.   If by chance your patient ran a fever and you have to complete the “sepsis protocol”, or if you decided not to start the  patient on a drug to prevent blood clots from developing, you can add another five minutes just to  remove these from your screen and actually get to your patient’ data.

After completing this I walk to the patient’s room to find my teary-eyed patient complaining about being awakened for blood drawing and how rough and inconsiderate the phlebotomist was. She is upset about the missed medications and alterations of her home medication schedule and her fears about how this would affect her and the plan to get her home.   The examination takes a few minutes and confirms that she is improving and moving towards going home soon.   I explain to the patient what I think should occur and get her input and approval and then search for her nurse to review it verbally. Its then back to the workstation to find a free computer so I may enter the orders I just reviewed with nursing.  A bedside computer station with a nurse present would cut 10 -15 minutes off the process but they are not available yet.  My iPad has access to the system at the bedside but the smaller screen makes entering orders difficult and offsets the convenience of a bedside computer.

As I enter my patient’s room, I see her face covered in tears.  She brightens up with a smile as I walk in and then begins to tell me about everything troubling her. Initially, most of my time is just spent listening and observing.  I listen intently to her concerns and fears and assure her she is moving towards a morning discharge.  I then phone her husband with a progress report.

It’s five flights of stairs down to the main floor. I notice that a helium balloon bouncing against the ceiling above my reach is still present for the third day.  When I leave the building after using my identification card once more to open the exit door, I trudge 2500 feet through the outdoor construction area back to the car to begin the now 20-minute ride to the office to see my morning patients.

I now understand why many of my colleagues only see patients in their offices. The sheer bureaucratic, protocol-driven nature of the hospital process makes caring for a patient infinitely more dangerous, more time consuming and more inefficient.   I cannot wait for this patient to be well enough to be discharged before another hospital protocol disrupts her recovery and makes her ill.

The inconvenience of coming to the hospital is exhausting.  Although, the look on a sick patient’s face when a familiar caregiver arrives to take charge and help them through the rough spots is still worth the trouble.

Influenza Vaccination in Adults

It is time once again to be thinking about taking your flu shot.   A recently published study by the National Foundation for Infectious Diseases (NFID) estimated that only 52% of US adults plan to take the flu shot.  Reasons for not being vaccinated include:

  • I do not believe it works (51%)
  • Concern it would cause an adverse effect (34%)
  • Concern that the vaccine would give them the flu (22%)

Health and Human Services Secretary Alex M. Azar II said, “Each season, flu vaccination prevents several million illnesses, tens of thousands of hospitalizations and thousands of deaths.  Over recent years, on average, flu vaccination has reduced the average adult’s chance of going to the doctor by between 30 – 60%.

A recent study performed by the northern California Kaiser Permanente Group, using seven years of flu season data, shows the immunity from the shot is near perfect for the first six weeks and then begins to wane. They estimate your post-vaccination chance of getting the flu, even if immunized, increases by 16% every 28 days after the shot but is near perfect for the first 42 days.

It is believed the Center for Disease Control (CDC) will recommend in future years that adults receive two flu shots each season. One will be administered at the beginning of the season and one six weeks later.  For the moment, the CDC acknowledges the flu season begins at different times in different regions of the country and suggests you receive your vaccination about two weeks before it arrives.

In South Florida, we typically see the arrival of the Influenza A virus after Thanksgiving. It peaks the last two weeks in January and first two weeks in February. For this reason, we suggest taking the shot later in the fall.

Vaccines are inactivated meaning they are not live and cannot give anyone the flu!