ACE Inhibitors Linked to Hallucinations In The Elderly

????????????????John Doane, MD, and Barry Stults, MD, from the University of Utah Health Science Center in Salt Lake City reported in the Journal of Clinical Hypertension on four cases of visual hallucinations in elderly patients taking the drug lisinopril for blood pressure control. ACE inhibitors are a popular and relatively safe drug. They are used for blood pressure control especially in diabetics.

The patients’ adverse effect profile has been limited to a dry allergic cough, elevated potassium, rash, angioedema and renal insufficiency.   They ranged in age from 92-101 and were being treated for hypertension or heart failure. Two had mild cognitive impairment, one had Alzheimer’s disease and one had vascular dementia. The time from beginning the drugs until hallucinations appeared varied from two months to six years. In each case when the drug was stopped the hallucinations resolved. In one case the patient was re-challenged with lisinopril and the hallucinations returned.

The authors conducted a thorough literature search and found several other reports of ACE inhibitor related hallucinations. In each case the hallucinations resolved when the drug was discontinued. It is believed that ACE inhibitors raise the level of opioid peptides causing these hallucinations. While the side effect is rare, it is certainly worth knowing about as the population ages and clinicians are looking for safe drugs to treat high blood pressure and heart failure.

The Benefits of Exercise and Fitness

Woman with DumbbellsThe highly acclaimed Cooper Clinic has been following 20,000 patients’ fitness levels for the last 40 years. They recently published an article in the Annals of Internal Medicine proclaiming that fitness in the middle years of life lowers your risk of developing dementia in your senior years. The Cooper Clinic has been following these patients for evaluation of cardiovascular fitness and development of heart disease but decided to use the same data to review who, if any, developed dementia by their 70th, 75th, 80th and 85th birthdays. All participants initially were screened with exercise treadmill testing. They found that those who were the fittest were 36% less likely to be diagnosed with dementia after age 65 than the least fit.

David Geldmacher, MD, of the University of Alabama at Birmingham, told MedPage Today that the potential benefit of exercise to reduce dementia risk is worth bringing up with patients, even though recommendations for exercise are made routinely for cardiovascular health reasons. Many patients are willing to forego exercise with the belief that sudden death by a heart related illness isn’t such a bad way to expire. On the other hand the thought of living with a chronic debilitating disease like dementia is highly undesirable and exercise might be an acceptable lifestyle change to prevent that process. Knowing that fitness can reduce the Alzheimer risk may give them further motivation to follow through with an exercise and fitness plan.

In an unrelated but equally fascinating study, researchers at the Durham Veterans Affairs Medical Center in Durham, North Carolina found that Caucasian men who participated in regular exercise at a moderate level were less likely to have prostate cancer on biopsy of suspicious areas of the prostate. If the biopsy did reveal prostate cancer the grade of the cancer tended to be lower indicating a more favorable prognosis. This study of 164 Caucasian men and 143 black men did not show any fitness protection for black men who exercised regularly. The authors went on to point out the small size of the study and the fact that the level and frequency of exercise was self-reported not measured or monitored by the research team. Other factors such as heredity, diet and lifestyle issues may be factors as well. They recommended further study to determine the exact relationship between exercise and prostate health or disease.

Both these studies strongly support the concept that regular exercise of a moderate level probably has strongly favorable influences in multiple areas of health. I will continue to urge my patients to get some form of regular exercise that they enjoy on a daily basis while the researchers confirm the long term benefit of regular exercise and fitness.

Too Much Calcium May Be Harmful For Women

Front view of woman holding seedlingThe Swedish Mammography Cohort, a population based group that includes 61,433 women born between 1914 and 1948 with a median follow-up of 19 years was used to answer the question of whether calcium intake can be harmful? The research team analyzed food intake by questionnaires and estimated the total calcium intake from food and supplements in the study group. Participants were divided into groups based on total daily calcium intake. One group consumed less than 600 mg of calcium per day. A second group consumed between 6000 and 999 mg a day. Group three consumed 1,000 to 1,399 mg per day. The last group consumed more than 1400 mg a day or the equivalent of drinking five 8 ounce glasses of cow’s milk.

The study was led by Karl Michaelsson, MD, of Uppsala University in Sweden and published in the online edition of the British Medical Journal. They found that the group consuming 1400 mg or more per day of calcium had a higher risk of death from cardiovascular disease, ischemic coronary disease and all causes than expected. The high calcium intake did not however increase the risk for strokes. At the other end of the spectrum were those individuals on an extremely low calcium diet with less than 600 mg per day. They were found to have an increased risk of death as well from all the causes mentioned above plus stroke.

Once again this appears to be a call for moderation in one’s diet. Too much or too little of anything is associated with consequences. At the current time postmenopausal women are advised to consume 1600 mg of calcium a day between diet and supplements. It may be time to look at that number and see how it applies to North American women as opposed to Swedish women who participated in this project.

Today’s Seniors Are Not as Healthy as Their Parents

Baby Boomer Couple, cropped

In the online version of the Journal of the American Medical Association an analysis of data compiled by the National Health and Nutrition Examination Survey ( NHANES) suggested that today’s baby boomers are not as healthy as their parent’s generation. The baby boomers, born between 1946 and 1964, may live longer but they do so with more complaints and more chronic illnesses.  The study compared the two generations at ages 46 and 64 on several health measures using the years 2007- 2010 for the baby boomers and comparing it to data they had from 1988- 1994 for the prior generation.

The demographics in the two groups indicated a larger number of Hispanics and non-Hispanic Blacks in the baby boomer generation than the previous generation.  The data in many cases was self-reported with only half as many baby boomers 13% reporting their health as “excellent” while their parents’ generation had 32% respond excellent to the same question.  The baby boomers reported that more were using walking assisted devices, more were limited in work and more had functional limitations than their parents’ generation. As a group, obesity is more common in the baby boomers (39% vs. 29%), as is high blood pressure, elevated cholesterol and diabetes.

The prior generation got more physical exercise than the baby boomers by a margin of 50% compared to 35% when asked if they were getting exercise at least 12 times per month. Smoking was more common in the prior generation.  The study authors concluded that we need to “expand efforts at prevention and healthy lifestyle promotion in the baby boomer generation.”

It is hard for me as a clinician to gain much insight from this data. Clearly the previous generation lived through a depression and fought two major wars. Their definition of “excellent” may be different than baby boomers whose expectations may be completely different from reality.

An epidemic of obesity has contributed to an increase in its associated diseases including diabetes, high blood pressure and lipid abnormalities. The goal of education and prevention is a wise one and needs to start in the preschools and elementary schools if we wish to be a healthier society

 

Lipid Levels Similar Regardless of Whether Patients Are Fasting Before The Test

Blood SampleAn article in the Archives of Internal Medicine, November 12th, 2012 edition, reviewed the lipid profiles of more than 200,000 patients who had different fasting times recorded before their blood was drawn. Many did not fast at all. The results showed that mean levels of total and HDL cholesterol didn’t differ much at all if the patients fasted or did not fast. Triglyceride levels were the most sensitive to eating or fasting. The data indicated that for the most part, unless your fasting triglyceride levels are 400 or greater there is no need to fast before checking your blood lipid levels.

Diabetics or patients with abnormal blood sugars are required to fast to accurately measure their fasting blood sugar levels. Since science and fact should govern our medical decision making, I changed my office lab testing policy beginning January 1, 2013. We will no longer ask patients to fast before blood drawing unless they are diabetics or have high triglycerides. This will make it far easier for patients who are wondering “what can I eat and drink the morning of my blood drawing for tests?” When we schedule appointments for patients being treated for elevated cholesterol we will no longer ask them to fast or not eat. We will reserve fasting appointments for patients who are suffering from diabetes mellitus or who have a history of elevated triglycerides.

If you are not diabetic and if you do not have extremely elevated triglyceride levels, please take your medications and eat before your scheduled appointment.

I will draw a fasting glucose blood test on all non-diabetic patients annually. Fasting is permitted if your visit is for your annual physical exam.

Inflammation and Vascular Disease

Heart, stethescopeI was privileged to hear Bradley Bale, MD and Amy Doneen, MSN, ARNP talk about the development of coronary artery disease and cerebrovascular disease in patients with low or few cardiac risk factors.  They cited American Heart Association studies looking at groups of men and women between ages 45 and 65 who have their first heart attack or stroke despite being in compliance with suggested lipid and blood pressure guidelines. They pointed out that the first Myocardial Infarct or Stroke occurred in 88% of women who met lipid guidelines and 66 % of men.  These are people who do not smoke, do not have untreated or uncontrolled lipid levels, are not diabetics and who lead an active life style.  They asked “why”?

Dr. Bale and Ms. Doneen work with the well respected cardiovascular Center of Excellence at the Cleveland Clinic program in Ohio, and believe that inflammation is the root of the problem.  They believe that soft plaque composed of lipids and other cells lurks beneath the endothelial cells lining blood vessels. In the presence of inflammatory stimulants, this soft plaque ruptures suddenly through the endothelial level into the blood stream. When it comes in contact with the blood flowing through the vessels the body believes we are bleeding and cut and chemical mediators are released that initiate the formation of a clot. When this clot occurs in a small coronary artery we have a heart attack or myocardial infarction or precipitate a lethal irregular heartbeat. When this clot occurs in the blood vessels of the brain, we have an acute stroke or cerebrovascular accident.

The key to prevention in the so called low risk patient is to detect the inflammation in advance, and treat it. They are firm believers in performing B Mode Duplex ultrasounds of the carotid arteries in the neck to look for the presence of soft plaque beneath the endothelial cell lining. This soft plaque is distinctly different from the safe but calcified plaque we can see on CT scans used for cardiac scoring studies.  They couple this imaging study with a series of complex blood tests which identify inflammation. These include a myeloperoxidase level, the Lp-PLA2 level, the urine microalbumen to creatinine ratio, a F2-IsoPs level and the cardiac specific CRP level.

These tests and studies in combination with a traditional history and exam, sugar and lipid levels and EKG can help us identify those “low risk” patients who actually are high risk for a heart attack or stroke. The cause of the inflammation is often difficult to spot and may be in your mouth with dental or periodontal disease or in your joints with inflammatory arthritis.  Patients with excellent dental hygiene and normal appearing gums may harbor specific inflammatory bacteria that put them at risk. While this seems a bit forward thinking, remember we once questioned the research that showed that bacteria (H Pylori) caused gastric ulcers and intestinal bleeding.

I have begun instituting the inflammatory blood marker panels in my practice. Labs are sent to the Cleveland HeartLab for this purpose. I will be initiating periodic carotid ultrasound studies for the appropriate patients in the coming year.

It is often difficult for clinicians to distinguish snake oil sold for profit from cutting edge science. I have tried to spare my patients from worthless but profit driven products. I am convinced the Cleveland Clinic is just ahead of the rest of us in offering these services and I will make them available to the appropriate patients and will do it in a financially structured manner that does not add out of pocket cost to the patient. It’s not about adding another profitable income stream to the practice. It’s about identifying individuals who shouldn’t have a heart attack or stroke before they do.

Remote Care for the Elderly, Choosing the Right Care Team

Senior Couple At HomeMy elderly and infirm parents live 15 minutes south of my home in an assisted living facility.  They moved there after it became apparent that they could not manage their affairs in their own home, have some degree of independence and socialization with friends and receive the care and supervision they needed to stay out of the hospital.  Their cognitive impairment and dementia made it necessary for me to be in contact with their personal physician and to be able to reach him if he is needed.

It would be far more difficult if I did not live close by.  What would I look for in a physician for my elderly parents if they did not live close by? I would want the physician to have some experience in geriatric medicine. That would include being fellowship trained in geriatric medicine or having some training and certification from the American Geriatrics Society.  A board certified internist or family practitioner with experience in caring for the elderly could do fine as well. The doctor would need to be available by phone for questions and available to see my parents on the same day that they develop a medical problem needing the doctor’s attention.  That physician should have hospital privileges at a local facility where my parents might be taken to by ambulance in an emergency so that he could follow them into an acute care hospital if necessary.

I also would prefer a doctor that had a professional relationship with a rehabilitation or skilled nursing facility so that they could be treated as they recover from an acute hospital stay in a rehab setting.  I love physicians who make house calls if the situation calls for it. While much more can be accomplished during most office visits than a home visit, sometimes the illness dictates the location where the care is provided.

The doctor should be a compassionate individual who is a great listener and who relishes the responsibility of being an advocate and champion for his patients.  It’s commonplace for the elderly to languish waiting for evaluation in the emergency department or to be put off when trying to make an appointment for a test or specialty visit.  Patients need a doctor with a staff who will help them through this process.

To find such a doctor I suggest you start by asking at the local hospital medical staff office. They know who does what and who is accepting new patients. Word of mouth is the best advertising so a testimonial from a friend familiar with the doctor and the practice is priceless.

While Internet rating services provide some information they are less valuable than a personal reference. Local and County Medical Societies are another great starting place in the search for a physician.  If you are looking for a direct pay or concierge type practice, I suggest you perform a thorough Internet search and interview any physician you are considering.

Three More Strikes Against Smoking

There is no doubt that cigarette smoking is a practice that contributes to poor health and earlier death. Despite this, the practice is still popular among the young. Over the last three weeks several new research articles have been published that support the concept that smoking is severely detrimental to your health.

An Australian study published in Stroke: Journal of the American Stroke Association pointed out that individuals who had a stroke at the time they were active smokers had a far worse outcome and long term outcome than non- smokers. It additionally showed that smokers had the stroke at a younger age than nonsmokers. The group was followed for another 10 years and had a higher incidence of strokes, heart attacks and deaths than the nonsmoking group. The study emphasized the devastation and cost of “healthy years of life lost” as a consequence of continuing to smoke.

In an online publication in the Lancet, researchers working in the “Great Britain Million Women Study” noted that women who quit smoking lived longer than women who continued – irrespective of the age they decided to stop smoking. They additionally lowered their chances of dying from lung cancer.

A study out of the Mayo Clinic in Rochester, Minnesota looked at the effect of indoor smoking bans on heart attack rates in a community. This study looked at the effect of secondhand smoke on individuals. The Mayo Clinic has an exhaustive and large data base of individuals in the Midwest who have come to their clinic for health care for generations. They believe that in their study population, the number and extent of cardiovascular risk factors has remained fairly constant but, since the institution of strict bans on indoor smoking, the number of heart attacks has dropped dramatically.

Narcotic Painkiller Use Increased in the Elderly

An investigative newspaper article published in the May 30, 2012 issue of the Milwaukee Journal Sentinel, in cooperation with online periodical MedPage Today, chronicles the increased use of narcotics for chronic pain relief in the elderly. The article highlights how in 2009 the American Geriatrics Society put together a panel of geriatric pain specialists who published geriatric narcotic pain relief guidelines that have led to the dramatic increase in use of narcotics in the elderly. There is apparently no outstanding or solid evidence that Opioids or narcotics actually work better than non-narcotic pain medications in relieving the chronic pain of senior citizens.  It is the Milwaukee Journal’s opinion that the members of the blue ribbon panel who made this decision received financial benefits from the pharmaceutical manufacturers who produce narcotic pain pills and were biased in their recommendations.  Individual members of the panel received financial rewards from the companies making the narcotic pain pills and the sponsoring organization, the American Geriatric Society, reportedly received $344,000 from Opioid manufacturers.

A study in the 2010 Annals of Internal Medicine looked at over 10,000 people who had received 3 or more Opioid prescriptions over a 90 day period. The researchers found that 51 had suffered an overdose including six deaths.  Of the 40 most serious overdoses, 15 occurred in those aged 65 or older.  A 2010 research paper in the Archives of Internal Medicine looked at 12,840 Medicare patients with an average age of 80 who had used Opioids, traditional anti-inflammatory drugs, or a class of non narcotic   prescription painkillers like Celebrex. Their findings included:

  • Opioid users were more than four times more likely to suffer a fall with a fracture than non-Opioid users
  • Deaths from any cause were 87% more likely in Opioid users.
  • Cardiovascular complications including heart attacks, strokes, and cardiac death were 77% higher in Opioid users than in users of NSAIDS.

In part, as a result of the American Geriatrics Society guidelines, Opioid use for pain relief has increased by over 32% since 2007.   Locally, we have seen the proliferation of pain clinics. These clinics, often owned by non-physicians, bear some responsibility for the proliferation of narcotic pain pills on the streets of America being used illegally.   Poorly conceived state legislation and the lack of surveillance and monitoring led out-of-state drug pushers to drive into Florida, hire individuals to doctor shop from pain clinic to pain clinic where they accumulate thousands of pills that are sold out of state on the streets illegally.  Ultimately this led to a law enforcement and statewide crackdown which drove illegal and legitimate pain specialists out of the state of Florida. It is almost impossible to find a certified pain physician in Palm Beach or Broward County who will take on a new patient under the age of 65 years old due to the legal hurdles recently imposed on them to crack down on the illegal dispensing of drugs.

George Lundberg, MD and Maria Sullivan, MD of Columbia University presented a sane and reasonable approach to pain pill management in MedPage Today in the June 11th issue.  They suggested that non narcotic pain products be tried initially. They encouraged doctors and nurses to discuss the side effects of narcotics with patients including constipation, sedation, addiction, and overdose and with long term use the risk of hyperalgesia and sexual dysfunction.

They noted the high abuse potential of short acting Opioids such as Dilaudid (hydromorphone) and Vicodin (Hydrocodone/acetaminophen) and pointed out that these drugs may be good for short term initial pain relief but not chronic use.  They reviewed the pharmacology of methadone and pointed out that it is responsible for far too many overdoses due to its basic metabolism and mechanism of action. They suggested never using it in patients who have not taken Opioid narcotics regularly.

They discussed the need for patients to keep controlled substances in a secure and locked place to prevent theft of the medication.

For those practitioners who prescribe Opioids for chronic pain they suggested having a chronic pain narcotic protocol including a medication contract with the patient that outlines its correct use. Psychological evaluation for abuse potential should be considered in all chronic pain patients prescribed narcotics. Urine toxicology screening periodically should be performed to look for abuse.  There are clinical interview screening materials such as the SOAPP (Screening and Opioid Assessment for Patients with Pain) form which helps identify individuals with a high risk of abuse.  Stratifying your pain patients into low, medium, and high risk individuals may help distinguish the level of surveillance necessary to safely treat the patients.

It would make great sense for the state of Florida and the Florida Medical Association to develop a common sense pain management course for practicing providers to take prior to renewing their state medical licenses.  The course would cover the newer pain protocols and medicines and review the safe and monitored use of Opioid narcotics.  We must treat and eliminate or reduce pain. We just need to do this in a safer manner.

Aspirin Use for Prevention of Cardiovascular Disease

A study by the Veterans Administration in the 1970’s on veterans over age 45 showed that if they were given aspirin they had fewer heart attacks and strokes.  This study didn’t divide the participants into men and women or patients who never had a heart attack or stroke versus patients who had known cardiac, Cerebrovascular and or Vascular Disease already.  The exact dosage of aspirin to take was never quite clarified either. For years physicians prescribed “baby aspirin” to patients over 45 to prevent heart attacks and strokes. While no definitive evidence existed to show the benefit was present in women as well as men, we tended to recommend the low dose aspirin in that group as well unless they were a high risk for bleeding.

Recent studies have questioned whether daily aspirin use for primary prevention of vascular disease is beneficial.  The current opinion is that a daily aspirin may cause more harm than good in women.  There is a feeling that the risk of bleeding may outweigh any benefit. The data is not quite as clear in men.  To add to the confusion, an article published in the journal Ophthalmology asserts that in a European study aspirin use was associated with an increased risk of developing wet, age related macular degeneration (AMD). Of the 4691 participants in the study, 36.4 % developed early AMD and 17% of that group took aspirin on a daily basis.  This is not the first study to raise this question with equivocal findings on several previous studies concerning the relationship between aspirin intake and AMD.  It is clear that further research is needed in this area.

The study is one of many that raise conflicts in approaching AMD and eye disease versus systemic health. This is especially a problem since these older AMD patients are the same ones who are more likely to already have cardiac, Cerebrovascular or Peripheral Vascular Disease and this is the very group that we know and agree that aspirin is beneficial in.

Clearly more studies are needed. I will continue to take my daily 81 mg of enteric coated aspirins unless I develop aspirin related gastritis, ulcers or GI Bleeding. My male patients over 45 years old with low or few risks of GI bleeding will continue to be advised to consider aspirin. With no studies showing a clear cut advantage for women taking aspirin for primary prevention of heart disease and stroke, I will present the pros and cons of therapy and advise it less frequently if the patient has a low risk of vascular disease or a high risk of bleeding.