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Q: My 88-year old mother often complains of various aches and pains. What is the safest over-the-counter painkiller for her to take? Aren’t some of them bad for your liver and kidneys?

A: Frequent aches and pains are a common problem for older adults.

If your mother has been complaining, you’ll want to make sure she gets a careful evaluation from her doctor. After all, frequent pain can be the sign of an important underlying health problem that needs attention. You’re also more likely to help your mom reduce her pains if you can help her doctors identify the underlying causes of her pain.

That said, it’s a good idea to ask what over-the-counter analgesics are safest for older people.

That’s because improper use of OTC painkillers is actually a major cause of harm to older adults.

So let me tell you what OTC painkiller geriatricians usually consider the safest, and which very common group of painkillers you should look out for.

What’s the safest OTC painkiller for an older parent?

For most older adults, the safest OTC painkiller for daily or frequent use is acetaminophen (brand name Tylenol), provided you are careful to not exceed a total dose of 3,000mg per day.

Acetaminophen is usually called paracetamol outside the U.S.

It is processed by the liver and in high doses can cause serious — sometimes even life-threatening — liver injury. So if an older person has a history of alcohol abuse or chronic liver disease, then an even lower daily limit will be needed, and I would strongly advise you to talk to a doctor about what daily limit might be suitable.

The tricky thing with acetaminophen is that it’s actually included in lots of different over-the-counter medications (e.g. Nyquil, Theraflu) and prescription medications (e.g. Percocet). So people can easily end up taking more daily acetaminophen than they realize. This can indeed be dangerous; research suggests that 40% of acetaminophen overdoses cases are accidental.

But when taken at recommended doses, acetaminophen has surprisingly few side-effects and rarely harms older adults. Unlike non-steroidal anti-inflammatory drugs (NSAIDs, see below), it does not put older adults at risk of internal bleeding, and it seems to have minimal impacts on kidney function and cardiovascular risk.

Be careful or avoid this common class of painkillers

At the drugstore, the most common alternatives to acetaminophen are ibuprofen (brand names Advil and Motrin) and naproxen (brand names Aleve, Naprosyn, and Anaprox).

Both of these are part of a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). Many people are familiar with these medications. But in fact, older adults should be very careful before using NSAIDs often or regularly.

Unlike acetaminophen, which usually doesn’t become much riskier as people get older, NSAIDs have side-effects that are especially likely to cause harm as people get older. These include:

  • Increased risk of bleeding in the stomach, small bowel, or colon. Seniors who take daily aspirin or a blood-thinner are at especially high risk.
  • Problems with the stomach lining, which can cause stomach pain or even peptic ulcer disease.
  • Decreased kidney function. This can be especially problematic for those many older adults who have already experienced a chronic decline in kidney function.
  • Interference with high blood pressure medications.
  • Fluid retention and increased risk of heart failure.

Experts have estimated that NSAIDs cause 41,00 hospitalizations and 3,300 deaths among older adults every year.

Recent research has also suggested that NSAIDs cause a small but real increase in the risk of cardiovascular events (e.g. heart attacks and strokes).

Because of these well-known side-effects of NSAIDs in older adults, in 2009 the American Geriatrics Society recommended that older adults avoid using NSAIDS for the treatment of chronic persistent pain. Today, NSAIDs remain on the Beer’s List of medications that older adults should avoid or use with caution.

Despite this fact, NSAIDs are often bought by seniors at the drugstore. Perhaps even worse, NSAIDs are often prescribed to older adults by physicians, because the anti-inflammatory effect can provide relief from arthritis pain, gout, and other common health ailments.

(Commonly prescribed NSAIDs include indomethacin, diclofenac, sulindac, meloxicam, and celecoxib. These tend to be stronger than the NSAIDs available without a prescription. However, stronger NSAIDs are associated with higher risks of problems, unless they are used as a cream or gel, in which case the risks are much less.)

Now let me share a true story. Many years ago, a man in his 70s transferred to my patient panel. He had been taking a daily NSAID for several months, prescribed by the previous doctor, to treat his chronic shoulder arthritis.

I cautioned him about continuing this medication, explaining that it could cause serious internal bleeding. He seemed dubious, and said his previous doctor had never mentioned bleeding. He wanted to continue it. I decided to let it slide for the time being.

A few weeks later, he was hospitalized for internal bleeding from his stomach. Naturally, I felt terrible about it.

This is not to say that older adults should never use NSAIDs. Even in geriatrics, we sometimes conclude that the likely benefits seem to outweigh the likely risks. (This conclusion must be reached in partnership with the patient and family; only they can tell us how much that pain relief means to them, and how concerned they are about the risk of bleeding and other side-effects.) It’s also possible to reduce the risk of bleeding by having a patient take a medication to reduce stomach acid.

But far too many older adults are never informed of the risks associated with NSAIDs. And in the drugstore, they sometimes choose ibuprofen over acetaminophen, because they’ve heard that Tylenol can cause liver failure.

Yes, acetaminophen has risks as well. But every year, NSAIDs cause far more hospitalizations among older adults than acetaminophen does.

Aspirin: a special NSAID we no longer use for pain

Aspirin is another analgesic available over-the-counter.

It’s technically also a NSAID, but its chemical structure is a bit different from the other NSAIDs. This is what allows it to be effective in reducing strokes and heart attacks. It is also less likely to affect the kidneys than other NSAIDs are.

(For more on the risks and benefits of aspirin, see this MayoClinic.com article.)

Aspirin is no longer used as an analgesic by the medical community. But many older adults still reach for aspirin to treat their aches and pains, because they are used to thinking of it as a painkiller. Aspirin is also included in certain over-the-counter medications, such as Excedrin.

Taking a very occasional aspirin for a headache or other pain is not terribly risky for most aging adults. But using aspirin more often increases the risk of internal bleeding. So, I discourage my older patients from using aspirin for pain.

Tips on safer use of OTC painkillers

In short, the safest OTC painkiller for older adults is usually acetaminophen, provided you don’t exceed 3,000 mg per day.

If you have any concerns about liver function or alcohol use or otherwise want to err on the safer side, don’t exceed 2,000 mg per day, and seek medical input as soon as possible.

You should also be sure to bring up any chronic pain with your parent’s doctor. It’s important to get help identifying the underlying causes of the pain. The doctor can then help you develop a plan to manage the pain. And don’t forget to ask about non-drug treatments for pain; they are often safer for older adults, but busy doctors may not bring them up unless you ask.

Now if your older parent is taking acetaminophen often or every day, you’ll want to be sure you’ve accounted for all acetaminophen she might be taking. Remember, acetaminophen is often included in medications for cough and cold, and in prescription painkillers. So you need to look at the ingredients list for all medication of this type. Experts believe that half of acetaminophen overdoses are unintentional, and result from people either making mistakes with their doses or not realizing they are taking other medications containing acetaminophen.

Last but not least: be sure to avoid the “PM” version of any OTC painkiller. The “PM” part means a mild sedative has been included, and such drugs — usually diphenhydramine, which is the main ingredient in Benadryl — are anticholinergic and known to be bad for brain function. (See 7 Common Brain-Toxic Drugs Seniors Should Use With Caution for more about the risks of anticholinergic drugs.)

My own approach, when I do house calls, is to check the older person’s medicine cabinet. If I find any NSAIDs or over-the-counter anticholinergic medications (e.g. antihistamines, sleep aids, etc), I discuss them with my older patient and usually remove them from the house unless there’s a good reason to leave them.

If acetaminophen isn’t providing enough pain relief

If acetaminophen doesn’t provide enough relief for your mom’s pains, then it may be reasonable to consider over-the-counter (or sometimes prescription) NSAIDs, preferably for a limited period of time. But be sure to discuss the risks and alternatives with the doctor first, and be sure to discuss possible non-drug approaches to lessen pain.

By being informed and proactive, your family can help your mom get better care for her pain, while minimizing the risk of harm from medications.

Questions? Please post them below.

The post How to Choose the Safest Over-the-Counter Painkiller for Seniors appeared first on Better Health While Aging.

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Q: How can we get my older mother to drink more water? She is susceptible to urinary tract infections and seems to be often dehydrated no matter what we do. We were also wondering if coffee and tea are okay, or should they be avoided to reduce dehydration?

A: Dehydration is indeed an important problem for older adults. It can be common even when it’s not hot outside.

Helping a senior increase their fluid intake, as you’re trying to do, is one of the best ways to reduce the risk of dehydration.

Now how to actually do this? Studies — and practical experience — suggest that the best approaches include:

  1. Frequently offering the older person a drink, preferably on a schedule,
  2. Offering beverages the person seems to prefer,
  3. Not expecting older adults to drink a large quantity at a single sitting,
  4. Addressing any continence issues that might be making the person reluctant to drink often.

But your question brings up other issues in my mind. Has frequent dehydration been confirmed? (Dehydration can be hard to correctly diagnose.) Have you been able to measure how much your mother drinks, and how does this amount compare to the recommended daily fluid intake for seniors?

Also, is the real goal to prevent or manage frequent urinary infections, and is increasing her hydration likely to achieve this?

So let’s review the basics of dehydration in older adults, and what’s known about helping older adults stay hydrated. I will then share some additional tips on helping your mother maintain hydration.

The Basics of Dehydration What is dehydration and what causes it?

Dehydration means the body doesn’t have as much fluid within the cells and blood vessels as it should.

Normally, the body constantly gains fluid through what we eat and drink, and loses fluid through urination, sweating, and other bodily functions. But if we keep losing more fluid than we take in, we can become dehydrated.

If a person starts to become dehydrated, the body is designed to signal thirst to the brain. The kidneys are also supposed to start concentrating the urine, so that less water is lost that way.

Why are older adults at higher risk for dehydration?

Unfortunately, the body’s mechanisms meant to protect us from dehydration work less well as we age. Older adults have reduced thirst signals and also become less able to concentrate their urine.

Other factors that put older adults at risk include:

  • Chronic problems with urinary continence, which can make older adults reluctant to drink a lot of fluids
  • Memory problems, which can cause older adults to forget to drink often, or forget to ask others for something to drink
  • Mobility problems, which can make it harder for older adults to get something to drink
  • Living in nursing homes, because access to fluids often depends on the availability and attentiveness of staff
  • Swallowing difficulties

Dehydration can also be brought on by an acute illness or other event. Vomiting, diarrhea, fever, and infection are all problems that can cause people to lose a lot of fluid and become dehydrated.

Last but not least, older adults are more likely to be taking medications that increase the risk of dehydration, such as diuretic medications, which are often prescribed to treat high blood pressure or heart failure.

A UK study of older adults in residential care found that 46% had impending or current dehydration, as diagnosed by blood tests.

How is dehydration diagnosed?

In older adults, the most accurate way to diagnose dehydration is through laboratory testing of the blood. Dehydration generally causes abnormal laboratory results such as:

  • Elevated plasma serum osmolality: this measurement relates to how concentrated certain particles are in the blood plasma
  • Elevated creatinine and blood urea nitrogen: these tests relate to kidney function
  • Electrolyte imbalances, such as abnormal levels of blood sodium
  • Low urine sodium concentration (unless the person is on diuretics)

(Doctors often sub-classify dehydration based on whether blood sodium levels are high, normal, or low.)

Dehydration can also cause increased concentration of the urine — this is measured as the “specific gravity” on a dipstick urine test. However, this is not an accurate way to test for dehydration in older adults, since we tend to lose the ability to concentrate urine as we get older. This was confirmed by a 2016 study, which found that the diagnostic accuracy of urine dehydration tests in older adults is “too low to be useful.

There are also a number of physical symptoms associated with dehydration. However, a 2015 study of older adults found that the presence or absence of dehydration symptoms is not an accurate way to diagnose dehydration.

Physical signs of dehydration may include:

  • dry mouth and/or dry skin in the armpit
  • high heartrate (usually over 100 beats per minute)
  • low systolic blood pressure
  • dizziness
  • weakness
  • delirium (new or worse-than-usual confusion)
  • sunken eyes
  • less frequent urination
  • dark-colored urine

But as noted above: the presence or absence of these physical signs are not reliable ways to detect dehydration. Furthermore, the physical symptoms above can easily be caused by health problems other than dehydration.

So if you are concerned about clinically significant dehydration — or about the symptoms above — blood tests results may be needed. A medical evaluation for possible dehydration should also include an interview and a physical examination.

What are the consequences of dehydration?

The consequences depend on how severe the dehydration is, and perhaps also on how long the dehydration has been going on.

In the short-term, dehydration can cause the physical symptoms listed above. Especially in older adults, weakness and dizziness can provoke falls. And in people with Alzheimer’s or other forms of dementia, even mild dehydration can cause noticeable worsening in confusion or thinking skills.

Dehydration also often causes the kidneys to work less well, and in severe cases may even cause acute kidney failure.

The consequences of frequent mild dehydration — meaning dehydration that would show up as abnormal laboratory tests but otherwise doesn’t cause obvious symptoms — are less clear.

Chronic mild dehydration can make constipation worse. Otherwise, a 2012 review found that the only health problem that has been consistently associated with low daily water intake is kidney stones.

A 2013 review on fluid intake and urinary system diseases concluded that it’s plausible that dehydration increases the risk of urinary tract infections, but not definitely proven.

Speaking of urinary tract infections (UTIs), if you are concerned about frequent bacteria in the urine, you should make sure this reflects real UTIs and not simply a sign of the older person’s bladder being colonized with bacteria.

This is a very common condition known as asymptomatic bacteriuria, and incorrectly diagnosing this as a UTI can lead to pointless overtreatment with antibiotics. (More on this issue below, or see Q&A: Why Urine Bacteria Doesn’t Mean a UTI Needs Antibiotics.)

How is dehydration treated?

The treatment of dehydration depends on:

  • Whether the dehydration appears to be mild, moderate, or severe
  • What type of electrolyte imbalances (such as high/low levels of sodium and potassium) appear on laboratory testing
  • If known, the cause of the dehydration

Mild dehydration can usually be treated by having the person take more fluids by mouth. Generally, it’s best to have the person drink something with some electrolytes, such as a commercial rehydration solution, a sports drink, juice, or even bouillon. But in most cases, even drinking water or tea will help.

Moderate dehydration is often treated with intravenous hydration in urgent care, the emergency room, or even the hospital. Some nursing homes can also treat dehydration a subcutaneous infusion, which means providing fluid through a small IV needle placed into the skin of the belly or thigh. This is called hypodermoclysis, and this is actually safer and more comfortable for seniors than traditional IV hydration.

Severe dehydration may require additional intervention to support the kidneys, and sometimes even requires short-term dialysis.

How to prevent dehydration in older adults?

Experts generally recommend that older adults consume at least 1.7 liters of fluid per 24 hours. This corresponds to 57.5 fluid ounces, or 7.1 cups.

What are the best fluids to prevent dehydration?

I was unable to find research or guidelines clarifying which fluids are best to drink. This is probably because clinical research hasn’t compared different fluids to each other.

As to whether certain fluids are dehydrating: probably the main fluid to be concerned about in this respect is alcohol, which exerts a definite diuretic effect on people.

The effect of caffeine on causing people to lose excess water is debatable. Technically caffeine is a weak diuretic. But real-world studies suggest that people who are used to drinking coffee don’t experience much diuretic effect.

Now, caffeine may worsen overactive bladder symptoms, so there may be other reasons to be careful about fluids containing caffeine. But as best I can tell, coffee and tea are not proven to be particularly dehydrating in people who drink them regularly.

The safest approach would still be to drink decaffeinated drinks. But if an older person particularly loves her morning cup of (caffeinated) coffee, I’d say to consider accommodating her if at all possible.

How to help older adults to stay hydrated?

A 2015 review of nursing home interventions intended to reduce dehydration risk concluded that “the efficacy of many strategies remains unproven.” Still, here are some approaches that are reasonable to try:

  • Offer fluids often throughout the day; consider doing so on a schedule.
  • Offer smaller quantities of fluid more often; older adults may be reluctant to drink larger quantities less often.
  • Be sure to provide a beverage that is appealing to the older person.
  • See if the older person seems to prefer drinking through a straw.
  • Identify any continence concerns that may be making the older person reluctant to drink. Keeping a log of urination and incontinence episodes can help.
  • Consider a timed toileting approach, which means helping the older person get to the bathroom on a regular schedule. This can be very helpful for seniors with memory problems or mobility difficulties.
  • Track your efforts in a journal. You’ll want to track how much the person is drinking; be sure to note when you try something new to improve fluid intake.
  • Offer extra fluids when it’s hot, or when the person is ill.
Practical tips for family caregivers

Let’s now return to the issues brought up in the question.

Family caregivers are often concerned about whether an older person is drinking enough. Since dehydration is indeed very common among older adults, this concern if very important.

However, before expending a lot of energy trying to get your mother to drink more, I would encourage you to consider these four suggestions:

1.Measure how much your mother is actually drinking most days.

This can require a little extra effort. But it’s very helpful to get at least an estimate of how much the person drinks. This can confirm a family’s — or doctor’s — hunch that the person isn’t taking in enough fluid, and can help the care team figure out how much more fluid is required.

Again, the recommendation for older adults is to consume at least 1.7 liters/day, which corresponds to at least 57.5 fluid ounces. In the US, where a measuring cup = 8 ounces, this is equivalent to 7.1 cups/day.

Keep a journal to record how much fluid your older parent is drinking. It’s generally important to track anything you want to improve.

2. Confirm that your mother is, in fact, often dehydrated.

As noted above in the section on diagnosing dehydration: physical symptoms and urine tests are not enough to either diagnose dehydration or rule it out.

Instead, consider these two approaches to confirming clinical dehydration. One is to see if her energy and mental state perk up when she drinks more. The other is to talk to the doctor and request blood tests to confirm dehydration.

Now, you don’t necessarily want to request blood tests every time you suspect mild dehydration. But especially if your mother’s dehydration has never been confirmed by a serum osmolality test, it would probably be useful to do this at least once.

3. If frequent urinary tract infections (UTIs) are a concern, learn about asymptomatic bacteriuria and try to determine whether these are real UTIs versus a colonized bladder.

Sometimes I’ve seen families hellbent on increasing hydration or taking other measures, because they are concerned about repeated or persisting urinary tract infections (UTIs).

But UTIs are a bit like dehydration. A UTI is a common problem in seniors and is potentially very serious. But it’s also easily misdiagnosed, even by professionals.

Sometimes, when an older person keeps being diagnosed with a UTI repeatedly, the problem is actually that the older person has asymptomatic bacteriuria. This is a very common condition in which an older person’s bladder becomes colonized with bacteria. It probably happens because people’s immune systems get weaker as they age.

So how is this different from a UTI? Both conditions will cause a positive urine culture, meaning that bacteria is in the urine. The main difference is that in asymptomatic bacteriuria, the older person doesn’t experience pain, inflammation, increased confusion, or other symptoms of infection.

In a young person, bacteria in the urine is very uncommon and almost always corresponds to a clinically significant infection. But in an older person, bacteria in the urine is common.

So you cannot diagnose a UTI in an older person just on the basis of a positive urine culture. Instead, the family and clinician must note other signs of infection, such as pain or delirium.

Families are often surprised to learn that clinical trials have repeatedly found that it is not helpful to treat asymptomatic bacteriuria, but it’s true. In fact, a 2015 study found that treating asymptomatic bacteriuria with antibiotics increased the likelihood of later having a real UTI, and that the real UTI was more likely to be antibiotic-resistant.

For more on this topic, see Q&A: Why Urine Bacteria Doesn’t Mean a UTI Needs Antibiotics.

4. Pay attention to figure out which fluids your mother prefers to drink and try scheduling frequent small drinks.

Ultimately, there’s no substitute for paying close attention, keeping track of your observations, and doing some trial and error to figure out what seems to improve things.

No doctor has a magic formula to get seniors to drink more. So identify the drinks your mother prefers, start tracking how much she drinks, and then start experimenting to figure out what works.

Usually, a combination of the following three approaches will improve fluid intake:

  • Offer a beverage the person likes,
  • Offer small-to-moderate quantities of the beverage on schedule,
  • Address continence issues.

Do you have any additional questions regarding the prevention of dehydration in older adults?

Post them below and I’ll see how I can help.

The post Q&A: How to Prevent, Detect, & Treat Dehydration in Aging Adults appeared first on Better Health While Aging.

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One of the greatest challenges, when it comes to Alzheimer’s disease and other dementias, is coping with difficult behaviors.

These are symptoms beyond the chronic memory/thinking problems that are the hallmark of dementia. They include problems like:

  • Delusions, paranoid behaviors, or irrational beliefs
  • Agitation (getting “amped up” or “revved up”) and/or aggressive behavior
  • Restless pacing or wandering
  • Disinhibited behaviors, which means saying or doing socially inappropriate things
  • Sleep disturbances

These are technically called “neuropsychiatric” symptoms, but regular people might refer to them as “acting crazy” symptoms. Or even “crazy-making” symptoms, as they do tend to drive family caregivers a bit nuts.

Because these behaviors are difficult and stressful for caregivers — and often for the person with dementia — people often ask if any medications can help.

The short answer is “Maybe.”

The medium-length answer is “Maybe, but there will be side-effects and other significant risks to consider, and we need to first attempt non-drug ways to manage these behaviors.”

In fact, no medication is FDA-approved for the treatment of these types of behaviors in Alzheimer’s disease or other forms of dementia.

But it is VERY common for medications — especially antipsychotics — to be prescribed “off-label” for this purpose.

This is sometimes described as a “chemical restraint” (as opposed to tying people to a chair, which is a “physical restraint”). In many cases, antipsychotics and other tranquilizing medications can certainly calm the behaviors. But they can have significant side-effects and risks, which are often not explained to families.

Worst of all, they are often prescribed prematurely, or in excessive doses, without caregivers and doctors first putting in some time to figure out what is triggering the behavior, and what non-drug approaches might help.

For this reason, in 2013 the American Geriatrics Society made the following recommendation as part of its Choosing Wisely campaign: “Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.”

You may now be wondering what should be the first choice. This depends on the situation, but generally, the first choice to treat difficult behaviors is NOT medication. (A possible exception: geriatricians do often consider medication to treat pain or constipation, as these are common triggers for difficult behavior.)

Instead, medications should be used after non-drug management approaches have been tried, or at least in combination with non-drug approaches. (Learn about these here: Tips for Managing Common Symptoms and Problems in Dementia Patients.)

Of course in certain situations, medication should be considered. If your family member has Alzheimer’s or another dementia, I want you to be equipped to work with the doctors on sensible, judicious use of medication to manage difficult behaviors.

In this post, I’ll review the most common types of medications used to treat difficult behaviors in dementia. I’ll also explain the approach that I take with these medications.

5 Types of Medication For Difficult Behaviors in Dementia

Most medications used to treat difficult behaviors fall into one of the following categories:

1.Antipsychotics. These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms. (For more on psychosis, which is common in late-life, see 6 Causes of Paranoia in Aging & What to Do.)

Commonly used drugs: Antipsychotics often used in older adults include:

  • Risperidone (brand name Risperdal)
  • Quetiapine (brand name Seroquel)
  • Olanzapine (brand name Zyprexa)
  • Haloperidol (brand name Haldol)
  • For a longer list of antipsychotics drugs, see this NIH page.

Usual effects: Most antipsychotics are sedating, and will calm agitation or aggression through these sedating effects. Antipsychotics may also reduce true psychosis symptoms, such as delusions, hallucinations, or paranoid beliefs, but it’s rare for them to completely correct these in people with dementia.

Risks of use: The risks of antipsychotics are related to how high the dose is, and include:

  • Decreased cognitive function, and possible acceleration of cognitive decline
  • Increased risk of falls
  • Increased risk of stroke and of death; this has been estimated as an increased absolute risk of 1-4%
  • A risk of side-effects known as “extrapyramidal symptoms,” which include stiffness and tremor similar to Parkinson’s disease, as well as a variety of other muscle coordination problems
  • People with Lewy-body dementia or a history of Parkinsonism may be especially sensitive to antipsychotic side-effects; in such people, quetiapine is considered the safest choice

Evidence of clinical efficacy: Clinical trials often find a small improvement in symptoms. However, this is offset by frequent side-effects. Studies have also repeatedly found that using antipsychotics in older people with dementia is associated with a higher risk of stroke and of death.

2. Benzodiazepines. This is a category of medication that relaxes people fairly quickly. So these drugs are used for anxiety, for panic attacks, for sedation, and to treat insomnia. They can easily become habit-forming.

Commonly used drugs: In older adults these include:

  • Lorazepam (brand name Ativan)
  • Temazepam (brand name Restoril)
  • Diazepam (brand name Valium)
  • Alprazolam (brand name Xanax)
  • Clonazepam (brand name Klonopin)

Usual effects: In the brain, benzodiazepines act similarly to alcohol, and they usually cause relaxation and sedation. Benzodiazepines vary in how long they last in the body: alprazolam is considered short-acting whereas diazepam is very long-acting.

Risks of use: A major risk of these medications is that in people of all ages, they can easily cause both physical and psychological dependence. Additional risks that get worse in older adults include:

  • Increased risk of falls
  • Paradoxical agitation (some older adults become disinhibited or otherwise become more restless when given these drugs)
  • Increased confusion
  • Causing or worsening delirium
  • Possible acceleration of cognitive decline

In older adults who take benzodiazepines regularly, there is also a risk of worsening dementia symptoms when the drug is reduced or tapered entirely off. This is because people can experience increased anxiety plus discomfort due to physical withdrawal, and this often worsens their thinking and behavior.

Stopping benzodiazepines suddenly can provoke life-threatening withdrawal symptoms, so medical supervision is mandatory when reducing this type of medication. (See How You Can Help Someone Stop Ativan for more information.)

Evidence of clinical efficacy: A recent review of clinical research concluded there is “limited evidence for clinical efficacy.” Although these drugs do have a noticeable effect when they are used, it’s not clear that they overall improve agitation and difficult behaviors in most people. It is also not clear that they work better than antipsychotics, for longer-term management of behavior problems.

3. Mood-stabilizers. These include medications otherwise used for seizures. They generally reduce the “excitability” of brain cells.

Commonly used drugs: Valproic acid (brand name Depakote) is the most commonly used medication of this type, in older adults with dementia. It is available in short- and long-acting formulations.

Usual effects: The effect varies depending on the dose and the individual. It can be sedating.

Risks of use: Valproic acid requires periodic monitoring of blood levels. Even when the blood level is considered within acceptable range, side-effects in older adults are common and include:

  • Confusion or worsened thinking
  • Dizziness
  • Difficulty walking or balancing
  • Tremor and development of other Parkinsonism symptoms
  • Gastrointestinal symptoms including nausea, vomiting, and/or diarrhea

Evidence of clinical efficacy: A review of randomized trials of valproate for agitation in dementia found no evidence of clinical efficacy, and described the rate of adverse effects as “unacceptable.” Despite this, some geriatric psychiatrists and other experts feel that valproate works well to improve behavior in certain people with dementia.

4. Anti-depressants. Many of these have anti-anxiety benefits. However, they take weeks or even months to reach their full effect on depression or anxiety symptoms.

Commonly used drugs: Antidepressants often used in older people with dementia include:

  • Selective serotonin reuptake inhibitor (SSRI) antidepressants:
    • Citalopram, escitalopram, and sertraline (brand names Celexa, Lexapro, and Zoloft, respectively) are often used
    • Paroxetine (brand name Paxil) is another often-used SSRI, but as it is much more anticholinergic than the other SSRIs, geriatricians would avoid this medication in a person with dementia
  • Mirtazapine (brand name Remeron) is an antidepressant that can increase appetite and sometimes increases sleepiness when given at bedtime
  • Trazodone (brand name Desyrel) is a weak antidepressant that is sedating and is often used at bedtime to help improve sleep

Usual effects: The effects of these medications on agitation is variable. SSRIs may help some individuals, but it usually takes weeks or longer to see an effect. For some people, a sedating antidepressant at bedtime can improve sleep and this may reduce daytime irritability.

Risks of use: The anti-depressants listed above are generally “well-tolerated” by older adults, especially when started at low doses and with slow increases as needed. Risks and side-effects include:

  • Nausea and gastrointestinal distress, especially when first starting or increasing doses (SSRIs)
  • SSRIs may be activating in some people, which can worsen agitation or insomnia
  • Citalopram (in doses higher than 20mg/day) can increase the risk of sudden cardiac arrest due to arrhythmia
  • An increased risk of falls, especially with the more sedating antidepressants

Evidence of clinical efficacy: A 2014 randomized trial found that citalopram provided a modest improvement in neuropsychiatric symptoms; however the dose used was 30mg/day, which has since been discouraged by the FDA. Otherwise clinical studies find that antidepressants are not effective for reducing agitation.

5. Dementia drugs. These are the drugs FDA-approved to treat the memory and thinking problems associated with Alzheimer’s disease. In some patients they seem to help with certain neuropsychiatric symptoms. For more on the names of these drugs and how they work, see 4 Medications to Treat Alzheimer’s & Other Dementias.

Note: I am not including medications to manage dementia-related sleep disturbances in this post. You can learn more about those here: How to Manage Sleep Problems in Dementia.

Practical tips on medications to manage difficult behaviors in dementia

You may be now wondering just how doctors are supposed to manage medications for difficult dementia behaviors.

Here are the key points that I usually share with families:

  • Before resorting to medication: it’s essential to try to identify what is triggering/worsening the behavior, and it’s important to try non-drug approaches, including exercise.
    • Be sure to consider treating possible pain or constipation, as these are easily overlooked in people with dementia. Geriatricians often try scheduling acetaminophen 2-3 times daily, since people with dementia may not be able to articulate their pain. We also titrate laxatives to aim for a soft bowel movement every 1-2 days.
  • No type of medication has been clinically shown to improve behavior for most people with dementia. If you try medication for this purpose, you should be prepared to do some trial-and-error, and it’s essential to carefully monitor how well the medication is working and what side-effects may be happening.
  • Antipsychotics and benzodiazepines work fairly quickly, but most of the time they are working through sedation and chemical restraint. They tend to cloud thinking further. It is important to use the lowest possible dose of these medications.
  • Benzodiazepines probably increase fall risk more than antipsychotics do, and are habit forming. They are also less likely to help with hallucinations, delusions, and paranoias. For these reasons, if a faster-acting medication is needed, geriatricians usually prefer antipsychotics to benzodiazepines.
  • Antidepressants take a while to work, but are generally well-tolerated. Geriatricians often try escitalopram or citalopram in people with dementia.
  • It is usually worth trying a dementia drug (such as a cholinesterase inhibitor or memantine) if the person is not already on these medications, as these drugs also tend to be well tolerated.

I admit that although studies find that non-drug methods are effective in improving dementia behaviors, it’s often challenging to implement them.

For people with dementia living at home, family caregivers or paid helpers often have limited time and energy to learn and practice behavior management techniques. Despite the risks of antipsychotics, family members are often anxious to get some relief as soon as possible.

As for residential facilities for people with Alzheimer’s and other dementias, they vary in how well their staff are trained in non-drug approaches.

What you can do about medications and difficult dementia behaviors

If your relative with dementia is not yet taking medications for behaviors, consider these tips:

  • Start keeping a journal and learn to identify triggers of difficult behaviors. You will need to observe the person carefully. Your journaling will come in handy later if you start medications, as this will help you monitor for benefit and side-effects.
  • Consider the possibility of depression. Consider a trial of escitalopram or a related antidepressant, but realize any effect will take weeks to appear.
  • If the person is often very agitated, or very paranoid, or if otherwise the behavioral symptoms are causing significant distress to the older person or to caregivers, it’s often reasonable to try an antipsychotic.
    • Be sure to discuss the increased risk of stroke and death with the doctor and among family members. This can be a reasonable risk to accept, but it’s essential to be informed before proceeding.
    • It’s best to start with the lowest dose possible.
    • If there have been visual hallucinations or other signs of possible Lewy-Body dementia, quetiapine is usually the safest first choice.
  • For all medications for dementia behaviors:
    • Monitor carefully for evidence of improvement and for signs of side-effects.
    • Doses should be increased a little bit at a time.
    • Especially for antipsychotics, the goal is to find the minimum necessary dose to keep behavior manageable.

If your relative with dementia is currently taking medications for behaviors, then you will have to consider at least the following two issues.

One is whether the behavior issues currently seem manageable or not. If behavior is still often very difficult, then it’s important to look into triggers and other behavioral management approaches.

Ongoing agitation or difficult behaviors may also be a sign that the medication isn’t effective for your relative. So it may also be reasonable to consider a change in medication. The best is to work closely with a doctor AND a dementia behavior expert; some social workers and geriatric care managers are very good with dementia behaviors.

The other issue is to make sure you are aware of any risks or side-effects that the current medications may be causing.

The main side-effects I see people with dementia experience are excess drowsiness, excess confusion, and falls. These are usually due to high doses of antipsychotics and/or benzodiazepines. In such cases, it’s often possible to at least reduce the dosages somewhat. Addressing any other anticholinergic or brain-dampening medications can also help.

Now should you aim to get your relative completely off antipsychotics, in order to reduce mortality risk, improve alertness and thinking, and to reduce fall risk?

I have found that sometimes tapering people completely off antipsychotics is possible, but it can be a labor-intensive process. Furthermore, studies find that a certain number of people with dementia “relapse” after antipsychotics have been discontinued. Another very interesting 2016 study of antipsychotic review in nursing homes found that stopping antipsychotics tended to make behavior worse unless the nursing home also implemented “social interventions.”

In other words, attempting to completely stop antipsychotic medications involves effort, may be followed by worse behavior, and is less likely to succeed if you cannot concurrently provide an increase in beneficial social contact or exercise. It is certainly worth considering, but in people who are taking more than the starter dose of antipsychotic, it can be challenging.

No easy solutions but improvement IS usually possible

As many of you know, behavior problems are difficult in dementia in large part because there is usually no easy way to fix them.

Many — probably too many — older adults with Alzheimer’s and other dementias are being medicated for their behavior problems.

If your family is struggling with behavior problems, I know that reading this article will not quickly solve them.

But I hope this information will enable you to make more informed decisions. This way you’ll help ensure that any medications are used thoughtfully, in the lowest doses necessary, and in combination with non-drug dementia behavior management approaches.

And if you are looking for a memory care facility, try to find out how many of their residents are being medicated for behavior. For people with Alzheimer’s and other dementias, it’s best to be cared for by people who don’t turn first to chemical restraints such as antipsychotics and benzodiazepines.

The post 5 Types of Medication Used to Treat Difficult Dementia Behaviors appeared first on Better Health While Aging.

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If someone in your family has been diagnosed with Alzheimer’s or another dementia, chances are that they’ve been prescribed one of the “dementia medications.”

But were they told what to expect, and how to judge if the medication is worth continuing?

I’ve noticed that patients and families often aren’t told much about how well these medications generally work, and or how to determine if it’s likely to help in your situation.

So in this post, I’ll explain how these medications work.  I’ll also address some of the frequently asked questions that I hear from seniors and families.

If someone in your family is taking one of these medications or considering them, this will help you better understand the medication and what questions you might want to ask the doctors. This is especially important if finances or medication costs are a concern.

Note: This article is about those drugs that have been studied and approved to treat the cognitive decline related to dementia. This is not the same as treating behavioral symptoms (technically called “neuropsychiatric” symptoms) related to dementia, such as paranoia, agitation, hallucinations, aggression, sleep disturbances, wandering, and so forth. There are no drugs FDA-approved to treat the behavioral problems of dementia. I will address the off-label use of psychiatric medication for this purpose in a future article. 

4 Medications FDA-Approved to Treat Dementia

FDA-approved medications to treat Alzheimer’s and related dementias basically fall into two categories:

Cholinesterase inhibitors. These help increase the amount of the neurotransmitter acetylcholine in the brain. Acetylcholine helps neurons function well.

  • Three such medications are FDA-approved to treat Alzheimer’s in “mild to moderate” stages:
    • Donepezil (brand name Aricept)
    • Rivastigmine (brand name Exelon)
    • Galantamine (brand name Razadyne)
  • Tacrine is a fourth cholinesterase inhibitor which was FDA-approved but is no longer in use due to a much higher risk of side-effects
  • Donepezil and rivastigmine have also obtained FDA-approval for the treatment of more advanced dementia

(For more on what “mild-to-moderate Alzheimer’s disease” means, see “How to Understand the Stages of Alzheimer’s & Other Dementias.”)

Memantine. This is the name of an actual drug rather than a class of drugs, but since it’s the only one available of its type, experts consider it the second category of dementia treatment drug.

  • Memantine (brand name Namenda) is FDA-approved to treat “moderate to severe” Alzheimer’s disease
  • Memantine is an “N-methyl-D-aspartate (NMDA) receptor antagonist.” It dampens the excitatory effect of the neurotransmitter glutamate in the brain.

Since over-excitation of the neurons has been associated with neurodegenerative disease, memantine is considered a “neuroprotective” drug. Hence it is potentially a “disease-modifying treatment.”

In comparison, cholinesterase inhibitors are considered “symptomatic treatment,” as they affect the function of neurons but not the underlying health of neurons.

In other words: memantine might slow down the underlying progression of Alzheimer’s, even if it doesn’t appear to be helping a person. Cholinesterase inhibitors don’t change the underlying progression of Alzheimer’s, but they can potentially help a damaged brain work a little better.

Frequently Asked Questions About Dementia Medications How well do cholinesterase inhibitors work?

This is a topic that has been intensively studied and somewhat debated. Of note, most major studies of cholinesterase inhibitors are industry-funded; only the AD2000 trial was not industry-funded.

Overall, in mild to moderate Alzheimer’s disease, the average benefit seems to be a small improvement in cognition and ability to manage activities of daily living. The effect has been sometimes compared to a few months delay in progression of symptoms. (It is not clear that treatment with cholinesterase inhibitors affects long-term outcomes such as the need for nursing home level of care.)

A 2008 review of the scientific evidence concluded that the effect of these drugs is statistically significant but “clinically marginal.”

But there’s a catch to consider: studies also suggest that although a fair number of people (30-50%) seem to experience no benefit at all, up to 20% may show greater than usual response. So there seems to be some individual variability in how these drugs work for people.

To date, we have not developed any good ways to tell ahead of time who will respond to these drugs.

So it’s important to follow a person’s cognitive symptoms, and side-effects, once they start taking a cholinesterase inhibitor. If it doesn’t seem to be helping, it’s reasonable to consider stopping the medication after a few months.

How well does memantine work?

In people with moderate to severe Alzheimer’s, memantine seems to provide some benefits, in terms of slowing the deterioration of Alzheimer’s. But again, the benefit overall seems to be fairly modest.

It’s not at all clear that people with mild to moderate Alzheimer’s benefit from memantine; a 2011 review concluded that the scientific evidence doesn’t support this claim.

Do these medications work for dementias other than Alzheimer’s disease?

These medications have been studied for other forms of dementia, including vascular dementia, Lewy Body dementia, Parkinson’s dementia, and mixed dementia.

(Bear in mind that the older people get, the more common it is to have mixed dementia, and the harder it is to make a specific determination of the underlying cause of dementia.)

Studies generally find that cholinesterase inhibitors are associated with modest improvements in symptoms in these other forms of dementia.

For memantine, some research suggests it can help with vascular dementia, although the benefits again seem to be quite modest.

The effect of memantine on Lewy-Body dementia and Parkinson’s dementia is less clear, with some research suggesting a small benefit but also reports that some people experience worsening hallucinations and delusions with memantine.

Do these medications work for mild cognitive impairment?

Not as far as we know. The research evidence so far indicates that dementia medications do not improve outcomes for mild cognitive impairment.

However, it remains very common for patients with mild cognitive impairment to be prescribed donepezil (brand name Aricept) or another cholinesterase inhibitor.

In principle, this should be done as a trial, meaning that the patient and clinician decide to “try” the medication, see if it’s helping with memory or other thinking difficulties, and stop if it doesn’t appear to be helping.

In practice, many people with mild cognitive impairment end up taking the cholinesterase inhibitor indefinitely. They may be reluctant to stop, but in other cases, it may be that the prescribing doctor doesn’t get around to checking on whether the medication is helping or not.

What are the side-effects of these medications?

Doctors — including geriatricians — consider these medications to be “well-tolerated.” This means that most people don’t experience more than mild side-effects, and serious adverse events are rare.

For cholinesterase inhibitors:

  • The most common side-effects are gastrointestinal and include nausea, diarrhea, and sometimes vomiting. These affect an estimated 20% of people.
  • People tend to adjust to gastrointestinal side-effects with time. It helps to start with a small dose and gradually increase. Rivastigmine is also available in a patch formulation, which tends to cause less stomach upset.
  • In the oral formulations, donepezil tends to cause fewer side-effects than rivastigmine and galantamine.
  • Some people also experience dizziness, a slowed heart rate, headaches, or sleep changes.

For memantine:

  • Dizziness is probably the most common side-effect.
  • Some people seem to experience worsened confusion or hallucinations.
  • Memantine generally seems to cause fewer side-effects than cholinesterase inhibitors do.
Is it common to take more than one medication for dementia at the same time?

It’s quite common for patients to be prescribed a cholinesterase inhibitor plus memantine.

This “combination therapy” has been studied in people with moderate-to-severe Alzheimer’s, and some research suggests a small benefit compared to treatment with just one medication. However, the benefit again appears to be modest at best.

A study of combination therapy in people with mild-to-moderate Alzheimer’s did not show benefit. There is no good research evidence indicating that combination therapy is beneficial in mild Alzheimer’s.

There is no reason to take more than one cholinesterase inhibitor at the same time.

At what point do you stop dementia medications? We’re not sure it’s making a difference.

Many patients and families feel these medications don’t have much effect. This isn’t surprising, since the research results usually find that the effect in most people is small to non-existent.

As cholinesterase inhibitors are “symptomatic” treatment and not disease-modifying, if there’s no sign of improvement after a few months on the maximum dose, many experts agree that it’s reasonable to stop the medication.

That said, as these medications are well-tolerated by most patients and are unlikely to cause harm to anything more than one’s wallet, it’s common for people to remain on cholinesterase inhibitors indefinitely.

As for memantine, this drug is potentially “disease-modifying.” So it may make sense to continue memantine for a few years, even if no improvement is noted by the clinician or family.

Experts generally agree that there’s not much value in continuing either category of medication once a person has reached the stage of advanced dementia, at which point a person is bedbound, unable to speak, and shows little sign of recognizing familiar people.

Do people get worse when they stop dementia medications?

Research suggests that some patients do appear to get worse after stopping cholinesterase inhibitors.

If this appears to be the case, it’s reasonable to resume the cholinesterase inhibitor.

The discontinuation of memantine hasn’t yet been rigorously studied. An observational study of nursing home residents suggested some worsening after stopping memantine.

Do any vitamins help treat dementia?

Vitamin E — which works as an anti-oxidant in the body — has been studied for the treatment of Alzheimer’s, and may be beneficial.

In 2014, a large study of patients with moderate-to-severe Alzheimer’s disease found that daily treatment with 2000 IU/day of Vitamin E resulted in less functional decline than treatment with placebo, memantine, or a combination of memantine and vitamin E.

Of note, since the study was conducted in the VA (Veteran’s Affairs) health system, most participants were men. And again, the benefit seen was modest.

It is not clear that vitamin E helps for milder Alzheimer’s, or mild cognitive impairment. Always talk to a doctor before trying vitamin E for brain health, as vitamin E can increase bleeding risk in some people.

No other vitamins have been shown to slow cognitive decline in Alzheimer’s or other dementias. In particular, although low vitamin D levels have been associated with a risk of developing dementia, no clinical research has shown that treatment with vitamin D helps people maintain cognitive function.

A study of vitamin B supplementation in the treatment of people with mild to moderate Alzheimer’s disease did not show any benefit. Note that participants in this study had normal vitamin B12 levels at baseline; the very common problem of vitamin B12 deficiency in older adults can cause or worsen cognitive problems.

A practical approach to dementia medications

It’s easy to get a bit lost in the weeds, when it comes to medications to treat the cognitive decline of Alzheimer’s and other dementias.

Overall, these are medications that seem to offer only a little — if any — benefit to most people.

They are indeed widely prescribed, because patients are usually anxious to do everything possible to preserve their mental abilities, and because doctors want to be able to offer *something*. And most of the time, they don’t seem to harm patients or cause significant side-effects.

I think it’s reasonable for people to take or try these medications, as long as they are aware of the evidence regarding the usually modest benefit.

So what should you do about medications, if you or your older relative has been diagnosed with Alzheimer’s or another dementia?

If you have already been on dementia medications for a while:

If you aren’t experiencing side-effects, you may want to continue on the medications indefinitely.

But if you are concerned about medication expenses and pill burden, consider a trial of stopping the medication.

After all, the overall benefit of these medications is small. And you can always restart dementia medications if you think the dementia symptoms got worse off the medication.

If you are just starting the dementia journey:

If you are debating whether to start medications for dementia, keep in mind the following points:

  • Only cholinesterase inhibitors are FDA-approved for mild to moderate dementia. You should definitely ask questions if a clinician proposes starting memantine during the early stages.
  • Cholinesterase inhibitors are for symptomatic treatment and do not alter the underlying neurodegeneration. They provide a modest benefit to some people but many people don’t seem to benefit. We are not yet able to tell ahead of time whose symptoms will improve with these medications.
  • A reasonable and careful approach is to work with the doctor on a “trial” of a cholinesterase inhibitor. This means:
    • Carefully documenting cognitive symptoms before starting the medication.
    • Starting the medication at a low dose, and increasing to a full dose over time.
    • Monitoring for side-effects, such as nausea, vomiting, or diarrhea. These do usually get better with time. Consider lowering the dose or switching to a patch formulation if the side-effects are difficult to handle.
    • Working with the clinician to reassess cognitive symptoms after 2-3 months. If no improvement has been noted by the patient, family, or clinician, consider stopping the cholinesterase inhibitor.
Other ways to preserve cognition and brain function in dementia

Here’s the most important thing to keep in mind, when it comes to managing the cognitive decline of Alzheimer’s and other dementias:

Medications are only a small part of the solution.

In fact, there are many non-drug ways to optimize brain function. They work for people who don’t have dementia too, so I’ve listed them in this post: How to Promote Brain Health: The Healthy Aging Checklist Part 1.

If you’re concerned about preserving brain function and delaying cognitive decline, you’ll want to review the ten approaches I cover in the brain health article.

For instance, people often don’t realize that many commonly used medications are “anticholinergic,” meaning they interfere with acetylcholine in the brain and worsen thinking. In other words, these medications essentially have the opposite effect of the cholinesterase inhibitors. Which is not so good for the brain.

In a perfect world your doctors and pharmacists would notice this problem and stop the anticholinergic medications, or at least discuss the pros and cons with you. But as our healthcare system is still highly imperfect, this may not happen unless you ask for a medication review.

Delirium is another common problem that can worsen dementia and often accelerates cognitive decline. So to manage dementia and delay cognitive decline, it makes sense to learn about delirium prevention.

The bottom line on medications to treat dementia

In short: the medications we currently have available to treat Alzheimer’s disease and other medications may help a little. The main harm people experience will be to their wallets. Don’t expect these drugs to work miracles and consider stopping them if you are concerned about drug costs or pill burden.

And above all, don’t forget to think beyond medications, when it comes to optimizing brain function and delaying cognitive decline in dementia.

The post 4 Medications to Treat Alzheimer’s & Other Dementias:
How They Work & FAQs
appeared first on Better Health While Aging.

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Have you ever been told that an older relative has anemia?

Or perhaps you noticed the red blood cell count flagged as “low” in the bloodwork report?

Anemia means having a red blood cell count that is lower than normal, and it’s very common in seniors. About 10% of independently living people over age 65 have anemia. And anemia becomes even more common as people get older.

But many older adults and families hardly understand anemia.

This isn’t surprising: anemia is associated with a dizzying array of underlying health conditions, and can represent anything from a life-threatening emergency to a mild chronic problem that barely makes the primary care doctor blink.

Still, it worries me that seniors and families don’t know more about anemia. If you or your relative has this condition, it’s important to understand what’s going on and what the follow-up plan is. (I’ve so often discovered that a patient didn’t know he or she had had anemia!) Misunderstanding anemia can also lead to unnecessary worrying, or perhaps even inappropriate treatment with iron supplements.

And since anemia is often caused by some other problem in the body, not understanding anemia often means that people don’t understand something else that is important regarding their health.

Fortunately, you don’t have to be a doctor to have a decent understanding of the basics of anemia.

This post will help you understand:

  • How anemia is detected and diagnosed in aging adults.
  • Symptoms of anemia.
  • The most common causes of anemia, and tests often used to check for them.
  • What to ask the doctor.
  • How to get better follow-up, if you or your relative is diagnosed with anemia.

Defining and detecting anemia

Anemia means having a lower-than-normal count of red blood cells circulating in the blood.

Red blood cells are always counted as part of a “Complete Blood Count” (CBC) test, which is a very commonly ordered blood test.

A CBC test usually includes the following results:

  • White blood cell count (WBCs): the number of white blood cells per microliter of blood
  • Red blood cell count (RBCs): the number of red blood cells per microliter of blood
  • Hemoglobin (Hgb): how many grams of this oxygen-carrying protein per deciliter of blood
  • Hematocrit (Hct): the fraction of blood that is made up of red blood cells
  • Mean corpuscular volume (MCV): the average size of red blood cells
  • Platelet count (Plts): how many platelets (a smaller cell involved in clotting blood) per microliter of blood

(For more information on the CBC test, see this Medline page. For more on common blood tests, see Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults.)

By convention, to detect anemia clinicians rely on the hemoglobin level and the hematocrit, rather than on the red blood cell count.

A “normal” level of hemoglobin is usually in the range of 14-17gm/dL for men, and 12-15gm/dL for women. However, different laboratories may define the normal range slightly differently.

A hemoglobin level below normal can be used to detect anemia.  Clinicians often confirm the lower hemoglobin level by repeating the CBC test.

If clinicians detect anemia, they usually will review the mean corpuscular volume measurement (included in the CBC) to see if the red cells are smaller or bigger than normal. We do this because the size of the red blood cells can help point doctors towards the underlying cause of anemia.

Hence anemia is often described as:

  • Microcytic: red cells smaller than normal
  • Normocytic: red cells of a normal size
  • Macrocytic: red cells larger than normal
Symptoms of anemia

The red blood cells in your blood use hemoglobin to carry oxygen from your lungs to every cell in your body. So when a person doesn’t have enough properly functioning red blood cells, the body begins to experience symptoms related to not having enough oxygen.

Common symptoms of anemia are:

  • fatigue
  • weakness
  • shortness of breath
  • high heartrate
  • headaches
  • becoming paler, which is often first seen by checking inside the lower lids
  • lower blood pressure (especially if the anemia is caused by bleeding)

However, it’s very common for people to have mild anemia — meaning a hemoglobin level that’s not way below normal — and in this case, symptoms may be barely noticeable or non-existent.

That’s because the severity of symptoms depends on two crucial factors:

  • How far below normal is the hemoglobin level?
  • How quickly did the hemoglobin drop to this level?

This second factor is very important to keep in mind. The human body does somewhat adapt to lower hemoglobin levels, but only if it’s given weeks or months to do so.

So this means that if someone’s hemoglobin drops from 12.5gm/dL to 10gm/dL (which we’d generally consider a moderate level of anemia), they are likely to feel pretty crummy if this drop happened over two days, but much less so if it developed slowly over two months.

The most common causes of anemia

Whenever anemia is detected, it’s essential to figure out what is causing the low red blood cell count.

Compared to most cells in the body, normal red blood cells have a short lifespan: about 100-120 days. So a healthy body must always be producing red blood cells. This is done in the bone marrow and takes about seven days, then the new red blood cells work in the blood for 3-4 months. Once the red blood cell dies, the body recovers the iron and reuses it to create new red blood cells.

Anemia happens when something goes wrong with these normal processes. In kids and younger adults, there is usually one cause for anemia. But in older adults, it’s quite common for there to be several co-existing causes of anemia.

A useful way to think about anemia is by considering two categories of causes:

  • A problem producing the red blood cells, and/or
  • A problem losing red blood cells

Here are the most common causes of anemia for each category:

Problems producing red blood cells. These includes problems related to the bone marrow (where red blood cells are made) and deficiencies in vitamins and other substances used to make red blood cells. Common specific causes include:

  • Chemotherapy or other medications affecting the bone marrow cells responsible for making red blood cells.
  • Iron deficiency. This occasionally happens to vegetarians and others who don’t eat much meat. But it’s more commonly due to chronic blood loss, such as heavy periods in younger women, or a slowly bleeding ulcer in the stomach or small intestine, or even a chronic bleeding spot in the colon.
  • Lack of vitamins needed for red blood cells. Vitamin B12 and folate are both essential to red blood cell formation.
  • Low levels of erythropoietin. Erythropoietin is usually produced by the kidneys, and helps stimulate the bone marrow to make red blood cells. (This is the “epo” substance used in “blood doping” by unethical athletes.) People with kidney disease often have low levels of erythropoietin, which can cause a related anemia.
  • Chronic inflammation. Many chronic illnesses are associated with a low or moderate level of chronic inflammation. Cancers and chronic infections can also cause inflammation. Inflammation seems to interfere with making red blood cells, a phenomenon known as “anemia of chronic disease.”
  • Bone marrow disorders. Any disorder affecting the bone marrow or blood cells can interfere with red blood cell production and hence cause anemia.

Problems losing red blood cells. Blood loss causes anemia because red blood cells are leaving the blood stream. This can happen quickly and obviously, but also can happen slowly and subtly. Slow bleeds can worsen anemia by causing an iron-deficiency, as noted above. Some examples of how people lose blood include:

  • Injury and trauma. This can cause visibly obvious bleeding, but also sometimes causes people to bleed into a space inside the body, which can be harder to detect.
  • Chronic bleeding in the stomach, small intestine, or large bowel. This can be due to many reasons, some common ones include:
  • Frequent blood draws. This is mainly a problem for people who are hospitalized and getting daily blood draws.
  • Menstrual bleeding. This is usually an issue for younger women but occasionally affects older women.

There is also a third category of anemias, related to red blood cells being abnormally destroyed in the body before they live their usual lifespan. These are called hemolytic anemias and they are much less common.

A major study of causes of anemia in non-institutionalized older Americans found the following:

  • One-third of the anemias were due to deficiency of iron, vitamin B12, and/or folate.
  • One-third were due to chronic kidney disease or anemia of chronic disease.
  • One-third of the anemias were “unexplained.”
How doctors evaluate anemia

Once anemia is detected, it’s important for health professionals to do some additional evaluation and follow-up, to figure out what might be causing the anemia.

Understanding the timeline of the anemia — did it come on quickly or slowly? Is the red blood count stable or still trending down with time? — helps doctors figure out what’s going on, and how urgent the situation is.

Common follow-up tests include:

  • Checking the stool for signs of microscopic blood loss
  • Checking a ferritin level (which reflects iron stores in the body)
  • Checking vitamin B12 and folate levels
  • Checking kidney function, which is initially done by reviewing the estimated glomerular filtration rate (included in most basic bloodwork results)
  • Checking the reticulocyte count, which reflects whether the bone marrow trying to produce extra red blood cells to compensate for anemia
  • Checking levels of an “inflammation marker” in the blood, such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
  • Evaluation of the peripheral smear, which means the cells in the blood are examined via microscope
  • Urine tests, to check for proteins associated with certain blood cell disorders

If the anemia is bad enough, or if the person is suffering significant symptoms, doctors might also consider a blood transfusion. However, although even mild anemia has been associated with worse health outcomes, research suggests that transfusing mild to moderate anemia generally isn’t beneficial. (This issue especially comes up when people are hospitalized or acutely ill.)

What to ask the doctor about anemia

If you are told that you or your older relative has anemia, be sure you understand how severe it seems to be, and what the doctors think might be causing it. This will help you understand the plan for follow-up and treatment.

Some specific questions that can be handy include:

  • How bad is this anemia? Does it seem to be mild, moderate, or severe?
  • What do you think is causing it? Could there be multiple causes or factors involved?
  • How long do you think I’ve had this anemia? Does it seem to be stable or is it getting worse?
  • Is this the cause of my symptoms or do you think something else is causing my symptoms?
  • Could any of my medications be involved?
  • What is our plan for further evaluation?
  • What is our plan for treating this anemia?
  • When do you recommend we check the CBC again? What is our plan for monitoring the anemia?

Be sure to request and keep copies of your lab results. It will help you and your doctors in the future to be able to review your past labs related to anemia and any related testing.

Avoiding common pitfalls related to anemia and iron

A very common diagnosis in older adults is iron-deficiency anemia. If you are diagnosed with this type of anemia, be sure the doctors have checked a ferritin level or otherwise confirmed you are low on iron.

I have actually reviewed medical charts in which a patient was prescribed iron for anemia, but no actual low iron level was documented. This suggests that the clinician may have presumed the anemia was due to low iron.

However, although iron deficiency is common, it’s important that clinicians and patients confirm this is the cause, before moving on to treatment with iron supplements. Doctors should also assess for other causes of anemia, since it’s very common for older adults to simultaneously experience multiple causes of anemia (e.g. iron deficiency and vitamin B12 deficiency).

If an iron deficiency is confirmed, be sure the doctors have tried to check for any causes of slow blood loss.

It is common for older adults to develop microscopic bleeds in their stomach or colon, especially if they take a daily aspirin or a non-steroidal anti-inflammatory drug (NSAIDs) such as ibuprofen. (For this reason — and others — NSAIDs are on the Beer’s list of medications that older adults should use with caution.)

Bear in mind that iron supplements are often quite constipating for older adults. So you only want to take them if an iron-deficiency anemia has been confirmed, and you want to make sure any causes of ongoing blood loss (which causes iron loss) have been addressed.

The most important take home points on anemia in older adults

Here’s what I hope you’ll take away from this article:

1.Anemia is a very common condition for older adults, and often has multiple underlying causes.

2. Anemia is often mild-to-moderate and chronic; don’t let the follow-up fall through the cracks.

3. If you are diagnosed with anemia or if you notice a lower than normal hemoglobin on your lab report, be sure to ask questions to understand your anemia. You’ll want to know:

  • Is the anemia chronic or new?
  • Is it mild, moderate, or severe?
  • What is thought to be the cause? Have you been checked for common problems such as low iron or low vitamin B12?

4. If you are diagnosed with low iron levels: could it be from a small internal bleed and could that be associated with aspirin, a non-steroidal anti-inflammatory medication such as ibuprofen, or another medication?

5. Keep copies of your lab reports.

6. Make sure you know what the plan is, for following your blood count and for evaluating the cause of your anemia.

Do you have questions about anemia in older adults? Please post them below!

You may also find it helpful to read these related articles:
Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults
How to Avoid Harm from Vitamin B12 Deficiency

The post Anemia in the Older Adult:
10 Common Causes & What to Ask
appeared first on Better Health While Aging.

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Q: My mother is 80.  She is very active (despite breaking her hip 2 years ago), she still attends water therapy 3 times a week at the YMCA, she drives to the base (which is 20 miles away) and pays her bills on time.  She is a retired Psych nurse and has shown signs in the past of paranoia. 

Lately, she has “heard” voices of her grandchildren in her home and called my sister. She also has difficulty with getting the right words to say out and has her sleep pattern out of whack and will call people at odd times of the night.  With her independence comes the fact she won’t share any medical information because she thinks we are out to get her committed.  

How can I test her/question her to find out the level of decline she may be in to make sure she is safe? — K

A: Great question. As you may know, it’s fairly common for aging parents to develop problems like the ones you are describing. Understandably, these problems are frustrating and worrying for adult children.

You are absolutely right to be concerned about your mom’s safety. I do have some ideas for how you can get started assessing her, which I share below.

But first I want to explain the most common causes of this type of behavior in older adults. That’s because one of the things you must do is help your mother and the doctors figure out why she’s developed these behavior changes and other symptoms.

A fair number of people don’t get around to the medical evaluation because they assume that these crazy behaviors are either normal aging (definitely false) or dementia such as Alzheimer’s (true about 40% of the time).

Furthermore, it’s often hard to get a resistant older parent medically evaluated.

Still, it’s worth persisting in this, because many causes of paranoia or other odd behavior in older people can be treated.

6 common causes of paranoid symptoms in the elderly

Paranoid symptoms (e.g. believing that someone is out to get you, or is taking your stuff, or is in the house at night) falls into a category of mental symptoms that is technically called “psychosis.”

Symptoms of psychosis can include:

  • Delusions, which means believing things that aren’t true or real.
  • Hallucinations, which means seeing or hearing things that aren’t there.
  • Disorganized thoughts or speech, meaning saying or thinking things that seem illogical or bizarre to others.

Psychosis is uncommon in younger people, but becomes much more common as people get older. That’s because any of these symptoms can emerge when people’s brains aren’t working properly for some reason.

2015 review article on “late-life psychosis” estimates that 23% of people will develop symptoms of psychosis in late life.

I like this review article because the authors organize the causes of late-life psychosis into six “Ds”:

  • Delirium (10 %).
    • This is a very common condition of “worse-than-usual” mental function, often brought on by the stress of severe illness, surgery, or hospitalization. See 10 Things to Know About Delirium for more.
  • Drugs, alcohol, and other toxins (11%)
    • Medication side-effects can cause delusions, hallucinations, or other forms of psychosis. Pay special attention to medications known to affect memory and thinking. Abuse of — or withdrawal from — alcohol or other substances can also cause psychosis symptoms.
  • Disease (10%)
    • Many physical health problems can interfere with brain function. These include electrolyte problems such as abnormal levels of sodium, potassium, calcium, or magnesium in the blood, low levels of vitamin B12 or folate, thyroid problems, severe liver or kidney dysfunction, infections, and neurological diseases. Brain damage from minor strokes can also cause psychosis symptoms.
  • Depression (33%) and other “mood disorders,” including bipolar disease (5%)
    • About 15% of people with major depression may experience psychotic symptoms. Delusions of guilt or deserved punishment are especially common.
  • Dementia (40%), including Alzheimer’s disease, Lewy-Body dementia, and others
    • Delusions are extremely common in dementia, especially delusions of theft, spousal infidelity, abandonment, and persecution. Hallucinations (especially visual hallucinations) are also common, especially in Lewy-Body dementia. For more on how dementia is diagnosed, see How We Diagnose Dementia: The Practical Basics to Know.
  • Delusional disorder (2%) and schizophrenia-spectrum disorders (1%)
    • These two conditions have many symptoms that overlap with those of dementia, delirium, or other conditions affecting thinking. Doctors must exclude these more common conditions before diagnosing a person with schizophrenia or delusional disorder. Schizophrenia affects an estimated 0.1-0.5% of people over age 65. Many were diagnosed earlier in life but some people can develop the condition later in life. Delusional disorder affects an estimated 0.03% of older adults.

The authors of this review article also note that it’s common for older adults to have vision and hearing problems, both of which can trigger or worsen delusions and hallucinations.

So as you can see, when older adults experience delusions, hallucinations, and paranoid thoughts, there is almost always something more going on with their health. Figuring out what is beneath the “crazy” or “irrational” or “paranoid” behavior is key.

Hence I recommend you keep these six causes  of paranoid symptoms in mind, as you try to find out more about how your mom has been doing.

How to check on “levels of decline” and safety

It’s great for you to be proactive and want to help check on your mother safety and situation. Ultimately you’ll need to work with professionals, but you can speed the process along by checking for common red flags, and bringing them to the attention of your mother’s doctor.

As a geriatrician, I generally try to assess an older person in the following five domains:

  • Ability to manage key life tasks
    • These include the ability to manage Activities of Daily Living (key tasks we usually learn as young children, such as walking, dressing, feeding ourselves, and toileting) and also Instrumental Activities of Daily Living (key tasks we learn as teenagers, such as managing finances, transportation, meal preparation, home maintenance, etc).
  • Safety red flags
    • This includes signs of financial vulnerability or exploitation, risky driving, leaving the stove on, wandering, or signs of elder abuse.
  • Physical health red flags
    • These include weight loss, declines in strength or physical abilities, falls, frequent ER visits, and complaints of pain.
  • Mood and brain health red flags
    • These include common signs of depression (especially sadness and/or loss of interest in activities), signs of loneliness or isolation, new or excessive worrying, as well as other signs of memory and thinking problems
  • Medication management red flags
    • These include signs of difficulty taking prescriptions as directed, checking on possible medication side-effects, and identifying medications that are on the Beer’s list of medications that older people should avoid or use with caution.

Because concerned family members often ask me about checking on an older parent, I created a guide with five checklists based on the five sections above: The Checking Older Parents Quick Start Guide.

You can print the guide and use the checklists to spot these red flags that often represent serious safety or health problems.

Now, no guide is going to enable you to diagnose your parent. And no guide can guarantee that you’ve identified and addresses the most important safety issues. You’ll need to work in person with professionals to do that.

But by being methodical in observing your mom and in documenting your observations, you will make it much easier for professionals to figure out why your mother has developed these behaviors you are concerned about.

Also, by identifying specific red flags or problem areas, you’ll be better equipped to work with your mom and other family members on addressing safety concerns. That’s because it’s much more effective to focus on issues that are specific and concrete (“I noticed that you seem to be having trouble with your grocery shopping), rather than simply telling an aging parent that you are worried about their safety.

Tips on following up on safety issues and memory problems

Once you’ve identified safety issues and signs of underlying health problems, you’ll want to follow up. You’ll need health professionals to help evaluate and manage any underlying health problems, and you may find you need help from other types of experts as well.

If your older parent is paranoid and resisting your involvement, this often becomes a stuck spot for families.

How to get unstuck depends on the situation. Here are some ideas that often help:

  • Relay your concerns to your parent’s doctor. The doctor needs to know about the symptoms and problems. The doctor may also be able to persuade your older parent to accept some help, or even the presence of another family member during medical visits.
    • Patient privacy laws (e.g. HIPAA) do not prevent families from providing information to a person’s doctor over that person’s objections.
    • The doctor will probably not disclose health information to you but may do so under certain circumstances. That’s because when a patient is “incapacitated”, doctors are allowed to disclose relevant health information to family members, if they feel it’s in the best interest of the patient. For more on when health providers may disclose information to family members, see 10 Things to Know About HIPAA & Access to a Relative’s Health Information.
    • If you send your concerns in writing, they will probably be scanned into the medical record.
    • Also ask if any social work services are available through your parent’s health provider.
  • Contact organizations that support older adults and families, for assistance and for referrals. Some good ones to try include:
    • Your local Area Agency on Aging; find it using the locator here.
    • Family Caregiver Alliance. The navigator showing state-by-state services is especially nice.
    • Local non-profits serving seniors and families. Try using Google to find these.
  • Get help from a geriatric care manager (now known as aging life care professionals) or other “senior problems” expert. This usually requires paying out-of-pocket, but can enable more hands-on assistance than is usually available through social workers and non-profits.
    • The ideal person will be good at difficult conversations with older adults, will be able to help you communicate with doctors if necessary, and will know what local resources are available to address any safety or living issues you detect.
  • Get advice from other adult children who have faced similar situations. You can find caregiving forums and message boards online, where people share ideas on getting through these challenges.
    • There’s an active forum of people caring for older relatives at AgingCare. You can find a lot of ideas and support there. However, most such forums have minimal moderation from professionals, so you should double-check on any medical, legal, or financial advice you get.
    • Daughterhood.org is a website and community for people helping older parents. Look to see if they have a local “Circle” near you.

When it comes to contacting the doctor and hiring an expert to help, it’s best if you can get your mom’s agreement before proceeding. (Or at least, not have her explicitly forbid you from doing these things). Here are some tips to help with your conversations:

  • Use “I” statements as much as possible. “I’ve noticed you’ve been calling people during the night. I’ve noticed you sometimes have difficulty with your words. I’m concerned and I’ve heard it’s important to have such symptoms evaluated by a doctor, because they can be due to treatable medical problems.”
  • Frame any suggestions you make as a way to help your mother achieve her goals. For most older adults, these include living at home for as long as possible, maintaining good brain function and physical function, and otherwise remaining as independent as possible.
  • Avoid relying on logic. Logic never works well when it comes to emotionally-charged subjects. And it especially doesn’t work if people are experiencing any difficulties with memory or thinking. So don’t expect your mom to be logical and don’t rely on logical arguments to convince her.

For more suggestions on approaching a parent who is resistant to help, see this article: “4 Things to Do When Your Parents Are Resisting Help.”

Now, if you find it causes your mother intense anxiety or agitation to discuss your concerns and your suggestions for helping her, it may be reasonable to just proceed. After all, you do have reasons to believe that some kind of health issue is affecting her thinking.

So especially if you’ve identified any safety problems, it’s reasonable to move ahead despite her preference that you not intervene.

In closing, I’ll reiterate that this is a very tough situation to navigate, and it usually takes time and persistence for families to make headway. Do try to take care of yourself as you work through this. Connecting with others facing similar challenges is a great way to get support and practical ideas on what to do next.

You may also want to listen to these two related podcast episodes, in which experts (an eldercare attorney and a geriatric care manager) offer advice on situations similar to the one you are in:

Solving Hard Problems in Helping Aging Parents

Helping Reluctant Parents Address Memory Concerns

 Good luck! Please feel free to post follow-up questions below.

The post 6 Causes of Paranoia in Aging & What to Do appeared first on Better Health While Aging.

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Q: I realize that I sometimes have difficulty connecting a name and a face.  I presume that this is mild cognitive impairment.

On researching the topic online, I find a variety of suggestions for alleviating it.  These include supplements (lipoic acid, vitamin E, omega 3s, curcumin), food choices (fish, vegetables, black and green teas), aerobic exercise, yoga, and meditation. 

Do these actually help with mild cognitive impairment? What’s been proven to work?

A: It’s common for older adults to feel they’re having trouble with certain memory or thinking tasks as they get older.

I can’t say whether it’s mild cognitive impairment (MCI) in your particular case. But we can review what is known about stopping or slowing cognitive changes in people diagnosed with MCI.

First, let’s start by reviewing what MCI is, and how it’s diagnosed. Then I’ll share some information on the approaches you are asking about, as well as other approaches for treating MCI.

What is Mild Cognitive Impairment?

Mild cognitive impairment (MCI) means having cognitive abilities (memory and thinking skills) that have become worse than “normal” for your age. However, the impairments can’t be bad enough to meet the criteria for dementia.

It’s important to have your memory and thinking skills assessed by a clinician. This is how you can find out if your difficulties fall within the range of “normal age-related changes” versus being worse than normal, which is a criterion for having MCI.

If you’re concerned about your memory, you should investigate further. But be careful about assuming your symptoms are MCI.

Many older people feel that their memory or thinking is getting worse. However, this doesn’t necessarily mean they have MCI.

This is because declines in certain types of memory and thinking skills are now known to be part of normal “cognitive aging.”

In fact, difficulty connecting “names and faces” is a common complaint among normal older adults. It’s probably due to the known slowing in brain processing speed that occurs as people age.

As of 2013, MCI is also called “mild neurocognitive disorder” whereas dementia has been renamed “major neurocognitive disorder.” While you might not need to know these more technical terms, it may save some confusion if you are reading about newer research. (Most practicing doctors still use the older terms however.)

Experts believe that some people with MCI are essentially in the very earliest stage of a disease such as Alzheimer’s or another type of dementia. Studies suggest that over 5 years, 30-40% of people with MCI will progress to dementia.

However, that’s only 30-40% of people. So not all MCI is early dementia. Some people with MCI never seem to get much worse, and some even seem to get better.

How is mild cognitive impairment diagnosed?

MCI is diagnosed through a clinical assessment done by a qualified doctor or other healthcare professional.

A clinical assessment should usually include:

  • Interviewing the patient regarding his concerns, and inquiring about difficulties managing life tasks
  • Assessing whether family members and other observers have noticed anything concerning
  • Evaluating cognitive abilities using a short office-based test, such as the Montreal Cognitive Assessmenttest
  • Checking prescribed and over-the-counter medications, to see if any are known to make thinking worse (see 4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory)
  • Evaluating for medical conditions, including mental health conditions and sleep disorders, that can worsen thinking or can mimic early dementia

Laboratory work is often necessary, to check for problems such as thyroid disorders, vitamin B12 deficiency, and electrolyte imbalances.

After this initial assessment, a person might be referred for additional neuropsychological testing. These tests provide a more in-depth assessment of specific memory and thinking skills. They can help further categorize MCI as “amnestic” (meaning the problems are mainly with memory) versus non-amnestic.

Ultimately, the process of diagnosing MCI is similar to diagnosing dementia: it requires documenting concerns and difficulties, objectively assessing cognitive abilities, and ruling out other medical problems (including medication side-effects and delirium) that might be interfering with brain function.

But in MCI, the cognitive impairments should not be severe enough to interfere with daily life.

What are proven ways to treat mild cognitive impairment?

In many clinical trials, the goal in “treating” mild cognitive impairment has been to reduce the risk of progression to Alzheimer’s or another dementia.

Unfortunately, almost nothing has been proven to work, although some approaches are promising.

In particular, no medications are FDA-approved for the treatment of MCI, as none have been shown to prevent progression to dementia.

If you’d like more information, the Canadian Medical Association Journal published: “Treatment for mild cognitive impairment: a systematic review and meta-analysis” in 2015.

Exercise for MCI

The approach I consider most promising is exercise, although it’s unclear which exercise is best. One randomized study showed an improvement in patients doing different exercises, another indicated that resistance training helped.

A sensible approach is to include all important types of exercise. That is: aerobic, resistance, balance, and flexibility exercises.

Although it may not be clear which one is best for MCI, all four are necessary to maintain overall health and mobility in older adults.

You can learn more about the four types of exercise at the National Institute on Aging’s site Go4Life.

Dietary approaches for MCI

There is research to suggest that diet plays a role in dementia. However, it’s not yet clear what particular diet will prevent MCI progressing.

I personally agree with the common-sense approach that a diet that is good for overall health is likely to be good for brain health.

If you’d like to read about nutrition studies in detail, I recommend Dr. Michael Greger’s book “How Not to Die.” It covers relevant nutrition research on brain health and many other aspects of health.

One of my favorite clinical nutrition trials is titled the “Cocoa, Cognition, and Aging (CoCoA) Study.” In 2012 the researchers published the results of a study in which they found that giving people with MCI a daily cocoa drink led to improved cognitive function and insulin metabolism eight weeks later.

Now, we still don’t know if daily cocoa would change the likelihood of having dementia a few years later. But it’s a promising result, and you can learn about more such promising foods in Dr. Greger’s book.

Supplements for MCI

Some researchers found that  a vitamin B supplement (a combination of folic acid, vitamin B6, and vitamin B12) reduces cognitive decline in MCI. But this may only be in people who have high homocysteine levels.

(Homocysteine is a common amino acid – one of the building blocks that make up proteins – found in the blood. High levels have been associated with low intake of folate and vitamin B12.)

large trial published in 2005 found that vitamin E had no effect on the progression of MCI.

A variety of other anti-oxidants have been studied, but so far nothing seems to be definitely beneficial. (A review can be found here.)

Medications for MCI

There are currently no medications that have FDA approval for the treatment of MCI.

Some medications have been trialed but have not been shown to prevent the progression of MCI. These include medications such as donepezil, galantamine, and rivastigmine (brand names Aricept, Razadyne, and Exelon, respectively.

One 2012 review published by the respected Cochrane Library concluded that these types of medicines ” should not be recommended for mild cognitive impairment.”

However, many doctors prescribe these medications to people with MCI, especially if they have amnestic MCI. In theory, this might help mitigate some of the memory symptoms.

But if a person with MCI doesn’t notice some improvement after starting the medication, they should not be surprised. And they should not feel obligated to continue the medication.

Yoga and meditation for MCI

Stress tends to worsen brain function. So it’s possible that stress-reducing activities like yoga or meditation might help in MCI.

Yoga has mainly been studied in older adults with “normal” cognition. Results suggest yoga can benefit cognition but further research is recommended.

Meditation may improve MCI. A small study found that mindfulness-based stress reduction was associated with encouraging brain changes on functional MRI scans.

Brain training for MCI

People sometimes wonder if “brain training” can keep MCI from progressing to dementia. So far this is unknown.

Much of the brain training research has studied whether the intervention improves memory and cognitive function in the short-term. (A review is here, and yes, some brain training seems to improve certain cognitive abilities in the short-term.)

My main recommendations for managing MCI

The bottom line is that no treatment has been convincingly proven to improve long-term outcomes in MCI. So I think it’s best to focus on general things that promote brain health.

That is:

  • Avoid brain-slowing medications
  • Avoid chronic sleep-deprivation
  • Avoid delirium
  • Pursue positive social activities, purposeful activities, and activities that “nourish the soul”
  • Find constructive ways to manage chronic stress (consider meditation or yoga)
  • Seek treatment if you have signs of depression or chronic anxiety
  • Stay physically active and exercise regularly
  • Address risk factors for cardiovascular disease
  • Consider the Mediterranean diet (or other healthy eating approaches)

For more information on these common-sense brain health approaches (which are generally good for physical health and healthy aging), see “How to Promote Brain Health: The Healthy Aging Checklist, Part 1.”

If you’re worried you might have MCI

You can see that this is a complex area. Mild cognitive impairment is not as simple to diagnose as diabetes, nor is it as easy to treat.

However, it’s just as important to see a doctor.

It’s great to be proactive and promote brain health through Don’t make assumptions about your brain health. That’s a huge risk.

Instead, if you have signs of MCI, make sure you get evaluated by a professional. See your doctor.

You can promote brain health (start by reviewing the approaches I recommend in the Healthy Aging Checklist Part 1.)

They can check what other factors may be affecting your memory and thinking. They can support you and help you find answers to your questions. They can help you manage your symptoms and provide peace of mind.

So don’t sit, and wait, and worry.

Pick up the phone and make an appointment. Make sure they check for medication side-effects and other medical problems that can worsen thinking. And make sure they know if you’ve been having trouble with finances, driving, or other life tasks.

And then if you are diagnosed with MCI, you can come back to this article for a refresher on what approaches are most promising, when it comes to treatment.

The post Q&A: What Can I Do to Treat Mild Cognitive Impairment? appeared first on Better Health While Aging.

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Q: I realize that I sometimes have difficulty connecting a name and a face.  I presume that this is mild cognitive impairment.

On researching the topic online, I find a variety of suggestions for alleviating it.  These include supplements (lipoic acid, vitamin E, omega 3s, curcumin), food choices (fish, vegetables, black and green teas), aerobic exercise, yoga, and meditation. 

Do these actually help with mild cognitive impairment? What’s been proven to work?

A: It’s common for older adults to feel they’re having trouble with certain memory or thinking tasks as they get older.

I can’t say whether it’s mild cognitive impairment (MCI) in your particular case. But we can review what is known about stopping or slowing cognitive changes in people diagnosed with MCI.

First, let’s start by reviewing what MCI is, and how it’s diagnosed. Then I’ll share some information on the approaches you are asking about, as well as other approaches for treating MCI.

What is Mild Cognitive Impairment?

Mild cognitive impairment (MCI) means having cognitive abilities (memory and thinking skills) that have become worse than “normal” for your age. However, the impairments can’t be bad enough to meet the criteria for dementia.

If you’re concerned about your memory, it’s important that you not assume it’s MCI. Instead, you’ll want to have your thinking skills assessed by a clinician. This is how you can find out if your difficulties fall within the range of “normal age-related changes” versus being worse than normal, which is a criterion for having MCI.

Studies find that many older people feel that their memory or thinking is getting worse. However, this doesn’t necessarily mean they have MCI.

This is because declines in certain types of memory and thinking skills are now known to be part of normal “cognitive aging.”

In fact, difficulty connecting “names and faces” is a common complaint among normal older adults. It’s probably due to the known slowing in brain processing speed that occurs as people age.

As of 2013, MCI is also called “mild neurocognitive disorder” whereas dementia has been renamed “major neurocognitive disorder.” While you might not need to know these more technical terms, it may save some confusion if you are reading about newer research. (Most practicing doctors still use the older terms however.)

Experts believe that some people with MCI are essentially in the very earliest stage of a disease such as Alzheimer’s or another type of dementia. Studies suggest that over 5 years, 30-40% of people with MCI will progress to dementia.

However, that’s only 30-40% of people. So not all MCI is early dementia. Some people with MCI never seem to get much worse, and some even seem to get better.

How is mild cognitive impairment diagnosed?

MCI is diagnosed through a clinical assessment done by a qualified doctor or other healthcare professional.

A clinical assessment should usually include:

  • Interviewing the patient regarding his concerns, and inquiring about difficulties managing life tasks
  • Assessing whether family members and other observers have noticed anything concerning
  • Evaluating cognitive abilities using a short office-based test, such as the Montreal Cognitive Assessment
  • Checking prescribed and over-the-counter medications, to see if any are known to make thinking worse (see 4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory)
  • Evaluating for medical conditions, including mental health conditions and sleep disorders, that can worsen thinking or can mimic early dementia

Laboratory work is often necessary, to check for problems such as thyroid disorders, vitamin B12 deficiency, and electrolyte imbalances.

After this initial assessment, a person might be referred for additional neuropsychological testing. These tests provide a more in-depth assessment of specific memory and thinking skills. They can help further categorize MCI as “amnestic” (meaning the problems are mainly with memory) versus non-amnestic.

Ultimately, the process of diagnosing MCI is similar to diagnosing dementia: it requires documenting concerns and difficulties, objectively assessing cognitive abilities, and ruling out other medical problems (including medication side-effects and delirium) that might be interfering with brain function.

But in MCI, the cognitive impairments should not be severe enough to interfere with daily life.

What are proven ways to treat mild cognitive impairment?

In many clinical trials, the goal in “treating” mild cognitive impairment has been to reduce the risk of progression to Alzheimer’s or another dementia.

Unfortunately, almost nothing has been proven to work, although some approaches are promising.

In particular, no medications are FDA-approved for the treatment of MCI, as none have been shown to prevent progression to dementia.

If you’d like more information, the Canadian Medical Association Journal published: “Treatment for mild cognitive impairment: a systematic review and meta-analysis” in 2015.

In January of 2018, the American Academy of Neurology issued their “Practice guideline update summary: Mild cognitive impairment. They suggest that clinicians recommend regular exercise and say they “may recommend cognitive training.” They make a stronger recommendation for stopping medications that interfere with cognition, and they reiterate that “no high-quality evidence exists to support pharmacologic treatments for MCI.”

Exercise for MCI

The approach that seems most promising is exercise, although it’s unclear which exercise is best. One randomized study showed an improvement in patients doing different exercises, another indicated that resistance training helped.

A sensible approach is to include all important types of exercise. That is: aerobic, resistance, balance, and flexibility exercises.

Although it may not be clear which one is best for MCI, all four are necessary to maintain overall health and mobility in older adults.

You can learn more about the four types of exercise at the National Institute on Aging’s site Go4Life.

Dietary approaches for MCI

There is research to suggest that diet plays a role in dementia. However, it’s not yet clear what particular diet will prevent MCI progressing.

I personally agree with the common-sense approach that a diet that is good for overall health is likely to be good for brain health.

If you’d like to read about nutrition studies in detail, I recommend Dr. Michael Greger’s book “How Not to Die.” It covers relevant nutrition research on brain health and many other aspects of health.

One of my favorite clinical nutrition trials is titled the “Cocoa, Cognition, and Aging (CoCoA) Study.” In 2012 the researchers published the results of a study in which they found that giving people with MCI a daily cocoa drink led to improved cognitive function and insulin metabolism eight weeks later.

Now, we still don’t know if daily cocoa would change the likelihood of having dementia a few years later. But it’s a promising result, and you can learn about more such promising foods in Dr. Greger’s book.

Supplements for MCI

Some researchers found that  a vitamin B supplement (a combination of folic acid, vitamin B6, and vitamin B12) reduces cognitive decline in MCI. But this may only be in people who have high homocysteine levels.

(Homocysteine is a common amino acid – one of the building blocks that make up proteins – found in the blood. High levels have been associated with low intake of folate and vitamin B12.)

large trial published in 2005 found that vitamin E had no effect on the progression of MCI.

A variety of other anti-oxidants have been studied, but so far nothing seems to be definitely beneficial. (A review can be found here.)

Medications for MCI

There are currently no medications that have FDA approval for the treatment of MCI.

Some medications have been trialed but have not been shown to prevent the progression of MCI. These include medications such as donepezil, galantamine, and rivastigmine (brand names Aricept, Razadyne, and Exelon, respectively).

One 2012 review published by the respected Cochrane Library concluded that these types of medicines ” should not be recommended for mild cognitive impairment.”

However, many doctors prescribe these medications to people with MCI, especially if they have amnestic MCI. In theory, this might help mitigate some of the memory symptoms.

But if a person with MCI doesn’t notice some improvement after starting the medication, they should not be surprised. And they should not feel obligated to continue the medication.

Yoga and meditation for MCI

Stress tends to worsen brain function. So it’s possible that stress-reducing activities like yoga or meditation might help in MCI.

Yoga has mainly been studied in older adults with “normal” cognition. Results suggest yoga can benefit cognition but further research is recommended.

Meditation may improve MCI. A small study found that mindfulness-based stress reduction was associated with encouraging brain changes on functional MRI scans.

Brain training for MCI

People sometimes wonder if “brain training” can keep MCI from progressing to dementia. So far this is unknown.

Much of the brain training research has studied whether the intervention improves memory and cognitive function in the short-term. A 2016 review found that brain training seems to improve certain cognitive abilities in the short-term.

My main recommendations for managing MCI

The bottom line is that no treatment has been convincingly proven to improve long-term outcomes in MCI. So I think it’s best to focus on general things that promote brain health.

That is:

  • Avoid brain-slowing medications
  • Avoid chronic sleep-deprivation
  • Avoid delirium
  • Pursue positive social activities, purposeful activities, and activities that “nourish the soul”
  • Find constructive ways to manage chronic stress (consider meditation or yoga)
  • Seek treatment if you have signs of depression or chronic anxiety
  • Stay physically active and exercise regularly
  • Address risk factors for cardiovascular disease
  • Consider the Mediterranean diet (or other healthy eating approaches)

For more information on these common-sense brain health approaches (which are generally good for physical health and healthy aging), see “How to Promote Brain Health: The Healthy Aging Checklist, Part 1.”

If you’re worried you might have MCI

You can see that this is a complex area. Mild cognitive impairment is not as simple to diagnose as diabetes, nor is it as easy to treat.

However, it’s just as important to see a doctor. So don’t make assumptions if you notice changes in memory or thinking. That’s a huge risk.

Instead, if you have signs of MCI, make sure you get evaluated by a professional. See your doctor.

You can promote brain health (start by reviewing the approaches I recommend in the Healthy Aging Checklist Part 1.)

They can check what other factors may be affecting your memory and thinking. They can support you and help you find answers to your questions. They can help you manage your symptoms and provide peace of mind.

So don’t sit, and wait, and worry.

Pick up the phone and make an appointment. Make sure they check for medication side-effects and other medical problems that can worsen thinking. And make sure they know if you’ve been having trouble with finances, driving, or other life tasks.

And then if you are diagnosed with MCI, you can come back to this article for a refresher on what approaches are most promising, when it comes to treatment.

The post Q&A: How to Diagnose & Treat Mild Cognitive Impairment? appeared first on Better Health While Aging.

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Have you been concerned about high blood pressure (hypertension)? Or are you worried about an older relative having a stroke or heart attacks?

You’re not alone. After all, hypertension is the most common chronic condition among older adults, and medications for blood pressure (BP) are among the most commonly taken drugs in the US.

Even more important: poorly controlled hypertension is a major contributor to the most common causes of death and disability in older adults: strokes, heart attacks, and heart failure.

So it’s certainly sensible for older adults – and for those helping aging parents – to think about blood pressure.

And once you start thinking about high blood pressure, you’ll probably start to wonder.

Are the blood pressure medications you’re taking enough? Is your blood pressure at the “right” level or should you and your doctors work on changing things?

And what about that major research – the SPRINT trial — that made the news in 2015? (In this study, older adults randomized to aim for a lower BP did better than those who got “standard” BP treatment.)

These are excellent questions to ask, so I’d like to help you answer them.

Now, I can’t provide exact answers on the Internet. But what I can do is provide a sensible process that will help you successfully address these questions.

In this article, I’ll share with you the process that I use to:

  1. Assess an older person’s blood pressure management plan, and
  2. Determine whether we should attempt changes.

If you’re an older adult, you can use this approach to get started assessing your own BP management plan. This will help you to better work with your doctors on assessing and managing your blood pressure.

If you are helping an older relative manage health, you can follow these steps on behalf of your relative.

But first, let’s review a few key terms related to blood pressure.

Key terms about blood pressure and hypertension:
  • Systolic blood pressure (SBP): the “top number” when BP is checked. This reflects the pressure in the arteries when the heart squeezes. It’s by far the most important number to consider when it comes to older adults.
  • Diastolic blood pressure (DBP): the “lower number” when BP is checked. This reflects the pressure in the arteries when the heart relaxes.
  • Pulse: the heart rate. Automatic BP monitors report pulse along with BP. Doctors must evaluate a person’s heart rate when considering a change in BP medication.
  • Hypertension: Usually defined as BP> 140/90, assuming the readings are taken in a doctor’s office. (There is a slightly lower cut-off if the readings are taken at home.) If only the systolic BP is high, this is called “isolated systolic hypertension.” This type of hypertension is very common in older adults, as aging is associated with both increases in systolic BP and decreases in diastolic BP.
How to better measure blood pressure

As you can imagine, a key component of optimizing BP management is to measure an older person’s BP and pulse.

Measuring BP allows us to:

  • Diagnose people with hypertension,
  • Determine how severe it is (which helps us all decide how important it is to intervene),
  • Evaluate how well people are responding to a treatment plan, whether that plan involves lifestyle changes or medication or both.

Measuring BP usually sounds straightforward.

People assume it’s just a matter of finding out what the BP was at the doctor’s office, or getting a reading from a home monitor, or maybe even a reading from a health fair or drugstore.

But in fact, research has shown that a single office-based BP reading often does not represent a person’s usual BP. One study even found that the “usual” way of measuring BP misdiagnosed 24-32% of volunteers!

This is because people are often anxious when at the doctor’s office, which can temporarily raise BP. Studies estimate this “white-coat hypertension” affects 10-20% of people.

Furthermore, BP is constantly changing a bit, moment to moment. So experts agree that it’s much better to obtain several readings and average them, in order to properly assess a person’s usual BP.

For instance, in the ground-breaking SPRINT trial of intensive BP lowering in older adults, the researchers checked BP by having participants first rest quietly in a room for five minutes. Then an automatic monitor checked BP three times in a row, with a one-minute interval between each check. The average of these three readings was then used to assess BP and make changes to hypertension medications, if necessary.

As you can imagine, this is not the way most people’s blood pressure is measured by their doctors.

So what’s better?

Currently, the “gold standard” for evaluating blood pressure is called “ambulatory blood pressure monitoring” (ABPM). It involves wearing a special monitor that checks BP every 15-60 minutes over 24 hours. The doctors then receive a report showing the average daytime BP and average nighttime BP.

Such monitoring provides excellent information for patients and doctors. In fact, research shows that ABPM is a better predictor of future cardiovascular events (e.g. heart attacks, strokes) than conventional office-based BP measurements are. However, ABPM is not yet widely available, since it requires special equipment and may not be covered by insurance.

So what is considered next best? Research shows that home BP measurements are better than “usual-care” office BP measurements. Meaning, home BP measurements correlate better to the BP that is measured if one uses the fancy 24-hour ambulatory monitoring approach.

Based on these facts, in 2008 the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association issued a joint scientific statement calling for home BP measurements to become a routine component of BP measurement in people with known or suspected hypertension.

They also suggested that clinicians review a week’s worth of home BP readings before making a clinical decision or changing a person’s medications.

(You can read the whole scientific statement, titled Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring for free! I especially recommend reading the abstract at the beginning, which summarizes the proven benefits of home blood pressure monitoring.)

Now that I’ve made the case for checking BP carefully at home, let me share the six-step process you can use to assess your blood pressure management plan.

A 6 step process for assessing a blood pressure management plan

1.Obtain a high-quality home blood pressure monitor.

Why: Studies have found that home-based measurements are better than office-based BP measurements. They better reflect a person’s BP over 24 hours.

Notes: See “Choosing & Using a Home Blood Pressure Monitor” for more details on choosing a monitor, and why I recommend a monitor such as the Omron 786N.

2. Check blood pressure twice a day, every day for one week.

Why: Since blood pressure is constantly changing a bit — or sometimes a lot — in the body, checking several days in a row means that you’ll have several readings that can be averaged.

Aim to check at the same times every day. An average of several daily readings provides a more accurate picture of a person’s BP.

Checking in the morning and evening is recommended by many experts. This is because BP can vary during the day, especially in people who are taking BP medications. But if checking twice a day seems too hard, just check once a day.

Experts also often say to check BP in the morning before any medications are taken. However, if there have been any concerns about falls, I like to review readings taken about an hour after medication. This is because I want to make sure the BP isn’t falling too low when a person takes their medication.

Optional but helpful: Use a “three measurements in a row” technique if possible. The SPRINT trial measured BP by letting participants rest quietly for five minutes, and then having the monitor check the BP three times in a row, with a one minute pause between each check. Those three readings were then averaged into a reading for the day.

Some home blood pressure monitors (such as the Omron 786N) have a feature that makes this easy to do; Omron calls this feature “TruRead.”

3. Make an up-to-date list of all current medications.

Why: Your doctors will need to know exactly what medications you are taking, in order to evaluate your blood pressure treatment plan.

Notes:

  • Start by listing those for heart or BP.
  • But list all others, because some medications that are not prescribed for BP can still affect BP (such as Flomax, which can be used to improve urination when a man has an enlarged prostate).
  • Also list all supplements, vitamins, herbs, and over-the-counter medications.
  • Be sure to note if any medication is not being taken exactly as prescribed. It’s especially important for the doctors to know if an older person has been skipping any of the medications that affect BP.
  • Note any concerns about side-effects, cost, or other concerns related to continuing the medication.

4. List the lifestyle approaches to lowering BP that you are following (or interested in).

Why: Although prescription medications are the main way doctors often try to treat hypertension, many lifestyle changes have been shown to help lower BP as well.

You’ll want to let your doctor know which of these you are using. Also let your doctor know if you’d be interested in incorporating any of these into your BP management plan.

Many of these lifestyle changes are great for older adults, because they benefit health in many ways but have fewer risks than taking prescription medication.

Note: Proven approaches to lower high blood pressure include:

5. Make an appointment to discuss blood pressure management with your usual doctor.

Why: Your doctor can help you identify a good target blood pressure goal, and can help you develop a plan to reach that goal. Be sure to bring up any concerns regarding falls, or other potential side-effects of treatment.

Notes:

  • Bring in your home BP readings and your up-to-date medication list.
  • Consider asking the doctor to check BP sitting and standing, especially if you’ve had any concerns about falls
  • Ask your doctor what target BP goal they recommend for you, given your health history.
    • Research indicates that the biggest benefit is in getting systolic BP down to the 140s. A systolic BP target goal of <150 is a good starting place for most older adults, as recommended by major guidelines in 2013 and also by more recent high blood pressure guidelines issued in 2017.
    • Results from SPRINT suggest that if you’re similar to the SPRINT participants, you may experience additional benefits by aiming for a systolic BP close to 120. If you’re considering this, be sure to read my article explaining SPRINT and related research, so that you’ll have a clear understanding of how likely you are to benefit (at best, an estimated 1 in 27 chance based on the research) and what are the risks and burdens.

6. Plan to follow-up on any changes to the plan.

Why: Whatever you and your doctors decide to do, you’ll want to make a plan for seeing how your blood pressure responds to the changes.

Note: Remember that experts say a week’s worth of home BP monitoring is more accurate than a follow-up BP check in the office.

Be sure to ask your doctor to specify:

  • When should you undertake this home monitoring? (Most BP medications will take their full effect within 1 week. Lifestyle changes will take weeks to months to have an effect.)
  • When will you be meeting — by phone or in person — to discuss the results of the follow-up BP monitoring?
  • What level of high (or low) BP should trigger a call to the office?

And that’s it!

Make the effort

Now, this approach is more work than usual. It takes a little more time and effort than just going to your doctor and having them check your blood pressure.

But the benefits make this time well spent. Think about it.

You and your doctor get a more accurate picture of what is going on inside your body.

You get to help create a blood pressure management plan that is just right for you.

You may even help prevent some serious health problems. Like a heart attack or stroke, or a serious fall due to incorrect medication.

No one likes the thought of letting a chronic condition get dangerously out of control. And no one likes to take more medication than they need to.

You can help keep this from happening.

Just follow this process for assessing a blood pressure management plan, and you’ll be on your way to confirming that you’re following a blood pressure management plan that’s right for you, or for your older parent.

The post 6 Steps to Better High Blood Pressure Treatment for Older Adults appeared first on Better Health While Aging.

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In another article, I’ve explained the key reasons that I recommend older adults and their caregivers have a blood pressure (BP) monitor at home.

To very briefly recap:

  • Many of the problems of older adults (including falls) can be related to blood pressure.
  • Home blood pressure measurements can help:
    • evaluate for drops in blood pressure with standing (a common cause of dizziness in elders)
    • check for serious illness, since these often (but not always) cause the blood pressure and pulse to be very different from usual
    • follow-up on blood pressure after a change in medication, which can help doctors and families figure out the best medication dosing for an older person much faster. This is safer for seniors.

In this post, I’ll share some tips on choosing and using a home BP monitor.

And don’t worry: I won’t tell you that you have to plan on checking every day for the rest of your lives. Although there are times when it’s great to check daily — like the week after a change in medication — the most important thing is to have a good BP monitor at home and know how to use it at least occasionally.

Tips for choosing a home blood pressure monitor

Here are the most important criteria to consider when choosing a BP monitor:

  • Is it easy to get accurate readings?  Accurate and reliable readings are key. To find an accurate BP meter for home:
    • Get an automatic digital monitor. Although manual cuffs are available, these require more training to use properly.
      • A good quality digital monitor will usually be more accurate and easier to work with over time.
    • Choose a monitor with a cuff that measures at the upper arm.
      • Wrist and finger cuffs tend to give inaccurate readings if the body position isn’t “just-so.”
    • Pick a BP monitor that has good reviews from Consumer Reports or another reputable non-profit organization.
      • Customer ratings at Amazon and other big online stores can also be helpful.
    • Plan to bring the BP monitor to the doctor’s office, so that staff can compare the monitor’s reading to their own clinic monitor. This is a good way to check the cuff’s accuracy.
  • Is the arm cuff properly-sized? It’s absolutely essential to have a cuff that is the right size for the person’s arm. Cuffs are usually available in sizes small, standard, and large.
    • A cuff that is too small will give readings that are falsely high, while a cuff that is too big will give readings that are falsely low.
    • According to the Mayo Clinic: “The inflatable part of the blood pressure cuff should cover about 80% of the circumference of your upper arm. The cuff should cover two-thirds of the distance from your elbow to your shoulder.”
    • To purchase a cuff, start by measuring the older person’s arm around the bicep area, using a cloth measuring tape.
      • 7-9 inches –> small cuff
      • 9-13 inches –> standard cuff
      • 13-17 inches –> large cuff
      • more than 17 inches –> ask the doctor for help finding an extra-large cuff, or even a “thigh cuff”
  • Is it easy to log the readings and share with the doctor? Remember, you’ll get a lot more help from a home BP monitor if it’s easy to log the readings and share the information with doctors or nurses when necessary.
    • Most digital BP monitors will store a certain number of readings in the monitor; some can even store readings for two different people.
      • But readings stored within the monitor can be hard to share with the doctor, so families often still log the blood pressure readings by hand.
    • Some BP monitors can connect to your home computer, so that the readings can be downloaded.
      • Check user reviews to make sure that most people have found this feature easy to use.
    • A few BP monitors can connect via Bluetooth to a smartphone, which is very convenient when it works well.
      • You can Google “bluetooth blood pressure monitor” and pick a one that has good user reviews. In general, there seem to be more monitors available for connecting to iPhone/iPad than to Android phones or computers.
  • Can the older person’s doctor recommend a home BP monitor? Although many doctors aren’t prepared to recommend a specific kind of home BP monitor, some primary care clinics are starting to regularly recommend home BP monitoring. See if your healthcare team can suggest a specific home device that they are used to working with.
A home blood pressure monitor I recommend (with caveats)

For a long time, I didn’t recommend a particular home blood pressure monitor to readers or even my own patients. This was mainly because although a number of well-reviewed digital BP monitors were available, most of them did not connect to phones or computers very easily.

However, I’ve recently been testing an Omron Bluetooth-enabled home BP monitor, and although it has some flaws, I feel it’s good enough to recommend.

The particular model I’ve been trying is the Omron 786N, and it’s currently available on Amazon for $65.

Features I like:

  • Omron is a reliable well-known brand of BP monitors, and their professional line is often used by doctors. I checked this digital monitor against my manual BP cuff and got the same reading.
  • “TruRead” features checks blood pressure three times in a row and then presents an average of the three readings. Since blood pressure is constantly changing a bit, this probably gives a more accurate measurement to record. Of note, this approach was part of the study protocol for the SPRINT study of standard vs intensive hypertension management in older adults. (I recommend setting the machine to allow 60-120 secs between each check.)
  • BP monitor transfers readings to smartphone app (iOS or Android) via Bluetooth.  Once the readings have been transferred to the Omron Wellness app, the readings can be emailed to another person. For those with an iPhone, the Wellness app can reportedly be configured to send results to your phone’s Apple Health app. Last but not least, BP and pulse data can also be viewed online, by logging into OmronWellness.com.
  • “Easy-Wrap ComFit Cuff” is easy to put on and position correctly. This BP monitor comes with a preformed cuff that accommodates arms 9-17 inches in circumference. I found the preformed cuff easy to put on, and the size range means this cuff should accommodate most older adults. (People who are extremely thin or quite obese may need to order a different cuff.

Flaws and problems with this Omron 786N monitor:

  • No option for adding comments to a reading. This is a problem with the Omron Wellness app rather than the device itself, but it still seems an important issue to mention. It would be much better if users could add notes to a reading. Important contextual information to note includes:
    • Whether the person was standing during the BP measurement, as we often recommend people check BP sitting and standing if we’re concerned about orthostatic BP changes. (This means BP drops signficantly when a person stands, and can increase fall risk.)
    • Whether a BP medication had recently been changed.
    • Whether the older person was feeling unwell at the time BP was checked, or whether the person was having palpitations or other heart-related symptoms.
  • No easy integration with personal health record systems. Although the Omron Wellness app apparently can transfer data to the iPhone Health app, this particular BP monitor does not easily transmit data to Microsoft Healthvault or other health information systems, as best I can tell.
  • Data export feature does not yield data that can be imported into other programs. Omron does offer the option of exporting the BP/pulse data as a “.csv” or Excel file. But when I tried this, I was unable to import it into a program like Microsoft Healthvault. When I reviewed the export files, I noticed that the export mixes numbers and letters in the same cell. (This is a no-no in data management.)

I am disappointed by the fact that one can’t add notes to a reading or export the data in a meaningful way. Still, the Wellness app does allow one to print a table of results or even email it. So even though one can’t import the BP data to another computer, at least this device should make it easier to share readings with one’s family and clinicians.

Tips for using a home blood pressure monitor

In general, when I advise families on using a home BP monitor, we cover three key topics: proper technique, when in the day to check, and how often every week to check.

  • Proper technique: The most important things to keep in mind are the position of the arm, and relaxing.
    • The upper arm with the BP cuff should be positioned at about the level of the heart (upper chest). A good way to do this is to have the older person sit in a chair, and rest the arm on a table nearby.
    • Don’t have the person hold their arm up and out. The arm with the cuff should be fairly relaxed. This sometimes means another person has to hold the arm up at the level of the upper chest.
    • Check the blood pressure when the person is quiet and relaxed. Talking, exercising, or getting revved up can increase the blood pressure.
  • When in the day to check: The conventional wisdom often suggests checking in the morning, before taking medication. However, because overtreatment of high blood pressure is such a common problem in the elderly, I often suggest that people check BP about an hour after taking any blood pressure medication.
    • If the older person is taking blood pressure medication, consider checking BP about an hour after the medication is taken, especially if there has been any concern about falls, dizziness, or poor balance.
      • Also consider checking the blood pressure sitting and standing if there has been any concern for falls. (See this post for more details on the common problem of blood pressure dropping with standing.)
    • Be sure to record what time of day the BP is checked. If you are monitoring BP regularly for a few days or weeks or even indefinitely, try to check at the same time(s) every day.
  • How often to check: You could certainly check every day, or even several times every day. But I find that caregivers and older adults often find checking BP tiresome…they usually have lots of other things to do! So how often to check depends on a) what’s going on with the person’s health, and b) what’s feasible for the elder and caregiver.
    • If the health issues seem stable and there have been no recent medication changes, consider checking BP once a week. This will provide some “baseline” information, so that when a health issue crops up, the doctors will be able to tell if a change in blood pressure seems related to the new or worsened symptoms.
    • If a blood pressure medication has been changed, or if you are worried about an older person’s health, try checking at least once a day for 7 days.
What to discuss with the doctor

Just how should you use a home BP monitor to improve an older person’s health without too much hassle? The best approach is to ask the doctor for some advice, because in the end it really depends on the particular health circumstances of every patient.

The goal, after all, of collecting BP data at home, is to gather information that can help the doctors help you. (And to help the doctors spot problems — like postural changes in blood pressure — that they might not otherwise notice in a busy clinic visit.)

Here are some questions you can ask the doctor:

  • “We have a home blood pressure monitor. How often would you recommend we check my mother’s blood pressure?”
  • “What time of day do you think it would be most useful for us to check her blood pressure?”
  • “Do you think it’s likely to help if we check her home BP every day indefinitely? Or would it be ok if we just check once per week?”
  • “We’re a little concerned because she occasionally falls or feels unsteady. Do you think it’s possible  that she might be on a little higher dose of blood pressure medication than she needs? Would it be helpful if we checked her BP sitting and standing for a few days?”
  • “We’ve been checking her BP sitting and standing over the past few days, and we noticed that the standing BP is often quite a bit lower. Couldn’t this lead to falls? Would it be possible for us to try lowering her BP medication a bit?”
  • “We’re having trouble checking the BP every day…we’re just a bit overwhelmed by things. How much should we prioritize checking BP every day? Could we perhaps check less often?”
Key take-home points

A home BP monitor is a very useful tool for older adults, and I always recommend families get one and learn to use it.

When choosing a home BP monitor, look for a well-reviewed digital BP machine that measures BP in the upper arm. Be sure to get a properly sized arm cuff, and have the accuracy of the machine checked at the doctor’s office.

Do think about how you will log the BP readings and share with the doctor. Consider a BP monitor that can send the readings to your smartphone or computer. At the very least, you may need to write down the BP numbers on a paper log (easier for you to do) or in a spreadsheet (easier for the doctors to assess).

The Omron 786N home blood pressure monitor is a good choice, as it is reliable, easy to use, and provides a Bluetooth connection for easy transfer of readings to the Internet.

In this post I offer some suggestions on what time of day to check, and how often. But the best is to talk to the older person’s doctor, to set up a plan that is a good fit for the older person’s medical situation (and still manageable for you!).

For more on better blood pressure management in older adults, see my post “What the New Blood Pressure Guidelines — & Research — Mean for Older Adults.”

The post Choosing & Using a Home Blood Pressure Monitor, & What to Ask the Doctor appeared first on Better Health While Aging.

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