79 year old mother refuses to train. 79 year old mother refuses to train. - Page 5

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Thread: 79 year old mother refuses to train.

  1. #41
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    Quote Originally Posted by Pluripotent View Post
    The most important aspect of a blood pressure medication is half-life. I generally use the American Society of Hypertension guidelines, slightly adjusted to fit individual patient needs. They write the board exam for HTN, and their recd are very different from the standard practice, which is what you are on (we forgot to mention the ubiquitous - and terrible - hydrochlorothiazide.

    The basic algorithm is this: start with an ARB (not losartan, it is worst-in-class). Skip ACE inhibitors completely because ARBs are better anyway and there is a not insignificant chance of life threatening angioedema with ACEi, also other side effects such as cough, which ARBs don't share. Olmesartan and telmisartan are good (because of long half-life and greater target receptor activity (fewer side effects).) If another drug is required, a calcium channel blocker is next (pretty much only choice is amlodipine). Next up is a thiazide diuretic (not HCTZ). Generally chlorthalidone, which is what most of the research was done with anyway (very few studies used HCTZ, so using it is not evidence based, which is supposed to be what people care about, but then they all go and use HCTZ - and it has a shit ton of side effects). Next up would be an aldosterone antagonist, such as spironolactone or eplerenone (which has the added benefit of countering the potassium wasting effects some people experience with thiazides. Only if all this is still not working do you add a beta-blocker (not metoprolol!) You want one with alpha effect for peripheral vasoconstriction, such as carvedilol (and at this point you would also be screening them for aldosteronism.)

    These are the guidelines. Of course this is not medical advice, because internet and I might not even be a doctor. So there you have it.
    Quote Originally Posted by David Kirkham View Post
    Damn. I'm on both lisinopril and metoprolol. Losartan made my heart race and gave me anxiety. It was horrible. (I now understand how bad that is when someone says they had an anxiety attack--glad that's in the rear view mirror).

    Any other BP suggestions I might want to inquire with my doctor about?

    Thanks!
    Pluripotent's post is an excellent summary, but if I recall correctly from meeting you at our seminar you have some additional medical history that has implications for your choice of medication. In other words, you (personally) aren't being treated for "just" hypertension.

  2. #42
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    Quote Originally Posted by Austin Baraki View Post
    Pluripotent's post is an excellent summary, but if I recall correctly from meeting you at our seminar you have some additional medical history that has implications for your choice of medication. In other words, you (personally) aren't being treated for "just" hypertension.
    Thanks for posting Austin. I really appreciate it. Thank you for teaching me how to dead lift! I still use your, "Chest to the wall!" cue. (Matt stills yells that one at me every couple of days.)

    I had a heart attack in 2013 at age 46. I am 50 now. It was a 100% blockage of the LAD and left diagonal at the fork. Strangely, my troponin level was only slightly elevated--it was either 0.2 or 2 and came right back down after the stent. I don't remember the exact level now. (As a side note, my father had an identical heart attack a year ago, though he was 80 yrs old, and suffered quite a bit of damage.)

    Nothing came back in any of my lab reports except a slightly enlarged ascending aorta, 4.4-4.6 cm. Everything else was normal--EKG, ultrasound, echo-cardiogram, angiogram (with the exception of the blocked artery he opened up with a stent). The surprised cardiologist said, "You must have unbelievable collateral circulation." I smiled, "Strong people are harder to kill."

    I don't know of any residual effects (except mental effects when I am under a heavy bar because a heart attack messes with you for a long time). The only thing I am really dealing with right now is hypertension which my nephrologist (a customer of mine, thank goodness) thinks is mostly aggravated by the radiculopathy in my left arm/shoulder. Rip thinks the pain might be Thoracic Outlet Syndrome and I think he is right. It sucks because it kills my bench. At least I can still press relatively pain free if I warm up properly.

    I sincerely appreciate any comments and do realize this is only an informal internet forum and anything said here is nothing more than an "idea for me to maybe research and talk about with my own doctor." Of course, that doctor very well may be you next week

  3. #43
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    Quote Originally Posted by Austin Baraki View Post
    Pluripotent's post is an excellent summary, but if I recall correctly from meeting you at our seminar you have some additional medical history that has implications for your choice of medication. In other words, you (personally) aren't being treated for "just" hypertension.
    Thanks. It is well rehearsed. I generally go over this with a colleague several times a month. And I used to teach the interns this when I was a resident, since you probably know what they were learning from the attendings. It's like the only meds that exist are hctz, metoprolol and lisinopril. And if those don't work, then goddammit, he's resistant! Time to start oral hydralazine and clonidine!

    The biggest study in hypertension lately was the renal denervation trials (and no one's heard of it!). A few years ago, everyone thought renal denervation was going to be the next big thing in resistant hypertension. So they designed a trial to study it. They got all these resistant hypertensives signed up and the plan was to randomize them into a medication arm and a renal denervation arm. But first, they decided to see if they were really resistant. So, they basically did the above algorithm on everyone. Problem was, once they got everyone on good meds, there weren't enough resistant hypertensives to do the trial anymore! They had to cancel the study and now nobody talks about renal denervation. The whole idea of clipping their nerves died once they put people on decent meds! Amazing. But still, no one knows about it and everyone keeps prescribing the same crap! Isn't it odd that something as ubiquitous as hypertension, which should be the bread and butter of any PCP and just basic knowledge is so misunderstood? It's unbelievable.

    In residency I had a clinic patient who was built like a football player. Huge black guy. Very muscular. He was in his late twenties and his kidneys were dying because no one could control his hypertension. I tried to get him on decent meds, but my attending wouldn't let me start anything I suggested, even though what he was on wasn't working. Instead, we referred him to a nephrologist, and guess what he put him on? He's black, so obviously blacks need to be on shit meds because reasons. (If you separate for race (self reported race because otherwise that would make the researchers eugenicists) in studies that were never designed to answer that question, then feed it into a meta-analysis -- ahhhhhh -- (that's a boys choir singing ahhhhhh in falsetto), the result is that blacks do better on shit meds, so shut up.) So obviously, he got put on clonidine and hydralazine, as well as metoprolol and whatever other 6th line hypertension medication they could find. I saw him after this and he was still uncontrolled. I expect he is probably on dialysis by now. Could I have prevented this? I don't know. Maybe. But the attendings wouldn't even let me try.

    I would also add that I would not necessarily stop meds if a patient is already on something that is working and they are happy with it. There is such a thing as mild hypertension that doesn't take much to control. You could make the argument that we really want to avoid the swings in blood pressure that short half-life meds produce (i.e. morning hypertension), since this is likely worse than a more steady elevated blood pressure, and you'd be right. And all the meds that are commonly prescribed have pretty short half-lives. But, pick your battles, I guess.

    It's also hard for me to change people's meds around as a hospitalist, since it's really an outpatient issue. So I really only do it if the meds they are on are clearly not working and I'm tired of the nurses calling me about it. Probably gets changed back anyway once that see their doc again. But sometimes they are between docs, and still on meds from a doc they will never see again. Then I can just go nutz.

  4. #44
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    Quote Originally Posted by Pluripotent View Post
    Thanks. It is well rehearsed. I generally go over this with a colleague several times a month. And I used to teach the interns this when I was a resident, since you probably know what they were learning from the attendings. It's like the only meds that exist are hctz, metoprolol and lisinopril. And if those don't work, then goddammit, he's resistant! Time to start oral hydralazine and clonidine!
    You need to get in touch with me. Through the Greysteel website. Please.

  5. #45
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    My thoughts on this have already come up on this forum in one way or another but I'll still post my two cents.

    It can be very challenging for more in-the-know ( or just more motivated) physicians to make meaningful changes within the confines of today's health care system. Fortunately there is currently a pretty strong push for and acceptance of exercise prescriptions up here in Canada but they generally do not involve strength training, especially not to the level that SS would entail.

    As a young doc who has recently taken over a practice from an old school doc with questionable practice habits, implementing strength training with my patients is one of several projects on the go. You mean I shouldn't be on these benzos + other sleep aids + narcotics + multiple other sedating/anticolinergic drugs, don't need regular physical exams and routine BW + see specialists for poorly worked up (actually take a history and use some clinical reasoning), (non) issues?... I liked my old doc and he knew what he was doing! This adds another layer of complexity to the lack of patient by-in.

  6. #46
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    Quote Originally Posted by Theban93 View Post
    On the other hand, do you guys think there's hope for someone who does not believe in pseudo-medical bullshit and actually wants to train, but is simply too lazy to do it?
    That depends, is there anyone who has more influence on her than you do? I know for me, there was no way I was ever going to convince my mom to do it. But I did convince my dad. After a couple years of him lifting, my mom started lifting as well. Now she's proud of what she can lift, so she's definitely sticking with it.

  7. #47
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    I also can report success -- both my mom and dad have been training for over a year now. Mom recently deadlifted 200 lbs (66 years old). I was lucky in that they live walking distance from a SSC.

  8. #48
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    Quote Originally Posted by Pluripotent View Post
    The most important aspect of a blood pressure medication is half-life. I generally use the American Society of Hypertension guidelines, slightly adjusted to fit individual patient needs. They write the board exam for HTN, and their recd are very different from the standard practice, which is what you are on (we forgot to mention the ubiquitous - and terrible - hydrochlorothiazide.

    The basic algorithm is this: start with an ARB (not losartan, it is worst-in-class). Skip ACE inhibitors completely because ARBs are better anyway and there is a not insignificant chance of life threatening angioedema with ACEi, also other side effects such as cough, which ARBs don't share. Olmesartan and telmisartan are good (because of long half-life and greater target receptor activity (fewer side effects).) If another drug is required, a calcium channel blocker is next (pretty much only choice is amlodipine). Next up is a thiazide diuretic (not HCTZ). Generally chlorthalidone, which is what most of the research was done with anyway (very few studies used HCTZ, so using it is not evidence based, which is supposed to be what people care about, but then they all go and use HCTZ - and it has a shit ton of side effects). Next up would be an aldosterone antagonist, such as spironolactone or eplerenone (which has the added benefit of countering the potassium wasting effects some people experience with thiazides. Only if all this is still not working do you add a beta-blocker (not metoprolol!) You want one with alpha effect for peripheral vasoconstriction, such as carvedilol (and at this point you would also be screening them for aldosteronism.)

    These are the guidelines. Of course this is not medical advice, because internet and I might not even be a doctor. So there you have it.
    Thank you very much for posting this.

    My mother-in-law has been off and on lifting for a while now (she's currently back at it Sully!). One of the things that has kept her from being as consistent as she should be is pain in her legs and some dizziness. A couple months ago my wife (an RN) brought up the possibility to her that some of this could be related to her BP meds, but she has remained on the same regimen. They were over for dinner last night and she was taking her BP meds with dinner, so I asked which one it was. She said it was metoprolol and that sounded familiar from reading your post ,so I pulled up the thread. Sure enough it was one of the ones you said to avoid. I just emailed her copies of your posts and a link to the American Society of Hypertension guidelines. Hopefully that will be enough to get her working with her doctor to get her on a better regimen, if she even needs to be treated. I don't remember how high her blood pressure was, but it may not have been over 150/90.

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