Hypertension Guidelines for Elderly

Blood pressure (hypertension) recommendations have been swinging back and forth for a number of decades. It seems that the people in power at the time decide the level and some are not considering the age and individuality, but determine what they want only.

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) jointly developed this guideline to present the evidence and provide clinical recommendations based on the benefits and harms of higher versus lower blood pressure targets for the treatment of hypertension in adults age 60 years or older. The target audience for this guideline includes all clinicians, and the target patient population includes all adults age 60 years or older with hypertension.

Going back in history, at first we said, don’t lower the blood pressure because you will decrease perfusion to vital organs and cause strokes, etc. Then it was “the lower the better” and that we should be aiming for presyncopal blood pressures. Then the ACCORD study came and 120 mm Hg was not clearly better than 135 mm Hg, so we said maybe “lower is not always better.” Then the SPRINT study came along and a BP of 120 mm Hg was better for CV events and death. Hence, the confusion and debate continues.

Since most diabetes patients do not die from diabetes but from cardiovascular disease causing strokes and heart attacks, we need to pay special attention in patients with diabetes.

This paper evaluated 21 studies of intensive blood pressure treatment. With treating BP to less than 150/90 mm Hg, nine trials had high-strength evidence that that there was a reduction in mortality, cardiac events, and stroke.

For BP less than or equal to 140/85 mm Hg, there were six studies that showed benefit with reductions in cardiac events and stroke, but a non-significant reduction in deaths.

What is the takeaway message from the two large studies, ACCORD and SPRINT? It could be that we should treat our patients gently and to avoid hypotension. Targeting below 150/90 mm Hg is clearly beneficial. Targeting below 140/85 mm Hg has benefits, but the law of diminishing returns kicks in at the lower end. The good news is that it is safe.

The studies did not emphasize the concept of measuring blood pressure outside the office to see if it is spiking out in the real world. This will help identify the white coat and masked hypertensive patients and may also tell us if medications are reducing blood pressures for the full 24 hours.

These are all important issues that could affect the outcomes of our hypertensive patients.

So there were 3 guidelines issued:

#1) ACP and AAFP recommend that clinicians initiate treatment in adults age 60 years or older with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events. (Grade: strong recommendation, high-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults age 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

#2) ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in adults age 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for recurrent stroke. (Grade: weak recommendation, moderate-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults age 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

#3) ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in some adults age 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for stroke or cardiac events. (Grade: weak recommendation, low-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

This guideline is based on a systematic review of published randomized, controlled trials for primary outcomes and observational studies for harms only.

How Blood Glucose Affects Your Body

For once WebMD is using numbers other than what the American Diabetes Association (ADA) recommends for blood glucose levels (they still list what the

ADA recommends, but at the end of the article).

When you have diabetes, your blood glucose levels may be consistently high. Over time, this can damage your body and lead to many other problems.

How much sugar in the blood is too much? And why is high glucose so bad for you? Here’s a look at how your levels affect your health.

What is the WebMD blood glucose recommended levels? They're less than 100 mg/dl after fasting for at least 8 hours. And they're less than 140 mg/dl 2 hours after eating.

During the day, levels tend to be at their lowest just before meals. For most people without diabetes, blood sugar levels before meals hover around 70 to 80 mg/dl. For some people, 60 is normal; for others, 90.

What's a low sugar level? It varies widely, too. Many people's glucose won't ever fall below 60, even with prolonged fasting. When you diet or fast, the liver keeps your levels normal by turning fat and muscle into sugar. A few people's levels may fall somewhat lower.

Doctors use these tests to find out if you have diabetes:

• Fasting plasma glucose test. The doctor tests your blood sugar levels after fasting for 8 hours and it’s higher than 126 mg/dl.

• Oral glucose tolerance test. After fasting for 8 hours, you get a special sugary drink. Two hours later your sugar level is higher than 200.

• Random check. The doctor tests your blood sugar and it’s higher than 200, plus you’re peeing more, always thirsty, and you’ve gained or lost a significant amount of weight. He’ll then do a fasting glucose level test or an oral glucose tolerance test to confirm the diagnosis.

Any glucose levels higher than normal are unhealthy. Levels that are higher than normal, but not reaching the point of full-blown diabetes, are called prediabetes.

According to the American Diabetes Association, 86 million people in the U.S. have this condition, which can lead to diabetes if you don't make healthy lifestyle changes that your doctor recommends. It also raises the risk for heart disease, although not as much as diabetes does. It's possible to keep prediabetes from becoming diabetes with diet and exercise.

Why are high blood glucose levels bad for you? Glucose is precious fuel for all the cells in your body when it's present at normal levels. But it can behave like a slow-acting poison.

• High sugar levels slowly erode the ability of cells in your pancreas to make insulin. The organ overcompensates and insulin levels stay too high. Over time, the pancreas is permanently damaged.
• High levels of blood sugar can cause changes that lead to a hardening of the blood vessels, what doctors call atherosclerosis.

Almost any part of your body can be harmed by too much glucose. Damaged blood vessels cause problems such as:

• Kidney disease or kidney failure, requiring dialysis
• Strokes
• Heart attacks
• Vision loss or blindness
• Weakened immune system, with a greater risk of infections
• Erectile dysfunction
• Nerve damage, also called neuropathy, that causes tingling, pain, or less sensation in your feet, legs, and hands
• Poor circulation to the legs and feet
• Slow wound-healing and the potential for amputation in rare cases

Keep your blood glucose levels close to normal to avoid many of these complications. The American Diabetes Association's goals for blood glucose control in people with diabetes are 70 to 130 mg/dl before meals, and less than 180 mg/dl after meals.

The FDA Needs Revision

The current FDA needs revision and a house cleaning, top to bottom. An article in Fee.Org lays out the reasons – FDA says pop-tarts are healthier than avocados.

According to the Food and Drug Administration (FDA), Frosted Flakes cereal and Pop Tarts are healthy foods, but foods containing large amounts of nuts are not. However, the FDA might be changing its tune.

Currently, in order to use the term “healthy” on a product’s packaging, the product in question must not exceed three grams of fat. However, this means products like almonds and avocados, which both have enormous health benefits, would be considered, “unhealthy” by the FDA’s standards.

Due largely to government diet guidelines issued in the 70s, “low fat” diets became a huge trend in the 80s and 90s, as many believed that fats found in food were responsible for weight gain. In the past several years, scientific advances have cast doubt on this paradigm, to say the least. Even Time Magazine recently ran a cover proclaiming, "Eat Butter. Scientists Labeled Fat the Enemy. Why They Were Wrong."

Not all fats are created equal. For example, the fats found in foods like nuts and avocados are incredibly healthy for you. However, thanks to the FDA standards, these healthy fats cannot be marketed to consumers as “healthy” products.

Given what we now know about fats, the FDA is considering revising its definition of “healthy.” The catalyst for this change is the company KIND, whose gluten-free bars contain large amounts of nuts, thus making its fat content too high to be deemed “healthy” under current FDA standards. The company would like to market its products as “healthy,” but have been unable to do so.

After the FDA reprimanded the company for putting “healthy and tasty” on their labels, KIND pushed back. After receiving a complaint from the company, the FDA decided it might be time to make some changes to their definition of “healthy.”

"We are pleased that the FDA is looking into" revising its definition, says Daniel Lubetzky, the CEO of KIND bars.

Other health experts have chimed in on the “great fat debate” as well. Thomas Sherman, an associate professor at Georgetown University, who teaches courses to medical students on nutrition, said, "Nuts have healthy fats ... that we know are good for cardiovascular health and mental health and are good sources of protein.” He continued, "Nuts are a wonderful component of our diet."

Although this is certainly not the first time government science has been found to be inaccurate, one thing that is certain, the FDA’s current definition of “healthy” is absolutely nuts.

Diabetes Psychosocial Care

The American Diabetes Association (ADA) is for doctors, but recently has published a position statement focused on aspects of psychosocial care in type 1 and type 2diabetes, published in Diabetes Care. Based on current diabetes research and recommendations from mental and behavioral health professionals, these comprehensive guidelines are a first from the ADA.

Deborah Young-Hyman, PhD, of the Office of Behavioral and Social Science Research at the US National Institutes of Health (NIH) in Bethesda, Maryland, and colleagues authored the position statement, which focuses on “the most common psychological factors affecting people with type 1 and type 2 diabetes,” according to an ADA press release.

“Providing care for the mental and physical health of people with diabetes simultaneously will improve both outcomes,” said Dr Young-Hyman in an email interview with Endocrinology Advisor. “It is not expected that any one clinician can provide all services. The biggest challenge is capacity: the need for more mental health providers who are knowledgeable about living with and managing the disease.”

Dr Young-Hyman added that topics were chosen based on a number of criteria: “The impact of psychosocial factors on people's ability to manage the disease (i.e., carry out self-management behaviors essential to achieving good outcomes); the prevalence of comorbid psychological conditions in the [type 1 and type 2 diabetes] populations; and the state of the evidence and expert opinion regarding standards of care and best practices.”

The guidelines focus on some of the most common psychological issues facing patients with diabetes: diabetes distress, depression, anxiety, and eating disorders. Additionally, the authors emphasize the role that self-management plays in successful care.

“Suboptimal self-management may be due to functional limitations (e.g., blindness, problems with dexterity, low health literacy and numeracy), lack of appropriate diabetes education…disruption of routines, or psychosocial barriers such as inadequate family and/or social support [or] misinformation,” the authors wrote, adding that clinicians caring for people with diabetes should evaluate patient needs on an individual basis to tailor solutions to specific problems.

“Providing care for the mental and physical health of people with diabetes simultaneously (integrated care) will improve both outcomes,” added Dr Young-Hyman when speaking with Endocrinology Advisor. “It is essential to put together a care team, with the patient at its center.”

Clinically significant psychopathology in people with diabetes can interfere with a person's ability to successfully carry out even basic self-management tasks. A 2016 study published in Diabetes Care revealed that in adults with type 2 diabetes, overall exposure to depression contributes to negative medical and psychiatric outcomes.

Participants in this study experienced an average of 1.8 episodes of major depressive disorder (MDD) with a mean duration of 23.4 months. Although analysis showed that median episode duration and recovery time decreased with each subsequent episode, the clinical burden of MDD in type 2 diabetes indicates the need for “consistent and progressive treatment” to prevent adverse consequences.

Similarly, anxiety disorders — including generalized anxiety disorder, body dysmorphic disorder, and post traumatic stress disorder — adversely affect people with type 1 and type 2 diabetes. Review of behavioral Risk Factor Surveillance System data published in Diabetic Medicine revealed that the estimated prevalence of generalized anxiety disorder in people with type 1 or type 2 diabetes is 19.5%; specific concerns include fears related to hyper- and hypoglycemia, not meeting blood glucose targets, fear of insulin injections or infusions, and complications.

Low Vitamin B12 from Metformin Use

This topic is worth repeating. Many doctors do not believe patients when they are asked to be tested for low vitamin B12 deficiency. More studies are confirming this to be true. The one weakness is the length of time a patient has been taking metformin and the dosage taken for what length of time.

One of our support group members has been taking the maximum dosage of about 2250 mg for five years and has now been tested for vitamin B12 deficiency. He does not remember the amount, but said his doctor gave him a shot and had him back the following week for a second shot. He is now taking a supplement of 1000 mg daily. His doctor has said in another three months that he will be tested again to see if he needs another shot.

The doctor has asked him to move to insulin, but has allowed him to delay this until his next vitamin B12 test. He is talking to the rest of us taking insulin and Allen is talking to him because of his experience with vitamin B12 deficiency. Several others have encouraged him to no ignore the doctor as he is a veteran and his cost for insulin will be affordable.

Researchers found that those at risk for low vitamin B12 levels are often not properly monitored. According to a study published in the Journal of the American Geriatrics Society, long-term metformin use is significantly associated with lower serum vitamin B12 levels, but those at risk often are not monitored for this deficiency.

Researchers conducted a retrospective cohort study to evaluate the association between long-term metformin therapy and monitoring serum vitamin B12 at a single Veterans Affairs Medical Center (VAMC) from 2002–2012. Veterans aged over 49 years with either type 2 diabetes receiving long-term metformin therapy (n=3,687) or veterans without diabetes and no metformin prescription (n=13,258) were included in the study.

Long-term metformin therapy was defined as a prescription for greater than or equal to 500mg daily for greater than or equal to 6 consecutive months. The study showed that only 37 percent of older adults with diabetes receiving metformin were tested for vitamin B12 levels after long-term metformin prescription. The average B12 concentration was significantly lower in the metformin-exposed group vs. those without diabetes (439.2pg/dl vs. 522.4pg/dl; P=0.0015)

Also, about 7 percent of patients with diabetes receiving metformin were considered vitamin B12 deficient (less than 170pg/dl) vs. 3 percent of patients without diabetes or metformin exposure (P=0.001).

After adjusting for gender, race, ethnicity, body mass index, and number of years treated at the VAMC, patients using metformin were 2–3 times more likely not to be tested for vitamin B12 status vs. those not exposed to metformin based on their age.

Since metformin is first-line therapy for treating type 2 diabetes, "clinical decision support should be considered to promote serum B12 monitoring among long-term metformin users for timely identification of the potential need for B12 replacement," concluded study author Vijaya Kancherla, PhD.

Sugar Is the Diabetes Problem

If you have someone that is constantly reminding you not to eat sugar, then tell him or her that they are also eating a lot of sugar. When they say they aren't, ask them if they are eating processed foods. If they claim that they are only eating real foods and raw foods, then ask if they are using salad dressings on their salads. If they say they only use olive oil and vinegar, then you may need to drop the topic.

Learn that sugar is not always bad and may be preferable to other sweeteners. When you read labels, always be on the look out for other sugars, particularly corn sugar, corn syrup, corn solids, and high fructose corn syrup. In addition, be on the lookout for hidden sugars. Many food manufacturers have added sugars that are not listed because they are below the amount requiring listing in the ingredients.

An alphabetical listing can be found here for the 56 names for sugar. I have this listed in my bookmarks because my wife and I had a long discussion about sugars recently. We needed to look up a few to better understand what they were and she even asked a nurse that she works with about a couple. Even she was not familiar with the name.

This listing is different than many I have seen and groups them by class of sugar. The discussion about the sugars is very interesting and they list common problems for many of the sugars. Again, I have this bookmarked and really enjoy reading it. This is something that I also refer to when reading the ingredient list and labels of foods that occasionally purchased.

If you are interested in finding listings of the different sugars, search on this - “names for other sugars” and bookmark your preferences.

Added sugar may be the single unhealthiest ingredient in the modern diet. On average, Americans eat about 15 teaspoons of added sugar each day, although sources vary on the exact figure.

Most of this is hidden within processed foods, so people don’t even realize they’re eating it. All this sugar may be a key factor in several major illnesses, including heart disease and diabetes.

Sugar goes by many different names, so it’s very difficult to figure out how much a food actually contains. During processing, sugar is added to food to enhance flavor, texture, shelf life or other properties.

Added sugar is usually a mixture of simple sugars such as glucose, fructose or sucrose. Other types, such as galactose, lactose and maltose, are less common.

Unfortunately, food manufacturers often hide the total amount of sugar by listing it under several different names on ingredient lists. Sugar is commonly added to processed foods. Manufactures often use several different kinds of sugar so they can hide the real amount.

Our March Support Group Meeting

We had our first March meeting on March 4. Only one person was absent and we all knew the reason. He had recently been involved in an accident and was recovering from some injuries. The three children were home and his daughter asked if she could come to the meeting. Brenda had said yes and the daughter was introduced to the group.

Brenda said that we have a lot to cover after two months without a meeting. She thanked everyone for paying his or her dues without a meeting and it was appreciated. Then she turned the meeting over to Allison.

Allison started by thanking me for several blog posts and stated that she wanted to use three of them, but not for this meeting. She continued that with the number of people that had the flu, she felt that topic needed to be covered. She said that we were fortunate not to have had anyone die or be hospitalized in critical condition. She asked how many had the flu shot this season. Only two hands were raised. Ouch, she exclaimed and let out an expletive.

Next, she said she is not a nurse, but that she is surprised that more do not have a flu shot. Several hands went up and when she called on Max, he said that he had a flu shot during the previous season, but became sick shortly after and when he was hospitalized, he was told that he had a high level of mercury in his system and the doctors told him not to get any more shots unless they were mercury free. Max said that the hospital forgot to order any that did not contain any mercury. Two others said the same applied to them.

Allison asked if any others had been tested and two more hands went up with one of them saying he had the test results and a copy of the order from the doctor. Allison asked to see the test results and was surprised at the information on the test results sheet.

Then she asked if there were some that had flu shots every other year. Most of the rest raised their hands and Allison said this might be why the rest has minor cases of the flu.

Allison ended the talk about flu and said she would have Brenda send out an email after she has talked to a couple of doctors about levels of mercury and if there are above average people with high levels of mercury.

Then Allison asked if anyone had other vaccines during the last year. Seven hands were raised and all said tetanus and they knew about the mercury in the tetanus vaccine.

Allison then asked about any other vaccinations and two said they had been vaccinated for hepatitis B, which also has mercury as part of the vaccine.

At that point Allison advised all members to ask if receiving a vaccination to ask if mercury is present in the vaccine,

She also added that you will hear the term thimerosal, which includes the mercury.

This raised several questions, which she wrote out as she was not aware of the answer and said she would get the answer and Brenda would email the answer.

With that, Allison said she was done and thanked everyone for being honest and aware of the potential problems.