Is there a dr in the house? About high BP, headaches and anxiety

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I was going to post this in the Parents Caring for Parents thread but figured it would get wider exposure here.

Last week, I was out of town taking care of my 91yo mom. Two weeks before, my mom was complaining about a severe headache so my sister took mom’s BP, and it was 191/88. At my urging, she called the doctor, who said to monitor it four times a day and to call back if things got worse. Also, to change mom’s Atenolol to first thing in the morning. My sister got one more super-high reading, but things seemed to settle down so they quit monitoring her. :roll_eyes: When I got there Wednesday, her BP was 147/81. The next day she had a super-high reading and was crying and said she had a headache and was miserable. Eventually, things improved and by the time I left Saturday, she was back in the 140s.

Mom also is on what I’m told is a low dose of an anxiety med and an antidepressant, maybe two.

I’m not on any of these three kinds of meds so I don’t have first-hand knowledge, but as I’m reading I’m getting more and more confused. My mom has a dr appt Friday, and I want to call the office with questions/concerns as I won’t be at the appt. I want to make sure my concerns are valid, which is why I am here.

Does anyone have experience with any of this? To me, BP regularly in the 140s and 150s doesn’t feel managed. Or is this level OK in older people? Next, I’m reading high BP does and doesn’t cause headaches. Any thoughts based on experience?

Lastly, what I’m really trying to determine is the relationship between her anxiety and high BP and headaches. If we up her anxiety meds, could that improve her anxiety and help lower her BP and eliminate headaches? My sister, who is in charge of mom’s medical care and will take her to the Friday doctor appointment, definitely feels there is stigma attached to the anxiety meds and antidepressants so my SIL, who cares for mom several days a week, and I don’t feel like my sister is the best advocate for her health and likely won’t relay our concerns about the need to up the anxiety meds. This is why I want to place a call to the doctor myself, but I want to be reasonable in my questions/expectations.

Any thoughts would be appreciated.

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Are you listed on your mom’s medical record as someone that the doctor’s office can talk to about her medical care?

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Good question. I’m not sure. I was going to call to ask whether I could be on speakerphone for the appt. and while on the phone express my concerns if they said no. Truthfully, I don’t have to engage in a back-and-forth with them; I just want my concerns known.

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Have you discussed your concerns with your mom? If she is okay with it, you might call the office with her on speaker phone and have her give verbal consent for you to share your concerns prior to the exam.

Edit: This might be a good time to review your mother’s advance directive or Power of Attorney for Heath Care

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Not really. Her short-term memory is so bad that if she gave me permission today at 9 she wouldn’t remember at 9:05. I feel good about the advance directives and health POA. She was in ICU in January so we had to make sure that was all locked down.

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You can communicate with the doc, but the doc cannot communicate with you, unless there is a release/proxy/formal consent. I would suggest putting your concerns in writing and faxing, with the preface “Dr. X I know you cannot respond but I want to list my concerns.”

Or give the list to your sister, depending on your relationship.

What anxiety med is your mom on? If it is a benzodiazepine, it can worsen memory loss. In our experience, quite a bit and quite quickly (next day!). Those meds and SSRI’s definitely have side effects which may be relevant. Gabapentin is often used in the elderly for anxiety and I cannot tolerate that at all, and that made my mother more out of it as well.

There are other ways to address blood pressure. My mother wasn’t even on a beta blocker. For me, beta blockers had huge side effects, but that’s me.

My mother was on a calcium channel blocker, amlodipine, the diuretic Lasix (furosemide) and later spironolactone (diuretic, aldosterone receptor antagonist, treats high bp and heart failure). A good cardiologist can look at this picture. Spiraolactone was a miracle drug and her bp stayed under 125 systolic, but it took some trial and error to find it.

What SSRI is she on?

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I like that idea, to put it in writing.

I don’t know all the meds she is on, but Gabapentin definitely is one, along with the Atenolol. Gosh, I feel like a bad daughter not knowing all the meds off the top of my head. And she doesn’t have a cardiologist.

She’s always been in such good health. She had breast cancer about seven years ago, and after that bout with anesthesia she took quite the downturn. And then she had a severe fall in January, and that exacerbated where we are now. She had an amazing recovery physically, but her dementia is really bad. I truly never considered that the drugs may be making it worse rather than better.

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I second this recommendation, and have done it with positive results when caring for several family members.

Also, while I don’t recall the various Rx meds he was on, my late father’s mental clarity improved dramatically when his meds were changed and/or reduced (years before his Alzheimer’s worsened.) I hope your mother’s doctor will take that concern seriously.

As for what’s a good enough BP reading, I’d love to know. I resisted increasing the dosage of my BP Rx after reading about the problems older patients have experienced with dizziness and fainting, and subsequent injuries, when their BP was lowered too much. The last time my dose was increased I was light headed in the morning and had to be careful about standing up too quickly. My torn meniscus hadn’t yet healed so I was concerned about doing more damage from another fall. After seeing what fall-related injuries did to both H’s late mother and grandmother, I’m wary of increasing that risk.

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I did this All.The.Time with my parents and I highly recommend. Even if I was going to be at the appointment. I found it helped the doctor be ready with what to look for and I also included info like “Mom had a bad reaction to XYZ which is why she was switched to ABC” etc so they have context. The doc doesn’t always have time to do a thorough chart review before the appt.

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Treating anxiety tends to increase dementia in my experience. My mother did Lunesta for sleep (for years) and after that kind of pooped out, we added low dose 100mg gabapentin as a booster at bedtime. This actually helped a lot because she was well-rested.

We had hospital docs who flat our refused to administer benzodiazepines because of their effect on dementia. Gabapentin tends to be given in large doses.

A cardiologist should maybe be consulted for the blood pressure.

I was primary proxy and had the MD invoke it due to dementia so I used the portal. I could see the meds, and communicate with the doc. You are in a hard in-between place with concern but no authority!

A geriatric psychiatrist is another great resource. Is her PCP a geriatrician?

I declined SSRI’s and anti-meds for my mother. With the heart and blood pressure issues I felt less is more. Once she went on hospice we did try Ativan, gabapentin and even Haldol but the effects on her cognition were so bad and they didn’t really address her perserveration, which I always felt was more of a brain glitch than anxiety.

What are the symptoms of your mom’s anxiety? Are there other ways to approach it other than meds, like more activities, hiring a visitor etc? The problem we had was that anti-anxiety meds affected my mom’s ability to do activities that would have helped the anxiety, so it was a vicious cycle. That said, SSRI’s can sometimes help anxiety without significantly affecting dementia, I believe. And our doc did say that gabapentin is being used this way for the very elderly, and many tolerate it.

This is a lot for the PCP to handle. It seems like more specialists might be needed!

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This is not what I practice so I suggest a call to the Dr and talk to them and or NP. High blood pressure can cause the headaches and anxiety can induce both.

You should have all her meds written down and with you. and get consent on her account. Trust me even if it’s in My Chart etc. Put it on an index card and do one for you also.

Elderly BP tends to fluctuate but it being unstable can be due to other underlying conditions. No one here can diagnose this for your mother. Dehydration also comes into the factor so make sure she’s eating and hydrated. This can have an affect on her kidney’s that can directly effect her BP and headaches.

Good luck to mom.

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And the diuretics I mentioned can dehydrate! It is a juggling act and the right docs can be really helpful.

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Yep. A vicious circle that the OP doctor can help with. BTW - OP I just wrote down my meds and put them on a card in my wallet. My wife has been on me to do it… Lol.

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A geriatrician is an excellent idea. When I go back in two weeks, I will raise the idea with my siblings.

“Concern with no authority” is the perfect way to put it. And being three+ hours away. The sibs on-site are getting worn out, I think, and don’t want to take anything on, like finding a new doctor or even pushing the current one. My sister says that she’s “uncomfortable” raising some of these issues in front of mom, so I think writing a letter will be well-received. If you’re reading between the lines, you can deduce that my sister wants all the authority but lacks follow-through.

My sister is resistant to hiring help. Everyone there is, truthfully, in questionable health. They won’t take her for a walk or sit outside with her while she tends to the yard. It’s a frustrating situation for me, but all the other things are fodder for another post and right now I want to stay focused on my mom’s immediate needs. Thanks, everyone, for the thoughts and letting me work through this here.

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High BP to this degree with severe headache is very alarming to me (and I am an MD). BP doesn’t need to be controlled below 140 or 150/90 in the elderly, because they might pass out and hit their head, or break something on the way down, or even have a heart attack from low circulation to the heart, and that would be the end of them. But high BP to the degree that you’re describing is dangerous. The anxiety is an issue, and could be contributing to hypertension, but that doesn’t mean that she couldn’t have a stroke from the high blood pressure caused by the anxiety. And high BP is not usually treated with anti-anxiety meds, although it may be that better control of the anxiety would help with the BP.

Someone needs to call her MD for a sooner appt and get her in ASAP. One of you needs to call and tell the nurse that your mother is having very high BP with severe headache, and ask for a sooner appt. If she has another episode like this before she can be seen, with very high BP and severe headache, take her to the best emergency room near you.

BP of 140/150 in this age range is fine. It’s the spikes to 190s with severe headache that have me alarmed. For now, what you can do is cut out all sodium in her diet - no added salt, no premade foods with salt. This may be difficult for you to arrange, especially if she’s used to a high salt diet. But essentially, it means home cooked fresh or frozen fruits and veggies, and home cooked grains and home cooked meats.

If she is absolutely known to have NO renal impairment, she could also use KCL salt-alternative at the table. Not only does it help with avoiding salt, consuming it actually decreases one’s blood pressure. But I would ask the doctor’s office first if this is okay. Cutting out salt is not dangerous, but adding potassium if the person has renal impairment can be a problem. Even though atenolol is a once a day med, if her episodes are occurring at almost 24 hours after her dose, it might be an option to switch her to twice a day dosing.

Doctors’ offices are extremely busy. I would recommend that you have one point person to speak with the doctor, and plan on visits to ask questions. Not a great idea for 3 caregivers to all be calling with questions. Alternatively, you could have the accompanying caregiver go in with a list of everyone’s concerns, and that caregiver could open up a cell phone on speaker with all of you listening during the visit, assuming that the doc is okay with this.

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Does your mom tend to get headaches, or is having a headache something new for her?

It is possible, but extremely rare, for a headache to be caused by high blood pressure. The blood pressure would have to be extremely high for this to occur, in other words she would have to be in what’s know as “hypertensive crisis” which isn’t just something that goes away when a person calms down. Conversely, pain and anxiety can easily raise a person’s blood pressure to 191/88, especially if they are starting from the ~147/81 range (my own blood pressure which is normal at baseline has gotten that high when I was in severe pain.) A brief increase in blood pressure due to pain to only ~191/88 is extremely unlikely to cause a stroke or other severe problem. Blood pressures in the systolic 140s-150s range is a fine goal for somebody in their 90s. Attempting to drive it lower is risky (increased falls etc.)

Anyway, the first thing I would figure out is are these headaches new or not. If having the occasional bad headache is an old problem for her, the answer is just to get these better under control. If these are new headaches, you should find out why she is having them. It is not normal to start getting severe headaches for the first time at age 91.

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OK, I’ve emailed a geriatrician to see whether she’s taking new patients and told my sister of my plan to contact the PCP to be involved Friday so she isn’t surprised.

Here are the RXs …

Quetiapine 1 nightly. This was started when she was in ICU after her fall in January.
Alprazolam 1 daily
Trazodone 1 nightly
and the Atenolol 1 daily

I don’t have the strength of each pill, but I remember my SIL saying she thought the Xanax was a low dose.

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I am not a doctor and only have experience as a caregiver of a parent with dementia for 7 years. We had experience with some of these meds and declined some of them.

Quetiapine is Seroquel, an antipsychotic used for schizophrenia, bipolar disorder… and my layman’s experience with psychiatry for a family member would indicate it is used for depression and/or sleep as well.

For the elderly: Quetiapine: Uses, Dosage, Side Effects, Warnings - Drugs.com

risk of death in the elderly with dementia. Medicines like this one can increase the risk of death in elderly people who have memory loss (dementia). This medication is not for treating psychosis in the elderly with dementia.

Several doctors told us that Xanax (and Ativan, other benzos) should not be given to anyone with dementia. The hospitalist refused to prescribe it . I observed cognitive changes within 24 hours in my mother and they didn’t always go away.

See the section in this link on Complications of Benzodiazepines in the Elderly
Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies - Mayo Clinic Proceedings

Trazadone is a relatively benign drug compared to benzos that can be used to avoid benzos. It is a type of antidepressant but in our experience was used to help with sleep. It carries a fall risk due to drowsiness , like the other meds.

Trazodone: a multifunctional antidepressant. Evaluation of its properties and real-world use | JOURNAL OF GERONTOLOGY AND GERIATRICS (jgerontology-geriatrics.com).

The question is, why are all these drugs needed at the same time? I am not a medical professional and there may be a reason. But Seroquel and trazadone together? Seems like a fall risk among other risks. I also wonder if the Xanax is as needed. Tapering off any of these will take time.

These all kind of dampen down the brain (layman’s way to express this) and the atenolol slows things down in a different way. I have no idea about the synergy with these. Maybe you could speak with a pharmacist and who knows, maybe they can reassure you. It seems like a lot, to me. Especially in the context of dementia, or does your mom have behaviors that need to be controlled?

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Excerpts from Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies - Mayo Clinic Proceedings

Observational studies consistently report that benzodiazepine use is associated with a statistically and clinically significant increase in risk of falls and fractures

Benzodiazepines are particularly strongly associated with hip fractures, which is concerning because up to one-third of patients with hip fracture die within a year

Benzodiazepines cause short-term cognitive deficits, particularly in memory, learning, attention, and visuospatial ability, and they are also associated with the development of lasting cognitive deficits and dementia.

Several studies have indicated that even after benzodiazepines are discontinued, the cognitive function of long-term users continues to be impaired in most cognitive domains, suggesting lasting and possibly irreversible cognitive deficits associated with benzodiazepine use.

Benzodiazepine use is associated with a considerable increase in all-cause mortality, with exposed patients dying at a 1.2- to 3.7-times higher rate per year compared with unexposed individuals. However, as with dementia, it remains unclear whether this connection is causal or whether these drugs are being prescribed more frequently to patients at higher risk of dying.

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My hospital based experience (RN) with Seroquel is that it is a first line drug for acute agitation in the demented elderly and has fewer deleterious effects. Whether needed after that ICU stay might be something to discuss with the physician, but removing it might cause more problems with agitation.

Aside from the Trazadone, which has a wide dosage range, she is not on anything for depression. Might this be increased, or another antidepressant added?

If poor appetite is an issue, there is an older antidepressant used for the frail elderly, mirtazepine. The side effect of weight gain combined with antidepressant effect was life changing for my mom in her 90s.

As mentioned above, keep the sodium out of her diet as much as possible, and increase intake of fruits and vegetables.

You mentioned the difficulty in getting her out for walks or yard work. Increasing activity, especially outside walking is great for anxiety, insomnia, depression, and her BP, if not acutely high. Just getting someone to walk with her regularly might help with many of these issues in addition to the meds.

Something to try for anxiety is a dose of tylenol on occasion. Or regularly. Google it-I found a dose helped many of my elderly patients settle into a calmer day.

And sympathies to you! The mix of family dynamics and concern for an elderly parent can be crazy making and certainly is exhausting.

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