I want to make you aware of common medication related issues I see often in the ER. Hopefully you can avoid these scenarios in your person.
If you have your person’s medication list handy, take a look at it while you read this. Write down any questions you might want to ask their care team.
Remember it is your job as their medical decision maker to know and understand their medication list. If you do not know your person’s medications, read my post about why this is an essential part of being an advocate for your person.
Knowing and owning your person’s medication list is your job.
It is also your job to know their goals of care.
You will not be able to critically analyze medications alongside their care team if you have not identified goals of care.
Read my post about goals of care here.
Think about it simply. You and your person’s care team need to know how much your person overall values quality of life versus the length of their life.
Before I dive into the medications, I want you to know this is general information.
Do not stop, start, or change the dose of any medication in you or your person without consulting a healthcare professional that knows your unique situation.
If you need help quickly, call your local pharmacy to ask a question.
Ok let’s talk medications.
First up, medications that increase risk of bleeding.
You should have some background information quickly.
When you start bleeding anywhere in your body the goal of your body is to form a clot. This is how we naturally stop bleeding. We want to form these clots. Clots are not always bad.
You form clots through two ways:
1 – Platelets. Cells that form clumps to stop bleeding from damage to a blood vessel.
2 – “Clotting factors” Proteins made in your liver. They become activated one by one in a domino effect lay down protein and form a clot at the site of bleeding.
Thus, there are two main ways medications make you more likely to bleed.
Medications that affect platelet function: Plavix (clopidogrel), Brilinta (ticagrelor), Aggrenox, Aspirin.
Other medications affect the functioning of the clotting factors: Xarelto, Eliquis, Pradaxa, Coumadin (warfarin), lovenox, heparin
This group is the true “blood thinner” class people talk about. There is a higher risk of bleeding with this group.
However, both classes of medication make it more likely that someone will bleed and have trouble forming clots quickly.
What do I see in the ER?
The most common complications I see are excessive bleeding after dental procedures, skin wounds, and nosebleeds.
First aid for a nosebleed is something people on blood thinners should learn ahead of time, just in case. (If you want a video on this, comment below.)
The more dangerous complications are true traumatic injuries (think falls, car accidents) causing organ injury and bleeding and gastrointestinal (GI) bleeding.
Remember falls increase as we age. There are so many reasons why we fall more as we get older. Anything you can do to risk falls in your person is critical and could save their life.
Bleeding in the brain is common in aging people in general.
Aging people have a higher risk of bleeding if they hit their head even if they are not on any of these medications. This is the reason why people 65 and older who come into the ER after a head injury almost always get a CT scan of their brain.
I’ve seen many bleeds with minor symptoms. I’m still surprised by them on occasion.
If someone on blood thinners falls and hits their head, they will have an even higher risk of bleeding.
Bleeding in the brain can be severe and life threatening.
I often have to intubate (procedure to put someone on a ventilator aka “breathing machine”) people immediately upon arrival to the ER due to concern for a large brain bleed
There is often no time for communication with family and I have to rely solely on paperwork on file in our computer system or what is sent with the person to help me know if they would or would not want this.
If I have no direction and they clinically need to be intubated, I don’t wait around. They get intubated.
If you want to know more about what intubation is you can read about it here.
GI bleeding is another potentially life-threatening adverse event from use of these medications. Depending on how “brisk” the bleeding and where it is happening in the body, people can be critically ill and die.
Use of blood thinners and medications that affect platelet functioning have to be considered very carefully.
The use of these medications in seniors has risen over the years and is commonplace.
Why are people on these medications?
They are used most commonly in people who have:
1- atrial fibrillation
2- had a stroke
3- blood clots in the legs and/or lungs
4- have had a heart attack
These medications no doubt prolong life.
They also decrease risk of diseases that can make people’s quality of life worse.
Because they are both life prolonging and potentially quality of life protecting, it can be hard to decide when to stop them.
Trust me when I say, many people are on them too long.
Let me be clear, I’m not telling you to stop these medications.
I want you to consider your person’s goals of care. If it does not make sense to stop them now, decide when you might do so.
Say your person has a blood clot in their leg. Clinically this diagnosis is called deep vein thrombosis aka DVT.
Maybe they also have a clot in one of their lungs as well. They are started on a true blood thinner. We’ll pick Eliquis as an example.
Treating this new blood clot in their leg is meant to prevent the clot from growing and traveling to their lungs.
When large blood clots travel through the veins to the right side of the heart and get stuck in the blood vessels going to the lungs, this can cause someone’s heart and lungs to fail.
A large blood clot in the lungs, aka pulmonary thromboembolism, can cause death.
If the person does not die, they may wind up with permanent disability due to damage to their heart or lungs.
Thus, you can argue the intention of having your person on Eliquis is to protect their current quality of life and prolong their life.
This is why goals of care are so important. You can not have a productive discussion with your person’s care team about the use of blood thinners if you do not have this figured out.
Their use needs to be considered on a case-by-case basis. It is all about risk vs benefit.
People who fall a lot, have a history of brain bleeding, and or history of gastrointestinal (GI) bleeding MUST have the use of these medications examined closely.
If your person is on a medication increasing their risk of bleeding, you must know the reason WHY they are taking it.
What are you trying to treat?
Are you trying to prevent a disease? Does your person have a good quality of life now?
If they could speak for themselves, would they want to have their life prolonged?
Repeated falling with head injuries is a common reason these medications are stopped. Keep this in mind.
I see at least one senior a day due to a fall. Medications that increase risk of bleeding make their work up more complicated because of increased risk for significant injury.
Let’s switch gears and talk a bit about medications that can directly contribute to or cause falls.
Have you heard the term “syncope?”
We use this medical term instead of saying someone “passed out.” There are many reasons why someone might pass out. I will not talk about them all here.
One cause of syncope I see frequently is low blood pressure, especially with position changes.
Maybe you’ve heard the term orthostatic syncope?
This is what I’m describing, passing out due to low blood pressure in relation to a position change. Usually from laying to standing or sitting to walking.
When your blood pressure becomes low it can mean your organs are not receiving the blood flow they typically are used to. This includes the brain.
When people’s blood pressure drops more than their brain is used to, they will commonly report lightheadedness. They sometimes pass out and lose consciousness.
If the person is aware it’s about to happen, they might be able to sit or lay down which decreases risk of serious injury from a fall.
Again, I can not cover all the reasons why someone can pass out or have low blood pressure in this post. I cover everything you need to know in my program.
I do want to stress that medications are often part of the issue. Say someone has an infection and is feeling lousy.
They are laying around in their house really only getting up to go to the bathroom or to get something to drink, maybe a tiny bit to eat.
It could be a “minor” infection like a typical cold or maybe it’s a bit worse – the flu, COVID, or a “GI” bug with a lot of vomiting and diarrhea.
People who are aging are hit harder. They are more likely to lay in bed, not eating and drinking well. They may live alone or have a spouse who can not help them due to their own medical issues.
When they lay in bed, they lose more muscle mass than they would have when they were younger. This exacerbates their general fatigue and weakness.
They get dehydrated. I think you can imagine how dehydration will make everything worse.
People living with dementia are even more at risk. They often become more confused and delirious when they are sick. This can also contribute to them not drinking enough fluid.
I can not tell you how many times I’ve seen patients come into the ER due to syncope clearly suffering from dehydration due to a viral illness.
It troubles me more and more, but is no longer shocking, that many of them either continued their blood pressure medications themselves, or their caregiver was still giving them.
Continuing to take their medications will likely lower their blood pressure, increase their risk of passing out, falls, and injury.
It also can cause kidney damage. Remember low blood pressure means less blood flow to the kidneys.
We already have naturally declining kidney function as we age. Chronic permanent kidney disease is common in seniors and in people living with dementia.
The kidneys are responsible for breaking down a lot of medications. If they are damaged due to less blood flow, they might not metabolize the drug as well. The drug could hang around longer causing even lower blood pressure.
This cycle goes round and round causing more potential for harm and more need for hospitalization.
Remember medications can be harmful. Sometimes they need to be held to prevent worsening effects.
I see you all out there wanting to take good care of your person living with dementia. You want to make sure they take their medications.
This example is just one of many reasons you must know the WHY behind all of the medications your person is taking. This is so important!
If you know your person is on two medications that treat high blood pressure and one that affects their heart rate, you will naturally wonder if they should continue these medications if they are not eating or drinking.
Part of planning is learning so you can anticipate. All medications should have a clear purpose and a goal in mind.
Consider when you might need to hold each of your person’s medications.
Include this question when you have a medication review visit with a pharmacist or your person’s doctor.
Doing this work could save your person from needing hospitalization. We all know the hospital is not the best place for someone living with dementia.
Consider your person’s goals of care. If they are on medications that prolong life, and they would not want to have their life prolonged anymore, talk with their doctor about the options.
You can always ask them what the risk to your person’s quality of life is if they come off the medication.
Don’t forget discussions about medications need to be done alongside a clear understanding of your person’s goals of care. If you do not do this initial work, you will struggle to make choices about medications as well as other medical decisions.
If you want help planning for your person’s future, please reach out.
We can chat on the phone about specific questions you have or if you want a better understanding of an issue unique to your person.
If you want to create a written plan for how you will handle the medical issues most likely to come up for your person now and going forward, I want to help you with my “Make Your Plan” program.
Send me an email brittanylamb@blambmd.com for more information.
You’ve got this caregiver. Thanks for reading.
Until next time, all my best to you,
Brittany Lamb, MD