PHARM NOTES

Neil Medical Group: The Leading Pharmacy Provider in the Southeast

Neil Medical Group: The Leading

Volume
Volume 17,
12, Issue
Issue 62

November/December
2014

Differentiating Between Dementias

Dementia is broadly characterized by cognitive degeneration.
It generally affects older adults starting around 60 years of
age causing disruption of the normal activities of daily living
(ADLs). The most common forms of dementia are Alzheimer
disease (AD), which accounts for 60-80% of dementias, dementia with Lewy body, which accounts for another 20% of
all dementias, and Parkinson disease dementia, which accounts for only about 3% of dementias. Other less common
dementias include vascular dementia and fronto-temporal dementia. It is estimated that 36 million people were diagnosed with
some form of dementia in 2011.
This number is expected to double
by 2030.
Early diagnosis allows individuals
to plan for their future while still
able to make decisions, decrease
healthcare cost, and allow for family education, financial planning,
and support system planning.
However, diagnosing dementia
can be challenging. This is especially true in the early stages,
due in part to varying presentations and the insidious onset of
the disease.
The newly released Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) gives clear guidelines and diagnostic criteria for early detection as well as differentiation of specific subtypes of dementia. The new DSM5 replaces the word dementia with the term neurocognitive
disorder (NCD). Also cognitive disorder not otherwise
specified is termed mild NCD. While the term dementia
has been replaced with NCD, it is still used because of the
familiarity of patients, families, and providers with the term.
Inside This
Issue:
Differentiating
Between
Dementias

The diagnosis of NCD requires evidence of cognitive decline

from prior higher levels of functioning expressed by the patient, reliable historian, or provider. The diagnosis is validated
by standardized testing which shows a decline in one or more
cognitive areas: attention (fluctuation or processing speed),
executive function (decision making and working memory),
learning and memory (short- and long term), language (word
finding and fluency), perceptual motor (visual and praxis), or
social cognition (inappropriate
attitude, dressing, and behavior). The possibility that NCD
is caused by delirium or other
mental disorders like a major
depressive disorder or schizophrenia must be ruled out.
The Mini-Mental Status Examination (MMSE) and the
Mini-Cog are the two most
frequently used assessment
tools for this testing. The
MMSE is most commonly
used and evaluates 7 categories of cognitive function. These areas are recall, learning,
orientation, attention, calculation, language skills, and three
dimensional skills. The brief assessment takes only about 7
minutes on average. This tool screens for dementia but is not
sensitive to consistently pick up mild NCD. The patients educational level, reading writing, language, motor and visual
skills must be taken into account in the interpretation of the
score.
The Mini-Cog is made up of a clock drawing test and the recall of three words. It requires only about three minutes to
give and removes educational and language variables with a
high degree of sensitivity.
continued on page 4

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Page 4 5

Page 6

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Page 8

Fish Oil:
An Overview

Conclusion:
Differentiating
Between Dementias

Hi-Dose Insulin:
Risk vs Benefits

Orthostatic
Hypotension:
A Review

NMG Contact
Information

Fish Oil: An Overview

Eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA) are omega-3 fatty acids. They are found in fish and
often called fish oil. Fish oil can be obtained by eating fish
or by taking supplements. The best source of fish oil is fatty
fish, such as salmon, mackerel, tuna, sturgeon, mullet, bluefish, anchovy, sardines, herring, trout, and menhaden. They
provide about 1 gram of omega-3 fatty acids in about 3.5
ounces of fish. For general health it is recommended that
two 3 to 4 ounce servings of fish are eaten per week. The
body does not produce its own omega-3s, therefore is dependent on outside sources for this essential fatty acid.
Fish oil is sold over-the-counter or by prescription
(Lovaza). Fish oil supplements are usually made from
mackerel, herring, tuna, halibut, salmon, cod liver, whale
blubber, or seal blubber and
often contain small amounts
of vitamin E to prevent spoilage. Fish oil supplements are
a dietary supplement and not a
drug. Most over-the-counter
supplements contain 200mg400mg of EPA plus DHA per
capsule. Many manufacturers
of over-the-counter supplements include the milligrams of
fish oil on their labels. However, less than one third of that
number is actually the essential omega-3 fatty acids. For
example, a fish oil capsule that is 1,000 mg fish oil may contain 200mg of EPA and 150mg of DHA, meaning the capsule
provides 350mg of omega-3 fatty acids. The FDA does not
have a specific recommended dosage for over-the-counter
fish oil. However, they do recommend that an average
healthy person (above the age of 5) should not take more
than 3,000 mg of fish oil per day (look for the amount of
EPA plus DHA, not the total amount of fish oil). Remember,
it is from the omega-3 fatty acids that we receive health benefits.

supplements with the USP Verified Mark which have been

tested for good quality and found to have levels of mercury,
PCBs, other heavy metals, and dioxins that are below acceptable safe limits. You should avoid cod liver oil due to its
relatively high vitamin A content.

Fish oil supplements are often low in mercury and other pollutants. For most people, mercury in fish is not a health concern, but the FDA has this advice for pregnant women, nursing mothers, and young children: Limit albacore tuna to 6
ounces/week; limit fish lower in mercury to 12 ounces/week;
avoid shark, swordfish, king mackerel, and tilefish; remove
skin and fat before cooking fish. It is best to choose fish oil

High Triglycerides: High triglycerides are associated with

heart disease and untreated diabetes. To reduce the risk of
heart disease, doctors believe it is important to keep triglycerides below a certain level. Researchers believe that fish oil
can reduce triglyceride levels by 20% to 50%. For high triglycerides, 2-4 grams of EPA plus DHA is recommended,
but should be under direct medical supervision. As men-

Page 2

Lovaza is a prescription drug used to treat high triglycerides and comes as a 1 gram softgel capsule and consists of
EPA 465mg and DHA 375mg. It is expensive and may cost
up to $165 per month. The recommended dose of Lovaza
is 4 grams as a single 4 gram dose by mouth once a day or as
2 grams by mouth twice daily. It is a concentrated form of
fish oil so you will take fewer capsules compared to over-the
-counter fish oil.
Uses and Effectiveness
Fish oil is primarily used to lower
triglycerides, a blood fat thats
linked to heart disease. Omega-3
fatty acids may help other cardiovascular effects such as lowering
heart rate and blood pressure, decreasing the risk of arrhythmia,
reducing inflammation, inhibiting
atherosclerosis, and reducing
thrombosis. Studies suggest omega-3 fatty acids could improve joint symptoms such as pain
and stiffness from rheumatoid arthritis by preventing production of pro-inflammatory signaling molecules. Additionally,
they may also boost the effectiveness of anti-inflammatory
drugs. A recent study also suggested that higher omega-3
fatty acid levels may improve brain health and hold promise
for delaying cognitive aging and dementia. To get to a high
enough level, people would have to eat oily varieties of fish
at least five times a week or eat it twice a week and take fish
oil supplements daily. Fish oil could protect against depression, cancer, and help with menstrual pain as well, but more
research is needed to determine the usefulness of these reported benefits.

Neil Medical GroupPharmacy Services Division

tioned above, Lovaza has been approved by the FDA to

help lower triglycerides at doses of 4 grams per day.
Heart Disease: Epidemiological evidence suggests a diet
high in omega-3 fatty acids has cardiovascular benefits. For
patients with heart disease, it is recommended to consume 1
gram daily of EPA plus DHA from fatty fish or supplements
under medical supervision. There is not enough evidence to
recommend fish oil supplements for primary prevention but
fish oil supplements may be a good choice for patients needing daily doses for secondary prevention. Fish oil may especially be useful as an alternative agent to fibric acid derivatives (i.e. Tricor, Lopid) in combination therapy with a
statin when myopathy is a concern. New cholesterol guidelines focus more on statins, less on non-statins and abandon
LDL goals. Do not routinely recommend non-statins (fish
oil, fibric acid derivatives, niacin, etc.) due to lack of clinical
evidence to improve cardiovascular outcomes UNLESS patients cannot tolerate statins.
Side Effects
Fish oil can cause side effects including belching, bad breath,
heartburn, nausea, loose stools, and rash. Taking fish oil supplements at the beginning of a meal or refrigerating/freezing
them can often decrease these side effects (you should not
freeze Lovaza per the manufacturer). You can also try liquid fish oil if these side effects are frequent and cause individual distress. Throw out capsules with a very strong or
spoiled taste, which may indicate that the fish oil is degrading
and becoming rancid. Fish oil does have a slight blood thinning effect; therefore it can increase the risk of bleeding and
bruising. This is especially important to consider if you take
other blood thinning medications. It is also important to tell
your doctor if you take fish oil supplements so he can advise
you as to the proper procedure that should be taken in preparation for surgery. People with a known allergy or hypersensitivity to fish should avoid fish oil or omega-3 fatty acid
products derived from fish.
Interactions
Antihypertensive medications: Fish oil may decrease blood
pressure and along with blood pressure medications may
cause your blood pressure to go too low.
Anticoagulant/Antiplatelet medications (aspirin, NSAIDS,
warfarin, heparin, enoxaparin, clopidogrel, etc.): Fish oil
may slow blood clotting and concomitant use may increase
the risk of bruising or bleeding.
Orlistat (Xenical, Alli): Orlistat may keep the beneficial fatty acids in fish oil from being absorbed by the body. Taking
fish oil and orlistat at least 2 hours apart may prevent this.

Birth Control Pills: Birth control pills may decrease the effectiveness of fish oil supplements by affecting their ability
to lower triglycerides.
Other Omega-3 Fatty Acid Products
There are other products that contain omega-3 fatty acids as
well, such as krill oil (ex: Mega Red Omega-3 Krill Oil capsules). Krill are small crustaceans similar to shrimp. The
composition of krill oil varies depending on which species of
krill from which it is extracted. Krill oil is promoted to have
similar benefits as fish oil, without the fishy taste and without
the necessity of taking as many capsules as fish oil, but there
is no evidence it reduces cardiovascular disease. Additionally, the amount of omega-3 fatty acids in krill oil products is
generally less than in fish oil products. Krill oil supplements
can cost five to ten times as much as fish oil supplements for
the same omega-3 fatty acid content. There is less research
on the use of fatty acids from krill oil compared to fish oil, so
for now, it is best to recommend fish oil supplements or Lovaza if the fishy taste isnt a problem.
Flaxseed is another source of omega-3 fatty acids. Flaxseed
contains the short chain omega-3 fatty acid called alphalinolenic acid. (Alpha-linolenic acid is also found in soybean
and canola oil and English walnuts). Unlike fish oil, flaxseed
does not lower triglycerides but can have a modest effect on
LDL cholesterol. Flaxseed is not a substitute for fish oil as it
is not a significant source of EPA and DHA (even though the
body can convert alpha-linolenic acid from flaxseed into EPA
and DHA). Flaxseed contains significant amounts of soluble
fiber and as with any source of fiber, may cause gas, bloating,
diarrhea, constipation, nausea, and dyspepsia. These side
effects are usually dose-dependent. Flaxseed may best be
viewed as part of a healthy diet and not necessarily a supplement. One teaspoon of flaxseed oil or 1 tablespoon of flaxseed daily should provide enough alpha-linolenic acid in the
diet.
A diet high in omega-3 fatty acids, such as fatty fish, does
have some cardiovascular benefits and is a reasonable health
measure, but the amount needed is not definitive. For most
healthy people, a variety of baked or broiled fish is a better
choice than fish oil supplements. Fried fish is unlikely to
have health benefits and may increase cardiovascular risks.
Fish oil supplements are a good choice for hypertriglyceridemia or secondary prevention. Fish oil may have a variety
of other health advantages from mental health and arthritis, to
blood pressure and aging, but more studies are needed to
know the true benefits.
Article by: Heather Eaton-Erskine, PharmD, CGP, FASCP
Regional Clinical Manager

Neil Medical Group Pharmacy Services Division

Page 3

Differentiating Between Dementias.continued from page 1

The medical diagnosis of NCD requires a complete physical
examination to rule out possible reversible or alternative
causes of dementia and to determine the appropriate testing
required. The American Academy of Neurology recommends screening for thyroid disorders and vitamin B-12 deficiency, both of which can cause cognitive impairment.
However, the cost/benefit of preforming a battery of generalized laboratory test remains controversial. These types of
tests might include electrolytes, testing for syphilis, and
complete blood count. Also, genetic testing is not recommended due to lack of sensitivity and specificity. Neuroimaging is controversial and only recommended if underlying
causes like neoplasm are suspected. The American Academy
of Neurology does suggest computer tomographic imaging
(CT) or magnetic resonance imaging (MRI) for evaluation of
cognitive impairment with an atypical presentation. Positron
emission tomography scan (PET) may show decreased blood
flow to the occipital lobe to confirm NCD with Lewy bodies.
Neurocognitive disorders caused
by AD are characterized by the
slow development of nonreversible brain disorders that result in
the permanent loss of neurons and
neuronal synapses. This destruction occurs primarily in the area of
the brain responsible for memory,
cognition, and function. The destruction is caused by extracellular
neurotic plaque and neurofibrillary tangles inside the neuron. This
destruction causes a decrease in
Acetylcholine - the neurotransmitter which enables learning. The
risk factors for NCD due to AD include family history and
increased age. However, the risk is gender neutral. Diagnostic criteria are as follows:
Major NCD due to AD: Two criteria must be met. The first
criterion is the presence of a genetic mutation or a positive
family history. The second criterion consists of three subcategories, all of which must be met: a) a decline in memory
and learning plus one other cognitive domain, b) insidious
and gradual presentation with possible brief plateaus, c) no
mixed etiology (cerebrovascular accident and/or sepsis). A
major probable diagnosis is given when both (a) and (b)
are present and possible when either (a) or (b) are met.
Mild NCD due to AD: There is a probable and possible
mild NCD due to AD. The probable is diagnosed when
there is a genetic mutation or family history. The possible
is diagnosed when there is no genetic mutation or family
history. Both still have evidence of memory and learning
decline that is gradual and insidious without extended plateaus and no evidence of mixed etiology.
Page 4

Individuals with NCD due to AD may have manifestations

such as visual spatial or visual perception disturbances and/
or motor and language defects in moderate to severe disease.
Social skills usually remain intact until late in the disease. In
the severe stage, muteness, gait disturbances, incontinence,
and complete dependence may occur.
The treatment of NCD due to AD revolves around only two
classes of medications. The Cholinesterase inhibitors (CEIs)
like Aricept , Exelon , and Razadyne and the N-methyl
-D aspartic acid receptor antagonists like Namenda. These
two classes have different modes of action and are generally
used in combination. Neither class alone or in combination
with other agents stop or reverse the disease process. They
simply slow the rate of cognitive decline, therefore preserving basic skills of daily living as long as possible.
A controversy remains over when either or both classes of
medications should be discontinued. There is evidence of accelerated decline
when the medications are
stopped. More research is
needed to determine guidelines for the most appropriate time for discontinuation
of therapy.
NCD with Lewy Bodies
(NCDLB) is the newest dementia diagnosis. The incidence of this type of dementia is about 7 per 1,000
persons among those 65
years old and older. This
diagnosis is often confused
with NCD due to PD. Both these types of dementia exhibit
similar motor and cognitive symptoms. They show profound
deficiencies of neurotransmitters along the dopamine and
cholinergic pathways. The cholinergic deficit is responsible
for the cognitive dysfunction and the dopamine deficit for
the motor dysfunction. These two types of dementia can be
differentiated by the chronological onset of symptoms.
NCDLB individuals exhibit cognitive symptoms before the
onset of motor symptoms.
NCDLB results from the collection of proteins, called Lewy
bodies that progress through the neuronal synapse. The functional deficits seen in NCDLB are greater than those seen in
NCD due to AD.
Risk factors for NCDLB are advanced ageusually at least
60 years old with the mean age of presentation at 75 years
old. Men have higher incidences of NCDLB than women.
Familial associations are rare.
DSM-5 criteria for NCDLB must first meet the initial mild
or major NCD criteria. Then the NCDLB criteria are again,
insidious and gradual onset. The classification of possible

Neil Medical Group Pharmacy Services Division

or probable NCDLB is made by various combinations of

core and suggestive features. Core features are fluctuating
attention and alertness, recurrent visual hallucinations, and
spontaneous Parkinsonism before cognitive deficits. The
suggestive features include rapid eye movement sleep disturbance and/or severe sensitivity to antipsychotic medications. Alternative medical explanations such as adverse drug
reactions, delirium, cerebrovascular disease/accident, or sepsis must be ruled out.
The clinical manifestations of NCDLB include auditory and
olfactory hallucination, depression, and delusions. Delirium
or any other cause for the fluctuating cognition must be
ruled out. Frequent falls, syncope, and orthostatic hypotension along with episodes of unexplained loss of consciousness also occur. In later more advanced NCDLB, incontinence, eating disorders leading to aspiration, sleep disorders,
and psychiatric symptoms may present. However, the usage
of antipsychotics is discouraged in NCDLB due to severe
sensitivity to these agents that can be fatal.
The treatment regimen for the cognitive symptoms of
NCDLB begins with CEIs. This class of medications is generally effective for symptoms including fluctuating cognition, hallucinations, and mood disorders. The motor symptoms can be treated with dopaminergic agents like Sinemet. However, be aware that these agents can cause psychotic symptoms such as visual hallucinations. Starting regimen for Sinemet is 25/100 one half tablet three times daily. Sinemet is then titrated gradually over several weeks
based on relief of symptoms and tolerability. Caution must
also be used in the discontinuation of these agents as it can
precipitate an exacerbation of motor symptoms that may
lead to dysphagia, aspiration and death.
Treatment with antipsychotic agents for mood swings and
hallucinations has been shown to increase the risk of death
in NCDLB. The uses of benzodiazepines, especially
Klonopin, at very low doses, can be used to treat the mood
swings associated with NCDLB. However, this class of
meds can increase the risk of falls and compound confusion.
While typical antipsychotic agents are not recommended, the
second generation/atypical antipsychotics, like Seroquel
have been shown effective and may be safer than Klonopin
in NCDLB. Again, caution and careful monitoring are required due to the increased sensitivity of NCDLB patients to
these medications.

Like NCDLB the DSM-5 criteria for NCD due to PD are

similar. The mild or major NCD criteria must be met. A diagnosis of PD must precede the cognitive impairment by at
least a year for the diagnosis of NCD due to PD. A
probable or possible NCD due to PD diagnosis is differentiated by two criteria. First, there must be no evidence of
mixed etiology present, like vascular dementia or sepsis.
Second, PD must be present before the onset of NCD.
Probable diagnosis is given if both criteria are met.
Possible diagnosis is given when only one criterion is met.
The major feature in the diagnosis of NCD due to PD is that
the cognitive decline occurred after the diagnosis of PD.
Other clinical symptoms of NCD due to PD are apathy, depression, anxiety, hallucinations, delusions, rapid eye movement sleep disturbances, and extreme daytime drowsiness.
The motor symptoms of PD are treated with dopaminergic
agents like Sinemet. The CEI, Exelon has shown significant improvement of the cognitive symptoms related to
NCD due to PD, especially those of attention and executive
function. Treatment with Namenda has also been shown to
significantly improve executive function, sleep and quality
of life and shows evidence of marked decline after discontinuation. Patients with NCD due to PD do not show the sensitivity to antipsychotic agents that are seen in NCDLB. NCD
due to PD patients may benefit from atypical antipsychotic
agents, especially Seroquel, to decrease or resolve psychosis but with some increase in motor dysfunction. Again, caution due to increased sedation and related falls is required.
The number of patients we will be caring for in the future
with Dementia/NCD is expected to increase to almost 72
million individuals worldwide by 2030. Early diagnosis and
treatment will help reduce overall cost of caring for these
individuals and more importantly should significantly improve their quality of life.

Parkinsons Disease (PD) is a motor system dysfunction

caused by the loss of dopamine producing cells in the brain.
Patients with PD can develop NCD due to PD, especially in
the late stages of the disease. NCD due to PD is associated
with the presence of Lewy bodies. The difference is that in
NCDLB the Lewy bodies are located in the cortical and midbrain areas and in NCD due to PD they are primarily located
in the midbrain area. The symptoms of NCD due to PD include cognitive, visuospatial, memory, and executive function along with the already present motor dysfunction related
to PD.
Neil Medical Group Pharmacy Services Division

Article by Steve Godfrey, PharmD

Page 5

High Dose Insulin: Risk vs Benefits

Article by Rhonda Gentry, RPh, CGP

possible: Make sure staff are well-educated, and that a dose

conversion chart and tuberculin syringes are readily available
when preparing U-500 doses. Ensure that doses for U-500 insulin are expressed on the MAR (medication administration
record) and medication label in terms of both units and volume, highlighting the use of a tuberculin syringe (i.e. 200units
(0.4ml in tuberculin syringe). These practices should be followed with other high-dose insulins when these products become available.
3. Perform an independent double check of all U-500
As the obesity epidemic continues
doses: Have two staff indeand insulin resistance problems
pendently check the drug, dose,
worsen, larger doses of insulin are
and measurement markings on the
more frequently required to meet
syringe to make sure the right
glycemic goals. This has led to an
product and dose is being provided
increased use of U-500 insulin
prior to administration. The check
when dose requirements exceed
should include a comparison to the
200 units per day. But along with
original medication order and verithe increased use of U-500 insulin,
fication of the blood glucose value.
ISMP (Institute for Safe Medica4. Verify and Highlight: Verify
tion Practices) has been receiving a
all U-100 insulin orders over 50
growing number of U-500 insulinunits to ensure that they are not for
related medication error reports.
the U-500 insulin, and highlight all
Although uncommon in long-term care (LTC) facilities at pre- U-500 insulin orders on the MAR
sent, U-500 insulin use is expected to increase in this setting.
5. Store U-500 vials in a designated location, segregated
Most of the medication error reports are related to dosing con- from other insulins: remove and store the vial in the designated location after each administration of a dose to the resifusion caused by not having a syringe with a U-500 scale.
This usually requires practitioners to rely on measuring doses dent. Remove and discard all U-500 vials when the resident is
with a U-100 syringe and teaching the patient to communicate discharged.
doses in syringe unitsthat is, measure 200 units of U-500 6. Make the product look different: Besides using tall-man
insulin by drawing up 40 syringe units on the U-100 syringe. lettering for look-alike insulin names, ensure that bold lettering is used for the U-500 concentration on the MAR, label, and
But too often, patients do not understand the difference becomputer order entry screens. Avoid dangerous abbreviations
tween U-100 and U-500, so they inaccurately state the actual
(e.g., U for units, leading decimals, trailing zeroes) on orders
dose, saying, for example, that they take 40 units of insulin,
which can lead to hyperglycemia if only 40 units are then pre- and electronic order entry screens. Use brightly colored auxilscribed. Worse, confusion can also lead to overdoses. If peo- iary warning labels on the product vial and container, and special packaging when possible.
ple using a U-100 syringe misunderstand syringe units, a
dose of 80 units of U-500 insulin might be prepared by meas- There are additional strengths of insulin now under developuring 80 units on the U-100 scale instead of 16 syringe units, ment that will only add to the confusion. Sanofi-Aventis is
developing U-300 glargine (LANTUS), Novo-Nordisk is deresulting in a dose of 400 units.
veloping U-200 degludec (brand name TRESIBA outside the
In order to help prevent errors and harm to residents who reUS), and Lilly is developing a U-200 HUMALOG (insulin
ceive the U-500 insulin, ISMP has suggested the following
lispro). Tresiba is already on the market in the United Kingstrategies:
dom and is ONLY available in a pen.
1. Communicate the dose in actual units: Always comUntil specialized dosing pens or special U-500 dosing syringes
municate U-500 insulin doses in actual units rather than
are made available, there continues to be a increased risk for
syringe units. If an order or entry is uncertain, clarify the
medication errors with high-dose insulin use. It is incumbent
dose with the prescriber.
upon all staff to employ strategies to decrease these potential
2. Use Tuberculin Syringes for U-500 doses whenever
risks as much as possible.
Humulin R is the brand name for Eli Lilly's recombinant human regular insulin. The usual version of Humulin R is U-100
and contains 100 units of insulin activity per 1 milliliter of fluid. But there's also a new, rarely-used version called U-500.
The U-500 insulin is 5 times more potent than U-100 insulin.
U-500 insulin contains 500 units of insulin activity per 1 milliliter of fluid. People may need to use U-500 if their diabetes is
not well-controlled with U-100. The U-500 version should be
used only for patients requiring doses above 200 units a day.

Page 6

Neil Medical Group Pharmacy Services Division

Orthostatic Hypotension: A Review

Orthostatic hypotension is a sudden drop in blood pressure
when a patient stands up. This phenomenon is also called postural hypotension.
In upright posture, blood pools in the veins of the legs and
trunk, reducing the venous return and thus the body blood
pressure. Normally, the low blood pressure will trigger a baroreceptor which activates a mechanism to compensate for the
pressure fall. Orthostatic hypotension occurs when the body
mechanism is impaired, or affected by illnesses or by drugs.
Therefore, orthostatic hypotension is more common in inpatients (60%) and in the elderly (30%) than in the middle age
(11%).
Etiology
Acute orthostatic hypotension:
Hypovolemia (hemorrhage, vomiting, diarrhea,
diuresis, dehydration)
Drugs
Prolonged bed rest
Adrenal insufficiency
Chronic orthostatic hypotension:
Age-related changes in blood pressure regulation
Drugs
Autonomic dysfunction (Parkinson's disease, dementia with Lewy bodies, vitamin B12 deficiency,
etc.)
Other Causes:
Postprandial (after meals) hypotension
Insulin response to high-carbohydrate meals
Blood pooling in the GI tract; this condition is worsened by alcohol intake
Causative Agents
Antidepressants
MAO inhibitors (selegiline)
SRIs (trazodone)
SSRIs (sertraline)
TCAs (amitriptyline)
Antihypertensives
Alpha-blockers (terazosin)
Mixed alpha-/beta-blockers (carvedilol)
Beta-blockers: (propranolol)
Calcium channel blockers (amlodipine)
Vasodilators: Hydralazine, nitrates (nitroglycerin)
Diuretics (hydrochlorothiazide, furosemide)
Antiparkinsonism drugs (levodopa)
Antipsychotic drugs: particularly Phenothiazines
(perphenazine)
Hypnotic drugs:
Barbiturates (pentobarbital)
Benzodiazepines (diazepam)

Orthostatic hypotension can cause dizziness, blurred vision,

faintness, seizure, chest pain, or stroke. These symptoms occur
usually within seconds to a few minutes after a sudden postural change, sometimes after heavy meals, exertion, and prolonged standing. The symptoms resolve quickly when patients
lie down. Risk factors include older patients (especially those
with isolated systolic hypotension), patients with diabetes,
severe volume depletion, baroreflex dysfunction or autonomic
insufficiency, and those taking drugs that can cause orthostatic
hypotension.
To diagnose, a patient should be kept supine for 5 minutes
then changed to an upright position for 2 to 5 minutes. Blood
pressures are obtained at each position and then compared.
Orthostatic hypotension is diagnosed if one or both of the following is present:
At least a 20 mmHg fall in systolic pressure
At least a 10 mmHg fall in diastolic pressure
Treatment
Non-pharmacologic
Stop the precipitating medication(s)
Increase dietary fluid and salt
Reduce the size and carbohydrate content of meals
Avoid alcohol
Patients should rise slowly from a resting position
Patients requiring prolonged bed rest should sit up each
day and exercise in bed when possible.
Pharmacologic (after non-pharmacologic treatments fail)
Fludrocortisone acetate (with adequate Na intake)
Vaso-constricting agents such as midodrine and
pseudoephedrine
Propranolol or other -blockers
Patients with high risk of orthostatic hypotension should do
the following:
Avoid sudden standing and prolonged standing
When wanting to get out of bed, sit up and wait a moment. Then swing the legs over the side of the bed and
wait again. Stand up slowly and hold onto something in
case they start to feel dizzy.
Exercise modestly and regularly to reduce venous pooling.
In hot weather, drink more fluids; avoid extreme exercising or doing anything that takes a lot of energy.
Sleep with the head slightly above the heart. This can be
done by raising the head of the bed.
Wear compression stockings.
Avoid drinking alcohol.
Article by Tai Tran, PharmD Candidate, Wingate School of Pharmacy

Neil Medical Group Pharmacy Services Division

Page 7

Neil Medical Group

Kinston Pharmacy
2545 Jetport Road
Kinston, NC 28504
Phone 800 735-9111

Pharmacy Services

Louisville Pharmacy
13040 East Gate Parkway
Suite 105
Louisville, KY 40223
Phone 866-601-2982

Mooresville Pharmacy
947 N. Main Street
Mooresville, NC 28115
Phone 800 578-6506

...a note from the Editor

Greetings to all the Pharm Notes Family,
I wanted to share some great wisdom from the poet Maya Angelou:
Ive learned that no matter what happens, or how bad it seems today, life does go on, and
it will be better tomorrow. Ive learned that you can tell a lot about a person by the way
he/she handles these three things: a rainy day, lost luggage, and tangled Christmas tree
lights. Ive learned that regardless of your relationship with your parents, youll miss them
when theyre gone from your life. Ive learned that making a living is not the same thing
as making a life. Ive learned that life sometimes gives you a second chance. Ive learned
that you shouldnt go through life with a catchers mitt on both hands; you need to be able
to throw some things back. Ive learned that whenever I decide something with an open
heart, I usually make the right decision. Ive learned that
even when I have pains, I dont have to be one. Ive learned
that every day you should reach out and touch someone.
People love a warm hug or just a friendly pat on the back.
Ive learned that I still have a lot to learn. Ive learned that
people will forget what you said, people will forget what you
did, but people will never forget how you made them feel.
Till next time
Cathy Fuquay
Pharm Notes Editor

Pharm Notes is a bimonthly publication by Neil Medical Group Pharmacy Services Division.
Articles from all health care disciplines pertinent to long-term care are welcome. References
for articles in Pharm Notes are available upon request. Your comments and suggestions are
appreciated. Contact:
Cathy Fuquay (cathyf@neilmedical.com)
1-800-862-4533 ext. 23489
Note: Periodically, we are asked to add a name to our distribution list. At this time, copies of
Pharm Notes newsletters are distributed in bulk to Neil Medical Group customers only.