Hypertensive Encephalopathy

Factual Questions
1

Last Monday, my 76-year-old mother-in-law’s blood pressure suddenly shot through the roof and my father-in-law took her to the emergency room of our local heart hospital. When they left home, she had a splitting headache and was starting to get incoherent. By the time they saw a doctor, she was completely incoherent, was having convulsions, and didn’t know where she was, to the point that she tore out one IV and the ER staff had to sedate her and put her in restraints. After a head CT scan, an EEG, an ECG, many blood tests, and a spinal tap, the doctors (two cardiologists and a neurologist) settled on a diagnosis of hypertensive encephalopathy. She was given IV Nitroprusside sodium and her blood pressure came down to 150 over 90 (from a high of 215 over 120, if I recall correctly). She remained incoherent and confused until the next afternoon, when she woke up enough to eat Jell-O and inquire about her grandchildren’s Halloween costumes. They did another EEG and ECG as well as a renal ultrasound, all of which we were told looked fine, and after she slept off the incredible amount of sedation she’d been given in the ER, she was pretty much herself again. She was released on Wednesday on a higher dose of oral Diovan than she’d been taking.

My mother-in-law is in generally good health for her age, but she has had a history of sudden blood pressure changes and she seems to react oddly to medication. Her doctor has tried at least four different medicines this year, and they haven’t gotten a consistent result from any of them (including the lower dose of Diovan that she’d been on before the hospitalization). She once had the experience of her pressure getting dramatically lower after her doctor took her off all blood pressure medications because he was worried about her renal function, but it then rose again after a month or two. Her blood pressure seems to stay at a decent level for the most part, but she gets these sudden dramatic increases at unpredictable intervals. She’s gone to the ER four times now for a severe headache and sometimes confusion in conjunction with extremely high blood pressure, but this last time was certainly the most dramatic and frightening episode. She has rheumatoid arthritis (in remission for the most part), mild osteoarthritis, and glaucoma. She’s also had some problems with arrhythmia in the past, which is why she has a cardiologist, but that’s been under control. There’s evidence that she’s had two small strokes in the past, but there was absolutely no evidence of anything this time around.

She’s been doing pretty well since she got home, although she’s very tired. She’s been having more vision problems (the vision of one eye was already somewhat limited from glaucoma), has had two somewhat severe headaches, and says that she’s having visual hallucinations when she watches TV in low light or closes her eyes to go to sleep. Her blood pressure has been staying around the same level it was when she was released from the hospital - high but not (as I understand it) immediately dangerous.

Now, my mother-in-law has an appointment with her ophthalmologist on Monday and one with her primary care doctor Tuesday. She has an appointment with her cardiologist for two weeks from now. I’m not really looking for specific medical advice here, but I’d like to know if anyone has any experience with this condition and, more specifically, any advice about what things we could be doing differently. My father-in-law took her to the Heart Hospital because he thought that high blood pressure was something her cardiologist would be best equipped to deal with, but now he’s afraid that he’d have been better off taking her to a general-care facility (although her cardiologist doesn’t have privileges at the local hospital that has the best emergency services). We’re all afraid that the root cause of such an unpredictable increase in blood pressure is going to be really difficult to track down and treat, and we’re terrified that she’ll have another episode in the meantime.

Any thoughts or advice? Unsupported opinions? Encouraging anecdotes? We’re trying to gather as much information as we possibly can at this point. Thank you all in advance.

2

Okay, one little bump for an impossibly long OP. To add information (as if it needed to be longer), I saw my mother-in-law today, and her vision’s improved, although she’s still got the hallucinations. She also told me she’s on Diovan and Atenolol.

3

I’m just speaking about general principles here, not your MIL’s case.

But if doctors have ruled out other causes for hypertension besides “essential hypertension” (and I expect they have in MIL’s case, given the workup you describe), then that patient may have high blood pressure just because their body is programmed that way.

In which case, the pressure can go up so high as to cause encephalopathy, and may need as many as five different antihypertensive meds (or more) to control it. Some folks are just real good at running high blood pressure at some point in their lives, and it takes a sledgehammer’s worth of pills to drive it down. And keeping it down can be difficult.

Once the encephalopathy has occurred (along with some old stroke damage), the symptoms can recur with lower blood pressure spikes.

my hierarchy of blood pressure meds goes something like this (order/type subject to change due to clinical situation). Start with one, add the next class as needed. Stop one only if side-effects require it.

  1. Diuretic (HCTZ or furosemide most often)
  2. ACE or ARB (like lisinopril or diovan)
  3. Beta blocker (metoprolol, atenolol)
  4. Calcium channel blocker (nifedipine, amlodipine, etc)
  5. Alpha blocker (clonidine)
  6. Minoxidil (that’s right, Rogaine)

Patients need to take their meds as directed, watch their salt intake, exercise as directed by their doc, and hope for the best.

Sounds like a tough case. My sympathies.

4

Wow, I’m sorry to hear this (and, sorry again, I missed your post first time through).

As always, Qadgop is right on (why he’s not in private practice pulling in the BIG bucks while catering to the really sick, and the really rich, and the really rich hypochondriacs, I don’t know).

In any case, one thing that everybody with high blood pressure needs to know is that there are a number of things that can undo the effects of the blood pressure medicine, or even elevate the BP by themselves.

So, for example:

  1. NSAIDs (nonsteroidal anti-inflammatory drugs) can most definitely elevate the BP (or counter the effect of BP meds). Since some are “over the counter” (at least in Canada), people often forget to tell their docs about them. Examples include drugs like Motrin, Ibuprofen, naprosyn, etc.

  2. A number of other OTC meds can raise the BP. As you’ll see if you check, many cold and allergy “remedies” have drugs in them which mimic the effects of adrenalin. This can be an especially potent effect if someone’s taking beta-blockers (like atenolol, metoprolol, etc.)

  3. Some prescription meds can elevate the BP or oppose BP medications. Some examples are steroids (prednisone) and the birth control pill.

  4. Alcohol can definitely increase the BP, and I’m not talking about huge amounts.

  5. Conversely, withdrawal of alcohol from someone who’s become dependent on it can lead to extreme elevations in BP.

  6. Probably not relevant in someone who’s generally well and out-of-hospital, but things like extreme pain, anxiety, or, most potently, “agitiated delirium” can also lead to a marked rise in BP.

  7. And, to be complete, I’ll include weight gain and lack of exercise as possible contributors to worsened BP control. Clearly, these are not acute nor precipitous.

I’m sure I’ve forgotten some, but I’m tired (and “post-op” from surgery I had a few days ago).

Oh, one more thing. When someone’s BP control begins to get severely worse after a long period of good control, one should at least think about so-called secondary causes of high BP. Things like pheochromocytoma and renal artery stenosis, and many other entities should be considered (not necessarily pursued, just considered.)

5

Thank you both for your replies. I’ll pass along what you’ve told me to my in-laws. I am encouraged by the way she seemed this afternoon - she’s pretty much back to herself, which means she’s intent on fussing over her family more than we can fuss over her.

One of the odd and frustrating things about this is that my MIL leads an unusually healthy life. She’s never had so much as a drop of alcohol, she’s never smoked, she avoids most OTC medications (and has certainly never indulged in any illegal drugs). She also lives in out the country, away from pollution, where she does more physical work than the vast majority of senior citizens. Although she was brought up on midwestern cooking (“there is no food that can’t be improved by the addition of bacon fat” seems to be the main theme), over the past twenty years she’s altered her cooking habits to drastically reduce the amounts of salt and fat she uses and to include many more fresh vegetables and leafy greens. Although she weighs more than she did in her salad days, her BMI is still around 22 or 23. She is, however, working on developing a more targeted exercise program, which pleases me, since it’s one of the few things I can help her with. She’s very motivated to keep on top of this, and I’ll continue to encourage her to take her medication exactly as prescribed (I suspect her independent-minded attitude sometimes leads her to be non-compliant, but she claims she does what the doctor tells her). My FIL is taking her blood pressure three times a day at this point and keeping a record for the doctors. They’ve been told to head for the hospital if it goes over a certain point, although I’m not sure what that level is.

Her primary care doc has expressed concern about her renal function in the past, to the extent of taking her off all meds - and her blood pressure promptly dropped and stayed down for two months without medication. The hospital did do a renal ultrasound which they said looked fine, whatever that means. I’ll suggest she ask her primary about that this week and that she bring up the possibility of secondary causes, as you mentioned, KarlGauss. Is it a good idea for her to continue pursuing this with her primary doctor and her cardiologist, or would it be prudent to seek out someone who might have more experience with blood pressure problems? Is there such a thing as a BP specialist, or is it such a generalized thing that the internist is the best choice?

Thank you both again for your help. Although I know that picking your brains on the SD doesn’t substitute for getting actual medical care, it sure is comforting to hear from people I whose opinions I respect in addition to talking to the doctors who are caring for my MIL.

6

Many of the Op’s mother-in-law’s symptoms are similar to my mom’s, however my mom also suffers from congestive heart failure and 40% arterial blockage in one leg, 60% in the other, thus the Warfarin (blood thinner), and thyroid condition.

**Qadgop’s list of meds are almost exactly as mom’s, but she’s not taking Minoxidil (<-- how does this benefit ??).

Few questions for OP:

  1. has she undergone a cardiac stress test?
  2. if she suffers from arthritis, side effects from some pain meds can cause hallucinations, is she/was she taking any at the time? Dehydration can cause hallucinations, too.
  3. does she have any arterial blockage? has she had a vascular ultrasound?
  4. has she had her thyroid tested?

my sympathies go out to you and your family, as well… like your MIL, my mom’s BP goes up and down like a rollercoaster.

7
  1. She’s had a stress test, but it’s been a while. Her only cardiac issue has been occasional arrhythmia.
  2. Although she has arthritis, the scare over Vioxx (and the fact she blames a similar medication for the small stroke she had years ago) has led her to cut out all pain medication except the very occasional regular Tylenol.
  3. There’s no evidence of arterial blockage, but she hasn’t had a full angiogram. They’ve done ultrasounds of various body parts, but not the whole shebang.
  4. She’s had complete bloodwork done recently, including thyroid and blood sugar tests, and it was fine.

I’m (obviously) not a doctor, but I understand that although Minoxidil is now thought of almost exclusively as a hair-loss treatment, it is a vasodilator that was designed to treat high blood pressure. It was only during testing that its effect on hair growth (and potential for the company’s bottom line) was noted.

I’m sorry to hear about your mom’s condition. It seems like just at the time our parents start to settle down and worry about us a little less, we start having to worry more about them!

8

A decent cardiologist should be a blood pressure specialist as a matter of course. Occasionally a nephrologist is helpful in managing blood pressure if the blood pressure elevation appears to be coming from a renal problem.

Otherwise, decent Internists and Family Medicine physicians should be able to handle 98+% of blood pressure problems out there.

Once I get to 5 meds, negative tests as described above, and still no BP control, that’s when I usually refer to cardiology. An able internist like our esteemed KarlGauss may well be able and ready to use more meds than that before throwing up his hands.

Good luck. Sometimes folks do everything right and still have bad health problems. As Damon Runyan once noted, “all life is 5 to 4 against”.

9

Minoxidil was originally marketed as a very effective antihypertensive.
Only after being used over time was it found to consistantly re-grow hair.

There are rare causes for hypertension that can sometimes be overlooked, like pheochromocytoma. I’ve only seen two cases in forty years. It would be covered by the list of tests your MIL recieved.