Would you be worried about this?

In My Humble Opinion
1

Hypothetical situations can be entertaining. Let’s say – you know, just for fun – that you know a sweet little old man who will soon turn 80. You see him every week. Alas, he has advanced kidney disease, brought on by Type 2 diabetes, exacerbated by the meds for same. For the kidney thing he gets some kind of injectable which is flown in, packed in ice. He has high blood pressure. He has gout. He has congestive heart failure.

Okay, so imagine that an old friend comes back into his life who says she “used to work in a pharmacy.” Time passes. After awhile, he mentions trouble sleeping. You buy him some melatonin because it is pretty safe, and well-tolerated in the elderly. Plus, it has worked for you. Next time you see him, he gives it back to you unopened, saying “his doctor told him it was bad for his kidneys.” You find out that the pharmacy woman has recommended diphenhydramine for sleeping, (contraindicated in the elderly) which he is taking. Time passes. Then he starts saying how he has lost his appetite. This worries you, it seems a bad sign. A couple weeks later, you notice several boxes of sudafed by his bed. You sit him down and talk to him, saying that this is why he’s not hungry – pseudoephedrine (sudafed) is what they make speed out of, for God’s sake! He says that, of all his health problems, the one that scares him the most is that he has trouble breathing at night. This is the first time he has mentioned it. He wears those nose-band-aid-looking things that open the sinuses. He tells you that his sinuses have collapsed, and that the sudafed makes it so that he can breathe. You are pretty sure the pharmacy woman is behind this too.

Are you concerned?

2

Depends - how old is this old friend? Is she age appropriate or is she a rail-thin thirty-year-old with crumbling teeth and skin lesions?

(Also, you say this is a hypothetical, but is any similarity to persons living or dead purely coincidental?)

3

Well, in this scenario, the pharmacy woman is, say, in her late 50’s. No, not a dope fiend; but if I were in a situation like this, I would have to say that she is either monumentally ignorant, or else she is not concerned with adverse effects to his health.

Any similarity to persons currently living but for who knows how long is purely coincintentional.

4

You don’t say how long ago she worked in a pharmacy - she could be acting in good faith but her knowledge could be out of date.

The age difference would make me go :dubious: but I don’t have enough info yet. What brought her back into his life? What do his kids/family/friends think of this lady?

5

She needed a place to stay. It’s possible that she worked at the pharmacy long enough to pick up a few things about what is commonly suggested for such-and-such a condition, and so she fancies herself informed. His family came down to visit, but they only stayed a short time, and that was before all the dangerous meds came up. Right before, actually. In this hypothetical situation, you have known him for nearly five years. You aren’t comfortable around her because she seems to view you as somehow a threat. (you are in your forties.)

6

But, here are some things to ponder:

*Nowhere in all your research about melatonin have you seen anything remotely suggesting that melatonin is hard on the kidneys. Diphenhydramine, however, is, according to Wikipedia, “on the ‘Beers list’ to avoid in the elderly.”

*The trouble breathing at night thing came up shortly after the diphenhydramine thing started.
Wiki says, “Further side-effects (to diphenhydramine) include increased heart rate, pupil dilation, urinary retention, constipation, motor impairment (ataxia), flushed skin, blurred vision at nearpoint owing to lack of accommodation (cycloplegia), abnormal sensitivity to bright light (photophobia), difficulty concentrating, short-term memory loss, visual disturbances, irregular breathing, dizziness, irritability, itchy skin, confusion, decreased body temperature (in general, in the hands and/or feet), erectile dysfunction, excitability, and, although it can be used to treat nausea, higher doses may cause vomiting.”

*It is just dumb to take a sleep aid and a stimulant at the same time.

7

The medicine stuff sounds like a red herring. Suddenly coming back into his life because she needed a place to stay, and being jealous of me, would raise red flags. Is he giving her money in addition to a place to stay?

I’m assuming they were romantically involved before - were they? Did they have a falling-out or did they just get too busy for each other?

Did his family meet her when she was in his life before?

Are other people warning him about her?

8

Unless he really does need the sinus pill, and needs the sleeping pill to counteract the stimulant.

Do other people think she’s trying to hasten his death? Would she benefit?

9

He’s getting worse. Drive him to his physician, tell the physician what’s going on, have the physician explain what’s contraindicated. Be prepared to speak firmly and insistently to medical professionals.

10

Is the old man mentally okay? Does he have trouble understanding things or making decisions? Does he remember your conversations from one week to the next? If so, I’d butt out. He’s an adult and has the right to do/take anything legal. The fact is, he’s on a whole lot of stuff with a whole lot of health conditions, and that rarely leads to a good night’s sleep. It could be the diphenhydramine causing his problems, or it could be one of his prescribed treatments. While I would definitely let him know that the way he’s using the diphenhydramine is not recommended (and it’s not - any chemical used to help one sleep should be used for only a few nights unless you’ve got a prescription which says otherwise), what he does with that information is up to him. At some point - and this point is different for different people - patients decide that retaining/maximizing what quality of life they have is more important than prolonging their years.

If he’s confused, then it’s time for a chat with his primary caregiver/Power of Attorney/closest family member. If he’s homebound, a home health care nurse can come in to do a medication reconciliation and speak with him about any concerns she has. If he’s able to go to the doctor, a yearly review of medications is a good idea for anyone, and the doctor can do it during an office visit.

Whatever you do, you’re probably going to have to enlist the help of someone who wears a labcoat. Friends are easy to ignore. Medical professionals (especially for men of a certain age) carry a lot more weight. As you can see with this gentleman in particular, even *working *at a pharmacy gives this woman’s advice more weight. You’ll have to find someone with credentials that trump her and whom he respects.

BTW, you’re conflating two drugs: diphenhydramine is an antihistamine that’s in the Sudafed that’s easy to buy without an ID. Pseudoephedrine is the “old” Sudafed, and the stuff that’s used to make meth, so you have to get it from behind the counter from the pharmacist. Diphenhydramine isn’t used to make meth, and it’s fairly benign stuff in most people, even old people. It’s not recommended for use in patients with kidney problems unless prescribed by a doctor, but it’s not something that terrifies me from a medical perspective.

11

Wow, many people with germane questions, and sound advice.

Uh, first of all, WhyNot, thanks for coming in, you’re a medical professional IIRC, right? --I am in fact talking about two separate OTC meds he’s taking:

She suggested the Diphenhydramine (Benadryl) as a sleep aid.

The Sudafed he is taking to “unblock” his sinuses, at bedtime. It is specifically the kind containing pseudoephedrine, I checked.

Other questions answered in no particular order:

Yes, he is mentally sound. Rather impressionable; I think also susceptible to persuasive females. But overall, scientifically-minded and rational. Being a man of his generation, I think that indeed he does put his trust in (male especially) doctors, and mistrusts herbals, supplements, etc. (But really! Melatonin has a large body of research behind it at this point. Jeez!)

And yes, I believe they must have been involved briefly at some point, but not anytime recently. His family was meeting her for the first time, I believe.

That is a very good point about the quality of life vs. longevity thing, and I couldn’t agree more. He said something like that to me today, when I told him that the sudafed is why he hasn’t been eating. He said that not being able to breathe at night is scary, and he’d rather put up with not eating if it means he can breathe.

The thing is, he has always had good days and bad days, and always had a good appetite. It’s only in the last 2 or 3 weeks that, every time I see him, he hasn’t eaten, and when I ask how he’s feeling he says, “Oh, just hanging on. Not good.” I dunno, maybe it’s a natural slide downhill.

But what I think happened is, he had some trouble sleeping, so he started taking the Benadryl; that interfered with his breathing, so he started taking the Sudafed. That interfered with his sleeping, so he’s taking more Benadryl … you get the idea.

You are absolutely right that I should butt out. I guess. I mean, I believe very strongly in the right to self-determination. Even if he just wanted to get a little buzz on, I would be cool with that. I’m just worried that this person with an undue influence (in my opinion) is encouraging him to take these meds that maybe aren’t even necessary. I have to wonder what would happen if he stopped taking them both.

He sees doctors every week, various specialities. Unfortunately, he is not at all the sort to be proactive, ask questions, etc. I am sure he has not discussed any of these meds with any of them.

I just hate to lose my friend. He’s hella sweet.

12

Yes, I’m an RN. A home health RN, actually. This is the kind of stuff I deal with all day. (And sometimes keeps me up at night.)

OH! :smack: OK, I get it now.

I think your interventions should revolve around this. This is the problem - he can’t breathe at night. So what else can he do to help him breathe at night that isn’t pseudoephedrine? Well, a saline spray can help. A neti pot would be even better, but might be a hard sell. Raising the head of his bed at least 45 degrees may help, if he’s having trouble breathing because of the CHF. Sticking 5 or 6 pillow underneath the mattress will raise the head of the bed without leaving him sliding over extra pillows in his sleep. At some point, CHF patients usually resort to sleeping upright in a chair - if he’s at this point, a more comfortable recliner may help him sleep better. He might actually need some oxygen at night now - only way to tell is to check his oxygen saturation levels as he sleeps.

He should consider weighing himself daily - at the same time in roughly the same clothes. This can help keep track of how much extra fluid his body is holding - extra fluid will eventually back up in the lungs and make it feel like he can’t breathe. If he gains more than 2 pounds in a day or 5 pounds in one week, his doctor needs to know that to adjust his medicine.

Could be. But I’d also want to know the state of his finances and his mouth before I decided that. Is he spending food money on Sudafed? Did he break a denture plate? People are really weird about food, and not being able to eat food. They often refrain from mentioning problems like that, and even lie when asked outright. If he’s having problems affording food, I’d try to find him some help with that (LINK, Meals on Wheels, local food pantries, etc.). If it’s a dental problem? sigh That’s really hard to fix unless the person is particularly well-off financially.

I do, yes. But I guess where I’m stuck is with why Benadryl would interfere with his breathing. It’s not a sedative, it doesn’t slow the respiratory drive. If anything, I’d expect Benadryl to dry him out and make his sinuses more “open” than normal. Benadryl, after all, reduces histamine and thus inflammation. So why would it make it harder to breathe? I guess it could cause a bit of rebound inflammation/congested feeling if discontinued quickly, but if he’s got boxes and boxes of the pills, it’s unlikely he’s been trying to quit.

Specialties are certainly to be expected in his case, and it’s good to see he’s taking care of himself by going. I do worry in cases like this about the left hand sometimes not knowing what the right is doing. One doctor will change a medication and it doesn’t get communicated to everyone else, so then another doctor changes something else, not knowing that there’s a different thing they should be considering, y’know? It’s extra important for him to carry an updated list of medications with him, and to give a copy to every nurse he sees, every time he’s at the doctor’s office. If at all possible, he should use only one pharmacy, so the pharmacist can be checking accurate and complete lists of his meds - WalMart’s pharmacists don’t have his medication list from CVS’s pharmacy!

Any chance he’d let you come along? Or, failing that, could you help him create a written list of questions, with lots of space for him to write down the answers he gets when he next sees the doctor?

And you are incredibly sweet to care so much. He’s lucky to have you in his life.

13

Hey, thanks for taking the time to answer me so thoroughly, WhyNot.

His teeth are great, far better than mine; his larder is very, very well-stocked because up until recently, he was a foodie, like unto myself. His finances are quite stable.

I think the oxygen is a much better idea; in fact, I have suggested it myself a few times but he hasn’t been interested. (personally, I myself would welcome the opportunity to ingest a little high-quality air, yannow?)

Well, you are definitely someone who Ought To Know, so if you are inclined to think that the two OTC meds he’s taking are not high on the list of risky activities, then maybe I just need to chill.

I will mention to him about retaining fluids and elevating his head, that’s a good point.

14

You are very welcome. But just to be clear - I do think you have *some *reason for concern and should encourage him to get things checked out by his actual healthcare providers, mentioning both the insomnia and the difficulty breathing at night.

I’m a nurse. I’m not his nurse. And I’m not a pharmacist, trained in depth in drugs and their interactions (I’m hoping someone like Hirka T’Bawa notices the thread. He’s got a doctorate in pharmacy!) and impact on complicated health conditions. If this were my patient, I’d recommend a medication reconciliation and look see by a pharmacist; I wouldn’t be so worried as to call an ambulance, but I’d be calling his primary care doctor within the week to suggest a check-up.

15

I just found out my friend has been in the hospital **since Saturday **-- and this is Wednesday! Pharmacy lady didn’t bother to call me and let me know, even though I know she has my cell number on her cell.

Oh, but wait, there’s more. I arrive today to do my little chores that I help him out with. One of his cats has a delicate stomach, and spits up some of his food pretty often. I noticed a spot on the floor near the bed, and got down on my hands & knees with a brush and carpet stuff to clean it up. The bed is on a pedestal, about two feet off the floor. I’m cleaning the cat spot, and I glance over at the floor under the bed, and I see that *she has hidden the silverware! * (I don’t think he did that – it’s been there for ages, and he has never been concerned about it. Besides, I don’t think he could lift it.)

Once I got over being indignant, I started thinking about it with more detachment. I sure hope I’m not being set up here.

I don’t know whether I should say something to him about it just in case, or if that would look suspicious, or what. He’s apparently doing okay and is being moved down to less-urgent care today, although they want him to start on dialysis soon.

What do you guys think?