My dad (in rehab for strength and stability work after a burst compression fracture in his L4 vertebrae) seems to be doing pretty well in his SNF/NH. But I have a medications questions...

He's on a blood pressure medicine (metoprolol/Lopressor) and has been on it since a heart attack in 2016. One nurse told my mom and I about 'parameters' which means he doesn't get the pill if his blood pressure is too low. Another nurse told us today that he often doesn't get the pill. I remember when he had a minor surgical procedure, that pill was the only one he was allowed to take the day of the procedure. So is this common?

Also, the hospitalist who sent him to the SNF for rehab prescribed muscle relaxants (methocarbomol/Robaxin) both to help allow him to heal and because the PTs at the hospital said he was very stiff and tense. He was getting one every 6 hours. Until today... when the doctor who is the head of the NH (I googled her, she's worked as a geriatrician since 1982) switched it to "as needed." No one told my dad that, and it was only me noticing he only got one pill when he usually got two, so that's annoying and we're complaining about it but... the nurse we asked said the doctor does often pull back on some medications to see if people really need them.

So... is this a common thing? A good thing? I feel like it could be a good thing... if someone had told us.

The update...........

We talked to the physical therapist today who said he's made a lot of progress but there is still a lot he needs to work on. The PT said he expects that my dad will keep making progress. He's walking 80 feet, while learning a walker, and the PT wants 100. He's getting more balanced, taking bigger steps, turning better. The PT is getting him out of a chair by himself (it was two people) and it's getting easier. He said it'll be a few weeks at least, if not more.

And that he promised he won't send my dad home without meeting with my mom and I a few times to teach us how to help safely when my dad needs help.

I'm feeling much more calm about this... so thank you to all of the kind people here who offered me support and advice and their own stories and counsel and good wishes!

(I ramble and get wordy. I know. I'm sorry! Thank you for listening and reading!)

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The med changes you mention don't seem too off to me. If his BP is low enough, he doesn't need the BP med and giving it to him would lower it even more, probably too low which could cause other problems.

And the muscle relaxer, I think it's a good idea to have it "as needed" instead of just giving it every X hours. If the pain is decreasing, then he may not need it at all. But this does put the burden on the patient of ASKING for the med. Went through this with my mom in rehab after knee replacement. Tylenol was given every X hours without asking but oxy and/or the muscle relaxer were by request only. It was hard to get her to ask enough to keep her pain under control and I was there with her 6 - 8 hours a day.
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feelinglost8 Oct 2019
That's exactly what I'm worried about, the burden being on him to ask for it. He's the sort of person who seems to see needing pain medication as a sign of weakness. We were told his particular injury is incredibly painful but at the hospital, just after his injury, he kept rating his pain as 3... so much so that a palliative care doctor sat with him and talked about the importance of taking his pain meds before therapy, because therapy would be painful. His oxycodone at the SNF is "as needed" and I think he's only asked for it three times, asking instead for Tylenol to "see if that takes care of it" even if he's rating his pain at a 4.

A nurse last night seemed very bothered that he said nobody talked to him and that nobody had called my mom about the change.
Good news all around.

Unfortunately the doctors don't usually ask or explain medication changes with family, she may have informed your dad and he forgot.

Don't get hung up on issues that don't help get your dad as well as possible. You need to save your energy. Remind him that he needs to ask if he is feeling overly tense.

He is making great progress, yahoo!
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feelinglost8 Oct 2019
You're right. I need to relax about the things I can't control. We can't be there all day and they've been doing this for a long time. He seems pretty well aware of everything so, to a large extent, whether or not to ask for the muscle relaxant or not is a choice only he can make. I'll just keep reminding him that it's an option.

Thanks very much for reminding me of all that !
Thank you for letting us know that your dad is improving and you are too!

My aunt (93) takes the metoprolol. We have to watch it because it lowers her pulse also. On days her pulse is already below a certain point, we hold it. Her bp runs high though so we have to give an alternate drug to keep the bp down but not affect the pulse as much. The muscle relaxer might be helping to control his bp.

Each morning Aunts BP and pulse are taken and meds given accordingly.

Re the muscle relaxant. If that enables your dad to do his therapy you might want to mention to the therapist that his meds have been changed to as needed. I say this because the therapist may notice that dad isn’t as cooperative if he hasn’t had the pill. I always tried to have my mom’s med or patch or ice (whatever she was using) given before her therapy so she could participate without too much pain. She fractured her back in a couple of spots once and had to have something to ease the pain in order to do the therapy. She had elevated liver enzymes so pain meds weren’t her first choice. She liked the lidocaine patches best. Her back didn’t hurt unless she moved. So when asked if she needed something she would say no because lying in bed or sitting still she was comfortable. But when she had to get up and move, the pain would come back. So you might want to help dad sort that out.

If you do take your dad home you might want to invest in a oximeter to check his pulse and a bp unit to keep tabs on that. We keep a daily log and it’s very helpful for Aunt. Then you don’t run the risk of overmedicating him.
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feelinglost8 Oct 2019
You know, after the nurses explained the parameters and when they don't give the metoprolol, I did start to wonder if maybe some of my dad's balance problems and lack of interest in exercise and the headaches and backaches he's complained about (backaches before his fall) could be from low blood pressure. I looked up symptoms and those are all symptoms. So maybe it'll be a good change.

I did tell my dad last night that maybe if therapy doesn't go as well without a regular muscle relaxant to let the therapist know that they changed that med and maybe the PT would argue for it, before PT at least. And a palliative care doctor at the hospital suggested he take his pain meds before therapy, to get the most out of therapy. She made him promise. Which he did. But he does not. He's the type of person who seems to see asking for pain meds (other than Tylenol) as a sign of weakness or something. And I get that, as someone who avoids doctors as often as possible, but it's also a little frustrating.

I think my dad is a lot like your mom, even with back fractures... if he's sitting or lying (and he doesn't wear the orthotic brace while lying down), whatever pain or discomfort he had been feeling, eases up. So he figures it's "not that bad" and says no to medication. He's only taken oxy a few times at the SNF, after bad days in therapy I believe. Mostly it's Tylenol, to "see if that takes care of it," or he just asks for help moving from his wheelchair to the bed to stretch out. Maybe not being regularly on the muscle relaxant will change that, and maybe they'll watch close and put him back on it (if therapists say so or something).

But if they try to end therapy because of lack of progress, I'm going to question the role "as needed" might've played in a lack of progress suddenly appearing, especially when he's just a month out of a burst compression fracture in his spine and he doesn't even have a follow-up with a neurosurgeon for two more weeks.

Thanks for share your story of your experience with your mother, especially with the similar back fractures, and your kind words!
Yes, very common to set parameters. I take this medication (metoprolol). It is notorious for "seniors on the floor". Often blood pressure is high in MD office and it is prescribed, but once in home and normal activity it is too much and pressure gets too low resulting in dizziness and falls, especially upon arising at night to go to the bathroom. Parameters are just what they say. They have to take the BP before giving the pill, and hold for a certain number. A shame this cannot be done in the home. I am about 180/90 when at MD office. Otherwise 110/60. Some folks have "labile" BP which means quite high at times, quite low at
Doctors will prescribe medications here just as though they are the patient's doctor, because in fact they are. The fact that seniors are getting so many BP meds is the single highest reason they have so many falls at home. Side note is that this is extra work for nursing. That they are doing this here is a VERY good sign.
If you wish to be informed as the health care POA then tell them and they will make a notation in the chart that you are to be informed (one person) of ANY medication changes, so that you are aware. Then you will need to stop by the station and check the medications record daily with the nurse.
I am relieved that he is progressing so well and you do need to ask if they can walk him outside a few times if this is what is expected when you take him home, because the whole sky above thing matters. Also it is excellent that PT says progressing well but needs more work because THIS is exactly the wording that buys the most time with medicare. If they say progressed well but cannot do more then Medicare will say he needs to be out of there. If they say he cannot help and cannot participate and therefore is no benefiting then Medicare will request discharge. So it is indeed going very well and I am happy for you.
NOW consider a good monitor for blood pressure that you can snap on his arm (finger and wrist are not as reliable) and it reads BP automatically. Because the reason he may have been falling may be he was ALWAYS getting too much blood pressure medication. You will want to take his pressure at home before giving meds that lower it. OMRON makes good blood pressure takers but if there is a medical supply store near go and ask what they recommend for novice BP takers in the home. This could PREVENT further falls.
And so glad you updated us, and things are looking up. We all freak out in the beginning of everything.
Helpful Answer (2)
feelinglost8 Oct 2019
Thanks so much! For the recommendation on an at-home BP monitor and for everything!

The PT stopped in his room while we were there and had us see how he's doing going from bed to chair (he wanted to take a nap anyway), with assistance, and repeated the same goals and expectations for much more progress to be made. He said the help my dad needs now is the maximum he'd expect or ask us to do. He said he's wants and expects him to come home needing much less than he did today. And then he said that he and another therapist at the NH do home visits and it could be arranged that he'd be the one to come, for about a month, to work with my dad at home! But then said "we're not there yet, that's a ways off... still got work to do here."

So I feel like we're in good hands with him.

Oh, and we did tell him that the muscle relaxant has been changed to "as needed" and he said he'll watch to see if that affects progress in PT and, if it does, see about getting it back on regular schedules.

And a nurse did tell my dad that if he asks for Tylenol, just ask for the muscle relaxant too.
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