ArcaMax

DEAR DR. ROACH: I am an 82-year-old woman who was diagnosed with glaucoma about three years ago. I have been taking latanoprost eye drops at bedtime since then.

A glaucoma specialist in my health maintenance organization recently recommended that I take salt tablets to raise my blood pressure (usually 115-120/60-70 mm Hg) to at least 130/70 mm Hg to get a better blood supply to my retina. The specialist added that current science says a blood pressure of at least 130 mm Hg is recommended for people in their 80s. Even with one or two salt tablets a day, I cannot consistently get to the specialist's goal numbers.

My regular physician says that this higher blood pressure is not recommended for cardiovascular health. Which doctor should I listen to? -- J.M.

ANSWER: Although your glaucoma specialist is correct that very low blood pressure can cause low blood flow to the retina, I disagree with the advice for salt tablets. A blood pressure of 115-120 mm Hg is just about optimal for a person in their 80s (and for younger people, too).

It is true than many years ago (back in the 1910s), physicians used to think that higher blood pressure was "essential" to get blood flow to the vital organs. But this thinking is long gone, even if the terminology ("essential hypertension") is still sometimes used.

Raising the blood pressure does not protect the retina in people with glaucoma. Unless your ophthalmologist is aware of something that I am not, I disagree with this advice. We have decades of studies showing that blood pressure in the range that you have it is good for the heart and blood vessels (especially those going to your brain, including your eye).

DEAR DR. ROACH: I'm writing in response to a recent column on Do Not Resuscitate (DNR) orders in advanced directives. I would note that performing CPR on an 80-year-old person, regardless of how healthy the person is, is likely going to break multiple ribs and possibly the sternum as you do compressions.

There is also a chance of puncturing a lung with a broken rib, depending on how long the code drags on. I'm a nurse; I've done CPR many times, and I've cringed at every crunch of bones I've heard as I pushed. Recovery from this may not ever be possible, depending on what caused the arrest. Bones heal slowly in the elderly.

You didn't discuss the survival rates of CPR inhospital versus out of hospital; obviously, the survival rate is much lower if an arrest happens out in public, usually because there is a delay in starting CPR. You also didn't discuss the possibility of neurological damage and decline with prolonged CPR. This can be exacerbated in older people due to the normal brain changes that happen with age, which are then affected by the decreased blood flow during cardiac arrest.

There is a joke in the nursing world, especially in ER and critical care: We get DNR tattooed on our chest when we turn 75. -- P.M., RN

ANSWER: I appreciate Nurse P.M.'s thoughtful response. I fully agree that CPR has the potential for many complications and that many people have an unrealistically favorable understanding of its outcomes. Many older people, especially those with chronic health conditions, should think carefully about a DNR order. I have seen many people's families regret going down a path that can be very long and unpleasant.

I would encourage you not to get a DNR tattoo (although I have seen ER nurses with them) as they are not legal documents. I also received a note from a lawyer who informed me that some states have complicated requirements, so an estate lawyer can help draft your wishes into a legally correct document.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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