Patient Adherence and Resistant Hypertension
Effective management of hypertension in an older individual requires an approach that promotes the patient’s adherence to its long-term treatment. The role of patient education cannot be overlooked with regard to explaining the goals of a therapeutic program and the importance of adherence to this program. There are several specific methods to enhance adherence to the long-term medical therapy of this condition. Written information describing the specific treatment and an agreed-upon blood pressure goal should be given to the patient. In general, a simpler regimen promotes patient adherence. The use of calendar or pillbox systems may be recommended to further assist patient adherence.
Blood pressure self-monitoring by the patient is another approach to involve the patient in the management of their hypertension and perhaps enhance adherence to therapy. Patient education regarding the significant benefits to be gained from adequate blood pressure control is of particular importance because hypertension is usually asymptomatic. The interdisciplinary geriatric team is well suited to promoting this approach.
To this end, it may be useful to involve nurses to provide reinforcement and feedback on the degree of blood pressure control during visits for blood pressure monitoring, dietitians to review dietary information and adherence, pharmacists to promote adherence to the medical regimen, and social workers to solicit the assistance of family members, if needed, and to review the financial burden associated with the cost of medical therapy.
The frequency of follow-up visits should be adjusted to reflect the patient’s degree of blood pressure elevation at presentation with closer follow-up indicated for those with stage 3 hypertension (i.e., a systolic blood pressure greater than 180 mmHg). With the exception of hypertensive urgencies (discussed next), attempts to reduce the patient’s blood pressure to target levels too rapidly are unnecessary and likely deleterious.
For most patients, an interval of 1 to 2 months is appropriate between visits to determine the need for dose titration. Given the age-related changes in systems that regulate blood pressure and impaired blood pressure homeostasis, overtreatment of hypertension may result in situational (postural or postprandial) hypotension. At all follow-up visits, it is imperative to determine the supine and standing blood pressure. It is good practice to titrate antihypertensive drug doses to achieve the target (seated) blood pressure only with the knowledge of whether this increase in dose could exacerbate preexisting postural hypotension.
It is also prudent to assess the patient’s adherence to his or her antihypertensive medication before recommending an increase in its dosage or considering switching to an alternative medication. For some patients, it will be important to obtain additional information derived from home or nonoffice setting blood pressure measurements.
Patients who fail to achieve adequate control of their blood pressure (failure to reach a target of 140/90) despite the use of three antihypertensive medications at maximal doses should be evaluated for causes of resistant hypertension. This evaluation should include an assessment of their adherence to the medical therapy, a review focused on potential drug interactions (e.g., nonsteroidal anti-inflammatory agents, corticosteroids, sympathomimetics, and alcohol), and an assessment for volume overload.
Other potential explanations for resistant hypertension are the presence of a secondary cause (renovascular hypertension in particular) or pseudohypertension, which should be evaluated as already outlined.