Adherence and hypertension in the geriatric patient
Managing hypertension in the elderly is a complicated task.
Hypertension is one of the most common chronic conditions that providers of geriatric care are challenged with managing. As the population gets older, issues associated with aging, such as providing quality medical care, including the management of hypertension, become increasingly difficult to address.
In many cases, poor adherence to a medication regimen is a reason for uncontrolled high blood pressure and a major predictor of nursing home placement in frail geriatric patients.1 Adherence rates in the elderly vary from 26% to 59%.2 Approximately 7.1 million die of complications of uncontrolled hypertension, so managing the problems that lead to poor adherence is a necessity for improving control of hypertension and overall quality of life.
Understanding adherence to treatment is key for primary care providers to effectively treat the elderly patient with hypertension. Factors found to prevent adherence include cognitive degeneration, lack of understanding, depression, complexity of treatment, and cost of treatment. Strategies to increase adherence target these barriers in order to improve cardiovascular health (Figure 1).
This article addresses issues in adherence to treatment in older adults. It provides evidence-based recommendations for interventions that nurse practitioners and physician assistants can use in clinical practice.
Management of hypertension in the elderly
Antihypertensive therapy is associated with a decreased incidence of stroke and risk for myocardial infarction and heart failure.3 Elderly individuals are already at an increased risk for these conditions; it is therefore particularly important to manage their hypertension effectively and appropriately.
The current guidelines of the Eighth Joint National Committee (JNC 8), released in December 2013, recommend a blood pressure goal below 150/90 mm Hg in all patients aged 60 years or older with uncomplicated hypertension.4 This goal, which is less stringent than the JNC 7 target blood pressure goal, is one of the ways in which providers are attempting to increase adherence and improve outcomes.5 However, barriers to meeting the goal still exist.
Adherence issues and recommendations
Cognitive degeneration. Cognitive degeneration affects much of the geriatric population. Each year, mild cognitive impairment affects more than 6% of Americans aged 70 to 89 years, whereas Alzheimer disease affects more than one-third of Americans aged older than 85 years. The accumulation of amyloid plaque, appearance of neurofibrillary tau tangles, and depletion of acetylcholine are some of the main pathologic changes that occur with the development of Alzheimer disease and cognitive degeneration.
Cognitive degeneration can range from mild disease with some functional dependence (eg, trouble managing finances) to moderate disease with greater dependency on others (eg, frequent inability to drive and some difficulty with bathing and shopping) to severe Alzheimer disease with motor and balance impairment and subsequent dependence on caretakers. The type of memory most commonly affected by cognitive loss is prospective memory—the ability to remember information pertaining to future events.6 Loss of prospective memory manifests as forgetfulness regarding upcoming appointments, medication regimens, and essentially all future planning involving disease management. Several studies have shown that a decrease in the mini mental state exam (MMSE) score is negatively correlated with adherence.7-10
There are many ways in which cognitive impairment can manifest and therefore, can potentially impact adherence. Effective blood pressure control does not make individuals "feel" better, and poor control does not make them feel worse. Therefore, patients with little understanding of the significance and consequences of uncontrolled hypertension often do not understand the importance of treatment. Several studies have shown that poor comprehension of treatment and management plans on the part of geriatric patients is a significant barrier to their adherence to medication.10-13 Elderly patients with hypertension and inadequate knowledge of other diseases they may have that are not related to their hypertension are less likely to be compliant.13-15
Tackling cognitive degeneration as an adherence issue in the management of hypertension is particularly challenging because studies have shown that hypertension as well as some other cardiovascular risk factors are strongly correlated with the development of dementia.16 However, several pharmacologic and nonpharmacologic means of addressing cognitive degeneration are available. The provider should consider both when seeking to assess adherence.
Providers must consistently identify and address any misunderstandings or knowledge gaps that a geriatric patient may have regarding a current treatment plan. Counseling the patient about the medication regimen significantly increases compliance rates, especially when the compliance issue is related to adverse effects or a misguided belief that the therapy is ineffective.15,17 Take the time needed to discuss the diagnosis with the patient and the importance of the treatment plan so that he or she leaves remembering and understanding it.
Memory aids have been shown to increase medication compliance in individuals with any level of cognitive impairment.10 Memory aids are tools and/or techniques used to remind the patient of any certain future task due. External aids are items the patient can touch or handle, therefore providing external sensory information; these include alarms, timers, notebooks, date books, "to-do" lists, calendars, tape recorders, conversation logs, and pillboxes. Allowing a patient to choose the aid with which he or she is most comfortable is also important because self-efficacy improves adherence.10,18 Taking a medication with a daily event, such as a meal, also increases adherence.19 These strategies do not improve cognitive ability but rather serve as ways around the impairment to maintain function and therefore adherence.
Some medications can be used concurrently with antihypertensive drugs to improve cognitive function, in turn improving adherence to the antihypertension medication. Acetylcholinesterase inhibitors are first-line agents for the treatment of mild to moderate cognitive disease.20 Other medications include N-methyl-D-aspartate (NMDA) receptor antagonists such as memantine and the monoamine oxidase type B inhibitor selegiline.