Depression. Depression is strongly linked to a lack of self-efficacy, especially when it comes to adherence.10,21 Hopelessness is a key factor in both depression and lack of self-efficacy, which in turn lead a patient to feel less motivated to adhere to therapy. 


Depression in the elderly is extremely common; more than 7 million people aged older than 65 years have it. There is a strong correlation between the diagnosis of a chronic condition, disability, and depression.22 Furthermore, the development of depression has been linked to the worsening of disability.23 Studies have shown an increase in mortality from cardiovascular disease among patients who are depressed.24 


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Although there are benefits to addressing depression that go beyond—and in some ways are more important than—improving adherence to medication, the primary care provider should consider it essential to screen all geriatric patients for depression when medication compliance is a concern. Several effective screening tools for depression are available, including the Geriatric Depression Scale. For those patients who are at risk, taking the time to discuss personal life issues during each visit may be all the therapy they need. When therapy is not enough, selective serotonin reuptake inhibitors (SSRIs) have been shown to be extremely effective for mitigating depressive symptoms in elderly patients.25


Because depression and lack of self-efficacy go hand in hand, particularly in elderly patients, clinicians can improve self-efficacy in order to guide their patients toward adherence. Primary care providers have always excelled at tailoring regimens to their patients’ lifestyles and needs. Establishing a sense of trust and sharing decision-making regarding a patient’s treatment plan increase the likelihood that the patient will follow through with that plan.10,26 The use of motivational interviewing techniques with a patient works to decrease the patient’s sense of desperation regarding his or her diagnosis. Providing hope for patients is an integral part of assisting them to feel motivated to participate in their plan. 


Complexity of the medication regimen. Polypharmacy is the term used to define prescription of multiple drugs across a variety of situations. Polypharmacy can be any of the following: (1) the use of five or more medications or the use of two or more medications to treat the same condition; (2) the use of two or more drugs of the same chemical class; (3) the use of two or more agents with the same or similar pharmacologic actions to treat different conditions; (4) the prescribing of more medication than is clinically indicated; and/or (5) a medical regimen that includes at least one unnecessary medication. Geriatric patients are the most vulnerable when it comes to polypharmacy.27 


The average geriatric patient takes between 3 and 5 medications daily.28 Two-thirds of community-dwelling people older than age 60 years take 4 or more medications, and those with chronic diseases may take up to 8 or more prescribed medications daily. A small subset of elderly patients who are frail and have multiple comorbidities take an average of 9 pills daily. 


Hypertension therapy involves the highest number of medications, usually an assortment of drugs of various classes. Studies provide strong evidence that as the number of daily doses of hypertension medication increases, patient adherence to the regimen increasingly fails.10,19 When investigating barriers to taking blood pressure medications, clinicians should conduct a medication reconciliation to identify the level of complexity of the medication regimen. 


If complexity is found to be a barrier, one of the most important things a clinician can do is to simplify the medication regimen to facilitate adherence. Monotherapy is often inadequate for controlling blood pressure and preventing cardiovascular disease outcomes in elderly patients. When adherence to a treatment plan is a challenge, however, simplifying the regimen should be a goal. The use of fixed-dose combination drugs rather than component-based free-combination therapy has been shown to improve compliance in several cases.17,29 It is recommended that the clinician taper or withdraw one medication at a time. This is important for diminishing adverse physiologic effects, such as hypotension and syncope, as well as patient confusion. 


Patients who have complex plans of care require frequent follow-up visits with a medication reconciliation at each visit. The clinician should perform a periodic review of each patient’s electronic medical records to stay organized and on top of the patient’s personalized antihypertensive therapy. Because continuity of care helps simplify the management of hypertension, one provider should manage the patient’s hypertension regimen. This helps reduce complications related to communication errors.10,13,18 


Blister packs are a relatively new and innovative way of organizing complicated medication regimens. These consist of pre-formed plastic packaging that can contain individual or multiple medications. The purpose of the packs is to help organize medication regimens so that the patient no longer has to organize pills according to when they must be taken throughout the day and week. Blister packs have been found to reduce the risk for noncompliance among consumers significantly.30 If disorganization or cognitive impairment is a potential barrier, the primary care provider can recommend this option and ask the pharmacist to implement blister packs in the patient’s care. 


Cost. The cost of medication is a substantial obstacle for the majority of the geriatric population. With the current gaps in today’s health care systems, many geriatric patients find themselves in the “doughnut hole.” With Medicare Part D, insurance pays for medications until a limit of approximately $3,000 is reached, at which time the patient must begin to pay out of pocket. 


Because the need for multiple medications to manage hypertension effectively is nearly unavoidable, the maximum Part D benefit is often quickly reached. This may leave patients unable to afford their medications. If they lack funds, elderly patients are more likely to not refill their prescriptions.18 


The rates of discontinuation of brand and generic medications do not differ. Therefore, generic medications may achieve similar results in regard to compliance.31 Choosing less expensive regimens, such as diuretics, over more costly medications is recommended when cost is a barrier to a patient’s adherence to treatment. Decreasing the number of medications can decrease confusion; additionally, it can reduce costs and may be especially beneficial for geriatric patients. 


Case study: A 70-year-old man with hypertension who is having trouble remembering to take his medication

A 70-year-old man is referred to your practice for primary care and management of his hypertension. He reports that he feels “overwhelmed” by his high blood pressure regimen and admits that he does not always remember to take each of his medications at the right time.

His vital signs are as follows: weight, 186 lb; height, 58.2 in; body mass index (BMI), 28.0; blood pressure, 168/88 mm Hg; heart rate, 80 beats/min; respiration rate, 16 breaths/min; oral temperature, 98.7˚F. His medications are the following: hydrochlorothiazide, 25 mg; lisinopril, 5 mg; metoprolol, 100 mg; atorvastatin, 20 mg; Colace (docusate sodium), 200 mg; vitamin D3, 2,000 IU.

A long list of medications may indicate confusion about polypharmacy and a complex regimen of prescribed therapy. Other assessments include a review of systems, past medical history, physical examination, mini mental state examination (MMSE), and the Geriatric Depression Scale.

For this patient, simplifying the medication list is an effective way to make it easier for him to follow a prescribed plan. Hydrochlorothiazide and lisinopril are available as a combination drug. Given the number of pills he has to take, the use of blister packs may alleviate his confusion about taking different medications in different containers. Having the patient set an alarm to take his medication at a certain time of the morning can provide an external reminder that helps him to keep on track. Additional cognitive health management and treatment for depression can be provided if necessary.

Conclusion 


The management of hypertension in the elderly is a complicated task that the health care provider must master. Poor adherence to medication is a clear contributor to the difficulty. Evidence shows that screening for adherence and addressing any factors that are leading to an individual’s lack of adherence are crucial to improving outcomes. Doing so involves not only understanding hypertension therapy in the context of the geriatric patient but also maintaining close contact with the geriatric patient and consistently assessing for any complications associated with therapy.


Primary care providers play an important role in alleviating the complications that may arise from lack of adherence. The use of individualized treatments that are tailored to the geriatric patient aligns with nurse practitioners’ and physician assistants’ foundational ideology of patient-centered practice. Clinicians not only diagnose and manage but also assess how contextual factors can impact the management of care. Assessing these factors on an ongoing basis will improve patient satisfaction and overall quality of life among the geriatric population. 

Michaela Jones, AGPCNP-BC, is a DNP candidate at Columbia University and a nurse practitioner at Mount Siani Hospital Department of Preventative Medicine in Manhattan. 

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From the May 01, 2016 Issue of Clinical Advisor

Topics:

Cardiology Cardiovascular Disease Geriatric Illnesses Hypertension