A 65-year-old woman comes to the office accompanied by her husband for follow-up of hypertension. She has been prescribed a thiazide diuretic, and her dose was increased at the last visit due to poorly controlled blood pressure. At today's visit, the patient's blood pressure remains elevated. Her husband says, "I'm trying to do everything I can to get her blood pressure under control. I cook healthy food and remind her to take the medication, but I'm not sure she's taking it." The patient says, "Taking the medication is a hassle; I know my pressure has been high but I feel absolutely fine." Which of the following responses by the physician is the most appropriate?
Nonadherence to medication is a common cause of poor clinical outcomes. Sustaining medication adherence for chronic, asymptomatic medical conditions (ie, "silent illnesses"), such as hypertension, is particularly difficult. This patient is likely nonadherent with medication, but her specific concerns about taking the antihypertensive are unclear. There may be multiple reasons for nonadherence, including inadequate understanding of the illness and the role of medication, complicated regimens, medication cost, side effects, illness perceptions, treatment beliefs, and psychological factors (eg, depression, anxiety, cognitive impairment, denial).
The best initial approach is to make the patient feel supported by normalizing her difficulty with adherence, followed by open-ended and nonjudgmental exploration of her reason(s) for nonadherence. Once an alliance is established and the specific factors are identified, the physician can more effectively intervene with a targeted intervention. Strategies to improve adherence include educating the patient; simplifying regimens; choosing generic (less costly) medications; addressing side effects and psychological issues; and increasing supervision, monitoring, and follow-up.
(Choices A and D) It would be inappropriate to recommend a change in medication or addition of a second medication without first addressing her likely nonadherence. These interventions could be considered if her blood pressure remained poorly controlled despite medication adherence.
(Choice B) Reviewing the patient's regimen and offering suggestions on how to improve adherence would be premature without first understanding the patient's perspective and exploring her specific concerns about taking her medication.
(Choice E) If the patient seemed reluctant to discuss her medication usage with her husband in the room, the physician might suggest that they speak with her husband not present. There is no evidence to suggest that this is necessary at this time.
(Choice F) Although assessing the patient's understanding of hypertension is important in providing targeted education, this statement aligns the physician with the husband rather than with the patient. She may feel attacked, which could put her on the defensive.
Educational objective:
Identifying and managing nonadherence is critical to improving outcomes for many chronic conditions, including hypertension. Creating an alliance by validating the patient's perspective and using an open-ended, nonjudgmental question is the most effective way to initiate a discussion.