Many Older Adults Do Not Take Blood Pressure Medications as Prescribed

Hypertension, or high blood pressure, is one of the most common chronic conditions in the U.S., affecting nearly one-third of all adults[1] and over two-thirds of those 65 or older.[2]

Keeping high blood pressure under control (lower than 140/90) is essential to preventing long-term complications of hypertension, including cardiovascular disease, stroke and kidney failure. Yet only half of all hypertensive adults successfully keep their blood pressure under control.[3]

In many cases, this is because patients do not adhere to medications prescribed for high blood pressure, meaning that they do not take their medications as directed by their health care professionals. For example, patients may skip doses or stop the medications prematurely. Nonadherence with blood pressure medications can lead to uncontrolled blood pressure and increases the risk for long-term complications of hypertension.[4]

Extent of nonadherence

A recent report from the Centers for Disease Control and Prevention (CDC), published in Morbidity and Mortality Weekly Report in September 2016,[5] examined the scope of, and factors associated with, nonadherence to blood pressure medications among older adults.

The study measured nonadherence using medical and pharmacy insurance claims, and classified older adults as nonadherent if they had access to their prescribed blood pressure medications less than 80 percent of the time.

Although the accessibility of medications does not always mean that patients actually take them, it is a more objective measure than self-reporting of nonadherence and correlates well with blood medication levels and cardiovascular disease outcomes.

The CDC study found that, of noninstitutionalized adults (those not in a hospital, nursing home or assisted living facility) 65 or older with continuous Medicare prescription drug coverage in 2014 who were prescribed blood pressure medications, one-fourth (26 percent) did not take those medications as prescribed. Nonadherence was slightly higher (29 percent) among those 85 or older.

Nonadherence was more common among racial and ethnic minorities: More than one-third of African-Americans, Hispanics and American Indians were nonadherent, compared with approximately one-quarter of whites. Those with lower incomes were also less likely to take their blood pressure drugs as prescribed: About one-third of older adults with a low-income subsidy (extra help to pay for Medicare prescription drug insurance costs including premiums and deductibles) were nonadherent, compared with just one-quarter of those with no subsidy.

Geographic location also mattered. Nonadherence was the lowest (19 percent) among older adults living in North Dakota, Minnesota and Wisconsin. It was slightly more common (29 percent) among older adults living in the South, which is called the “stroke belt” region because it has an unusually high incidence of stroke and other cardiovascular diseases. Nonadherence was the highest (32 percent or higher) among older adults in Louisiana, Mississippi and Washington, D.C.

Medication class and drug regimen complexity also played a role in nonadherence. Older adults on diuretics had the highest nonadherence level (29 percent), whereas patients taking angiotensin-II receptor blockers had the lowest (17 percent).

Nonadherence was slightly higher when patients had to take two types of blood pressure medications (27 percent), compared with those who took medicine from only a single class (23 percent). Older adults taking a single class of blood pressure medication tended to be slightly less nonadherent (23 percent) than those taking two classes of medications (27 percent) and those taking three or more classes (28 percent). Similarly, older adults taking fixed-dose combinations (whose drugs were combined in a single pill) tended to be less nonadherent (23 percent) than those taking separate pills (27 percent). The study’s findings are corroborated by prior research that shows that medication nonadherence is a common problem among patients with chronic conditions in general.[6]

Factors behind nonadherence

Multiple factors can cause patients not to take their medicine as prescribed.[7] First, patients may avoid taking blood pressure medications because of unacceptable side effects.

Second, patients may have a poor understanding of their disease, the risks and benefits of their medicine, and the risks of nonadherence. Health care professionals may not communicate these benefits and risks adequately, may fail to involve patients in determining their medication regimens, or may fail to educate patients properly about how and when to take their medication. Third, complex combinations of medication may make it hard for patients to follow prescribed regimens.

A final major reason for patients neglecting to take their medication as prescribed is cost. Millions of Americans without prescription drug insurance have no means to pay for their medications. Even those with prescription drug coverage may be unable to afford the out-of-pocket costs for their drugs. Overall, blood pressure medications represented one-fifth of the total out-of-pocket prescription costs for older adults. These costs can be prohibitive and can make it difficult to adhere to prescriptions, especially for older adults with low incomes.

What You Can Do

If your physician or nurse practitioner determines that you need to be on medications to control your high blood pressure, you should take these medications as directed to control your blood pressure and minimize your risk for the long-term complications of hypertension. If you find your treatment regimen unaffordable or hard to follow, or if you experience side effects or are concerned about the drugs’ safety or effectiveness, consult your prescriber to discuss a more reasonable and tolerable treatment regimen.

You can boost your adherence by establishing a daily routine. For example, take your medications at the same time every day. Consider using medication organizers, pill reminders or notifications on your cellphone to remind yourself to take your medications.

Regularly monitor your blood pressure away from your doctor’s office by getting blood pressure measurements using the machines available in many pharmacies or with a blood pressure monitoring device that you can use at home. Research links self-monitoring of blood pressure to better blood pressure control, potentially lowering the risk for the long-term complications of hypertension.[8]

Do not rely on medications alone to control your blood pressure: Healthy lifestyle changes — including weight and stress reduction, a low-sodium diet, smoking cessation, and regular daily exercise[9],[10] — should always be the first steps in managing hypertension, and continue to be an important self-care component even when you need medications to control your blood pressure.

Refernces

[1] Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the US: National Health and Nutrition Examination Survey, 2011-2012. National Center for Health Statistics Data Brief, No. 133. Hyattsville, MD: Centers for Disease Control and Prevention; 2013.

[2] Ritchey M, Chang A, Powers C, et al. Vital Signs: Disparities in antihypertensive medication nonadherence among Medicare Part D beneficiaries — United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(36):967-975.

[3] Centers for Disease Control and Prevention. High blood pressure facts. February 2015. >http://www.cdc.gov/bloodpressure/facts.htm. Accessed October 7, 2016.

[4] Ritchey M, Chang A, Powers C, et al. Vital Signs: Disparities in antihypertensive medication nonadherence among Medicare Part D beneficiaries — United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(36):967-975.

[5] Ibid.

[6] Brown MT, Bussell JK. Medication adherence: Who cares? Mayo Clin Proc. 2011;86(4):304-314.

[7] Ibid.

[8] Erden S, Ozkaya HM, Denizeri SB, Karabacak E. The effects of home blood pressure monitoring on blood pressure control and treatment planning. Postgrad Med. 2016;128(6):584-590.

[9] Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA. 2003;289(19):2560-2571.

[10] James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.