Effective Counseling for Patients with Hypertension
Silent conditions, such as hypertension, that lead to devastating comorbidities (eg, cardiovascular diseases, stroke, renal failure) require an arsenal of tailored, persuasive messages when counseling opportunities arise.
Classification and Standards of Care
Hypertension (systolic blood pressure ??140 mm Hg or diastolic pressure ??90 mm Hg) is America's most common primary diagnosis, prompting 35 million office visits annually. Risk increases with age: those who are normotensive at age 55 have a 90% lifetime risk of developing hypertension.
Prevalence rates declined steadily from 1960 to 1998. From 1999 to 2000, however, prevalence surged by 31.3%, a surge many experts link to increasing obesity rates. Moreover, ~30% of sufferers are oblivious to their hypertension, and those receiving treatment often become nonadherent.1,2
Essential hypertension lacks identifiable causes. Secondary hypertension can occur as a result of drugs or biologics, disease states, or other causes. Systolic and diastolic readings demarcate 3 stages of hypertension (Table 1). People with prehypertension, a stage added in 2003, have double the risk for developing hypertension. Each increment of 20/10 mm Hg doubles cardiovascular disease risk.1
Hypertension responds to both lifestyle changes and pharmacotherapy. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends exercise, weight reduction, sodium restriction, moderation of alcohol intake, and a diet rich in fruits and vegetables and low in fat for all stages. Pharmacologic treatment options include > 50 agents, as well as combinations of agents, in 14 classes. Table 1 summarizes the JNC 7 recommendations. Generally, most patients require > 2 antihypertensive medications to achieve normal pressure.1
Counseling hypertensive patients requires insight, creativity, and ingenuity, because fixed messages will fall flat. Nevertheless, effective counseling covers 3 essential themes: improving health status with adherence, providing information on adverse effects and contraindications, and promoting healthy behaviors. Always begin by asking patients what prescribers told them previously, in order to save time and to identify information deficits quickly.
Emphasizing Medication Adherence
Because patient adherence is lower for symptomless conditions, 3 it is crucial to emphasize controlling blood pressure and to list the risks of medication nonadherence. Inform patients about what to do if they miss a dose. Repeat the name of the medication frequently so that patients become familiar with it.
Make suggestions that incorporate multiple daily doses into the patient's routine. Be cautious, however, about pairing medications with meals: some patients eat only 2 meals a day; others may have 4. Instead, specify the number of times per day to take the medication. Ask specific questions about the patient's ability to follow directions, such as "This medication must be taken twice; when in your day do you think you would take it?"
Adverse Effects and Contraindications
Make adequate counseling ideal by offering tips for coping with common adverse effects (Table 2). Note rare but serious side effects, and describe the circumstances under which patients should contact their provider. Warn patients about drug, food, or OTC product interactions and other contraindications.
Highlight transient side effects, reinforcing the fact that many??such as orthostasis or gastrointestinal complaints?? are temporary. Counsel patients about the dangers of stopping the medication before talking to their physician. Sudden termination of many antihypertensives may lead to rapid, dangerous blood pressure escalation.4 Tell patients to keep enough medicine to last through weekends, holidays, or vacations. Suggest carrying an extra prescription in a billfold or purse in case of an emergency.
Provide written information to reinforce counseling, especially when someone else picks up the patient's medication. Always encourage patients to call the pharmacy with questions.
Promoting Healthy Behaviors
JNC 7 recommends lifestyle modifications, with good reason. Reducing weight by 10 kg (22 lb) reduces blood pressure by 5 to 20 mm Hg; exercising 30 minutes daily is associated with a reduction of 4 to 9 mm Hg; and reducing sodium intake can affect pressure by 2 to 4 mm Hg.1
Effecting changes in health behaviors involves helping the patient set realistic, achievable goals. Suggest small changes that elicit firm commitments. Patients may balk at 30 minutes of exercise but be willing to commit to 10 minutes a day. They may roll their eyes at a 10% weight reduction but commit to losing 5 lb. Sometimes adding new behaviors (eg, exercising) is easier than eliminating old habits (eg, eating salty chips).
Many patients monitor their own blood pressure. They should be told to keep a log and to record their pressure at the same time each day. Additionally, they should take their cuff with them when they visit their doctor to ensure that they are taking readings correctly and that the machine is calibrated accurately.
End counseling sessions by eliciting commitment. Prod patients gently by saying "What problems do you anticipate with the things we discussed today?" Patients who have confidence and trust in their care providers are more likely to follow directions than those who do not. Building confidence begins with demonstrating a genuine interest in what happens to the patient, and communicating your concern by saying "See you next month, OK?"
Dr. Zanni is a health-systems consultant and a former commissioner of mental health for the District of Columbia. Ms. Yeznach Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health. The opinions expressed are those of the authors and not necessarily those of any government agency.
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