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Cracking the Commitment Code: Understanding Why Blood Pressure Adherence Is So Difficult

Author: By Dr. Christian Mende, MD, FACP, FACN, FASN, FAHA

Published: June 27, 2023

Blood pressure management is a critical aspect of maintaining overall health and preventing cardiovascular diseases. However, despite the known benefits of adhering to blood pressure management routines, many individuals find it challenging to maintain consistent adherence over the long term. Here, we will delve into the psychological and behavioral aspects that make it difficult for individuals to stick to their blood pressure management routines. By understanding these challenges, we can develop strategies to overcome them and improve long-term adherence.

Lack of Immediate Symptoms:

One of the primary reasons why blood pressure adherence is challenging is the lack of immediate symptoms associated with high blood pressure. Unlike other health conditions where symptoms may serve as a reminder to follow treatment plans, high blood pressure is often asymptomatic. This makes it easy for individuals to underestimate the seriousness of the condition and overlook the importance of adhering to their prescribed routines.

Research studies have highlighted the significance of the asymptomatic nature of high blood pressure in compromising adherence. A study published examined the adherence to antihypertensive medication among hypertensive patients and found that individuals with uncontrolled blood pressure were less likely to report symptoms or perceive a need for medication adherence. Understanding the asymptomatic nature of high blood pressure is crucial for healthcare providers to design effective strategies to promote adherence and manage this silent yet potentially dangerous condition.

Complex Treatment Regimens:

Blood pressure management often involves a combination of lifestyle changes, medication, and regular monitoring. This complex treatment regimen can be overwhelming and demanding, leading to difficulties in adherence. Individuals may struggle to incorporate various changes into their daily lives, such as modifying their diet and salt intake, exercising regularly, taking medications at specific times, and ideally monitoring blood pressure readings weekly. The more complex the routine, the higher the chances of non-adherence.

Complex treatment regimens often involve multiple medications, which can be expensive, especially if individuals do not have adequate insurance coverage or limited financial resources. The cost of medications can act as a barrier to adherence, as individuals may struggle to afford all the prescribed medications or may ration their doses to make them last longer, resulting in flawed adherence.

Some individuals, particularly the elderly or those with cognitive impairments, may have difficulties understanding and following complex treatment regimens. Complicated instructions, multiple medications, and scheduling complexities may overwhelm individuals with limited cognitive or functional abilities, making it challenging for them to adhere to the prescribed regimen.

It’s also important to acknowledge the universal human tendency towards procrastination and laziness. Many individuals are guilty of making promises to themselves and their loved ones, but frequently postponing those actions until a future date, commonly referred to as “starting on Monday.” In addition, research indicates that younger individuals tend to be less inclined to make necessary lifestyle adjustments to maintain their long-term health. Unfortunately, this lack of initiative and delayed action can have detrimental consequences as they age, potentially leading to irreversible health conditions.

Shift to Monitoring in the Home:

In efforts to improve adherence, many providers have shifted patient care and monitoring to the home, as in-home blood pressure measurements are proving more reliable.

A study published in the American Journal of Hypertension compared blood pressure readings obtained at home and in the doctor’s office. The study found that even the most standardized office blood pressure measurements can be misleading in a considerable proportion of subjects, and out-of-office blood pressure measurements should be used before making a diagnosis of hypertension and to guide treatment.

The study concluded that in case of disagreement between office blood pressure and out-of-office blood pressure measurements (ambulatory or home), decisions should always be based on the latter, provided the accuracy of the out-of-office measurement has been confirmed.

Another published study investigated the relationship between home blood pressure measurements and cardiovascular events. The study followed a large cohort of individuals and found that home blood pressure measurements were a better predictor of future cardiovascular events compared to clinic blood pressure measurements. This study further emphasized the value of home blood pressure monitoring in assessing an individual’s cardiovascular risk.

Home blood pressure monitoring offers several advantages over measurements taken in a clinical setting. Firstly, it eliminates the 30-40% of those that suffer from “white hypertension,” which refers to the phenomenon where blood pressure readings are elevated in a medical setting due to stress or anxiety. By measuring blood pressure in the comfort of one’s own home, individuals can obtain more accurate and representative readings.

Furthermore, home blood pressure monitoring allows for multiple measurements to be taken over time, providing a better understanding of an individual’s blood pressure patterns. This longitudinal data can aid in the identification of white coat hypertension or masked hypertension, conditions that may not be evident in a single visit to the doctor’s office. Additionally, home monitoring encourages individuals to take an active role in managing their blood pressure and promotes self-awareness of their condition.

The Challenge Persists, Awaiting Solutions:

While trending statistics prove both a preference and improved outcomes from in-home vital sign monitoring, the world is still perfecting the devices to do the job.

The growing popularity of wearables and in-home vital sign monitoring has led to advancements in technology; however, there are still challenges that need to be addressed. One significant concern is the lack of FDA approval or clearance for many wearable devices. The FDA plays a crucial role in ensuring the safety and effectiveness of medical devices, including those used for vital sign monitoring. Without proper FDA oversight, the reliability and accuracy of the data generated by wearables may vary, leading to inconsistent results.

subsequent study published in the American Hypertension Journal examined the accuracy of different non-validated blood pressure devices, including wearables. The researchers found significant variations in the accuracy of these devices, with some showing high accuracy while others demonstrated considerable discrepancies. This highlights the need for regulatory oversight to ensure the reliability of devices used for vital sign monitoring.

The Future of Improved Adherence:

Efforts are underway to improve the reliability and usability of medical devices for vital sign monitoring. The FDA has recognized the need to establish regulatory frameworks specific to digital health technologies to ensure patient safety and device effectiveness. Ongoing research and development aim to enhance the accuracy, consistency, and user-friendliness of devices, making them more suitable for widespread use in monitoring vital signs at home.

To address challenges in the meantime, healthcare providers can simplify treatment regimens, provide clear instructions, and offer support and education to enhance adherence. Patient-centered approaches, such as personalized medication plans, simplified dosing schedules, reminder systems, and regular follow-up, can help individuals overcome barriers and improve their adherence to complex blood pressure treatment regimens.

I, personally, am looking forward to the technological advancements ahead and partnering with academic institutions, other providers, patients, and researchers alike to improve healthcare for all.