Patient Case

Mr. Engle, a 70-year-old patient, comes to the pharmacy with his wife to fill a new prescription. The technician notices that the prescription is for the same antihypertensive agent that Mr. Engle has been taking, but now he will be taking a higher strength. Mrs. Engle asks if the technician knows of any place she and her husband can get more information on controlling his high blood pressure. They realize the importance of controlling his blood pressure, but feel that they “just don’t know enough.” She explains that they have a difficult time reading due to failing eyesight, but would like to better understand what to do for him. They also mention that they do not remember what they are told as well as they used to, so they need it to be repeated often. Mr. Engle’s physician schedules appointments for him every six months. They are looking for a way to have more frequent interaction with someone who can better educate them, along with checking to see that they are successful in reducing his blood pressure.

Case Discussion

Again, this is a patient who needs to be referred to the pharmacist for counseling. Taking a medication every day may sound simple, but it is amazingly easy to find one wondering if it was today or yesterday that he or she took blood pressure medication. Such simple tools as a weekly or monthly pill minder can make a big difference in compliance with daily medications. Expense can be another reason some patients may not take their medication every day or split pills and take only half some days. Patients who are not taking their medication every day are probably not getting their blood pressure down as low as the doctor wants or expects. As a result, that patient may be given an increase in dose or an additional medication. This, of course, may only complicate things. Or, maybe the patient is taking his medications as he is supposed to, but still is not getting the results desired. In this case his medications should be re-examined to see if a different drug, dose or combination would be more effective. What’s important to keep in mind is that the goal of medication is to have a good health outcome. Any patient who is having difficulty getting a good health outcome should be talking with the pharmacist. The technician often is the person who can notice when patients have concerns or are confused. The technician should ask the pharmacist to speak with the patient.

It also is important to pay attention to Mr. and Mrs. Engle’s concern that they want to be able to see if what they are doing is being successful in lowering Mr. Engle’s blood pressure. Patients with high blood pressure are not just given medication— they also are given a number of lifestyle changes that they should follow. These usually include decreasing salt, increasing exercise and losing weight. All of these things take effort. It is important for patients to feel that all that effort is accomplishing something. These patients likely will benefit from getting feedback on their blood pressure levels more often than once every six months. Some senior citizen houses or organizations offer blood pressure screenings on a regular basis. Other community-based services, including screening done in retail pharmacies, also may be an option. For others, purchase of a home blood pressure monitor would be a good option. In the case of Mr. and Mrs. Engle, it would be important to help them select one with large numbers. A memory function might also be of interest to them.

all the pieces necessary to obtain a blood pressure measurement. Most devices have adjustable cuff sizes or have the option to purchase a larger cuff if needed. The patient simply puts on the cuff, presses a button and waits for the reading. Many devices provide a large display for easy reading of the measurement.

Of course, to get a correct reading, patients need to read and follow the directions. Patients should be encouraged to avoid the consumption of caffeine or alcohol or the use of tobacco products for at least 30 minutes prior to taking a reading because these can increase blood pressure levels. When the patient is ready to take a reading, he or she first should sit still for five minutes. He or she should sit in a chair which supports the back and allows the feet to rest uncrossed on the floor. The arm used for the reading should be placed on a table or pillow at heart level. The patient should take two or three readings, separated by two to three minutes (Table 3).

Patients may ask why there is some variation in their blood pressure readings. It is normal for blood pressure to vary throughout the day. Blood pressure can even vary slightly with each heartbeat. It increases with activity and decreases at rest. It is higher in cold weather and during periods of stress.

To get an accurate assessment of blood pressure, it is recommended that that patient monitor his or her blood pressure at the same time each day. A single elevated blood pressure reading is not an immediate cause for alarm. The patient should keep a log of blood pressure readings that he or she can bring to the physician. In this way, home monitoring not only helps the patient, it also gives the physician additional information.

drug less than those who did not perform home-monitoring. The cost of medicine in the home monitoring patients was more than $1,000 less per 100 patients for one month of treatment. Although this study found that these patients had no more organ damage than those whose pressures only were measured in the physician’s office, other studies have shown that home monitoring can reduce the risk of organ

damage or heart complications.

Self-monitoring of blood pressure allows patients to play an active role in their care. They can feel empowered to maintain lifestyle modifications and to adhere to medication therapy.

Most pharmacies now sell automated and semi-automated blood pressure machines. The most common and easiest to use are the digital devices. The device contains

CONTINUED MONITORING

FOR ACHIEVEMENT OF GOALS

Studies have shown that as many as half of patients with hypertension do not get to goal. A number of reasons exist for not achieving blood pressure goals, including poor blood pressure measurement techniques, poor medication adherence, white coat syndrome and poor adherence with lifestyle modifications.

Inaccurate measurement of blood pressure can result in falsely elevated readings. Two of the most common mistakes are taking a measurement without having the patient sit quietly for five minutes and using a cuff that is too small. These are both corrected easily, but the pharmacist should evaluate for the potential of these problems, both in their own blood pressure screenings and in home monitoring.

Falsely elevated blood pressure readings also can be caused by white coat syndrome. This phenomenon is associated

Drug Store News

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May/June 2008