The case: A preventive pill goes unswallowed

“Doctor, he won’t take his blood pressure meds,” Mr. B’s son said, sighing and looking exasperated. Internally, I sighed too, wishing things could be easier for this man whose 82-year-old father had mild Alzheimer’s dementia.

Among the many challenges of assisting a loved one whose mind is slowly slipping, coping with frequent refusals to take recommended medications seems to be among the most common -- and most frustrating.

In Mr. B’s case, I hadn’t prescribed much: just one blood pressure pill. My patient for years, Mr. B has always preferred to take as few medications as possible. But after a minor stroke a few years before, he still had very high blood pressure, and these facts substantially raised his risk for another stroke. Like most geriatricians, I usually focus on avoiding disability. Most of my patients tell me they’d like to live at home for as long as possible. That's why strokes, which often cause devastating losses in one’s function, are among the most feared consequences of untreated very high blood pressure. Hence, the medication for Mr. B.

But Mr. B. wouldn’t take his blood pressure pill, despite multiple talks with me, and the frequent pleas of his son. He’d tell us he didn’t want to have another stroke, and that he knew his high blood pressure was apt to cause that. Still, he wouldn’t take his pill.

The challenge: Coping with a person’s resistance to medications.

Even before dementia develops, many people resist taking the medications doctors prescribe. Often this can be due to poor communication: Studies have shown that many doctors rarely explain the purpose of medications, or confirm that a person’s questions and concerns have been addressed. Good communication takes time, and sufficiently exploring a person’s concerns about medications can involve repeated discussions over several visits. Even then, there can be resistance. This is especially common when dementia has affected a person’s ability to organize his thinking and understand reasonable explanations. Sometimes creative compromising and negotiation can persuade a reluctant patient. But not always.

So it was with Mr. B. We’d been having the pill-refusal conversation for over a year. I’d offered him alternative pills. I’d suggested we start with just a teensy dose. A more experienced geriatrician had talked with him. A fresh-faced young resident had talked with him. The geriatric psychiatry service had talked with him. All to no avail. Mr. B. always had some kind of vague excuse for why he wasn’t taking his pill, and finally our team concluded that he was unlikely to be persuaded. We knew he had mild dementia, and even though his goals were to maximize quality of life, as well as to remain independent and functional for as long as possible, he couldn’t quite accept that taking his blood pressure pill would help him with that goal.

This was hard for his son, however, who felt that his father no longer had the mental ability (what doctors call the “decision-making capacity”) to decide whether to take medicine. “You need to do something about this,” he insisted to me.

The solution: A benefit-burden analysis

In Mr. B's case, I did what geriatricians often do: I discussed with Mr. B’s son the benefits and burdens of trying to insist that his father take his pill, given the stated goal of maximizing quality of life.

The benefits were pretty clear: Taking the blood pressure pill would reduce Mr. B’s risk of stroke and heart complications. Without treatment, he likely had a 10 to 30 percent chance of stroke over the next five years. Lowering his blood pressure might bring that risk down to 5 to 15 percent.

But the burdens of insisting on the pill were considerable. Even if we all agreed that Mr. B lacked the capacity to decide on taking medicine, given his repeated refusals and resistance to our coaxing, how could we make him take a pill? Modern medicine has achieved amazing technical successes, but there’s still no device to magically insert pills into people who don’t want them. I worried that this helpful pill had morphed into a cause of daily stress and conflict for Mr. B. and his son. Was this burden worth the benefit of reducing Mr. B’s stroke risk?

Ultimately, on hearing it presented this way, Mr. B’s son decided that no, the burden of a daily struggle to force a pill wasn’t worth the preventive benefit of treating Mr. B’s high blood pressure. “I wish he would take it, but he and I will get along better if I stop worrying and bugging him about it,” he concluded.

My prescription:

Sometimes, as doctors and caregivers, we find ourselves facing a situation in which none of our options feel good. Thinking through the benefits and burdens of each option can help us with these difficult decisions.