Family Medicine · Year 3 · from Family Medicine
Case 2: Medication Non-Adherence
Patient Demographics
- Age: 54 years old
- Sex: Female
- Occupation: Hotel housekeeper
Chief Complaint
"I'm here to refill my blood pressure medicine."
History of Present Illness
Ms. Rosa Martinez is a 54-year-old woman presenting for medication refill. She was diagnosed with hypertension 2 years ago and started on lisinopril. Her pharmacy records show her last refill was 6 weeks ago for a 30-day supply. When asked directly, she admits she "sometimes forgets" to take her medicine. She says, "I feel fine, so I don't think I need it every day."
She also mentions she stopped her cholesterol medicine (atorvastatin) because it was "making my muscles hurt."
Current Medications (prescribed)
- Lisinopril 10 mg daily
- Atorvastatin 20 mg daily (patient reports not taking)
Vital Signs
- BP 162/98 (repeated: 158/94)
- HR 82
- BMI 29
Adherence Assessment
Non-judgmental questioning approach: "Many people find it hard to take medications every day. There's no wrong answer here - I just want to understand so I can help. How has it been for you with your blood pressure medicine?"
Patient response: "Honestly, I probably only take it a few times a week. I feel fine without it, and I'm worried about side effects."
Pharmacy refill records: Last 12 months
- Expected refills: 12
- Actual refills: 6
- Medication Possession Ratio: 50%
Identifying Barriers to Adherence
| Barrier Category | Patient's Specific Barriers |
|---|---|
| Medication-related | Side effect concern (statin - muscle aches); Multiple daily doses challenging |
| Condition-related | Asymptomatic disease - "I feel fine" |
| Patient-related | Forgetfulness; Belief that medication not needed if asymptomatic |
| Health system | English is second language; Health literacy concerns |
| Cost | Denies cost concerns (has insurance) |
Assessment
- Hypertension, uncontrolled due to medication non-adherence
- Hyperlipidemia - statin discontinued due to side effects
- Medication non-adherence - 50% adherence rate
Management Plan - Addressing Adherence
1. Education (Health Literacy Appropriate):
- Used teach-back method with Spanish interpreter
- Explained: "High blood pressure is called a 'silent killer' because you can feel perfectly fine but it's still damaging your heart, kidneys, and brain. Taking the medicine prevents heart attacks and strokes even when you feel well."
- Visual aid: Showed pictures of healthy vs. damaged blood vessels
2. Simplify Regimen:
- Changed from lisinopril to amlodipine/losartan combination pill (single daily dose)
- This addresses both BP control and the statin issue by using a different class
3. Address Statin Side Effects:
- Discussed that muscle aches with statins are common but often improve
- Options discussed:
- Try a different statin (rosuvastatin has lower myalgia rates)
- Try lower dose
- Try every-other-day dosing
- Patient elected to try rosuvastatin 5 mg daily
4. Practical Adherence Strategies:
- Pill organizer provided
- Linked medication to daily routine: "Take with morning coffee"
- Involved family: Husband will remind her
- Spanish-language medication information sheet provided
5. Motivational Interviewing:
- Explored importance: "On a scale of 1-10, how important is preventing a stroke to you?" - Patient: "10, my mother had a stroke"
- Explored confidence: "How confident are you that you can take this pill every day?" - Patient: "Maybe 6"
- Problem-solving: "What would help you feel more confident?" - Patient: "If my husband reminds me and I keep it by the coffee pot"
- Re-assessed confidence: "Now?" - Patient: "8"
6. Follow-Up Plan:
- Return in 4 weeks for BP recheck
- Phone call in 1 week by staff to check on adherence
- Repeat lipid panel in 6 weeks
Follow-Up (4 weeks)
- BP: 138/86 (improved)
- Reports taking medication "almost every day"
- Pill count consistent with good adherence
- No muscle aches on rosuvastatin
Teaching Points
- Non-judgmental assessment: Opening with "Many people find it hard..." normalizes the struggle and encourages honesty.
- Identify specific barriers: Adherence is not a single problem. Each patient has unique barriers requiring tailored solutions.
- Simplify regimens: Every additional daily dose decreases adherence. Combination pills and once-daily dosing improve adherence.
- Motivational interviewing: Exploring importance and confidence, then problem-solving specific barriers, is more effective than lecturing.
- Asymptomatic disease: Patients with conditions like hypertension often struggle to take medication for something they can't feel. Education and regular monitoring are essential.