A 68-year-old woman comes to the office to discuss lipid-lowering therapy. She was prescribed rosuvastatin 6 months ago following a transient ischemic attack, but her pharmacy sent a notice to the physician a week ago that she has not filled her prescription for the past 3 months. The patient otherwise feels well and has had no recurrent neurologic symptoms. When asked why she is not taking her medication, she says, "I feel great without it. The ministroke was the scariest thing that ever happened to me, and now that I have put it behind me, I don't want the medication to remind me about my problem all over again." Which of the following is the most appropriate response to this patient's statement?

Question

A 68-year-old woman comes to the office to discuss lipid-lowering therapy.  She was prescribed rosuvastatin 6 months ago following a transient ischemic attack, but her pharmacy sent a notice to the physician a week ago that she has not filled her prescription for the past 3 months.  The patient otherwise feels well and has had no recurrent neurologic symptoms.  When asked why she is not taking her medication, she says, "I feel great without it.  The ministroke was the scariest thing that ever happened to me, and now that I have put it behind me, I don't want the medication to remind me about my problem all over again."  Which of the following is the most appropriate response to this patient's statement?

Quizplus · Accepted Answer

The psychological impact of serious illness and injury, including initial fear and residual stigma or shame, frequently affects patients' self-image and subsequent personal health decisions. This patient's statement indicates that she negatively associates her statin medication (eg, rosuvastatin, used for secondary prevention of recurrent cerebrovascular events) with memories of her initial transient ischemic attack (TIA), leading her to be nonadherent to therapy. Improving adherence in this patient should begin with an empathetic appreciation of her TIA and its effect on her emotional well-being. The physician should show respect for her feelings and experiences, avoid judgmental or critical statements, and encourage development of new, positive associations (eg, linking the medication to lower cholesterol and improved future health). If the patient comes to associate the statin with improved health, she may be more likely to adhere to therapy. (Choice B) This statement superficially acknowledges patient autonomy but primarily puts the attention and responsibility on the physician and does little to explore the patient's motivations and priorities. It is unlikely to influence the patient's medication adherence. (Choice C) Although this patient is avoiding thinking about her TIA, this is primarily due to negative associations rather than denial of the seriousness of the illness or likelihood of recurrence. Discussing whether she believes another event is likely would be less productive than encouraging new, positive associations. (Choice D) This statement attempts to universalize the patient's concern and could be helpful for someone who is resistant to therapy due to embarrassment or shame. However, it does not promote positive associations with the treatment and is therefore less likely to improve adherence in this patient. (Choice E) Focusing on adverse outcomes and complications of nonadherence is likely to reinforce this patient's negative associations of treatment and may make her more resistant to treatment. Educational objective: The psychological impact of serious illness frequently affects patients' self-image and personal health decisions, including medication adherence. Encouraging patients to develop positive associations (eg, linking treatment with improved health), rather than negative associations (eg, linking treatment with memories of disease), can improve adherence to therapy.

A 68-Year-Old Woman Comes to the Office to Discuss Lipid-Lowering