When faced with difficult-to-control cardiovascular risk factors, clinicians need to address the potential role of patient adherence to medication. Among the elderly in particular, careful consideration must be paid to accurately diagnosing an adherence problem in the context of often worsening atherosclerosis. This process includes moving beyond relying on clinical intuition to ascertain whether a patient has "real" (e.g., identifiable) reasons for suboptimal risk factor control and becoming comfortable using evidence-based questions and other ancillary data, when available, to more objectively identify patients with adherence issues. Once identified, a tailored search for an etiology that explores elderly specific patient, physician, and health care system factors needs to be conducted to understand why adherence is a problem for the patient. Finally, clinicians should employ simple tools and clear communication to work with patients and to help them overcome the relevant barriers.