Journal of Survey in Fisheries Sciences 9(1) 145-151 2022

A Study On Assessing Factors Associated With Medication Non-

Adherence And Evaluating Medication Adherence In Elderly
P. Lakshmi1, Dr. B Ramya Kuber2*
Abstract:
Medication compliance refers to the degree or extent of conformity to the recommendations about day-to-day
treatment by the provider with respect to the timing, dosage, and frequency 1. Patient medication compliance
is an important parameter in management of chronic diseases in elderly patients. The present study aimed to
evaluate medication non-compliance barriers and the effectiveness clinical pharmacist intervention in
promoting medication adherence in geriatric patients with chronic diseases.an prospective observation study
was conducted in total of 275 patients aged above 60 years with chronic illness were (178 women and 97 men).
The patients’ mean age (SD) was 55 (±23.934) years. Approximately 38.9% were illiterate, primary education
(23.2%), secondary education 17.09% high school, 12.4% Bachelor’s degree education, 5.8% Master’s degree)
and 2.5% PhD holders were documented in the study. The MMAS scores were categorised previously into the
following 3 levels of adherence: high adherence (score, 8), medium adherence (score 6 to 8), and low adherence
(score < 6). The study population had 53.84%% with low adherence, 31.63% medium adherence, and 14.5%
high adherence. All the values are found to be significant as p≤0.05. The common barriers of medication non-
compliance founded during the study are polypharmacy 97patients, forgetfulness in 158 patients, duration of
therapy 146 patients, lack of hope in 95 patients, psychological attitude in 102 patients & 133 patients reported
as on subside symptoms. Pharmacist involment in improving medication adherence is very much needed to
improve therapeutic outcome. This study suggests that it is importance of targeting social support in screening
and intervention approaches in order to improve adherence among diverse patients.

Keywords: Medication Compliance, Elderly, Geriatric, Pharmacist, Screening

1
Research Scholar, Institute of Pharmarmaceutical Technology, Sri Padmavati Mahila Visvavidyalayam
(Women’s University), Tirupati- 517502
2
*Professor, Institute of Pharmarmaceutical Technology, Sri Padmavathi Mahila Visvavidyalayam (Women’s
University), Tirupati- 517502

*Corresponding Author: - Dr B Ramya Kuber

*Professor, Department Of Pharmacognosy, Institute Of Pharmaceutical Technology, Sri Padmavati Mahila
Visvavidyalayam, Tirupati, Andhra Pradesh, India 517502, Email Id: lakshmi.puligundla@gmail.com

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Journal of Survey in Fisheries Sciences 9(1) 01-07 2022

Introduction nonadherence in isolation3. One approach has

been increasing patient knowledge about
Medication compliance refers to the degree or disease and treatment which may include
extent of conformity to the recommendations disseminating drug information via audio-
about day-to-day treatment by the provider visual information, individual or group
with respect to the timing, dosage, and instruction, warnings about side effects, and
frequency1. Patient medication compliance is written information in the form of leaflets,
an important parameter in management of articles, or books. Another strategy is
chronic diseases in elderly patients. Patient influencing the treatment experience, which
compliance with physician's medication includes the doctor–patient relationship, and
instructions has been a growing concern for the way of providing care (Becker, 1985). In
nearly two decades. Elderly patients are general, the literature indicates that the
thought to have more difficulty following patient– provider relationship, which may
prescription instructions because they include the development of a cooperative,
generally have more medications prescribed, active relationship between doctor and patient,
often suffer from cognitive decline, and and answering all of a patient’s questions, is an
frequently have physical limitations such as important predictor of patient satisfaction and
failing eyesight and hearing17. Exhibiting a consequently, of adherence13,4.
genuine concern to patients for the importance
of drug therapy and adherence to directions is There is a lack of information concerning
the first step to improve compliance. Providing adherence to chronic drug treatment. To the
adequate verbal and written medication best of our knowledge, there is no adequate
instruction, and implementing routine tool for measuring adherence to chronic
assessment of medication compliance should medication therapy in the rural population
greatly improve response to drug therapy and while taking into consideration socio-
decrease adverse effects18. economic and cultural factors1,7,8.
Adherence to medication is an important
predictor of illness course and outcome in The real issue of noncompliant behaviour is
disease. Medication adherence behaviour lies how it influences health outcome. Every
on a continuum from complete adherence to clinician has several examples of how
prescribed medication, through partial noncompliant behaviour by patients has
adherence, to complete non-adherence. There resulted in failed treatment or drug toxicity3.
are a number of approaches for evaluating Adherence to a prescribed drug therapy has a
medication-taking behaviour. The main major influence on the therapeutic outcomes
methods are patient and clinician report, pill and the efficiency of the healthcare system.
counts, and biological methods (such as blood Adherence to a drug therapy requires that a
or urine drug concentrations), each of which patient has the intention to be adherent and
confers different advantages and follow through the medication regimen7,10.
2
disadvantages . The patient might have limitations in the
ability to manage the medication schedule
Nonadherence may be particularly devastating independently or take the right drug in the right
for older adults, as recent data indicate that dose at the right time via the right route of
approximately 15% of nonelective hospital administration that will lead to unintended
admissions in the elderly are due to non-adherence, which can be corrected by
nonadherence to medications. Physical adherence intervention in contrast to the
limitations are a barrier to adherence that may intended non-adherence, which is a consent
present a greater challenge in the geriatric and self-determined decision of a patient to
population than in other population3. Many alter or not make use of the proposed
strategies for improving pharmacological therapy11,12,15.
adherence among older adults have been The present study aimed to evaluate
developed in recent years. These approaches medication non-compliance barriers and the
have focused primarily on addressing one or effectiveness clinical pharmacist intervention
two of the aforementioned risk factors for

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 A Study On Assessing Factors Associated With Medication Non-Adherence And Evaluating Medication Adherence In
Elderly

in promoting medication adherence in geriatric 8 and 6-8 were considered adherent, and a
patients with chronic diseases17,18. score < 6 was considered as non-adherent in
our study.
Method The common barriers affecting medication
The study was designed as a prospective cross- non-compliance among chronic disease
section study conducted in largest patients was recorded. The terms used to
public hospital in Rayalaseema region of evaluate medication non adherence was
Andhra Pradesh i.e., SVRR government polypharmacy, forgetfulness, duration of
general hospital, Tirupati, Andhra Pradesh, therapy, lack of hope, psychological attitude
India, between June 2022 and December 2022. and on symptoms subsided. The subjects who
The patients who aged above 60 years and with enrolled in the study were followed up after
chronic diseases were included in the study. one month during their review visits to the
The patients who are not willing to participate hospital. Again, the MMAS-8 questioner was
in the study and having immunocompromised used to record the adherence responses
disease are not included in the study. details6,17.
Participants were randomly recruited during Data was analysed using Stata 13.0 software.
regular outpatient visits at general medicine Descriptive analysis was reported as
department. All patients were informed of the frequency, percentage and mean scores. T-test
objective of the study and gave written consent was done used to evaluate the relationship
before inclusion in the study, which was between the dependent (medication adherence
approved by the institutional ethical and literacy), and independent variables
Committee. (demographic characteristics of the
Patients were asked to complete a self- participants). Pearson correlation was used to
designed proforma that contained three parts: assess the relationship between mean baseline
history information form (socio-demographic, and follow up visit scores. All the differences
age, education, medical history, medication of estimated variables were considered
data), the MMAS-8 scale, and list of non- statistically significant if P<0.05.
compliance barriers.
Results
Measures: A total of 275 patients aged above 60 years
MMAS-8 First, the scale was used to measure with chronic illness were recruited for our
the medication adherence among study study (178 women and 97 men). The patients’
population. The scale is composed of eight mean age (SD) was 55 (±23.934) years.
items.15 Seven items (item 1 to item 7) are Approximately 38.9% were illiterate, primary
yes/ no questions, in which a ‘‘no’’ answer education (23.2%), secondary education
received a score of 1, and a ‘‘yes’’ answer 17.09% high school, 12.4% Bachelor’s degree
received a score of 0, except for item 5, which education, 5.8% Master’s degree) and 2.5%
was reverse scored. Item 8 is measured on a PhD holders were documented in the study.
five-Responses of ‘‘never,’’ ‘‘once in a while,’’ The mean time (SD) regarding disease
‘‘sometimes,’’ ‘‘usually,’’ and ‘‘all the time’’ distribution among the patients was
were scored 1, 0.75, 0.50, 0.25, and 0, hypertension was 105 (52.5 ±35.341) followed
respectively, whereas for item were scored ‘‘1’’ by diabetes mellitus 97 (48.5 ±29.797) and
for ‘‘never’’ and ‘‘0’’ for other responses. The cardiovascular diseases 73 (36.5 ±9.009).
total scores ranged from 0 to 8. Scores of 8, 6- over all socio-demographics and disease
8, and < 6 indicate high, medium, and low characteristics are summarized in Table 1.
adherence, respectively. Patients with scores of

Table 1
SAMPLE NO OF LOW MEDIUM HIGH p
CHARECTERSTICS SUBJECTS ADHERANCE ADHERANCE ADHERANCE value
(n=275) (n=275) (n=275) (n=275)
MEAN (SD) MEAN (SD) MEAN (SD) MEAN (SD)
Age 55 ±23.934
GENDER n(%)

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Journal of Survey in Fisheries Sciences 9(1) 01-07 2022

Male 178 (64.72%) 95 (34.54%) 56 (20.36%) 27 (9.8%) 0.039

Female 97 (35.2%) 53 (19.3%) 31 (11.27%) 13 (4.7%)
EDUCATION LEVEL
Illiterate 107 (53.5 68 (34 ±18.017) 27 (13.5 ±4.851) 12 (6 ±2.772) 0.438
±24.254)
Primary Education 64 (32 ±2.772) 33 (16.5 24 (12 ±6.93) 7 (3.5 ±0.693)
±9.009)
Secondary Education 47 (23.5 ±3.465) 22 (11 ±1.386) 17 (8.5 ±0.693) 8 (4 ±2.772)
Bachelor’s Degree 34 (17 ±4.158) 13 (611 ±1.386) 12 (6 ±2.772) 9 (4.5 ±2.079)
Education
Master Level Education 16 (8 ±1.386) 7 (3.5 ±0.693) 6 (3 ±1.386) 3 (1.5) ±0.693
Ph.D. 7 (3.5 ±0.693) 5 (2.5 ±0.693) 1 (0.5 ±0.693) 1 (0.5 ±0.693)
DISEASES
Hypertension 105 (52.5 59 (29.5 29 (29.5 ±14.552) 17 (8.5 0.047
±35.341) ±14.552) ±10.394)
Diabetes mellitus (I&II) 97 (48.5 ±29.797) 53 (26.5 27 (13.5 ±9.009) 17 (8.5 ±2.079)
±18.71)
Cardiovascular 73 (36.5 ±9.009) 36 (18 ±2.772) 31 (15.5 ±9.009) 6 (3 ±2.772)

Responses of the items of the MMAS-8 were previously into the following 3 levels of
recorded. A total score of all items was adherence: high adherence (score, 8), medium
calculated with a sum score ranging from 0 to adherence (score 6 to 8), and low adherence
8 for adherence. Frequencies, mean, median (score < 6). The study population had
and standard deviation were calculated for the 53.84%% with low adherence, 31.63%
sum scores. MMAS-8 score was calculated if medium adherence, and 14.5% high adherence
the respondent answered at least 6 of 8 items. table1.
The MMAS scores were categorised

Table 2
MMAS baseline (yes) baseline (no) follow up (yes) follow up (no) Association with
Items n=275 (%) n=275 (%) n=275 (%) n=275 (%) MMAS yes scores
(baseline vs follow-
up) p scores
Item1 198 (72%) 77 (28%) 69 (25.09%) 206 (74.90) 0.04
Item2 177 (64.36%) 98 (35.63%) 83 (30.18%) 192 (69.81%) 0.069
Item3 156 (56.72%) 119 (43.2%) 77 (28%) 198 (72%) 0.005
Item4 142 (51.63%) 133 (48.36%) 86 (31.27%) 189 (68.72%) 0.059
Item5 146 (53.09%) 129 (46.9%) 123 (44.71%) 152 (55.27%) 0.001
Item6 184 (66.9%) 91 (33.09%) 167 (60.72%) 108 (39.27%) 0.037
Item7 186 (67.63%) 89 (32.26%) 92 (33.45%) 183 (66.54%) 0.039
Item8 176 (64%) 97 (36%) 157 (57.09%) 118 (42.90%) 0.001
N= No of patients; p≤ 0.05 = significant

The individual scores were calculated for each which indicates non-compliance at baseline
item (n=8) presented in moriskey medication visit. The data obtained was corelated baseline
adherence scale. The scores were recorded with follow up were indicates statistically
both in two visits i.e., baseline & follow up significant (p≤0.05) all items except item
(patients next visit after their baseline visit). 2(p=0.069) and item 4(p=0.059) Table2.
Majority of the subjects were responded yes

Common Barriers Noted Low Moderate High P Values

Poly Pharmacy (N=205) 97 (3 ±2.772) 63 (31.5 ±2.079) 45 (22.5 ±0.693) 0.039
Forgetful Ness (N=158) 79 (39.5 ±20.096) 43 (21.5 ±2.079) 36 (18 ±2.772) 0.056
Duration Of Therapy (146) 62 (31 ±1.386) 49 (24.5 ±6.237) 35 (17.5 ±2.079) 0.098
Lack Of Hope (95) 39 (19.5 ±0.693) 27 (13.5 ±2.079) 29 (14.5 ±3.465) 0.07
Psychological Attitude (102) 46 (23 ±9.702) 29 (14.5 ±0.693) 27 (13.5 ±4.851) 0.007
On Symptoms Subside (133) 67 (33.5 ±9.009) 45 (22.5 ±3.46) 21 (10.5 ±0.693) 0.01
Values are expressed as N, Mean ± SD, P value <0.05, significant. SD: Standard Deviation, N=no
of patients

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 A Study On Assessing Factors Associated With Medication Non-Adherence And Evaluating Medication Adherence In
Elderly

The common barriers of medication non- The results in table 2 reveals that health care
compliance founded during the study are team (physician, nurse, pharmacist) involment
polypharmacy 97patients, forgetfulness in 158 in improving awareness in medication
patients, duration of therapy 146 patients, lack adherence can gives positive results. These
of hope in 95 patients, psychological attitude findings are similar to this study conducted by
in 102 patients & 133 patients reported as on witry et al9 on Pilot and Feasibility of
subside symptoms (Table 3). Combining a Medication Adherence
Intervention and Group Diabetes Education
Despite the significance of our findings, our for Patients with Type-2 Diabetes.
study has substantial drawbacks, including the
fact that it is a cross-sectional study rather than The overall medication adherence documented
a randomised clinical trial. As a result, it can in the baseline group was 38.7%, which
only provide the adherence rate for a specific climbed to 75.7% in the follow-up research. In
time period, which is problematic because the follow-up study, medication adherence
adherence rates have been shown to alter over increased by 37% compared to the baseline
time. research.

Discussion Four themes were identified as impediments to

The medication adherence assessment in drug adherence: lifestyle problems, patient
clinical practice is very essential but also incompatibility, medication forgetfulness, and
challenging. The most simple and economical nonexpert counsel. These ideas are constantly
method to receive information was from present in the illness process and decrease the
routine practice setting. however, their patients' efforts to live normally and take their
accuracy and agreement with other data medicine. The common barriers for
sources remain questionable, leading to a need medication non-compliance founded in our
for validity investigation6. The original study was poly-pharmacy and forgetfulness.
MMAS-8 was originally tested by Moriskey et As our study was on elderly people where they
al, and it was found that the scale was reliable have higher comorbidities and reduced mental
with good concurrent and predictive validity in ability leads to polypharmacy and
primarily low-income patients with forgetfulness. These results were similar to
hypertension patients where it is also easily study conducted by Agh T et al15 on factors
applicable to evaluate medication adherence in associated with non-adherence to medication
patients with chronic illness1,2,6. in patients with chronic diseases.

The demographic findings in our study reveals Conclusion

the majority of patients were male and In comparison to the baseline study, a
illiterates are more than other groups of substantial 37% improvement in medication
education. These results were due to as our adherence was seen among the study
study site is government general hospital were population in the follow-up research. The
majority of patients visited from below medication adherence is most common in
poverty class. These findings were similar to elderly patients. Patients who have risk factors
MacLaughlin EJ3 et al study. for poor adherence should be constantly
evaluated in order to optimise their drug-
The hypertension is most common illness taking behaviour. Pharmacist involment in
founded in study population was hypertension improving medication adherence is very much
as it shows increasing prevalence of needed to improve therapeutic outcome. This
hypertension in elderly people where these study suggests that it is importance of targeting
findings are similar to Eric J. MacLaughlin et social support in screening and intervention
al3 & Parker K et al20 study where they approaches in order to improve adherence
documented majority of hypertension patients among diverse patients.
in their study than other illness.
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Journal of Survey in Fisheries Sciences 9(1) 01-07 2022

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