Factors Associated with Medication Adherence among the Elderly with Chronic Multimorbidity

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Factors Associated with Medication Adherence among the Elderly with Chronic Multimorbidity

https://doi.org/10.21203/rs.3.rs-1606261/v1

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Introduction

: Medication adherence is a key healthcare issue in the elderly and a challenging factor influencing the success of treatment. The present study aimed to determine the factors associated with medication adherence in the elderly with chronic multimorbidity.

Materials and Methods

The present study was descriptive-analytical and examined 800 elderly people using multi-stage random sampling method. The research collected data using a demographic questionnaire, a standard questionnaire on medication adherence in chronic diseases, and standard questionnaires on patient satisfaction with physician communication, which were completed via interviews and self-report. In present study, the elderly were classified into three groups based on having chronic diseases: people with a chronic disease, people with two chronic diseases, and people with three chronic diseases and more. SPSS24 was used for data analysis.

Results

The research results indicated that 426 individuals (53%) had two diseases, and 199 individuals (25%) had three diseases and more. Diabetes had the highest frequency (25%). The mean score of medication adherence of the elderly was 105.5 (± 49.04), and the mean score of the elderly's satisfaction with the physician’s communication was 66.48 (± 11). In the elderly with three or more diseases, a one-unit increase in satisfaction with the physician’s communication, medication adherence rate increased by 0.04 units.

Conclusion

It is suggested to implement new and innovative intervention strategies to improve health literacy, medication adherence, and adherence monitoring methods to better manage diseases in the elderly with chronic multimorbidity.

Adherence

Medication

Chronic diseases

Multimorbidity

Elderly

The number of the elderly is increasing in the world by increasing the life expectancy in terms of the lifestyle changes[1]. As the world's population ages, the prevalence of the elderly with multimorbidity, defined as the presence of two or more chronic diseases, is increasingly common[2]. The elderly multimorbidity is associated with poorer health outcomes such as lower health-related quality of life, increased use of healthcare services, increased disability, weakness, and mortality[3].

Medication adherence is a process by which the patients consume their medications as prescribed[4]. Among patients at 65 years of age and older, 82% are prescribed one drug, and 60.3% have prescriptions with three or more drugs [5]. Since older people are more susceptible to multiple diseases, they are at higher risk of non-adherence to medication than the younger population[6]. The medication adherence is about 50% among the elderly, and 20% -25% of prescriptions are never fully consumed [7]. Non-adherence to medication can be associated with frequent hospitalizations, lack of receiving treatment benefits, high treatment costs, and a large number of doctor visits [8].

Medication adherence is a multidimensional phenomenon and complex health behavior affected by many cultural, socio-economic, familial, and individual factors[9, 10]. However, several factors are involved in the medication adherence in the elderly[5, 11]. However, most studies on the determinants of non-adherence to medication have focused on the elderly with single chronic conditions despite the urgent need to understand medication adherence in the elderly with chronic multimorbidity[12].

Identifying variables affecting medication adherence in the elderly with multimorbidity will be a step towards developing elderly-based strategies to optimize their care. The present study aimed to determine the factors associated with medication adherence in the elderly with chronic multimorbidity.

The present study was descriptive-analytical and examined 800 elderly with chronic multimorbidity (based on the information contained in their electronic files) who visited the comprehensive health centers of Sabzevar County in Razavi Khorasan Province in 2021.

Sampling

The multi-stage random sampling method was used. First, Sabzevar County was divided into four clusters based on having four health networks (Khoshab, Joveyn, Joghatai, and Davarzan). Secondly, two health centers or health bases were randomly selected from each cluster, and then the samples were selected from the health centers using the availability sampling and were included in the study.

Sample size

The sample size of study was equal to 800 based on similar studies[13, 14] and according to Cochran's formula with a 95% confidence level.

cochran-formula

Inclusion and exclusion criteria

Inclusion criteria: No history of mental illness and psychotic disorders (based on information contained in the elderly electronic record), and consent to participate in the study. Elderly patients who received medications by the caregiver were excluded from the study. The elderly were divided into three groups based on the presence of chronic diseases (myocardial infarction, heart failure, peripheral artery disease, stroke, liver disease, chronic obstructive pulmonary disease, peptic ulcer disease, and diabetes mellitus). People with a chronic disease, people with two chronic diseases, and people with three chronic diseases and more were included. (The elderly with a chronic condition were utilized as a baseline against which other groups were compared.)

Data collection

Data were collected using the standard questionnaire of medication adherence by Modanloo et al. [15]), the standard questionnaire of the patient satisfaction with the physician communication, and the demographic information questionnaire, through a trained questionnaire and by asking the elderly, and entering their answers in the questionnaire.

Demographic information questionnaire: This questionnaire included demographic information.

Questionnaire of medication adherence in chronic diseases: This questionnaire has 40 items in seven fields. Its subscales include efforts for treatment (9 questions), willingness to participate in treatment (7 questions), ability to adapt (7 questions), integration of treatment with life (5 questions), adhesion to medication (4 questions), commitment to treatment (5 questions), and hesitation in implementing the treatment (3 questions). The answer to each question was scored on a 5-point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree). The questionnaire was designed and psychometrically evaluated by Modanloo et al. for adult and elderly patients with chronic multimorbidity[16, 17]. The content validity of questionnaire was equal to 0.91 in Modanloo’s research. The internal consistency of questionnaire was calculated by calculating Cronbach's alpha of α=0.921, and the reliability of the medication adherence tool was measured using the test-retest method with a time interval of two weeks, and the correlation coefficient was reported to be 0.875[18].

The Questionnaire of Satisfaction with Physician Communication: This questionnaire has 24 questions in 5 fields. Its subscales include satisfaction with relationship building (7 questions), satisfaction with collecting information about diseases and treatment (4 questions), Satisfaction with empathy in terms of communication with physician (5 questions), Satisfaction with respect (4 questions), and satisfaction with a joint decision (4 questions). The answer to each question was scored on a 5-point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree). Cronbach's alpha coefficient of the questionnaire was 0.78-0.90 in a study by Mahmoudian et al. The validity and reliability of questionnaire were confirmed[19].

Ethical Considerations

After providing the elderly's first consent, the study objective and supporting organization were provided to the elderly in order to adhere to ethical research norms. Additionally, the elderly were informed that all of their information would be kept secret by the researcher and that the surveys would be completed anonymously. The study was approved with the ethical code of IR.BHN.REC.1400.004 at Behbahan University of Medical Sciences.

Statistical methods

Mean, standard deviation, and percentage were utilized for the descriptive analysis of data. Chi-square and linear regression tests as well as IBM SPSS Statistics software (Ver. 24) were used to analyze data, and the significance level was considered 0.05.

Based on the results, the mean age of participants was 65.54 ± 4.59 years, and 53.38% of them were female. Furthermore, 172 participants (22%) had one disease, 426 (53%) had two diseases, and 199 (25%) had three or more diseases. 235 (55%) in the female population and 191 (52%) in the male population had two diseases. 299 (53%) illiterate individuals had two diseases. 31 employees (39%) had more than three diseases. The results indicated that there was a significant relationship between age, gender, job status, and the number of chronic diseases of the elderly (P < 0.05) (Table 1). Among the elderly, diabetes was the most common (25%). (Fig. 1)

Table 1

Demographic information of the participants in the study based on the number of chronic diseases
Variable	Status	One disease N (%)	Two diseases N (%)	Three diseases and more N (%)	\({\varvec{\chi }}^{2}\) (p)
Gender	Male	70 (19)	191 (52)	109 (29)	8.27 (0.016)
	Female	102 (24)	235 (55)	90 (21)
	Sum	172 (22)	426 (53)	199 (25)
Jon status	Married	108 (22)	254 (52)	124 (26)	6.27 (0.72)
	Single	5 (31)	9 (0.56)	2 (0.13)
	Divorced	4 (22)	11 (0.61)	3 (0.17)
	Widow (widower)	49 (2)	141 (57)	58 (23)
	Sum	166 (22)	418 (54)	187 (24)
Education level	Illiterate	125 (22)	299 (53)	136 (24)	10.61 (0.10)
	Primary school	31 (22)	68 (47)	45 (31)
	Secondary school	5 (13)	23 (61)	10 (26)
	High school diploma and higher	10 (2)	34 (68)	6 (12)
	Sum	171 (22)	424 (54)	197 (24)
Job status	Housewife	99 (19)	293 (56)	127 (24)	21.88 (< 0.001)
	Employed	19 (24)	29 (37)	31 (39)
	Others	54 (29)	97 (53)	33 (18)
	Sum	172 (22)	419 (54)	191 (24)
Life status	Single	60 (21)	158 (55)	70 (24)	8.54 (0.38)
	With spouse and children	49 (21)	117 (51)	64 (28)
	Only with spouse	55 (25)	111 (51)	52 (24)
	Only with children	5 (13)	27 (69)	7 (18)
	Sum	170 (22)	414 (53)	195 (25)

The research results indicated that 29.13% of the elderly had poor medication adherence, 49.13% had moderate medication adherence, 9.39% had good medication adherence, and 28.18% had very good adherence. The mean score of medication adherence was 92.31 (± 23.3) in the elderly with two chronic diseases and 61.79 (± 24.28) in the elderly with three or more chronic diseases. (Table 2)

Table 2

Medication adherence of the elderly based on the number of chronic diseases
Variable	One disease Mean ± SD	Two diseases Mean ± SD	Three diseases and more Mean ± SD	Sum Mean ± SD
Efforts for treatment	41.08 (4.48)	17.92 (6.01)	11.88 (4.56)	21.68 (12.1)
Willingness to participate in treatment	28.4 (1.32)	14.11 (5.03)	8.62 (2.56)	15.86 (8.07)
Ability to adapt	31.95 (3.48)	15.44 (5.11)	12.05 (6.26)	18.32 (9.11)
Integration of treatment with life	22.82 (2.49)	10.2 (3.35)	7.81 (3.38)	12.44 (6.52)
Adhesion to medication adherence	18.26 (1.99)	9.03 (2.95)	6.8 (3.45)	10.53 (5.15)
commitment to treatment	22.82 (2.49)	14.56 (3.65)	9.91 (5.21)	15.27 (5.99)
Hesitation in implementing the treatment	13.69 (1.49)	9.75 (2.89)	6.32 (3.68)	9.78 (3.85)
Total medication adherence	178.67 (16.87)	92.31 (23.3)	61.79 (24.28)	105.5 (49.04)

Based on the results, 58.43% of the elderly were satisfied with the way that physicians communicate. The mean score of satisfaction with the physicians’ communication was 63.66 (± 9.92) in the elderly with two chronic diseases and 61.87 (± 8.61) in the elderly with three or more chronic diseases. (Table 3)

Table 3

Elderly satisfaction with how the physicians communicate based on the number of chronic diseases
Variable	One disease Mean ± SD	Two diseases Mean ± SD	Three diseases and more Mean ± SD	Sum Mean ± SD
The peace of mind received from communicating with the physician	15.69 (1.56)	13.87 (2.97)	12.31 (2.55)	13.57 (2.83)
Physician’s communication skills	28.28 (3.01)	14.61 (3.74)	16.8 (3.82)	18.96 (6.4)
Information received about the disease	14.66 (1.52)	10.22 (2.86)	10.88 (3.7)	11.54 (3.56)
Physician's attention	7.65 (0.76)	15.57 (2.16)	12.39 (2.69)	12.14 (3.56)
Participation in treatment	11.15 (1.08)	9.9 (3.36)	9.73 (2.74)	10.09 (2.72)
Total satisfaction	77.42 (7.76)	63.66 (9.92)	61.87 (8.61)	66.48 (11)

The results showed that there was a significant association between age and medication adherence in senior patients with a single ailment; in other words, a 10-year increase in age lowered medication adherence by 7.3 units in elderly patients with one disease. There was a statistically significant relationship between satisfaction and physician's communication and medication adherence in the elderly with one disease. In other words, one unit increase in satisfaction enhanced the rate of medication adherence by 0.64 units. Furthermore, there was a significant relationship between satisfaction and medication adherence in the elderly with three diseases and more, In other words, one unit increase in satisfaction enhanced the rate of medication adherence by 0.04 units. The results indicated that there was not any significant relationship between medication adherence and gender, job, marital status, and education level. (Table 4)

Table 4

Factors affecting medication adherence in the elderly based on the number of chronic diseases
Predictive variables	One disease			Two diseases			Three disease and more
Predictive variables	\(\beta\)	\(t \left(p\right)\)	\(P\)	\(\beta\)	\(t \left(p\right)\)	\(P\)	\(\beta\)	\(t \left(p\right)\)	\(P\)
Age	-0.73	-3.17	< 0.001	0.12	0.39	0.70	0.54	1.25	0.22
Gender
Male	-	-	-	-	-	-	-	-	-
Female	-1.73	-0.75	0.45	-1.04	-0.36	0.71	-3.62	-0.5	0.61
Job
Housewife	-	-	-	-	-	-	-	-	-
Employed	-4.58	-0.77	0.44	-4.97	-0.78	0.44	0.32	0.04	0.96
Other	-4.00	-1.19	0.23	-4.12	-0.96	0.34	0.15	0.02	0.98
Marital status
Married	-	-	-	-	-	-	-	-	-
Single	-5.09	-0.98	0.33	-2.83	-0.31	0.75	-3.72	-0.23	0.82
Divorced	-2.01	-0.35	0.73	-13.99	-1.57	0.11
Widow (widower)	-2.72	-1.21	0.23	-3.3	-1.20	0.22	7.76	1.59	0.12
Education level
Illiterate	-	-	-	-	-	-	-	-	-
Primary school	0.35	0.13	0.89	-1.22	-0.35	0.72	-0.38	-0.07	0.94
Secondary school	-6.10	-1.9	0.19	-7.29	-1.33	0.18	-2	-0.21	0.83
High school and higher	0.84	0.21	0.83	0.19	0.03	0.97	-9.6	-0.75	0.45
The elderly satisfaction with physician’s communication	1.64	15.58	< 0.001	-0.23	-1.78	0.08	1.04	5.06	< 0.001

Because elderly patients often have multimorbidity which requires medical treatment, it is usually assumed that poor medication adherence is more common in the elderly. Thus, it is vital to understand the variables impacting medication adherence in the elderly in order to take appropriate efforts to enhance it. The present study aimed to determine the factors associated with medication adherence in the elderly with chronic multimorbidity.

Increasing the number of chronic diseases in the elderly decreased the mean score of medication adherence. Various studies indicated that the elderly with chronic multimorbidity and consumption of separate medication prescriptions for each disease had less medication adherence than the elderly who had fewer chronic diseases and simpler medication schedules[20, 21]. Multidrug therapy in terms of the presence of several diseases, complex treatment regimens, and doses more than twice a day are among the factors with negative effects on medication adherence, and continued consumption of medication in the elderly[22, 23]. Moreover, living alone, and the inability to plan for daily medication can be associated with non-adherence to medication in the elderly[24, 25]. The results of our study were consistent with other studies in this field [26–31] .

The current research discovered that as the number of chronic diseases in the elderly increased, their mean satisfaction with the way doctors communicated declined. Other studies have emphasized the critical nature of clinicians' ability to communicate with patients. Rowland-Morin et al. thought that active listening to patients had the potential to improve patient satisfaction and medication adherence [32]. Furthermore, listening to the patients and paying attention to their emotions strengthened the physician-patient relationship, increased the patient trust in physicians, and improved health outcomes[33]. It seems that the physicians’ empathy and effective relationship with the patients play important role in coping with and accepting the diseases and can be the main factor in medication adherence [34]. Patients' satisfaction in terms of communicating with physicians is a key factor in advancing the treatment process and achieving the treatment process and can affect the control and treatment of diseases because patients, who have a satisfactory relationship with their physicians, are more likely to follow physicians' instructions[19, 35]. To improve medication adherence in the elderly, the physicians should teach patients to promote medication adherence by an adequate explanation of the drug instructions and can increase patients' beliefs and knowledge about health and related therapies by consulting with them about any reluctance or hesitation in taking drugs[5, 11, 36].

The results indicated that medication adherence decreased with age in the elderly with one chronic disease. In older patients, the belief that drugs did not help them and had no effect on their diseases might be a factor in non-adherence to medication[37]. It might be the reason why many elderly people refuse to take their prescriptions or stop receiving therapy. Furthermore, limitations such as hearing or vision loss, as well as loss of skills owing to severe osteoarthritis of the limbs, may make it difficult for them to appropriately consume their medications. In some countries, the unaffordability of drug treatment is another major constraint on medication adherence in the elderly[38].

Considering the important role of medication adherence in managing chronic diseases, the following interventions are suggested to improve it in the elderly.

Behavioral interventions

In terms of adherence, the goal of behavioral interventions is to correct the elderly's behavior towards medication, such as holding structured counseling sessions by a trained nurse and holding a drug management program by pharmacists[39].

Educational interventions

Healthcare providers can teach the elderly to promote medication adherence by providing enough explanation about the way of taking medication, talking to the elderly about unwillingness to take medication, and discussing their beliefs and knowledge about health and related therapies[40]. Interventions for improving adherence should not only focus on the elderly, but should also cover the broader context, and other components of the healthcare system[39].

Integrated care interventions

Integrative care is defined as a set of organizational techniques and models to increase connectivity, coherence, and collaboration within and between healthcare providers at different levels, and it can be important to the success of an intervention and determines its effectiveness[41]. Therefore, improving medication adherence in the elderly requires coordination and cooperation of relevant elements[39].

Self-management interventions

Self-management intervention aims to inform the patients about their diseases to play a more active role in treatment[42]. Using technological tools in self-management interventions is increasing, including telephone support/counseling alone, telemedicine/ telehealth/ telecare/ telemonitoring, web-based interventions/ interactive computer health communications, and cell phones/ text messages[39]. Self-management interventions have benefits for the patients with chronic diseases in terms of knowledge, self-efficacy, and health status[43].

Risk communication interventions

Perceived risk is the main dimension of intentional non-adherence to medication and is defined as perceived probability, probability, or susceptibility to harm, and is a prominent construct in many explanatory theories of health behavior [44]. In texts about adherence, the extent to which patients engage in a behavior, in this instance medication adherence, is determined by their unique evaluation of the risk associated with the action and the consequent detrimental or protective outcomes. Therefore, healthcare providers need to have effective risk communications to ensure accurate information about risks and benefits and enable the patients to make informed decisions[45].

Packing and daily reminders

There are many different types of reminders, such as reminder phone calls, text messages, pagers, interactive voice response (IVR) systems, video calls, medicine boxes, or personalized towels[45] that can be used to improve medication adherence in the elderly.

Management of cognitive impairment or dementia

Cognitive impairment in the elderly is a challenge to optimize their care and treatment, and it requires adjustment via attention to environmental barriers and facilitators[46].

It is suggested to detect determinants of medication adherence in the elderly with chronic multimorbidity through qualitative studies.

The limitations of the present study included the completion of questionnaires by self-report, and interviews by interviewers.

Oral drug consumption is usually the most common way of use. Using oral drugs becomes a repetitive task in aging, and despite the daily use of drugs, there is still a possibility of forgetting to take the pills by patients, or even they may doubt whether they have taken the medicine on time or not? The weekly medicine box will be very helpful and effective in this regard by keeping the medicines in a completely hygienic place, as well as reminding the elderly about drugs. Furthermore, the smart medicine box and using various software help both the elderly and their caregivers improve their medication adherence. Regarding the decrease in medication adherence among the elderly as the prevalence of chronic diseases increases, it is critical to give education and intervention regarding the critical nature of medication adherence in the elderly in order to improve disease management.. Furthermore, establishing a proper relationship between the patient and the physician, especially in the elderly who have more than one chronic disease, can be effective in medication adherence of the elderly.

Ethics approval and consent to participate

The study was approved with the ethical code of IR.BHN.REC.1400.004 at Behbahan University of Medical Sciences. All methods in this study on humans described in the manuscript were performed in accordance with national law and the Helsinki Declaration of 1975 and its later amend. The informed consent form was obtained from all the participants and for illiterates from their Legal representative.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The financial resources of this research are provided by Behbahan Faculty of Medical Sciences.

Authors' contributions

VB: data collection. FH: data analysis. SHP: design of the study and revision of the manuscript. EN: critical review of the manuscript. All the authors read and approved the final manuscript.

Acknowledgements

I would like to express my sincere gratitude to the elderly who participated in this study and helped us in this research.

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No competing interests reported.

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Factors Associated with Medication Adherence among the Elderly with Chronic Multimorbidity

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Abstract

Introduction

Materials and Methods

Results

Conclusion

Figures

Introduction

Method: Study Design And Population

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

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