|Year : 2017 | Volume
| Issue : 2 | Page : 86-89
Adherence for medication among self-reporting rural elderly with diabetes and hypertension
Parveen Singh1, Rajiv Kumar Gupta1, Rayaz Jan1, Sunil Kumar Raina2
1 Department of Community Medicine, GMC, Jammu, Jammu and Kashmir, India
2 Department of Community Medicine, RPGMC, Kangra, Himachal Pradesh, India
|Date of Web Publication||20-Apr-2017|
Sunil Kumar Raina
Department of Community Medicine, RPGMC, Kangra, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Background: Elderly population (age group with >60 years of age) is usually beset with multiple morbidities. Many medications (drugs) are generally prescribed for the management and care of such morbidities. For majority, consumption of such medications on a regular basis is not an easy option, therefore giving rise to nonadherence for medications. The study was conducted with the objective to assess adherence to medication for hypertension and Type 2 diabetes mellitus (T2DM) among rural elderly. Materials and Methods: A cross-sectional observational study was conducted among all rural elderly (more than 60 years of age) being managed for hypertension and type 2 diabetes, using a pretested and semi-structured questionnaire. Results: The number of female elderly was more than the male. Nearly 56% of the elderly with hypertension were not taking regular medication, whereas the comparative figure was 50% for elderly with T2DM. Compliance of treatment in geriatrics with both hypertension and diabetes in relation to the genders was found to be nonsignificant (P> 0.05). The main reasons identified for this were costs of medications, adverse events of drugs, fear of addiction, and declining memory. Conclusions: Nonadherence to medication among the elderly for hypertension and T2DM in this rural study was not uncommon.
Keywords: Adherence, elderly, hypertension, rural, type 2 diabetes mellitus
|How to cite this article:|
Singh P, Gupta RK, Jan R, Raina SK. Adherence for medication among self-reporting rural elderly with diabetes and hypertension. J Med Soc 2017;31:86-9
|How to cite this URL:|
Singh P, Gupta RK, Jan R, Raina SK. Adherence for medication among self-reporting rural elderly with diabetes and hypertension. J Med Soc [serial online] 2017 [cited 2017 Aug 21];31:86-9. Available from: http://www.jmedsoc.org/text.asp?2017/31/2/86/204822
| Introduction|| |
India is in demographic transition. The elderly individuals (≥ 60 years of age) who were 20 million in 1950 are likely to touch 324 million by 2050. With 8.3% of population aged 60 years or more, India has a substantial elderly population. Nearly 75% of this population resides in rural areas. Globally, about 60% of the world's elderly resides in developing nations. The rapid increase in number and proportion of elderly has wide-ranging social, economic, and medical implications.
Medications are probably the single most important health-care technology in preventing illness, disability, and death in people of all ages in general and elderly in particular.
Increasing medication use with age is common to address specific symptoms, improve or extend quality of life, or heal curable conditions. The use of multiple medications contributes to the adherence challenges in the aging population.
Adherence means the extent to which patient's behavior coincides with the medical or health advice. Average adherence decreases from about 80% in elderly patients taking medication once daily to 50% in those taking medication four times a day., Globally, full compliance to treatment of chronic illnesses is 50%. However, it is far less than this in developing countries including India.
Extensive PubMed search reveals a paucity of data on medication adherence and determinants of nonadherence among geriatrics with hypertension and diabetes. Therefore, the present study was planned with the aim to asses medication adherence and causes for nonadherence in rural elderly reporting with hypertension and type 2 diabetes mellitus (T2DM).
| Materials and Methods|| |
The study was conducted as a cross-sectional population-based survey. The study was conducted in Miran Sahib Health zone of RS Pura health block in Jammu district in North-West India, involving 518 elderly (above 60 years of age) individuals being managed for hypertension and/or T2DM.
Background of study area
RS Pura, located in the South-West of Jammu city, adjacent to the Indo-Pak border covers an area of 273 sq km with an average density of 658/sq km. The block comprises 176 villages and one town (RS Pura town) and has an estimated population of 1, 79,636. The Health block RS Pura is divided into 8 health zones.
As the first step, one of the health zones out of the eight health zones was selected by simple random sampling. The zone thus selected was identified as the study area for carrying out this cross-sectional survey. The selected zone (Miran Sahib Health zone) comprised a population of 24,811 spread over 24 villages.
As part of second step, a house–to-house survey covering the entire zone was conducted to identify elderly being managed for hypertension and/or T2DM. Therefore, all elderly (above 60 years of age) reporting with a history of being managed for hypertension and/or T2DM were included in the study. The self-reporting was confirmed by corroborating with evidence in the form of doctors/registered medical practitioners' prescriptions available with elderly. Only those elders with evidence in the form of doctors/registered medical practitioners' prescriptions were included in the study. A total of 518 individuals completed the study.
All the study participants were interviewed using a predesigned and pretested questionnaire. The data regarding sociodemographic characters were collected followed by detailed information on adherence for medication for hypertension and T2DM. Further reasons for not taking medications were also elicited.
The study protocol was approved by the Institutes Ethics Committee. The procedure was explained to the participants at least a day before the study, and informed written consent was obtained from each.
- Being managed for hypertension and type 2 diabetes mellitus: All elderly having completed a minimum of one follow-up after start of pharmacological treatment
- Currently married: Women or men, who have been married and are not either divorced, widowed, or separated.
The association between variables such as sex and duration of disease was determined using Pearson's Chi-square test. P< 0.05 was considered statistically significant.
| Results|| |
During the course of this study, a total of 518 elderly individuals were interviewed, and 53.47% (277/518) of them were females. Majority (60.23%) of the study population was in the 60–69 years of age group and 66.21% of them were currently married, and an equal proportion of them were illiterate. Hinduism was the main religion, and 75.4% (391/518) respondents were living in joint families [Table 1].
During the current study, the authors could identify 153 elderly with hypertension, 68 elderly with type 2 diabetes, and 31 elderly with both hypertension and diabetes.
The results showed that 56% of respondents with hypertension were not taking regular medication. Importantly, 16% of hypertensive respondents were not taking any antihypertensive medication at all. Treatment compliance between genders for hypertensive medication was not found to be significant statistically (P > 0.05) [Table 2].
|Table 2: Treatment compliance for medication for hypertension only, diabetes only, and both|
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In comparison to elderly with hypertension, more (50%) diabetic elderly was taking regular medication [Table 2]. No statistically significant association was found between gender and treatment compliance. Further 45% of elderly with diabetes and hypertension (comorbidity) were taking regular treatment.
Among various reasons for noncompliance/nonadherence, cost of the medication was the main factor.
Other factors elicited were fear of addiction in case of analgesics, adverse effects of medications, and diminishing cognitive functions make them difficult to remember sometimes - complex regimens.
| Discussion|| |
In the present study, the females outnumbered their male counterparts. There was a discernible effect of age in the gender distribution of the study population with a higher number of females in the age group of 60–69 years and >80 years age group in comparison to males. In the 70–79 years age group, though males were slightly more in number. It is best explained on the basis of better life expectancy among the females. The proportion of females (53.47%) in the current study was similar to that reported by studies conducted in the USA and Europe., In contrast, some studies from India reported a higher percentage of males., In the current study, 60.23% (312/518) of the respondents were in the 60–69 years age group, which is in agreement with those reported by Chandrashekhar et al. and Lena et al. However, in contrast, Goel et al. reported only 47.2% respondents in this age group. Almost 66.02% of illiteracy rate in the current study was consistent with National Sample Survey (NSS) 2004 study  where 73.7% of rural elders were reported to be illiterate.
Nearly 43.7% of the elderly with hypertension in the current study were found to be taking antihypertensives regularly which was in contrast to 77% adherence rate reported by Natarajan et al. Natarajan et al. also reported a relationship between older age and better patient adherence to antihypertensive medications. Lack of health-care provider was reported to be a barrier to medication adherence in patients with hypertension, whereas patients with more primary care visits had less difficulty taking their medication. These findings underline the need for health workers at the grass root level and importance of interventions to support healthy lifestyle changes which might be beneficial in improving medication adherence. To further improve the adherence rates, the European Society of Hypertension and European Society of Cardiology have suggested the use of low-dose combinations compared with full-dose monotherapy. One striking finding in the current study was that 16% of the elderly with hypertension were not taking any antihypertensive medication at all which remains a cause of concern.
Regarding adherence to antidiabetic medication, 50% of the respondents were on regular medication which was in tune with 47.85% reported by Medi et al. In contrast, higher adherence rates (76.92%) were reported by Sanjeev et al., whereas Kirkman et al. reported an adherence rate of 69%.
This all is a pointer toward different sets of factors operating in the geriatric populations leading to varying rates of nonadherence in different studies. Kirkman et al. further reported lower odds of adherence in patients who were younger, new to diabetic therapy, and taking few other medications, which suggests that acceptance of a chronic illness diagnosis may be an important determinant of medication taking behavior. The results of the current study have not shown much difference for nonadherence of diabetic medication on the basis of sex, but lower rates of medication adherence in women have been reported for a variety of chronic conditions including diabetes mellitus.,
Further, those elderly who were suffering from T2DM with hypertension as comorbid condition comprised only 5.98% of the total patients and drug adherence rates among them were 45%. Putnam et al. reported high adherence rates of medication among patients who were suffering both from hypertension and diabetes.
When the reasons for nonadherence were elicited, most of the respondents had more than one response. Among the common reasons for nonadherence, cost of medications, fear of addiction, adverse events, and difficulty to remember were prominent. The authors presume that since two-third of the respondents were illiterate and majority of them dependent financially, they were the key reasons for nonadherence. In a similar vein, Medi et al. reported a lack of finances, forgetfulness, being busy, in access to medicines among the key factors for nonadherence.
Small sample size drawn from a limited geographical area due to which results cannot be generalized is a major limitation of the current study.
| Conclusions|| |
Nonadherence to pharmacological management for hypertension and T2DM among rural elderly is not uncommon. Therefore, it is important for the medical officers and health workers in the rural areas to educate elderly patients about long-term complications of chronic diseases such as hypertension and diabetes mellitus along with counseling regarding compliance to prescribed medicines.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther 2001;23:1296-310.
Salzman C. Medication compliance in the elderly. J Clin Psychiatry 1995;56 Suppl 1:18-22.
Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006;54:1516-23.
Gavilán Moral E, Morales Suárez-Varela MT, Hoyos Esteban JA, Pé rez Suanes AM. Inappropriate multiple medication and prescribing of drugs immobile elderly patients living in the community. Aten Primaria 2006;38:476-80.
Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, Wickizer SW, et al.
Potentially inappropriate medication use in the community-dwelling elderly: Findings from the 1996 medical expenditure panel survey. JAMA 2001;286:2823-9.
Shah RB, Gajjar BM, Desai SV. Drug utilization pattern among geriatric patients assessed with the anatomical therapeutic chemical classification/defined daily dose system in a rural tertiary care hospital. Int J Nutr Pharmacol Neurol Dis 2012;2:258-65. [Full text]
Chandrashekhar R, Gududur AK, Reddy S. Cross-sectional study of morbidity pattern among geriatric population in urban and rural area of Gulbarga. Med Innovatica 2014;3:36-41.
Lena A, Ashok K, Padma M, Kamath V, Kamath A. Health and social problems of the elderly: A cross-sectional study in Udupi taluk, Karnataka. Indian J Community Med 2009;34:131-4.
] [Full text]
Goel PK, Garg SK, Singh JV, Bhatnagar M. Unmet needs of the elderly in rural population of Meerut. Indian J Community Med 2003;28:4. [Full text]
Natarajan N, Putnam W, Van Aarsen K, Beverley Lawson K, Burge F. Adherence to antihypertensive medications among family practice patients with diabetes mellitus and hypertension. Can Fam Physician 2013;59:e93-100.
Vawter L, Tong X, Gemilyan M, Yoon PW. Barriers to antihypertensive medication adherence among adults – United States, 2005. J Clin Hypertens (Greenwich) 2008;10:922-9.
Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al.
2007 ESH-ESC practice guidelines for the management of arterial hypertension: ESH-ESC task force on the management of arterial hypertension. J Hypertens 2007;25:1751-62.
Medi RK, Mateti UV, Kanduri KR, Konda SS. Medication adherence and determinants of non-adherence among South Indian diabetes patients. J Soc Health Diabetes 2015;3:48-51. [Full text]
Sanjeev K, Ritesh S, Garg SK, Chopra H, Bano T, Jain S, et al
. Status of morbidities in geriatrics age group with special reference to spouse in an urban area of Meerut. Int Organ Sci Res J Humanit Soc Sci 2014;19:58-60.
Kirkman MS, Rowan-Martin MT, Levin R, Fonseca VA, Schmittdiel JA, Herman WH, et al.
Determinants of adherence to diabetes medications: Findings from a large pharmacy claims database. Diabetes Care 2015;38:604-9.
Rolnick SJ, Pawloski PA, Hedblom BD, Asche SE, Bruzek RJ. Patient characteristics associated with medication adherence. Clin Med Res 2013;11:54-65.
Manteuffel M, Williams S, Chen W, Verbrugge RR, Pittman DG, Steinkellner A. Influence of patient sex and gender on medication use, adherence, and prescribing alignment with guidelines. J Womens Health (Larchmt) 2014;23:112-9.
Putnam W, Lawson B, Buhariwalla F, Goodfellow M, Goodine RA, Hall J, et al.
Hypertension and type 2 diabetes: What family physicians can do to improve control of blood pressure – An observational study. BMC Fam Pract 2011;12:86.
[Table 1], [Table 2]