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  • Factors Associated with Medication Adherence

    In Frail Urban Older Adults:

    A Descriptive and Explanatory Study

    by

    Anne-Marie O’Brien

    A Dissertation Presented in Partial Fulfillment of the Requirements for the Degree

    Doctor of Philosophy

    Approved April 2014 by the Graduate Supervisory Committee:

    Karen Marek, Chair

    David Coon Bronwynne Evans

    ARIZONA STATE UNIVERSITY

    August 2014

  •      i  

    ABSTRACT

    The treatment of individuals with multiple chronic conditions represents the single

    largest driver of Medicare costs. The use of prescription drugs is a major component in

    the treatment/management of chronic disease in the United States. Medication

    nonadherence, however, is a common problem among older adults and leads to

    significant morbidity and mortality. Whereas, the problem of medication nonadherence

    has been a primary focus of research for the last thirty years, much is still unknown about

    which older adults are most at risk for medication nonadherence, as well as what are

    effective theory-based interventions to improve a person’s medication self-management.

    The purpose of this descriptive explanatory study was to better understand the self-

    management behavior, medication adherence, in a sample of frail urban older adults. The

    study used a combination of quantitative and qualitative methods to analyze data from a

    larger twelve-month study of a nurse care coordination intervention. Ryan and Sawin’s

    (2009) Individual and Family Self-Management Theory served as the study’s conceptual

    framework for identifying the context and processes involved in the older adults’

    medication self-management. Quantitative results found several individual- as well as

    family-level predictors for medication nonadherence. Qualitative analyses identified three

    overarching themes to describe the participants’ struggles along the multistep process of

    medication adherence. Additionally, a cultural domain described the need for more

    information from participants to understand their nonadherence. Integration of the results

    further increased our understanding of medication-self management in these frail older

    adults, and offers direction for clinical practice and future research.

  •      ii  

    DEDICATION

    To my Mom and Dad as well as the participants and caregivers in this study who have

    shared their stories. As Richard Castle (a.k.a. Rob Hanning, 2013) reminds us, “The story

    always matters…the story points us to the solution.” May this work help us to improve

    the health and well-being of cognitively impaired older adults and the families who care

    for them.

  •      iii  

    ACKNOWLEDGMENTS

    I would like to thank my dissertation advisor, Dr. Karen D. Marek, for chairing

    my committee and for her generosity in sharing her medication adherence data sets with

    me. I would also like to thank Dr. David Coon and Dr. Bronwynne Evans for serving on

    my committee. Their expertise was greatly appreciated. I would also like to thank Linda

    D. Bub for serving as an expert consultant, and for sharing her unique experiences with

    the participants and their caregivers. I also wish to thank my professors, Drs. Mary Mays,

    Nelma Shearer, Julie Fleury, and Perla Vargas for their gifts of teaching and scholarship.

    As always, it takes a community of family and friends in order to achieve such an

    endeavor. A special thanks to my parents who instilled in me, from an early age, both a

    love of learning and a passionate commitment to improving the lives of those around us. I

    am grateful to my wonderful colleagues, Carolyn Hickman, Jewel Bishop, and Angela

    Allen, who shared this journey with me. I have many great memories of our talks inside

    and outside class, and I look forward to many more. I also want to thank my unofficial

    “professors”, Drs. Marie Griffin, John Hepburn, Mike White, Danielle Wallace, Eric

    Hedberg, and Chuck Katz, as well as my dear friends Alyssa White, and Peter & Sydel

    Maher for helping guide my way. No matter what Rob and I think about our desert

    “experiment”, your friendship made it all worthwhile. I also want to thank Liam, Aidan,

    Megan, Jim, Jimmy, Conor, and Ryan for reminding me about what is important in life:

    Family. Being together again in VA and spending summers at RFD sustained me through

    it all! Finally, I wish to thank my greatest mentor, Dr. Robert J. Kane, who for thirty

    years has been my toughest coach and biggest fan. There are no words to express how

    lucky I am to have you in my life.

  •      iv  

    TABLE OF CONTENTS

    Page

    LIST OF TABLES ................................................................................................................ vii

    LIST OF FIGURES.............................................................................................................. viii

    CHAPTER

    1 INTRODUCTION ..................................................................................................... 1

                       Background ....................................................................................................................................... 1    

                       Purpose  Statement......................................................................................................................... 4  

                       Conceptual  Framework ............................................................................................................... 4    

                       Research  Questions ....................................................................................................................... 8    

                       Assumptions ..................................................................................................................................... 9    

                       Definition  of  Variables.................................................................................................................. 9    

                       Significance  of  Medication  Adherence .............................................................................. 10    

                       Chapter  Summary ....................................................................................................................... 15    

    2 REVIEW OF THE LITERATURE ................. ........................................................ 17

                       Medication  Adherence .............................................................................................................. 17    

                       Causative  Factors  of  Medication  Nonadherence .......................................................... 22    

                       Qualitative  Studies  on  Medication  Self-­‐Management ................................................ 35    

                       Medication  Adherence  Interventions  Targting  Older  Adults................................. 38    

                       Nursing  Interventions  on  Medication  Adherence  in  Older  Adults ...................... 41    

                       Chapter  Summary ....................................................................................................................... 48    

    3 METHODS .............................................................................................................. 49

                         Design............................................................................................................................................... 50    

  •      v  

    CHAPTER                                            Page

                       Procedures  for  Data  Collection ............................................................................................. 53    

                       Protection  of  Human  Subjects............................................................................................... 54    

                       Data  Analysis ................................................................................................................................. 54  

                       Quantitative  Component................................