Impact of caregivers and clinical pharmacists in enhancing medication adherence among the elderly

 Corresponding author: Jaidev Kumar BR Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Impact of caregivers and clinical pharmacists in enhancing medication adherence among the elderly Mahima Prakash M D, Sai Meenakshitha Panyala, Jennifer James, Mahima H Krishna and Jaidev Kumar BR * Department of Pharmacy Practice, JSS College of Pharmacy, JSSAHER, Mysuru - 570015, Karnataka, India. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 114-119 Publication history: Received on 31 August 2025; revised on 06 October 2025; accepted on 08 October 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.24.1.0892 Abstract Medication adherence is a critical component of effective healthcare, particularly among the elderly who often face challenges such as polypharmacy, cognitive decline and multiple chronic conditions. Non-adherence to a therapeutic regimen may result in negative outcomes for the patient and may be exacerbated in them with co-morbidities that require multiple drug therapy. A prospective cohort study was conducted over six months from November 2022–April 2023 involving elderly participants aged more than 60 years from Mysuru residents and various outpatient departments of JSS Hospital. Data was collected from two groups those with caregivers and without caregivers. Medication adherence was assessed using the Medication Adherence Rating Scale (MARS). Non-adherent participants from the group without caregivers received counselling and were reassessed after two months. Out of 287 participants, 108 had caregivers and 179 did not have caregivers. Adherence was significantly higher among those with caregivers (76.85%) compared to those without (44.13%). After counselling, adherence in the previously non-adherent group improved markedly, with 51 out of 100 showing better adherence. Caregivers play a crucial role in enhancing medication adherence among the elderly. Patient counselling proved effective in improving adherence. Interventions focusing on caregiver involvement and consistent patient education are essential for optimal medication management in geriatric populations. Keywords: Medication Adherence; Elderly; Polypharmacy; Caregivers; Patient Counselling; MARS Questionnaire 1. Introduction India, now the most populated country in the world, faces a demographic transition with a rapidly aging population. According to a United Nations report, the share of India’s population aged 60 and above is projected to increase to 20% by 2050, amounting to one in every five individuals being elderly.[1] This significant shift places enormous pressure on the healthcare system to provide for the complex needs of the elderly. As individuals age, due to multiple comorbid conditions such as hypertension, diabetes and cardiovascular diseases which commonly require more than five medications.[2] While polypharmacy may be clinically necessary, it significantly increases the risk of adverse drug events, drug interactions and poor adherence to medication regimens.[3] Medication adherence is defined as the “extent to which a patient takes their medication as prescribed by their healthcare provider”. Poor adherence is a global concern, particularly among older adults, with non-adherence contributing to increased morbidity, hospitalizations and healthcare costs.[4][5] Non-adherence rates among the elderly can range from 40% to 75%, especially in those managing chronic diseases.[3][6] Several factors contribute to World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 114-119 115 poor adherence, including forgetfulness, adverse effects, poor understanding of medication use, financial burden, and complex dosing schedules.[6][7] Moreover, patients’ beliefs about the necessity and risks of medication often influence their adherence behaviors.[6] Caregivers are individuals who assist the elderly patients in taking their medications, as well as their overall needs. These caregivers can either be a family member or a professional attendant who assist the elderly with medication management. Caregivers play a critical role in organizing medications, reminding patients to take their doses and monitoring treatment responses.[7] In addition to caregiver support, patient counselling delivered by clinical pharmacists, has shown enhancement in medication and promotes adherence.[8] Counselling helps patients recognize the importance of consistency in medication use, potential side effects and the consequences of non-adherence.[9] In India, the issue of poor adherence is particularly concerning, with studies indicating that nearly 50% of patients fail to follow prescribed treatments for conditions like cardiovascular diseases and diabetes.[10] This is often exacerbated by limited access to health education, social support and geriatric-specific services. Therefore, there is a need to implement strategies that focus on both caregiver involvement and patient education to improve adherence in elderly populations. This study aims to assess medication management practices among elderly residents and to evaluate the impact of caregiver presence and patient counselling on medication adherence. 2. Methodology The study was designed as a prospective cohort study and was conducted over a period of six months, from November 2022 to April 2023, among elderly residents of Mysuru City. The participants were selected from various outpatient departments of the hospital and residents of Mysuru city. Ethical clearance for the study was obtained from the Institutional Ethics Committee of JSS Medical College, Mysuru. Patients aged 60 years and above, of either gender, residing in Mysuru and prescribed with polypharmacy were included in the study. Those who were bedridden or had cognitive impairments were excluded. After obtaining informed consent in both English and Kannada, the demographic details, medical history and information on current medications were collected using a data collection form. Medication adherence was assessed using the Medication Adherence Rating Scale (MARS), a 10-item self-report questionnaire where higher scores indicate better adherence. Based on the presence of a caregiver, the participants were categorized into two groups those with caregivers and those without. The adherence levels in both groups were compared using the MARS scores. The non adherent study participants in the group without a caregiver were provided with patient counselling by clinical pharmacists. Counselling focused on the importance of medication adherence, the consequences of non-adherence and the correct way to take medications. Participants were followed up after two months and their adherence levels were reassessed using the same MARS questionnaire. Data was entered into Microsoft Excel and descriptive statistics was used to analyze. The findings were used to determine the impact of caregiver presence and patient counselling on medication adherence in the elderly population. 3. Results A total of 310 elderly individuals initially agreed to participate in the study. Among which 287 participants were enrolled, 108 participants (37.63%) had caregivers, while 179 participants (62.37%) without caregivers. In the caregiver group, the majority were in the middle-old category (45.37%) followed by young-old (36.11%) and old-old (18.51%). Participants without a caregiver group had a higher proportion in the young-old category (49.72%). (Table 1) Gender distribution showed a female predominance (50.09%) in the caregiver group and male predominance (53.07%) in the group without caregivers. In the caregiver group 74.07% (n=80) were non-smokers and non-alcoholics followed by 13.88% (n=15) smoker and alcoholic, 7.40% (n=8) alcoholics and 4.62% (n=5) smokers. Among the study participants without a caregiver group 68.15% (n=122) were non-smokers and non-alcoholics followed by 18.99% (n=34) smoker and alcoholic, 9.49% (n=17) alcoholics and 3.35% (n=6) smokers. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 114-119 116 Table 1 Socio-Demographic of the participants Characteristics Category With caregiver (n=108) Without caregiver (n=179) Age Young old (60-69) 39 (36.11%) 89 (49.72%) Middle old (70-79) 49 (45.37%) 67 (37.43%) Old-Old (>80) 20 (18.51%) 23 (12.8%) Gender Male 53 (49.07%) 95 (53.07%) Female 5 (50.09%) 84 (46.92%) Social habits Smoker and alcoholic 15 (13.88%) 34 (18.99%) Non-smoker and non-alcoholic 80(74.07%) 122(68.15%) Smoker 5 (4.62%) 6 (3.35%) Alcoholic 8 (7.40%) 17 (9.49%) MARS questionnaire responses revealed distinct differences in adherence behavior between the two groups. 20.37% of participants with caregivers reported forgetting to take their medication, compared to 64.24% without caregivers. Similarly, 49.07% of the caregiver group admitted to being careless about taking medicines and 77.09% in the withoutcaregiver group. (Table 2) In terms of stopping medication when feeling better, only 11.11% of the caregiver group reported this behavior, compared to 27.37% in the non-caregiver group. Around 60.89% without caregiver stop taking medicine after feeling worse. Moreover, 100% of the caregiver group believed that staying on medication could prevent illness, compared to 91.62% in the group without caregivers. Table 2 Questionnaire Responses Questions With caregiver (n=108) Without caregiver (n=179) Do you ever forget to take your medication? Yes 22 (20.37%) No 86 (79.6%) Yes 115(64.24%) No 64 (35.7%) Are you careless at times about taking your medicines? Yes 53(49.07%) No 55 (50.92%) Yes 138(77.09%) No 41 (22.90%) When you feel better do sometimes stop taking your medicines? Yes 12 (11.11%) No 96 (88.8%) Yes 49 (27.37%) No 130 (72.62%) Sometimes if you feel worse when you take the medicine, do you stop taking it? Yes 69 (63.88%) No 39 (36.11%) Yes 109 (60.89%) No 70 (39.10%) I take my medication only when I am sick. Yes 1 (0.92%) No (99.07%) Yes 10(5.58%) No 169 (94.41%) It is unnatural for my mind and body to be controlled by medication. Yes 91 (84.25%) No 17 (15.74) Yes 141 (78.77%) No 38 (21.22%) My thoughts are clearer on medication. Yes 90(83.33%) No 18(16.66%) Yes 123 (68.71%) No 56 (31.28%) By staying on medication, I can prevent getting sick. Yes 108 (100%) No 0 Yes 164 (91.62%) No 15 (8.37%) I feel weird like a zombie on medication. Yes 8 (7.40%) No 100 (92.59%) Yes 13 (7.26%) No 166 (92.73%) Medication makes me feel tired and sluggish. Yes 23(21.29%) No 85 (78.70%) Yes 82(45.81%) No 97 (54.18%) World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 114-119 117 Medication adherence was assessed using the Medication Adherence Rating Scale (MARS). In the caregiver group, 76.85% (83 participants) were classified as adherent, while only 44.13% (79 participants) without-caregiver group were adherent. This clearly indicates that the presence of caregivers significantly improves adherence among elderly patients. (Table 3) Assessment of medication adherence of both groups were done by asking questions from MARS questionnaire. It was found that among the 108 study participants who had a caregiver 83 (76.85%) were adherent and 25 (23.14%) were non adherent. Among the 179 study participants who did not have a caregiver it was found that 100 (55.86%) were non adherent and 79 (44.13%) were adherent. The 100 non-adherent study participants from the group without caregiver was provided with counselling regarding the importance of medication adherence and were followed up after two months. The study participants who received counselling were followed up and their adherence was assessed again by MARS questionnaire. It was found that 130 (54.83%) study participants’ adherence improved post counselling and 42 (45.96%) remained non adherent. Table 3 Adherence Assessment Category Adherent Non-adherent With Caregiver (n=108) 83 (76.9%) 25 (23.1%) Without Caregiver (n=179) 79 (44.1%) 100 (55.9%) Before patient counselling (Without caregiver, n=179) 79 (44.1%) 100 (55.9%) After patient counselling (Without caregiver, n=179) 130 (54.83%) 49 (45.96%) 4. Discussion This study assessed the medication management practices among elderly residents in Mysuru, focusing on the impact of caregiver presence and patient counselling on medication adherence. This study indicates that elderly individuals above 60 years with caregivers exhibited significantly higher adherence (76.85%) compared to those without caregivers (44.13%). Moreover, patient counselling improved adherence in 51% of non-adherent participants, underlining the effectiveness of direct patient education. The role of socio-demographic factors also cannot be ignored. Male participants and those in the younger-old category (60–69 years) were more often non-adherent, which is consistent with the findings of Smaje et al., who reported that gender and age can inversely affect medication adherence.[11] The presence of caregivers significantly improved adherence levels in this study. Caregivers help bridge the gap between complex medication regimens and patient limitations, including cognitive decline and low health literacy. Prior studies have highlighted the crucial role caregivers play in ensuring medication is taken correctly, managing side effects and providing emotional support Research by Muñoz-Contreras et al. supports our findings, showing that caregiver involvement improves adherence, especially in patients with dementia or multiple chronic conditions.[12] The intervention of patient counselling also showed promising results. Out of 100 initially non-adherent participants who received counselling, 51 demonstrated improved adherence upon follow-up. Counselling provides elderly patients with clarity on the importance of medication use, consequences of non-adherence and the benefits of adherence, even when symptoms improve. This aligns with previous findings that emphasize the need for continuous education to counteract intentional non-adherence and misbeliefs about medications.[Error! Reference source not found.Error! Reference source not found.,Error! Reference source not found.] Studies have shown that personalized counselling, especially by clinical pharmacists, can positively influence patient outcomes in chronic disease management.[13] Moreover, participants without caregivers were more likely to forget medication or stop it prematurely due to side effects or feeling better, behaviors that align with those described by Sirey et al., who noted that up to 41% of older adults report at least one non-adherent behavior due to psychological or practical barriers.[14] These include forgetfulness, negative beliefs about medication and cost concerns all relevant to the population studied here. Another factor contributing to non-adherence is the complexity of treatment regimens in polypharmacy. The association between polypharmacy and adverse outcomes, including increased mortality and hospitalizations, has been documented in studies such as those by Huang et al. and Brahma et al.[15][16] Interventions such as regular medication World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 114-119 118 reviews, as recommended by Cross et al., can help streamline therapy and reduce pill burden, thereby supporting better adherence.[17] The positive impact of pharmacist-led interventions is well-supported by Marcum et al., who found that adherence improved significantly when patients received education and follow-up from pharmacists.[18] Similarly, Capiau et al. concluded that medication counselling provided prior to hospital discharge helps improve knowledge, reduce readmissions and support adherence, especially among the elderly.[19] In rural and resource-limited settings, the lack of caregiver support and minimal access to health education tools exacerbate the issue. Look and Stone found that rural caregivers play an indispensable role in the management of elderly patients’ medications, especially when formal health systems are under-resourced.[20] This emphasizes the need to incorporate caregiver support into national elderly healthcare policies. The study indicates that non-adherence is multifactorial, involving personal, systemic and therapeutic components. As highlighted by Balkrishnan, interventions must be multifaceted and tailored to address both modifiable and nonmodifiable predictors of adherence.[21] 5. Conclusion This study highlights the significant challenges associated with medication management among the elderly population in Mysuru City, particularly in the context of polypharmacy and age-related cognitive and physical limitations. The findings demonstrate that the presence of a caregiver plays a crucial role in improving medication adherence. Elderly individuals with caregivers showed significantly higher adherence levels compared to those without. Furthermore, patient counselling was found to be an effective intervention in enhancing adherence among non-compliant individuals. By educating patients about the importance of medication adherence and proper usage, healthcare professionals, especially clinical pharmacists, can positively influence treatment outcomes. Therefore, integrating caregiver support and regular patient counselling into geriatric care strategies is essential for promoting better medication adherence, reducing adverse health outcomes and improving the overall quality of life in the elderly. Compliance with ethical standards Acknowledgments The authors are grateful to the Principal, all the Faculties of Department of Pharmacy Practice, JSS College of Pharmacy, Mysuru, Community Pharmacists, patients and leadership of JSS AHER for their constant support and guidance. Disclosure of conflict of interest The authors have no conflicts of interest to declare that are relevant to the content of this article. Ethical Approval Ethical clearance for the study was obtained from the Institutional Ethics Committee of JSS Medical College, Mysuru. Statement of informed consent Informed consent was obtained from all individual participants included in the study. References [1] PTI. Share of population over age of 60 in India projected to increase to 20% in 2050: UN. Economic Times. 2019, https://economictimes.indiatimes.com/news/politics-and-nation/share-of-population-over-age-of-60-inindia-projected-to-increase-to-20-in-2050-un/articleshow/68919318.cms, Last accessed on 13/04/2023 [2] Ross SM. Defining polypharmacy and understanding its risks and benefits. Cureatr.com. 2021, https://blog.cureatr.com/defining-polypharmacy-and-understanding-its-risks-and-benefits, Last accessed on 13/04/2023 [3] Alhabib MY, Alhazmi TS, Alsaad SM, AlQahtani AS, Alnafisah AA. (2022). Medication adherence among geriatric patients with chronic diseases in Riyadh, Saudi Arabia. Patient Prefer Adherence. 10.2147/PPA.S363082 World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 114-119 119 [4] Dobbels F, Van Damme-Lombaert R, Vanhaecke J, De Geest S. (2005) Growing pains: non-adherence with the immunosuppressive regimen in adolescent transplant recipients. Pediatric Transplantation. 10.1111/j.13993046.2005.00356.x [5] Neiman AB, Ruppar T, Ho M, Garber L, Weidle PJ, Hong Y, et al. (2017) CDC grand rounds: Improving medication adherence for chronic disease management — innovations and opportunities. Morbidity and Mortality Weekly Report. 10.15585/mmwr.mm6645a2 [6] Horne R, Chapman SCE, Parham R, Freemantle N, Forbes A, Cooper V. (2013) Understanding patients’ adherencerelated beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the NecessityConcerns Framework PLOS One. 10.1371/journal.pone.0080633 [7] Shockney LD. The role of caregivers in ensuring patient adherence to oral oncolytic therapy. Conquer. 2016 https://conquer-magazine.com/issues/2016/vol-2-no-1-february-2016/333-the-role-of-caregivers-inensuring-patient-adherence-to-oral-oncolytic-therapy Last accessed on 13/04/2023 [8] Thevar P. Importance of patient counselling for rapid recovery. Medium. 2017 https://medium.com/@priya.thevar/importance-of-patient-counselling-for-rapid-recovery-5c65f183a9a2 Last accessed on 13/04/2023 [9] Kvarnström K, Westerholm A, Airaksinen M, Liira H. (2021) Factors contributing to medication adherence in patients with a chronic condition: A scoping review of qualitative research. Pharmaceutics. 10.3390/pharmaceutics13071100. [10] Sandilya S. ‘Lack of adherence to medical aid is a critical public health challenge.’ The Indian Express. 2021 Oct 6 https://indianexpress.com/article/cities/pune/lack-of-adherence-to-medical-aid-is-a-critical-public-healthchallenge-7555016/, Last accessed on 13/04/2023 [11] Smaje A, Weston-Clark M, Raj R, Orlu M, Davis D, Rawle M. (2018) Factors associated with medication adherence in older patients: A systematic review. Aging Med (Milton). 10.1002/agm2.12045. [12] Muñoz-Contreras MC, Segarra I, López-Román FJ, Galera RN, Cerdá B. (2022) Role of caregivers on medication adherence management in polymedicated patients with Alzheimer’s disease or other types of dementia. Front Public Health. 10.3389/fpubh.2022.98793 [13] Jimmy B, Jose J. (2011) Patient medication adherence: measures in daily practice. Oman Medical Journal. 10.5001/omj.2011.38 [14] Sirey JA, Greenfield A, Weinberger MI, Bruce ML. (2013). Medication beliefs and self-reported adherence among community-dwelling older adults. Clinical Therapeutics 10.1016/j.clinthera.2013.01.001 [15] Huang Y-T, Steptoe A, Wei L, Zaninotto P. (2021). The impact of high-risk medications on mortality risk among older adults with polypharmacy: evidence from the English Longitudinal Study of Ageing. BMC Medicine. 10.1186/s12916-021-02192-1. [16] Brahma DK, Wahlang JB, Marak MD, Ch Sangma M. (2013). Adverse drug reactions in the elderly. Journal of Pharmacology and Pharmacotherapeutics. 10.4103/0976-500X.110872 [17] Cross AJ, Elliott RA, Petrie K, Kuruvilla L, George J. (2020). Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications. Cochrane Database Systemic Review. 10.1002/14651858.CD012419.pub2. [18] Marcum ZA, Jiang S, Bacci JL, Ruppar TM. (2021). Pharmacist-led interventions to improve medication adherence in older adults: A meta-analysis. Journal of American Geriatric Society. 10.1111/jgs.17373 [19] Capiau A, Foubert K, Van der Linden L, Walgraeve K, Hias J, Spinewine A, et al. (2020) Medication counselling in older patients prior to hospital discharge: A systematic review. Drugs and Aging. 10.1007/s40266-020-00780-z [20] Look KA, Stone JA. (2019). Contextual factors influencing medication management by rural informal caregivers of older adults. Research in Social and Adminstrative Pharmacy. 10.1016/j.sapharm.2018.10.007 [21] Balkrishnan R. (1998). Predictors of medication adherence in the elderly. Clinical Therapeutics: 10.1016/s01492918(98)80139-2