Open Journal of Nephrology, 2012, 2, 38-43
http://dx.doi.org/10.4236/ojneph.2012.23007 Published Online September 2012 (http://www.SciRP.org/journal/ojneph)
Factors Influencing Behavior of Taking Medicine in
Elderly Patients Undergoing Hemodialysis
Kumiko Ozawa1, Setsuko Niki1, Seiko Yamanouchi1, Hideaki Yamabe2, Toshiko Tomisawa2,
Maiko Kitajima2, Mayumi Urushizaka2, Kumiko Kawasaki2, Chieko Itaki2, Yuka Noto2, Morito Endo3
1School of Nursing, Hachinohe Junior College, Hachinohe, Japan
2Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan
3Faculty of Human Health Science, Hachinohe University, Hachinohe, Japan
Received July 19, 2012; revised August 27, 2012; accepted September 10, 2012
ABSTRACT
Purpose: The elderly are often faced with multiple diseases, in particular hemodialysis (HD) which requires many
kinds of medication. This study examined the factors influencing the behavior of taking medicine in elderly patients
undergoing HD. Subjects and Methods: The subjects comprised 70 outpatients >65 years undergoing HD (48 male
and 22 fe- male). The mean age of the patients was 72.5 ± 4.4 years. The mean duration of dialysis history was 6.1 ± 5.2
years. We performed a questionnaire survey using Medication Assessment Tool, The Kidney Disease Quality of Life
(QOL) —Short Form and Acceptance for Dialysis Instrument. Result: Two factors related to poor behavior of taking
medicine: dialysis history <2 years and poor acceptance of dialysis. The multiple regression analysis showed patient
satisfaction (
 = −0.329, p < 0.01) and symptoms/problems (  = −0.273, p < 0.05) as significant independent variables
relating to behavior of taking medicine. Conclusion: Poor behavior of taking medicine is related to a short dialysis pe-
riod, poor acceptance and poor satisfaction of dialysis therapy in elderly patients.
Keywords: Behavior of Taking Medicine; Hemodialysis; Adherence; Elderly Patient
1. Introduction
The number of patients undergoing hemodialysis (HD)
for chronic kidney disease is increasing every year. The
mortality rate of HD patients is also increasing. In Japan,
the total number of dialysis patients was 297,126 and the
number of patients newly inducted to HD was 37,532 in
2010. For the causative diseases, the first position of the
new dialysis patient was diabetic nephropathy. In par-
ticularly, elderly patients newly inducted to HD are in-
creasing (mean age: 67.8 ± 13.3); the ratio of the patients
older than 65 years was 63.5% and older than 75 years
was 34.9% [1].
The elderly are often faced with multiple diseases,
such as diabetes mellitus, hypertension, heart disease, and
cerebrovascular disease. The processes of excretion of
waste material, adjustment of water and electrolyte bal-
ance, hormonal resolution and excretion and activation of
vitamin D work poorly in HD patients, requiring elderly
HD patients to take many kinds of medicine. Graveley et
al. have reported that the incidences of side effects and
interactions of medicines occur 2 - 3 times more often in
elderly people than in young people [2].
Other studies [3-6] have reported that adherence to
medicine is influenced by several factors: lifestyle, effect
of treatment, side effects, anxiety about the disorder,
confidence in treatment, simple explanation of the med-
icine, presence of social or family support, and relation-
ship between nurses and patients. Moreover, poor adher-
ence to medicine is frequent in elderly patients [7].
Nurses also have a role in ensuring patients carry out
self-care adequately. Therefore, we thought that the be-
havior of taking medicine should be properly evaluated.
There are few studies on the behavior of taking medi-
cine in elderly HD patients. The purpose of this study
was to elucidate the factors influencing the behavior of
taking medicine in elderly patients undergoing HD.
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K. OZAWA ET AL. 39
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2. Subjects and Methods
2.1. Subjects
Subjects were 70 patients >65 years undergoing HD.
Inclusion criteria were more than three months since the
induction of HD, no major change in treatment content
within the past three months and diagnosis of psychosis
or dementia.
We collected individual clinical records and carried
out a questionnaire survey. The questionnaire survey was
carried out either during dialysis or after dialysis. When
it was difficult for the patient to complete the survey
in-house, we had them complete it at home, and collected
it by collection box within a week. When it was difficult
for the patients to write by themselves, the survey was
taken verbally. The clinical record includes causative
disease, dialysis history, weight gain rate between dialyses,
clinical data, presence of diabetes, treatment content and
type of oral medication. Clinical data was the most re-
cently obtained data before the dialysis.
2.2. Behaviors of Taking Medicine
Medication Assessment Tool (MAT) [8] was used to
study the behavior of taking medicine by the patients.
MAT was developed to evaluate whether an outpatient
understands how to take oral medicine and it consists of
11 items (Table 1). As for the evaluation, each item was
evaluated on a 4-point scale from 1 to 4 with a total score
between 11 and 44. A high score indicates problems in
acceptance of taking the medicine.
2.3. Measuring QOL
The Kidney Disease Quality of Life-Short Form instru-
ment (KDQOL-SFTM; version 1.3) was used for this study.
Table 1. The items of the MAT.
1 Is it easy to understand how to take medicine?
2 Are you worried about side effect of the medicine taking now?
3 Do you understand why medicine is necessary by oneself?
4 Is the explanation of the medicine helpful to understand medicine?
5 Do you feel an effect of the medicine?
6 Is the medicine helpful to prevent sick deterioration?
7 Do you think that it is not good to depend on medicine?
8 Is the expense of the medicine a burden?
9 Do you think that there may be less medicine than now?
10 Is the work to take the medicine troublesome?
11 Does the taking medicine go well generally?
One item marks from 1 to 4 points.
It was developed to evaluate the quality of life of patients
with chronic kidney disease; its reliability and validity
have been confirmed [9]. It consists of the kidney disease-
specific instrument of 43 items and the Short-Form
Health Survey of 36 items (SF-36), which is a generic
instrument. It takes around 15 - 20 min to answer, which
is a burden for elderly people. Therefore, we changed the
SF-36 to the Short-Form Health Survey of 8 items
(SF-8TM), which can measure the same health concept
with a shortened questionnaire, reducing the burden on
elderly patients [10]. The score of all variables is high
when QOL is good. The content of KDQOL-SFTM and
SF-8TM is shown in Table 2.
Twenty eight items of KDQOL-SFTM consist of four
variables: symptoms/problems (KD1), effect of kidney
disease (KD2), burden of kidney disease (KD3) and sleep
(KD6); and six items consist of two variables: cognitive
function (KD4) and quality of social interaction (KD5).
There are also two items of social support (KD7) in
KDQOL-SFTM that evaluate the relationship between
patients and their family or friends, and three items,
which consist of two variables, dialysis staff encoura-
gement (KD8) and patient satisfaction (KD9), to evaluate
the relationship between the patient with medical staff.
Six items of SF-8TM consist of general health percep-
tions (SF8GH), physical functioning (SF8PF), role func-
tioning physical (SF8RP), bodily pain (SF8BP), vitality
(SF8VT), and social functioning (SF8SF) to evaluate the
physical state of the patient. The other two items of
SF-8TM consist of mental health (SF8MH) and role func-
tional emotional (SF8RE) to evaluate the psychological
state of the patient.
Table 2 .Variables in SF-8TM and KDQOL-SFTM.
Variable
SF-8TM
General Health Perceptions (SF8GH)
Physical Functioning (SF8PF)
Role Functioning Physical (SF8RP)
Bodily Pain (SF8BP)
Vitality (SF8VT)
Social Functioning (SF8SF)
Mental Health (SF8MH)
Role Functional Emotional (SF8RE)
Physical Component Summary (PCS-8)
Mental Component Summary (MCS-8)
KDQOL-SFTM
Symptoms/Problems (KD1)
Effect of kidney disease (KD2)
Burden of kidney disease (KD3)
Cognitive function (KD4)
Quality of social interaction (KD5)
Sleep (KD6)
Social support (KD7)
Dialysis staff encouragement (KD8)
Patient satisfaction (KD9)

K. OZAWA ET AL.
40
2.4. Evaluation of Acceptance of Dialysis
Acceptance of the dialysis instrument [11] consists of ten
items and was developed to evaluate the psychological
adjustment level of patients with chronic kidney disease,
from dialysis induction to the maintenance period (Table
3). In the evaluation, each item was evaluated on a
4-point scale 1 to 4, with a total score between 10 and 40.
A high score indicates that the receptive level is low.
2.5. Statistical Analysis
All data were expressed as means ± SD and the com-
parison between the mean of each item was carried out
using t-test, analysis of variance, U-test of Mann-Whitney.
The data were analyzed using SPSS Statistics 18.0 soft-
ware (SPSS, Chicago, IL, USA). We considered p < 0.05
as statistical significant.
2.6. Ethical Consideration
This study was approved by the Committee of Medical
Ethics of Hirosaki University Graduate School of Medicine,
Hirosaki, Japan. The subjects gave us informed consent.
3. Results
3.1. Relationship between Patients’ Characteristics
and Total MAT Score
The α trust coefficient of Cronbach’s of the total MAT
score was 0.777.
We examined the relationship between patients’ chara-
cteristics and MAT. The MAT score of the patients with
a dialysis history of less than 2 years was significantly
higher than those with more 2 years of history (p < 0.05).
The MAT score showed no relation with other character-
istics (Table 4).
3.2. Relationship between Patients’
Characteristics and Each Item on MAT
We compared the mean value of each item on MAT with
the patients’ characteristics. For the question, “Is it easy
Table 3. The items of the acceptance for dialysis instrument.
1Are you afraid that you think that you must undergo dialysis all
the time in future
2Are you anxious whether you can live by dialysis more how many
years?
3Are you anxious whether a physical complication does not occur?
4Are you anxious in future whether you can continue wor
k
(housework)?
5Are you anxious in future whether you can do life (economic
aspects)?
6Are you angry when you think why oneself must undergo dialysis?
7Do you realize the situation to have to undergo dialysis?
8Do you think that you had better die if you undergo dialysis, o
r
you do not want to undergo dialysis?
9How long do you receive explanation about the dialysis by the
chief physician?
10How long do you understand dialysis?
One item marks from 1 to 4 points.
Table 4. The comparison between mean value of the total MAT score and the patients’ characteristics.
Characteristic Group N (%) Mean ± SD p Value
Sex Male 48 (68.6) 21.7 ± 4.4 ns
Female 22 (31.4) 21.9 ± 5.3
Age (years) 65 ~ 74 46 (65.7) 21.8 ± 4.2 ns
≧75 24 (34.3) 21.5 ± 5.6
Housemate Lodger 61 (87.1) 21.6 ± 4.9 ns
No 9 (12.9) 22.7 ± 3.0
Education level Elementary school or Junior high school
graduation 37 (52.9) 22.0 ± 4.9 ns
University or High school graduation 33 (47.1) 21.5 ± 4.5
Causative disease Glomerulonephritis chronic 12 (17.1) 22.2 ± 2.0 ns
Diabetic nephropathy 37 (52.9) 21.7 ± 5.2
Nephrosclerosis 4 (5.7) 23.0 ± 5.7
A multiple cystic kidney 3 (4.3) 18.3 ± 7.0
Others 14 (20.0) 21.7 ± 4.4
<2 17 (24.3) 24.0 ± 3.9 *
Dialysis history (years) ≧2 53 (75.7) 21.1 ± 4.8
A water well-controlled group 55 (78.6) 21.4 ± 4.9 ns
Weight gain rate between the dialysis A water poor-controlled group 15 (21.4) 23.0 ± 3.5
Presence 37 (52.9) 21.7 ± 5.2 ns
Presence or absence of diabetes Absence 33 (47.1) 21.7 ± 4.1
An insulin injection 23 (62.2) 22.3 ± 5.4 ns
Diabetic treatment contents An oral antidiabetic drug 4 (10.8) 17.2 ± 7.0
Only as for the diet 10 (27.0) 22.4 ± 3.4

K. OZAWA ET AL. 41
Continued
HbA1c (%) <6 15(40.5) 20.8 ± 4.5 ns
6.0 - 6.9 13(35.1) 22.4 ± 6.6
≧7 9(24.3) 22.4 ± 4.5
<5 22(31.4) 20.6 ± 5.2 ns
The kind of the oral medicine(kinds) ≧6 48(68.6) 22.3 ± 4.5
Ht (%) <30 15(21.4) 22.3 ± 5.2 ns
30 - 32 22(31.4) 20.7 ± 5.8
≧33 33(47.1) 22.2 ± 3.6
＊p < 0.05, ns：not-significant. Data analysis：An U-test of Mann-Whitney (Age), A t-test(Sex, Housemate, Dialysis history, Weight gain rate between the dial-
ysis, Diabetic presence, The kind of the oral medicine), An analysis of variance (Education level, Causative disease, Diabetic treatment contents, HbA1c, Ht).
to understand how to take the medicine?” the water
well-controlled group showed a significantly lower score
than the water poor-controlled group (p < 0.01). For “Are
you worried about side effects of the medicine your tak-
ing now?” the group that had graduated university or
high school (continued education) showed a significantly
lower score than the group that had only graduated ele-
mentary school or junior high school (limited education)
(p < 0.05). The group with a dialysis history of ≥2 years
showed a significantly lower score than the <2 year
group (p < 0.05). For “Do you understand why you must
take medicine by yourself?” the continued education
group showed a significantly lower score than the limited
education group (p < 0.001). Moreover, for “Is the ex-
planation of the medicine helpful to understand the
medicine?” the continued education group showed a sig-
nificantly lower score than the limited education group (p
< 0.05). For “Is the medicine helpful to prevent the
worsening of your illness?” the group with a housemate
showed a significantly lower score than the group with-
out a housemate (p < 0.01). For “Is the expense of the
medicine a burden?” women showed a significantly
lower score than men (p < 0.05). For “Does taking the
medicine generally go well?” the group of the dialysis
history of ≥2 years showed a significantly lower score
than the <2 year group (p < 0.05). There was no signifi-
cant difference between the scores regarding age, causa-
tive disease and the number of types of oral medication.
3.3. Relationship between QOL and MAT Score
Relationship between QOL and MAT score was exam-
ined. The mean value of the total MAT score showed
significant negative correlations with SF8RE (r = −0.24,
p < 0.05), MCS-8 (r = −0.29, p < 0.05) in the SF-8TM,
KD1 (r = −0.38, p < 0.01), KD2 (r = −0.30, p < 0.01),
KD4 (r = −0.32, p < 0.01), KD5 (r = −0.30, p < 0.05),
KD6 (r = −0.31, p < 0.01), KD7 (r = −0.35, p < 0.01),
KD8 (r = −0.33, p < 0.01), and KD9 (r = −0.38, p < 0.01)
on the KDQOL-SFTM (Table 5). The multiple regression
analysis was used for the variables with a coefficient of
correlation of more than 0.3 to determine variables sig-
nificantly associated with MAT. Factors that influence
MAT based on the multiple regression analysis are
shown in Table 6. The mean value of the total MAT
score showed significant negative correlations with KD9
(  = −0.329, p < 0.01) and KD1 (  = −0.273, p < 0.05)
(Figure 1).
3.4. Relationship between MAT Score and
Acceptance of Dialysis Instrument
The mean value of the total MAT score showed a sig-
nificant positive correlation with the acceptance of the
dialysis instrument (r = 0.24, p < 0.05) (Figure 2). This
result means poor behavior of taking medicine relates to
the poor acceptance of the dialysis therapy.
Table 5. Factors of QOL influencing the MAT by the corre-
lation analysis.
Variable (item) r p
Role Functional emotional (SF8RE)a−0.24 *
Mental component summary (MCS-8)−0.29 *
Symptoms/problems (KD1)−0.38 **
Effect of kidney disease (KD2)−0.30 **
Cognitive function (KD4)−0.32 **
Quality of social interaction (KD5)a−0.30 *
Sleep (KD6)−0.31 **
Social support (KD7)−0.35 **
Dialysis staff encouragement (KD8)a−0.33 **
Patient satisfaction (KD9)a−0.38 **
*p < 0.05, **p < 0.01. a：Pearson’s product moment correlation coefficient,
Others：Spearman’s rank correlation coefficient.
Table 6. Factors of QOL influencing the MAT by the mult-
iple regression analysis.
Variable Standard β p value
Patient satisfaction (KD9) −0.329 **
Symptoms/problems (KD1) −0.273 *
Cognitive function (KD4) −0.189 ns
Sleep (KD6) 0.014 ns
Social support (KD7) −0.139 ns
Dialysis staff encouragement (KD8) −0.222 ns
Adjusted R2 = 0.219, *p < 0.05，**p < 0.01, ns: not-significant.

K. OZAWA ET AL.
42
Figure 1. The mean value of the MAT score showed in part-
icularly strong relation with Patient satisfaction (KD9) by
multiple regression analysis (β = −0.329, p < 0.01). This result
means poor behavior of taking medicine relates to the poor
satisfaction of dialysis therapy. The mean value of the MAT
score showed in particularly strong relation with Symptom/
Problem (KD1) by multiple regression analysis (β = −0.273,
p < 0.05). This result means poor behavior of taking medici-
ne relates to the poor healthy satisfaction of the symptom.
Figure 2. The mean value of the total MAT score showed a
significant positive correlation with acceptance of the dial-
ysis instrument (r = 0.24, p < 0.05). This result means poor
behavior of taking medicine relates to the poor acceptance
of dialysis therapy.
4. Discussion
The mean age of the patients in this study was 72.5 ± 4.4
years. The number of types of oral medication was 7.4 ±
3.1. Uejima et al. reported that patients older than 70
years take about five types of medication, which is twice
that of patients younger than 40 years in Japan [12]. Eld-
erly patients usually have multiple diseases and tend to
take many medications; these rates increase for elderly
HD patients. Moreover, elderly patients are more likely
to forget to take their medicine, with noon being the most
frequent time to forget [12].
We compared the mean value of the total MAT score
relative to patients’ characteristics. Patients with a dialy-
sis history of more than 2 years, showed significantly
better adherence to taking their medicine than those with
less history. Siegal et al. have reported that an elapse of
memory is more frequent in short-term HD patients than
long-term HD patients [13]. Cukor et al. also noted
memory lapse as a factor of worsened adherence of taking
medicine in HD patients [14], as supported by our results.
We compared the score of each item in MAT relative
to patients’ characteristics. In regards to understanding
how to take the medicine, water well-controlled patients
had significantly better understanding than water poor-
controlled patients. Lindberg et al. also reported that ad-
herence of taking medicine is influenced by the avoid-
ance of unnecessary fluid intake [15]. Water restrictions
may therefore be a factor of poorer adherence to taking
medicine.
Patients with less than 2 years of dialysis history also
felt more apprehension of side effects of the medicine
compared with those with more than 2 years of history,
which was consistent with the total MAT score results.
Patients with less than 2 years of dialysis history are
thought to be unstable physically and psychologically,
have poor disease acceptance, and apprehension for side
effects of the medicine, which may worsen adherence. It
is well known that side effects of medicine are associated
with poor adherence [7,15-17].
Patients with a high school or university education had
a better understanding of how to take their medicine than
those with less education. This result suggests that pa-
tients are more likely to take their medicine after having
understood the need of the medicine. We found no sig-
nificant difference for the causative disease and MAT
score, which is consistent with the results of Yuzawa [8].
The total MAT score showed significant negative cor-
relations with SF8RE, MCS-8, KD1, KD2, KD4, KD5,
KD6, KD7, KD8, and KD9. These results mean that if
daily activity of HD patients for cognitive function and
quality of social interaction are good, and the patients
were satisfied with social support and the dialysis care,
adherence is good in HD patients. Therefore, it is thought
that the behavior of taking medicine is strongly associ-
ated with the QOL of HD patients.
In addition, the MAT score showed a particularly
strong relationship with patient satisfaction and symp-
toms/problems by multiple regression analysis. Ferrans et
al. have also reported that patient satisfaction of dialysis

K. OZAWA ET AL.
43
care is significantly correlated with the mental state,
QOL, renal function and symptoms of the patient [18].
Therefore, it is important to improve patients’ satisfac-
tion, psychological adaptation and QOL.
As we showed a strong connection between behavior
of taking medicine and patients’ satisfaction for the di-
alysis care provided by medical staff, more attention
should be placed on the consultation situation of medical
staff when patients have doubts in taking medicine and
questions about their health, for further understanding of
the patient’s relationship with medical staff.
Moreover, the total MAT score showed a significant
positive correlation with acceptance of the dialysis in-
strument. Thus, more acceptable dialysis treatment may
lead to improved adherence. Much effort is still needed
to help patients accept dialysis therapy.
5. Conclusion
Poor behavior of taking medicine is related to a short
dialysis period and the degree of patient satisfaction for
dialysis therapy. It is important to improve patient satis-
faction for dialysis care, increase healthy satisfaction
regarding symptoms, and allow patients to better accept
their disease.
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