OBJECTIVES: To measure the impact of illness burden and medication beliefs on medication compliance of elderly with hypertension using a tool that pictorially represents the burden of illness on self. METHODS: A cross-sectional research design, utilizing convenience sampling strategies and self-administered surveys of elderly hypertensive residents living in New York City senior care centers. Medication compliance was measured using Morisky’s test, medication beliefs were measured using beliefs about medication questionnaire (BMQ), and illness burden was operationalized by implementing Pictorial Representation of Illness and Self Measure- Revised II (PRISM-RII) instrument.  PRISM is a novel and visual measurement tool of suffering that consists of two components, namely, self illness separation (SIS) and illness perception measure (IPM).Additionally, two index scores, namely World Health Organization (WHO-5) wellbeing score and Suffering Question (SQ) scores were also computed to further examine interrelationships among study variables. RESULTS: About 33% of the 120 hypertensive elderly cohorts who responded to the survey were found to be noncompliant with their blood pressure medications. Morisky’s score correlated significantly and positively with both BMQ differential scores (r= -0.303, p=0.001) and SIS component scores (r= -0.425, p= 0.000) respectively.  General Overuse (GO) scores and IPM component scores correlated positively with Morisky’s score (r= 0.347 & 0.440, p=0.000).  SIS correlated positively with WHO-5 (r= 0.142, p= 0.126) and negatively with IPM (r= -0.841, p= 0.000). CONCLUSIONS: Beliefs about the benefits of taking medications outweigh the costs and risks of taking them. Higher perceived illness burden in hypertension translates into lower medication compliance in elderly. PRISM-RII may be a useful measure of illness burden in compliance research in elderly populations. The study underscores the importance of incorporating patient perceptions about medications and illness burden into decisions involving hypertension management.