Vol. - No.

- JOURNAL OF VASCULAR NURSING PAGE 1

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The effect of depression on adherence to

antihypertensive medications in elderly
individuals with hypertension
Ezgi Demirt€
urk, MSc, RN, and Rabia Hacıhasano
glu Aşılar, PhD, RN

This study was carried out to find the effect of depression on adherence to antihypertensive medications in elderly in-
dividuals with hypertension. The descriptive study population consisted of hypertensive individuals aged 65 years and
older, who presented to one of the three Family Health Centers located in the provincial center of Erzincan. No sampling
was attempted, and 350 people who met the inclusion criteria were included in the study. The study data were collected
between May and September 2014 by face-to-face interviews using a descriptive questionnaire, the Medication Adherence
Self-Efficacy Scale-Short Form for hypertensive patients, and the Geriatric Depression Scale. Depression was found in
57.1% of all the elderly in this study and in 72.6 % of those aged 80 years and older. A moderately significant negative
correlation was found between depression and the mean medication adherence self-efficacy score. In conclusion, early
diagnosis and treatment of depression symptoms is an important factor in the management and treatment of hypertension.
For this reason, it is important for the nurse and other health professionals working in primary care to observe hyperten-
sive elderly people for depression symptoms, to consider the effect of depression on adherence to medication in coping with
the disease. (J Vasc Nurs 2018;-:1-11)

Aging is a process starting in the intrauterine period and in the elderly is an important mental disorder not treated in
lasting until the end of life, and 65 years of age is accepted Turkey for not being sufficiently diagnosed. Studies by using
as the beginning of old age in this process.1 The Turkish Statis- the Geriatric Depression Scale (GDS) have shown that its prev-
tical Institute has reported that the ratio of the population aged alence is 16% in subjects aged 706 years and older and 62.2% in
65 years and older has reached 8.2% in 2015.2 Because old age subjects aged 65 years and older.7 Blood pressure, which other-
is a process in which many physiological, psychological, and wise is normal, starts to fluctuate in times of depression, and
social changes are experienced, the prevalence of chronic dis- blood sugar deviates from its normal values. Many studies
eases increases and older people need more medical treatment have shown that when depression accompanies heart attack, it
and care.3 Emergence of chronic diseases usually occurs in pe- can aggravate heart-related problems of patients and the risk
riods of depression,4 and one of the major causes of physical of having another heart attack.4 The result of a meta-analysis
disorders and troubles in the elderly is depression.5 Depression of prospective cohort studies has shown that depression is a ma-
jor risk factor in developing high blood pressure.8 As the elas-
ticity of blood vessels diminishes at advanced ages, the
prevalence of hypertension increases.9 According to the data
From the Ahi Evren Chest, Heart and Vascular Surgical of the PatenT2 study, the prevalence of hypertension in Turkey
Education and Research Hospital, Trabzon, Turkey; Professor, is 67.9% in the 60–69 years age group, 85.2% in the 70–79
Erzincan Binali Yıldırım University Faculty of Health Sciences, years age group, and 76.3% in those aged 80 years and older.10
Department of Public Health Nursing, Erzincan, Turkey. According to the Seventh Report of the Joint National Commit-
Address correspondence to: Rabia Hacıhasanoglu Aşılar, PhD, tee, hypertension occurs in more than two-third of individuals
RN, Professor, Faculty of Health Sciences Erzincan Binali after the age of 65 years.11 It has been reported to be 89% in
Yıldırm University, Department of Public Health Nursing, Erzin- a study conducted abroad with the geriatric population12 and
can 24030, Turkey (E-mail: rabia_hhoglu@hotmail.com). 52% in another study.13 Promoting positive beliefs that hyper-
tension can be controlled with treatment is important.14 It is
This study was accepted as a postgraduate thesis in 2015 at the known that uncontrollable hypertension reduces longevity, de-
Erzincan University, Health Sciences Institute. creases are seen in morbidity and mortality in severe and mild
cases receiving treatment,15 and many factors play a role in
This study was presented at a poster presentation in the First
the inability to control hypertension.16
International Health Sciences Congress, June 29 to July 1,
Nonadherence to medication appears to be a complicated
2017, Aydın, Turkey..
problem involving various risk factors particularly in older peo-
1062-0303/$36.00 ple living alone.17 A study performed with older hypertensive
Copyright Ó 2018 by the Society for Vascular Nursing, Inc. people living in communities reported lack of knowledge in
https://doi.org/10.1016/j.jvn.2018.06.001 86% of the elderly, inadequate control of blood pressure in
67%, and nonadherence to treatment in 40%.18 In another study
PAGE 2 JOURNAL OF VASCULAR NURSING - 2018
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carried out with hypertensive elderly, being aged 70 years and Outcomes and measures
older and having a systolic blood pressure (SBP) $ 160 mm
Instruments. The data were collected using a descriptive ques-
Hg was reported to be a major obstacle in achieving the targeted
tionnaire, the GDS, and the Medication Adherence Self-Efficacy
blood pressure.19 One of the important factors in controlling Scale-Short Form (MASES-SF). The blood pressure, height, and
blood pressure is a high level of adherence by patients to their weight measurements of the patients were taken.
antihypertensive treatment. Besides helping individuals adhere The descriptive questionnaire consisted of 12 questions in total,
to medication and gain healthy lifestyle behaviors, as well as nine to inquire the sociodemographic characteristics of the patients
providing information about their diseases,20 nurses also have (age, gender, education, marital status, perceived income level, avail-
the responsibility to provide health education to the elderly about ability of social support, perceived health, solitary living, and accom-
recognizing depression symptoms and consultancy service in di- panying diseases) and three to inquire their hypertension (date of
recting them to appropriate units. Depression, hypertension and receiving hypertension diagnosis, years of using medication due to hy-
drug compliance are important problems in the elderly. However, pertension, and number of antihypertensive medications used daily).
we have not encountered any study in our country that investi- The GDS was developed by Yesavage et al22 in 1983 and was
gates the effect of depression on the adherence to antihyperten- tested for validity and reliability by Ertan and associates in 1997.23
sive medication. It is a self-report depression scale for older population consisting of
It has been reported that this situation in which depressive 30 questions, which are to be answered as yes/no, on how the person
symptoms lead to inadequate control of the blood pressure and has felt in life in the past week. The lowest score obtained from the
development of hypertension-related complications should be scale is 0 and the highest 30; with scores 0–10 meaning ‘‘no depres-
considered during the treatment of depressive/hypertensive pa- sion’’, 11–13 meaning ‘‘possible depression’’, and a score equal to or
tients, and they should be approached more attentively and given above 14 meaning ‘‘definite depression.’’23 When calculating the
extra care so that the side effects of antidepressants on the blood GDS score, 1 point is given to each ‘‘no’’ answer and 0 point to
pressure are minimized.21 each ‘‘yes’’ answer to the questions 1, 2, 7, 9, 15, 19, 21, 27, 29, and
30 and 1 point to each ‘‘yes’’ answer and 0 point to each ‘‘no’’ answer
In view of the aforementioned information, answers to the
to the questions 3–6, 8, 10–14, 16–18, 20, 22–26, and 28.22,23 The
following questions are sought in this study, which was carried
Cronbach’s alpha coefficient was 0.92 in the validity and reliability
out to reveal the effect of depression on adherence to antihyper-
study of Ertan et al,23 whereas it was found as 0.86 in the present study.
tensive medication in older hypertensive people. The MASES-SF was revised and tested for validity and reli-
ability by Fernandez et al.24 The scale was tested for validity and
Study questions reliability in our country by Hacıhasano glu et al.25 Questioning the
factors affecting the regular use of antihypertensive medications
1. Do the descriptive characteristics of the elderly affect by hypertensive patients, the scale consists of 13 expressions assess-
depression? ing the self-efficacy/confidence level of the individual in agreeing
2. Do the descriptive characteristics of the elderly affect with these expressions. Scoring is from 1 to 4, and the lowest score
adherence to antihypertensive medication? obtained from the scale is 13 and the highest being 52. Higher scores
3. Does depression affect adherence to antihypertensive indicate better adherence to the antihypertensive drug therapy. The
Cronbach’s alpha coefficient of the scale was 0.92, and we found
medication in the elderly?
it as 0.95 for this study.
4. Is there a relationship between the scores of depression
Arterial blood pressure measurements were performed after letting
and adherence to medication? the older hypertensive patients rest for 10–15 minutes by taking their
systolic and diastolic blood pressures from the right arm in a sitting po-
MATERIALS AND METHOD sition. After a 5–10 minutes break, a second measurement was per-
formed, and the average of the two measurements was recorded. Care
Design was taken to prevent the patients from smoking and taking caffeine (cof-
fee, coke) within 30 minutes before the measurements. An ERKA brand
This descriptive study was conducted in the Family Healthcare (Perfect Anaroid Model, Serial No: 09008298) sphygmomanometer
_ on€
Centers (FHCs) in the central districts of Karaagaç, In€ u, and was used in all patients for these measurements. Based on Korotkoff
Mimar Sinan in the province of Erzincan between May 2014 and sounds, the systolic blood pressures (SBP) and diastolic blood pressure
September 2014. The study population consisted of individuals (DBP) values were recorded. Controlled blood pressure was defined as
aged 65 years and older who presented for any indication of the SBP < 150 mm Hg and DBP < 90 mm Hg. Controlled values were taken
FHCs. Recruitment continued until the sample size of 350 was as SBP < 140 mm Hg and DBP < 90 mm Hg for the elderly who had
met based on the power calculation. diabetes alongside hypertension.26
Data collection. The study data were collected between May and
Participants September 2014 through face-to-face interviews after a certain
The inclusion criteria are as follows: 1) being 65 years of age and sequence in the waiting rooms of Karaa _ on€
gaç, In€ u, and Mimar Sinan
older, 2) having diagnosed with essential hypertension and started FHCs during 2–3 days of the weeks in which the investigators were
antihypertensive treatment at least a year ago, and 3) agreeing to available. The forms were completed in 20–25 minutes on average.
take part in the study.
The exclusion criteria are as follows: 1) having any physical
disorder (hearing and/or speaking disorders), 2) mental disability,
Statistical analyses
3) mental disorder (depression and psychotic disorder), or 4) In the analysis of data, the descriptive characteristics were given
cancer. as numbers, percentages, and means. The Shapiro-Wilk test was
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TABLE 1 TABLE 1

DISTRIBUTION OF DESCRIPTIVE CONTINUED

CHARACTERISTICS OF HYPERTENSIVE
ELDERLY (N = 350) Descriptive Characteristics n (%)

Descriptive Characteristics n (%) Diastolic blood pressure

Controlled 230 (65.7)
Age Uncontrolled 120 (34.3)
65–69 153 (43.7) Ort
(Sd)
70–74 90 (25.7) Duration of hypertension (y) 10.36
7.17
75–79 56 (16.0) Duration of treatment (y) 10.24
7.19
$80 51 (14.6) Number of medications used 1.25
0.45
Gender daily
Women 182 (52.0) Age (years) (min: 65; max: 87) 71.77
5.67
Male 168 (48.0) Sd, standard deviation.
Education status *No weak hypertensive individual.

Illiterate 119 (34.0)

Literate 76 (21.7)
Primary/secondary school 131 (37.4) used to determine if the data were distributed normally. The Kruskal-
Wallis Variance Analysis and Mann-Whitney U-Test were used to
High school/university 24 (6.9) compare the descriptive characteristics to MASES-SF. The Mann-
Marital status Whitney U-Test was used to identify the differences between the
Married 237 (67.7) groups. The descriptive characteristics were compared to GDS using
the chi-squared analysis. Correlation Analysis was used to determine
Single/widowed/divorced 113 (32.3)
the relationship of MASES-SF and GDS scores with each other and
Income level some variables. The statistical analyses were carried out on the SPSS
Income < expenditure 152 (43.4) (Statistical Package for Social Science for Windows) package pro-
Income = expenditure 183 (52.3) gram version 22.0, and the level of significance was accepted as
P < 0.05.
Income > expenditure 15 (4.3)
Social support Ethical principles
Yes 111 (31.7)
Written permission was obtained from the Erzincan Public
No 239 (68.3) Health Directorate, and an ethical approval from the Ethics Commit-
Perceived health tee of Erzincan University was also obtained to be able to conduct
Good 72 (20.6) the study. The elderly subjects who met the inclusion criteria were
explained about the purpose, plan, and benefits of the study; they
Moderate 214 (61.1) were told that they could leave the study anytime they wished, and
Poor 64 (18.3) written/verbal consents were obtained from those who volunteered.
Living alone status
Alone 61 (17.4) RESULTS
Not alone 289 (82.6) From those with hypertension, 43.7% were in the 65–69 years
Comorbid illnesses age group, 52% were female, 44.6% were obese, and 56.3%
Yes 168 (48.0) could not control their systolic and 34.3% their diastolic blood
pressure. The duration of having been diagnosed with hyperten-
No 182 (52.0)
sion was 10.36
7.17 years, the duration of treatment was
Body mass index, kg/m2* 10.24
7.19 years, the number of antihypertensive medication
Normal (18.5–24.9) 43 (12.3) used daily was 1.25
0.45, and the mean age was
Overweight (25–29.9) 151 (43.1) 71.77
5.67 (65–87 years) (Table 1).
Obese (30 and over) 156 (44.6) Depression was found in 57.1% of the hypertensive elderly
with a mean score of 19.67
4.25 (Figure 1). The mean score
Systolic blood pressure
was 15.12
6.43 for the entire subjects.
Controlled 153 (43.7) The prevalence of depression was found to be the highest in
Uncontrolled 197 (56.3) the 80 years and older age group and lowest in the 65–69 age
(Continued ) groups, and further analysis revealed that the difference
PAGE 4 JOURNAL OF VASCULAR NURSING - 2018
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using the Beck Anxiety Scale, 36.5% of hypertensive patients

were found to experience mild anxiety and 13.5% experience se-
vere anxiety.27 Another study showed that 56% of hypertensive
patients experienced anxiety, 20% experienced stress, and 4%
experienced depression.29 These results demonstrate that there
is an important relationship between hypertension and mental
disorders, and these patients should also be assessed mentally.
In the present study, the prevalence of depression was found
to be considerably high in the elderly aged 80 years and older. A
study carried out with the elderly has reported that as age ad-
vances hypertension and depression increase,28 and another
Figure 1. Depression statuses and mean scores. study performed with hypertensive people aged 25 years and
older has reported that individuals aged 65 years and older
have the highest rate of depression.30 The results of the present
study suggest that old age is a predictive risk factor for depres-
originated from the 80 years and older age group. Furthermore, a sion, and apart from personal characteristics, the extent to which
significant correlation was found between depression and gender, individuals take their disease seriously and care about it can be
education, marital status, perceived income, perceived health, effective on the outcome.
and living alone (P < .05; P < .01) (Table 2). The difference in Being female is one of the risk factors increasing the risk of
the educational status originated from the high school/university depression in the elderly.31 In this study, the prevalence of
graduates, and there was a significant difference in all groups depression was found to be considerably higher in women
with respect to the others for income and perceived health. than in men. Studies carried out with older people have re-
As seen in Table 2, the depression statuses of the hypertensive ported that depression occurs more in women,6,28 and study
elderly had no significant correlation with receiving social sup- with hypertensive people reported that the prevalence of
port, additional disease, and body mass index (BMI) statuses of depression is significantly higher in women than in men.30
them or whether their systolic and diastolic blood pressures These results support the results of the present study.
were under control (P > .05). In this study, the prevalence of depression was found to be
As seen in Table 3, a significant difference between the edu- significantly lower in the elderly who were graduates of high
cation, perceived income and health, additional chronic disease, school/university than in those who were illiterate and graduates
diastolic blood pressure, and depression statuses of the hyperten- of primary/secondary school. In a study carried out with hyper-
sive elderly with their medication adherence self-efficacy scores tensive elderly, the prevalence of depressive symptoms was re-
was found (P < .05; P < .01). According to the result of the ported to be significantly higher in the illiterate hypertensive
Mann-Whitney U-Test that was carried out to determine from elderly than in literate ones,32 and in another study carried out
where the difference in education originated, it originated from with hypertensive people having a high cardiovascular risk, the
the group which was unable to read and write, whose income prevalence of depression was found to be significantly higher
was less than their expenses for the income status, and which in those with a low educational status than in those who had a
had depression for the depression status, and there was a statisti- moderate and high level of education.33 These results support
cally significant difference in all groups with respect to the others the results of the present study, all showing that education and lit-
for perceived health. eracy in health care are important factors in perceiving the seri-
No significant difference was found between the medication ousness of the disease.
adherence self-efficacy scores of the hypertensive elderly and The prevalence of depression was significantly higher in
their age, gender, marital status, receiving social support, living those who were single/widowed/divorced among the subjects
alone, and BMI statuses or whether their systolic blood pressures included in the study than in those who were married. A recent
were under control (P > .05) (Table 3). study has also found that depressive symptoms are seen more
No significant correlation was found between GDS and the frequently in hypertensive elderly who are not married than in
year of hypertension diagnosis, duration of treatment, or number those who are married.32 The results of the present study suggest
of drugs used daily and between the mean MASES-SF score and that being married may provide mental support by increased
the number of drugs used daily (P > .05). There was a very weak sharing, but an individuals’ belief in treatment and paying atten-
positive correlation between the mean MASES-SF score and the tion to their health can also be effective regardless of marital
year of diagnosis and duration of treatment (P < .01) and a mod- status.
erate negative correlation between the mean MASES-SF and Another result of this study was that the group perceiving to
GDS scores (P < .001) (Table 4). have more income than their expenses had the lowest depression
rate, whereas the group perceiving to have less income than their
expenses had the highest depression rate, and there was a signif-
DISCUSSION
icant difference among all the groups. In a study carried out with
Some mental problems can be seen in people with a chronic hypertensive elderly, the prevalence of depressive symptoms was
disease such as hypertension,27 and one of such mental problems found to be higher in those having less income than in those hav-
is depression.28 In this study, depression was found at a rate of ing more income.32 The result of the reported study supports the
57.1% with a mean score of 19.67
4.25 (Figure 1). In a study result of this study, which suggests that factors such as lifestyles,
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TABLE 2

COMPARISON OF DESCRIPTIVE CHARACTERISTICS AND DEPRESSION STATUSES

GDS Depression Status

Descriptive Characteristics No, n (%)y Possible, n (%)y Yes, n (%)y Test and Significance

Age
65–69 47 (30.7) 29 (19.0) 77 (50.3) X2 = 14.265; P = .027*
70–74 18 (20.0) 19 (21.1) 53 (58.9)
75–79 17 (30.4) 6 (10.7) 33 (58.9)
$80 12 (23.5) 2 (3.9) 37 (72.6)
Gender
Women 37 (20.3) 29 (16.0) 116 (63.7) X2 = 8.901; P = .012*
Male 57 (33.9) 27 (16.1) 84 (50.0)
Education status
Illiterate 23 (19.3) 18 (15.1) 78 (65.6) X2 = 19.887; P = .003**
Literate 17 (22.4) 11 (14.5) 48 (63.1)
Primary/secondary school 40 (30.5) 23 (17.6) 68 (51.9)
High school/university 14 (58.3) 4 (16.7) 6 (25.0)
Marital status
Married 73 (30.8) 43 (18.1) 121 (51.1) X2 = 11.122; P = .004**
Single/widowed/divorced 21 (18.6) 13 (11.5) 79 (69.9)
Income level
Income < expenditure 22 (14.5) 26 (17.1) 104 (68.4) X2 = 37.274; P < .001
Income = expenditure 60 (32.8) 29 (15.8) 94 (51.4)
Income > expenditure 12 (80.0) 1 (6.7) 2 (13.3)
Social support
Yes 25 (22.5) 21 (18.9) 65 (58.6) X2 = 2.060; P = 0.357
No 69 (28.9) 35 (14.6) 135 (56.5)
Perceived health
Good 43 (59.7) 11 (15.3) 18 (25.0) X2 = 63.387; P < .001
Moderate 45 (21.0) 40 (18.7) 129 (60.3)
Poor 6 (9.4) 5 (7.8) 53 (82.8)
Living alone status
Alone 14 (23.0) 4 (6.5) 43 (70.5) X2 = 6.840; P = .033*
Not alone 80 (27.7) 52 (18.0) 157 (54.3)
Comorbid illnesses
Yes 48 (28.6) 24 (14.3) 96 (57.1) X2 = 0.947; P = .623
No 46 (25.3) 32 (17.6) 104 (57.1)
Body mass index
Normal (18.5–24.9) 9 (20.9) 7 (16.3) 27 (62.8) X2 = 3.235; P = .519
Overweight (25–29.9) 44 (29.1) 28 (18.6) 79 (52.3)
Obese (30 and over) 41 (26.3) 21 (13.5) 94 (60.2)
Systolic blood pressure
Controlled 46 (30.1) 22 (14.4) 85 (55.5) X2 = 1.608; P = .448
Uncontrolled 48 (24.4) 34 (17.2) 115 (58.4)
(Continued )
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TABLE 2

CONTINUED

GDS Depression Status

Descriptive Characteristics No, n (%)y Possible, n (%)y Yes, n (%)y Test and Significance

Diastolic blood pressure

Controlled 67 (29.1) 38 (16.5) 125 (54.4) X2 = 2.322; P = .313
Uncontrolled 27 (22.5) 18 (15.0) 75 (62.5)
*P < 0.05; **P < 0.01.
GDS, Geriatric Depression Scale.
y
Row percentage.

expectations from life, and values of individuals may be another study investigating the relationship between depression
effective. symptoms and obesity in hypertensive people showed that a
Depression is associated with both lack of health-improving high BMI could be a variable associated with depression symp-
behaviors and hypertension.34 In this study, it was found that toms and hypertension.39 The results of these three presented
perceived health was significantly correlated with presence of studies do not show similarities with the result of the present
depression scores. The correlation was significant in all the study. It is thought that, in addition to difference in individual
groups with respect to the others, but the group that perceived and cultural characteristics, how the social support was received
their health being poor had the highest depression scores, and and from whom and how the effects of weight and accompanying
the group that perceived their health being good had the lowest disease are perceived can be effective.
depression scores. A study carried out with older people found In this study, it was found that those who were illiterate had
that the group perceiving their health as being poor had a signif- the lowest MASES-SF score, whereas those who were graduates
icantly higher mean depression score and lower quality of life of high school/university had the highest score. Another study
score.7 The results of the present study suggest that besides the has reported that those with a high level of education use their
sociocultural characteristics of the elderly and the fact that medications regularly and has found a significant correlation be-
they may have experienced important life events threatening tween education level and drug use.40 Another study found that
their mental or physical health, factors such as lifestyle and belief adherence to antihypertensive medication was significantly
in treatment can also be effective. higher in graduates of a university.41 The results of the reported
It was found in the present study that the prevalence of study support the result of this study, which suggests that educa-
depression was significantly higher in those living alone. It is tion is an important factor in health literacy and comprehending
known that loneliness can lead to various mental and physical seriousness of a disease.
disorders.35 In a study carried out with older people, a strong cor- In this study, it was found that those who perceived their in-
relation was found between perceived loneliness and presence of come as being satisfactory had significantly higher MASES-SF
depression.36 The results of the present study suggest whether or scores than those who perceived their income as being poor. It
not feeling lonely can be effective alongside perceived disease was found in a meta-analysis that a poor income status was an
and paying attention to it in the elderly. important factor in nonadherence to antihypertensive drugs,42
In this study, no significant correlation of social support, co- and in another study, it was found that patients with a good eco-
morbid illnesses, BMI, and systolic and diastolic blood pressure nomic status had significantly higher rates of adherence to anti-
status with GDS score was found. No significant correlation was hypertensive drugs.43 The results of the present study suggest
reported between high SBP and anxiety or depressive symptoms that income level is a major factor in having access to health-
in a study carried out with the elderly,37 and no significant corre- care services and medication, whereas lifestyles, life expecta-
lation was reported between blood-pressure-control status and tions, and values of individuals may also play a role.
presence of depression in another study carried out with hyper- A significant difference was found in this study between
tensive patients aged 25 years and older.30 The results of the re- perceived health and MASES-SF scores. The difference was sig-
ported study are similar to the results of this study. A study nificant in all groups with respect to the others, but the group that
carried out with individuals with hypertension in China has re- perceived their health being poor had the lowest adherence to
ported that there is a negative significant correlation between so- medication scores, and the group that perceived their health be-
cial support perceived from the family and depression.38 Another ing good had the highest adherence to medication scores. Poor
study that examined predictors of depression in black women quality of life is an important factor hindering adherence to anti-
with hypertension reported that greater number of comorbidities hypertensive medication.44 It has been reported that positive
was significantly associated with higher depression scores.34 An beliefs about treatment are important in shaping the adherence-
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TABLE 3

COMPARISON OF DESCRIPTIVE CHARACTERISTICS AND MASES-SF SCORES

Descriptive Characteristics N (%) MASES-SF, Med.(25%–75%) Test and Significance

Age (y)
65–69 153 (43.7) 33.0 (26.0–39.0) KW = 2.853; P = .414
70–74 90 (25.7) 33.5 (26.0–39.0)
75–79 56 (16.0) 35.5 (25.0–39.0)
$80 51 (14.6) 32.0 (24.0–39.0)
Gender
Women 182 (52.0) 33.0 (26.0–39.0) MW-U = 14703.000; P = .536
Male 168 (48.0) 34.0 (26.0–39.0)
Education status
Illiterate 119 (34.0) 31.0 (24.0–37.0) KW = 15.241; P = .002**
Literate 76 (21.7) 33.0 (26.0–39.0)
Primary/Secondary school 131 (37.4) 35.0 (26.0–39.0)
High school/University 24 (6.9) 37.5 (30.5–43.0)
Marital status
Married 237 (67.7) 35.0 (26.0–39.0) MW-U = 11666.500; P = .051
Single/Widowed/Divorced 113 (32.3) 32.0 (25.0–38.0)
Income level
Income < expenditure 152 (43.4) 31.0 (24.0–37.0) KW = 14.437; P = .001**
Income = expenditure 183 (52.3) 35.0 (26.0–39.0)
Income > expenditure 15 (4.3) 35.0 (29.0–44.0)
Social Support
Yes 111 (31.7) 32.0 (26.0–38.0) MW-U = 12212.500; P = 0.232
No 239 (68.3) 34.0 (26.0–39.0)
Perceived health
Good 72 (20.6) 36.5 (26.0–41.0) KW = 12.018; P = .002**
Moderate 214 (61.1) 34.0 (26.0–39.0)
Poor 64 (18.3) 27.5 (23.0–37.0)
Living alone status
Alone 61 (17.4) 33.0 (28.0–38.5) MW-U = 8162.000; P = .363
Not alone 289 (82.6) 34.0 (26.0–39.0)
Comorbid illnesses
Yes 168 (48.0) 35.0 (26.0–39.0) MW-U = 12056.500; P = .001**
No 182 (52.0) 33.0 (24.0–38.0)
Body mass index
Normal (18.5–24.9) 43 (12.3) 33.0 (24.0–38.0) KW = 1.495; P = .474
Overweight (25–29.9) 151 (43.1) 35.0 (26.0–39.0)
Obese (30 and over) 156 (44.6) 32.5 (26.0–39.0)
Systolic blood pressure
Controlled 153 (43.7) 35.0 (26.0–39.0) MW-U = 13599.500; P = .117
Uncontrolled 197 (56.3) 32.0 (26.0–39.0)
(Continued )
PAGE 8 JOURNAL OF VASCULAR NURSING - 2018
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TABLE 3

CONTINUED

Descriptive Characteristics N (%) MASES-SF, Med.(25%–75%) Test and Significance

Diastolic blood pressure

Controlled 230 (65.7) 35.0 (26.0–39.0) MW-U = 11878.032; P = .032*
Uncontrolled 120 (34.3) 31.5 (24.0–38.0)
Depression status
No 94 (26.9) 38.0 (32.0–42.0) KW = 60.563; P < .001
Possible 56 (16.0) 37.0 (31.0–39.0)
Yes 200 (57.1) 28.0 (23.0–36.0)
*P < 0.05; **P < 0.01.
Med., median; MASES-SF, Medication Adherence Self-Efficacy Scale-Short Form; MW-U, Mann Whitney-U test; KW, Kruskal Wallis.

related behaviors, particularly in older hypertensive people, and a of this study, which suggests that factors such as personal char-
positive perception of disease, a low level of perceived disease acteristics, lifestyles, and belief in treatment may be effective.
burden, and positive beliefs about drugs increase adherence to In this study, it was found that those with an additional
medication.45 The results of the reported study support the result chronic disease had significantly higher MASES-SF scores
than those with no such disease. Another study has reported
that having more than one disease is a significant and determi-
nant variable in increasing adherence to medication.46 This result
TABLE 4 may have been influenced by the individual characteristics of the
sample as well as perceived accompanying disease and its out-
RELATIONSHIP OF MEAN MASES-SF AND GDS comes in individuals.
SCORES WITH EACH OTHER AND WITH SOME In this study, it was found that there was significant difference
VARIABLES between the diastolic blood pressure and MASES-SF score.
Those with diastolic blood pressure under control had signifi-
Variables r P cantly higher MASES-SF score than those whose blood pressure
was not under control. Another study using the Hill-Bone
Compliance to High Blood Pressure Therapy Scale reported
GDS that the blood pressures of patients increased as their compliance
Duration of 0.020 .715 to the total and medical subdimension of the scale decreased.47
hypertension (y) We think that many factors such as the sociodemographic and
Duration of 0.001 .981 cultural characteristics of the patients included in the study,
treatment (y) perceived severity of the disease, and belief of treatment may
have played a role in this result.
Number of 0.082 .127
Moreover, no significant difference between the MASES-SF
medications used
score and age, gender, marital status, social support, living alone,
daily
BMI, and SBP status with MASES-SF score was found. It has
MASES-SF been reported in a systematic review that old age alone is not
Duration of 0.180 .001* an effective factor for nonadherence in patients with chronic
hypertension (y) heart failure.48 In some studies, it was reported that there was
Duration of 0.179 .001* no significant difference between gender and adherence to medi-
treatment (y) cation,14,46,49 whereas in other studies with hypertensive people
aged 20 years and older, it was reported that marital status is
Number of 0.004 .939
not a major factor in adherence to medication.14,50 A
medications used
qualitative study also reported that receiving insufficient social
daily
support from the patient’s close associates was one of the
GDS 0.494 < .001 reasons for not taking antihypertensive drugs.51 In another study,
*P < 0.01. it was found that there was no significant correlation between
GDS, Geriatric Depression Scale; MASES-SF, Medication Adherence BMI, blood-pressure-control status, and adherence to medication
Self-Efficacy Scale-Short Form. in hypertensive patients.43 A study exploring the errors of antihy-
pertensive drug use in older individuals reported that living with
Vol. - No. - JOURNAL OF VASCULAR NURSING PAGE 9
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spouse and children, with relatives, or living alone was not an ond being that the study was conducted in only 3 FHCs in the
effective factor in making errors in drug use.52 central province.
The other results of the study were that depression had no
significant correlation with the year of diagnosis, duration of
disease treatment, and the number of medications used daily, CONCLUSION AND RECOMMENDATIONS
and there was no significant correlation between the number
One of the most striking results of the study was that depres-
of medications used daily and the mean MASES-SF score;
sion was found in 57.1% of all the elderly and in 72.6% of those
but, there was a very weak positive significant correlation
aged 80 years and older. The major variables increasing the prev-
between the year of diagnosis and duration of treatment and
alence of depression were being aged 80 years and older, being
the MASES-SF scores (Table 4). It was reported in a study
female, not being a graduate of high school/university, being sin-
that there was no significant correlation between the year
gle/widowed/divorced, having less income than expenses, poor
of diagnosing hypertension and the prevalence of depres-
perception of health, and living alone. Being illiterate, having
sive symptoms32 and in other studies that adherence to medi-
less income than expenses, poor perception of health, uncon-
cation increased significantly as the duration of treatment
trolled diastolic blood pressure, and having depression decreased
lengthened.46,47 Another study carried out with the
the medication adherence self-efficacy score significantly, and
population aged 40 years and older showed that there was
having an additional chronic disease and year of diagnosis and
no significant correlation between the year of diagnosing
extended duration of treatment increased the medication adher-
hypertension and adherence to antihypertensive drugs,49 and
ence self-efficacy score significantly. There was also a moderate
one study showed that there was no significant correlation be-
negative correlation between depression and mean medication
tween the duration of using antihypertensive drugs and adher-
adherence self-efficacy scores. Early diagnosis and treatment
ence to antihypertensive medication in women patients with
of depressive symptoms is an important factor for the treatment
and without depression.53 The results of the present study
and management of hypertension. In this respect, it is important
show that besides personal characteristics, the severity of
for nurses working in primary health-care institutions and other
the disease, characteristics of the drugs used, average number
health professions to monitor the hypertensive elderly especially
of medications being not too many, and many disease-related
for symptoms of depression.
factors may play a role in these results. All these results
represent the answers to the first and second questions of
the study.
REFERENCES
Depressive symptoms are one of the obstacles among clin-
ical factors influencing adherence to antihypertensive medica- 1. Akdemin N. Yaşlılık Sorunları ve Hemşirelik Bakımı. Iç _
tion,44 and nonadherence to medication is an important Hastalıkları ve Hemşirelik Bakımı. In: Akdemir N, Birol L,
problem in the elderly.17 In this study, it was found that the editors. Genişletilmiş €
uç€
unc€u baskı. Ankara: Sistem ofset;
medication adherence self-efficacy scores of the hypertensive 2011.
patients with depression were significantly lower than those 2. T€ _
urkiye Istatistik _
Kurumu. Istatistiklerle Yaşlılar 2015 Haber
of the patients without depression or carrying a possible risk B€ulteni. Sayı:21520; http://www.tuik.gov.tr/PreHaberBulten
of depression (Table 3). Moreover, a moderately significant leri.do?id=21520. Accessed March 17, 2016.
negative correlation between depression and the mean medica- €
3. Ozbek S, Kaya E, Tekin A, et al. Yaşlılarda tedaviye uyum.
tion adherence self-efficacy scores of the participating patients T€urk Geriatri Dergisi 2006;9(3):177-81.
was found (Table 4). These results explain the third and fourth 4. Mete EH. Kronik hastalık ve depresyon. Klinik Psikiyatri
questions of the study. A study carried out with women re- 2008;1(Ek 3):3-18.
ported that there was a significant correlation between poor 5. David A, Casey MD. Depression in the elderly: a review and
medication adherence and depressive symptoms,34 and another update. Asia-Pacific Psychiatry 2011;4:160-7.
study reported that depression did not affect medication adher- 6. Kulaksızo glu IB, G€ urvit H, Polat A, et al. Unrecognized
ence, but the prevalence of depressive symptoms was higher in depression in community-dwelling elderly persons in Istan-
the group not adhering to medication.54 A longitudinal bul. Int Psychogeriatr 2005;17(2):303-12.
modeling study reported that onset of depression increased 7. Bakar N, Aşılar RH. Factors affecting depression and quality
the risk of nonadherence to medication in hypertensive of life in the elderly. J Gerontol Geriatr Res 2015;4:249.
males,53 and another study reported that mental functioning 8. Meng L, Chen D, Yang Y, et al. Depression increases the risk
disorder was a major obstacle for taking antihypertensive of hypertension incidence: a meta-analysis of prospective
medication.55 The results of the reported study support the cohort studies. J Hypertens 2012;30(5):842-51.
result of this study, which suggests that the risk of depression 9. Kaur R, Khanna N. Pathophysiology and risk factors related
is an important factor in hindering compliance with to hypertension and its cure using herbal drugs. Spatula DD
medication. 2012;2(4):245-56.
10. T€urk Hipertansiyon ve B€ obrek Hastalıkları Derne gi. T€
urk
Hipertansiyon Prevalans Çalışması PatenT2; 2012. http://
LIMITATIONS
www.turkhipertansiyon.org/prevelans_calismasi_2.php. Ac-
There are two limitations of the study, first being that the sub- cessed January 3, 2015.
jects participating in the study were assessed for depression using 11. Chobanian AV, Bakris GL, Black HR, et al. Sevent report of
only the GDS and were not assessed by a specialist, and the sec- the joint national committee on prevention, detection,
PAGE 10 JOURNAL OF VASCULAR NURSING - 2018
www.jvascnurs.net

evaluation and treatmenClood pressure. The JNC 7 Report. J fect on disability and cognitive impairment in older subjects.
Am Med Assoc 2003;289(19):2560-72. Arch Gerontol Geriatr 2011;52(3):253-7.
12. Triantafyllou A, Douma S, Petidis K, et al. Prevalence, 29. Kretchy IA, Owusu-Daaku FT, Danquah SA. Mental health
awareness, treatment and control of hypertension in an in hypertension: assessing symptoms of anxiety, depression
elderly population in Greece. Rural Remote Health 2010; and stress on anti-hypertensive medication adherence. Int J
10(2):1225. Ment Health Syst 2014;8:25.
13. Hammami S, Mehri S, Hajem S, et al. Awareness, treatment 30. Neupane D, Panthi B, McLachlan CS, et al. Prevalence of
and control of hypertension among the elderly living in their undiagnosed depression among persons with hypertension
home in Tunisia. BMC Cardiovasc Disord 2011;11(65): and associated risk factors: A Cross-Sectional Study in Urban
1471-2261. Nepal. PLoS One 2015;10(2):1-11.
14. Lo SH, Chau JP, Woo J, et al. Adherence to antihypertensive 31. Eker E, Noyan A. Yaşlıda depresyon ve tedavisi. Klinik Psi-
medication in older adults with hypertension. J Cardiovasc kiyatri 2004;7(Ek-2):75-83.
Nurs 2016;31(4):296-303. 32. Ma L, Tang Z, Sun F, et al. Risk factors for depression among
15. Ergin A, Topsakal R. Hipertansiyon; Fizyopatoloji, Klinik ve elderly subjects with hypertension living at home in China.
Tanı. In: Erol Ç, editor. Klinik Kardiyoloji. Ankara, MN: Int J Clin Exp Med 2015;8(2):2923-8.
Medikal ve Nobel Tıp Kitabevi; 2004. 33. Mejia-Lancheros C, Estruch R, Martınez-Gonzalez MA,
16. Hacıhasanoglu R. Hipertansiyonda tedaviye uyumu etki- et al. PREDIMED Study Investigators. Blood pressure
leyen fakt€orler. TAF Prevent Med Bull 2009;8(2):167-72. values and depression in hypertensive individuals at high
17. Thiruchselvam T, Naglie G, Moineddin R, et al. Risk factors cardiovascular risk. BMC Cardiovasc Disord 2014;109(14):
for medication non adherence in older adults with cognitive 2-8.
impairment who live alone. Int J Geriatr Psychiatry 2012; 34. Abel WM, Crane PB, McCoy T. Predictors of depression in
27(12):1275-82. black women with hypertension. Issues Ment Health Nurs
18. Park E, Kim J. Vulnerable older adults with hypertension 2014;35(3):165-74.
demonstrate age-and gender specific presentations of hyper- 35. Mushtaq R, Shoib S, Shah T, et al. Relationship between
tension management problems. Int J Appl Eng Res 2015; loneliness, psychiatric disorders and physical health? a re-
10(4):10149-62. view on the psychological aspects of loneliness. J Clin Diagn
19. Choi SW, Kim MK, Han SW, et al. Characteristics of hyperten- Res 2014;8(9):1-4.
sion subtypes and treatment outcome among elderly Korean 36. Stek ML, Vinkers DJ, Gussekloo J, et al. Is depression in old
Hypertensives. J Am Soc Hypertens 2014;8(4):246-53. age fatal only when people feel lonely? Am J Psychiatry
20. Hacıhasanoglu R. Hipertansiyon y€ onetiminde hemşirenin 2005;162(1):178-80.
sorumlulukları. Fırat Sa glık Hizmetleri Dergisi 2009;4(12): 37. Ringoir L, Pedersen SS, Widdershoven JW, et al. Prevalence
154-64. of psychological distress in elderly hypertension patients in
21. Scalco AZ, Scalco MZ, Azul JBS, et al. Hypertension and primary care. Neth Heart J 2014;22(2):71-6.
depression. Clinics (Sao Paulo) 2005;60(3):241-50. 38. Hu HH, Li G, Arao T. The association of family social sup-
22. Yesavage JA, Brink TL, Rose TL, et al. Development and port, depression, anxiety and self-efficacy with specific hyper-
validation of a geriatric depression screening scale: a prelim- tension self-care behaviours in Chinese local community.
inary report. J Psychiatr Res 1982-1983;17(1):37-49. J Hum Hypertens 2015;29(3):198-203.
23. Ertan T, Eker E, Şar V. Geriatrik depresyon € olçe
ginin T€
urk 39. Kabir AA, Whelton PK, Khan MM, et al. Association of
yaşlı n€ufusunda geçerlilik ve g€uvenilirli
gi. Noropsikiyatri symptoms of depression and obesity with hypertension: the
Arşivi 1997;34(2):62-71. Bogalusa Heart Study. Am J Hypertens 2006;19:639-45.
24. Fernandez S, Chaplin W, Schoenthaler AM, et al. Revision 40. Demirba g BC, ve Timur M. Bir grup yaşlının ilaç kullanımı
and validation of the Medication Adherence Self-efficacy ile ilgili bilgi, tutum ve davranışları. Ankara Sa
glık Hizmet-
Scale (MASES) in hypertensive African Americans. J Behav leri Dergisi 2012;11(1):1-8.
Med 2008;31:453-62. 41. Zyoud SH, Al-Jabi SW, Sweileh WM, et al. Relationship
25. Hacıhasanoglu R, G€ oz€um S, Çapık C. Validity of the Turkish of treatment satisfaction to medication adherence: find-
version of the Medication Adherence Self-efficacy Scale- ings from a cross-sectional survey among hypertensive
short form in hypertensive patients. Anadolu Kardiyol patients in Palestine. Health Qual Life Outcomes 2013;
Derg 2012;12:241-8. 11:191.
26. James PA, Oparil S, Cartel BL, et al. Evidence-based 42. Lemstra M, Alsabbagh MW. Proportion and risk indicators
guideline for the management of high blood pressure in of nonadherence to antihypertensive therapy: a meta-anal-
adults: Report from the Panel Members Appointed to the ysis. Patient Prefer Adherence 2014;8:211-8.
Eighth Joint National Committee (JNC 8). JAMA 2014; 43. Hacıhasano glu Aşılar R, G€
oz€
um S, Cant€ urk Ç, et al. Reli-
311(5):507-20. ability and validity of the Turkish form of the eight-item
27. Aydogan U,€ Mutlu S, Akbulut H, et al. Hipertansiyon Hasta- Morisky Medication Adherence Scale in hypertensive pa-
larında Anksiyete Bozuklu gu. Konuralp Tıp Dergisi 2012; tients. Anadolu Kardiyol Derg 2014;14(8):692-700.
4(2):1-5. 44. Krousel-Wood MA, Frohlich ED. Hypertension and depres-
28. Scuteri A, Spazzafumo L, Cipriani L, et al. Depression, hy- sion: coexisting barriers to medication adherence. J Clin Hy-
pertension, and comorbidity: disentangling their specific ef- pertens (Greenwich) 2010;12(7):481-6.
Vol. - No. - JOURNAL OF VASCULAR NURSING PAGE 11
www.jvascnurs.net

45. Rajpura J, Nayak R. Medication adherence in a sample of population of Kanchipuram district in Tamil Nadu, South In-
elderly suffering from hypertension: evaluating the influence dia. Indian J Community Med 2015;40(1):33-7.
of illness perceptions, treatment beliefs, and illness burden. J 51. Shima R, Farizah MH, Majid HA. Qualitative study on hy-
Manag Care Pharm 2014;20(1):58-65. pertensive care behavior in primary health care settings in
46. Wang W, Lau Y, Loo A, et al. Medication adherence and its Malaysia. Patient Prefer Adherence 2014;17(8):1597-609.
associated factors among Chinese community-dwelling 52. Kasar KS, Karadakovan A. Yaşlı bireylerde antihipertansif
older adults with hypertension. Heart Lung 2014;43(4): ilaç kullanım hatalarının incelenmesi. J Cardiovasc Nurs
278-83. 2017;8(15):20-7.
47. G€un Y, Korkmaz M. Hipertansif hastaların tedavi uyumu ve 53. Sj€osten N, Nabi H, Westerlund H, et al. Effect of depression
yaşam kalitesi. Dokuz Eyl€ €
ul Universitesi Hemşirelik onset on adherence to medication among hypertensive pa-
Y€uksekokulu Elektronik Dergisi 2014;7(2):98-108. tients: a longitudinal modeling study. J Hypertens 2013;
48. Krueger K, Botermann L, Schorr SG, et al. Age-related 31(7):1477-84.
medication adherence in patients with chronic heart fail- 54. Maguire LK, Hughes CM, McElnay JC. Exploring the
ure: a systematic literature review. Int J Cardiol 2015; impact of depressive symptoms and medication beliefs on
184:728-35. medication adherence in hypertension-a primary care study.
49. Zakaria N, Baharudin A, Razali R. The effect of depressive Patient Educ Couns 2008;73(2):371-6.
disorders on compliance among hypertensive patients under- 55. Vawter L, Tong X, Gemilyan M, et al. Barriers to antihy-
going pharmacotherapy. Psychiatry 2009;10(2):1-11. pertensive medication adherence among adults-United
50. Venkatachalam J, Abrahm SB, Singh Z, et al. Determinants States, 2005. J Clin Hypertens (Greenwich) 2008;10(12):
of patient’s adherence to hypertension medications in a rural 922-4.