Vol. - No.

- JOURNAL OF VASCULAR NURSING PAGE 1

www.jvascnurs.net

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
lasting until the end of life, and 65 years of age is accepted
as the beginning of old age in this process.1 The Turkish Statis-
tical Institute has reported that the ratio of the population aged
65 years and older has reached 8.2% in 2015.2 Because old age
is a process in which many physiological, psychological, and
social changes are experienced, the prevalence of chronic dis-
eases increases and older people need more medical treatment
and care.3 Emergence of chronic diseases usually occurs in pe-
riods of depression,4 and one of the major causes of physical
disorders and troubles in the elderly is depression.5 Depression
From the Ahi Evren Chest, Heart and Vascular Surgical
Education and Research Hospital, Trabzon, Turkey; Professor,
Erzincan Binali Yıldırım University Faculty of Health Sciences,
Department of Public Health Nursing, Erzincan, Turkey.
Address correspondence to: Rabia Hacıhasanoglu Aşılar, PhD,
RN, Professor, Faculty of Health Sciences Erzincan Binali
Yıldırm University, Department of Public Health Nursing, Erzin-
can 24030, Turkey (E-mail: rabia_hhoglu@hotmail.com).
This study was accepted as a postgraduate thesis in 2015 at the
Erzincan University, Health Sciences Institute.
This study was presented at a poster presentation in the First
International Health Sciences Congress, June 29 to July 1,
2017, Aydın, Turkey..
1062-0303/$36.00
Copyright Ó 2018 by the Society for Vascular Nursing, Inc.
https://doi.org/10.1016/j.jvn.2018.06.001
in the elderly is an important mental disorder not treated in
Turkey for not being sufficiently diagnosed. Studies by using
the Geriatric Depression Scale (GDS) have shown that its prev-
alence is 16% in subjects aged 706 years and older and 62.2% in
subjects aged 65 years and older.7 Blood pressure, which other-
wise is normal, starts to fluctuate in times of depression, and
blood sugar deviates from its normal values. Many studies
have shown that when depression accompanies heart attack, it
can aggravate heart-related problems of patients and the risk
of having another heart attack.4 The result of a meta-analysis
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
of the PatenT2 study, the prevalence of hypertension in Turkey
is 67.9% in the 60–69 years age group, 85.2% in the 70–79
years age group, and 76.3% in those aged 80 years and older.10
According to the Seventh Report of the Joint National Commit-
tee, hypertension occurs in more than two-third of individuals
after the age of 65 years.11 It has been reported to be 89% in
a study conducted abroad with the geriatric population12 and
52% in another study.13 Promoting positive beliefs that hyper-
tension can be controlled with treatment is important.14 It is
known that uncontrollable hypertension reduces longevity, de-
creases are seen in morbidity and mortality in severe and mild
cases receiving treatment,15 and many factors play a role in
the inability to control hypertension.16
Nonadherence to medication appears to be a complicated
problem involving various risk factors particularly in older peo-
ple living alone.17 A study performed with older hypertensive
people living in communities reported lack of knowledge in
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
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carried out with hypertensive elderly, being aged 70 years and
older and having a systolic blood pressure (SBP) $ 160 mm
Hg was reported to be a major obstacle in achieving the targeted
blood pressure.19 One of the important factors in controlling
blood pressure is a high level of adherence by patients to their
antihypertensive treatment. Besides helping individuals adhere
to medication and gain healthy lifestyle behaviors, as well as
providing information about their diseases,20 nurses also have
the responsibility to provide health education to the elderly about
recognizing depression symptoms and consultancy service in di-
recting them to appropriate units. Depression, hypertension and
drug compliance are important problems in the elderly. However,
we have not encountered any study in our country that investi-
gates the effect of depression on the adherence to antihyperten-
sive medication.
It has been reported that this situation in which depressive
symptoms lead to inadequate control of the blood pressure and
development of hypertension-related complications should be
considered during the treatment of depressive/hypertensive pa-
tients, and they should be approached more attentively and given
extra care so that the side effects of antidepressants on the blood
pressure are minimized.21
In view of the aforementioned information, answers to the
following questions are sought in this study, which was carried
out to reveal the effect of depression on adherence to antihyper-
tensive medication in older hypertensive people.
Study questions
1. Do the descriptive characteristics of the elderly affect
depression?
2. Do the descriptive characteristics of the elderly affect
adherence to antihypertensive medication?
3. Does depression affect adherence to antihypertensive
medication in the elderly?
4. Is there a relationship between the scores of depression
and adherence to medication?
MATERIALS AND METHOD
Design
This descriptive study was conducted in the Family Healthcare
_ on€
Centers (FHCs) in the central districts of Karaagaç, In€ u, and
Mimar Sinan in the province of Erzincan between May 2014 and
September 2014. The study population consisted of individuals
aged 65 years and older who presented for any indication of the
FHCs. Recruitment continued until the sample size of 350 was
met based on the power calculation.
Participants
The inclusion criteria are as follows: 1) being 65 years of age and
older, 2) having diagnosed with essential hypertension and started
antihypertensive treatment at least a year ago, and 3) agreeing to
take part in the study.
The exclusion criteria are as follows: 1) having any physical
disorder (hearing and/or speaking disorders), 2) mental disability,
3) mental disorder (depression and psychotic disorder), or 4)
cancer.
- 2018
Outcomes and measures
Instruments. The data were collected using a descriptive ques-
tionnaire, the GDS, and the Medication Adherence Self-Efficacy
Scale-Short Form (MASES-SF). The blood pressure, height, and
weight measurements of the patients were taken.
The descriptive questionnaire consisted of 12 questions in total,
nine to inquire the sociodemographic characteristics of the patients
(age, gender, education, marital status, perceived income level, avail-
ability of social support, perceived health, solitary living, and accom-
panying diseases) and three to inquire their hypertension (date of
receiving hypertension diagnosis, years of using medication due to hy-
pertension, and number of antihypertensive medications used daily).
The GDS was developed by Yesavage et al22 in 1983 and was
tested for validity and reliability by Ertan and associates in 1997.23
It is a self-report depression scale for older population consisting of
30 questions, which are to be answered as yes/no, on how the person
has felt in life in the past week. The lowest score obtained from the
scale is 0 and the highest 30; with scores 0–10 meaning ‘‘no depres-
sion’’, 11–13 meaning ‘‘possible depression’’, and a score equal to or
above 14 meaning ‘‘definite depression.’’23 When calculating the
GDS score, 1 point is given to each ‘‘no’’ answer and 0 point to
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
to the questions 3–6, 8, 10–14, 16–18, 20, 22–26, and 28.22,23 The
Cronbach’s alpha coefficient was 0.92 in the validity and reliability
study of Ertan et al,23 whereas it was found as 0.86 in the present study.
The MASES-SF was revised and tested for validity and reli-
ability by Fernandez et al.24 The scale was tested for validity and
reliability in our country by Hacıhasano glu et al.25 Questioning the
factors affecting the regular use of antihypertensive medications
by hypertensive patients, the scale consists of 13 expressions assess-
ing the self-efficacy/confidence level of the individual in agreeing
with these expressions. Scoring is from 1 to 4, and the lowest score
obtained from the scale is 13 and the highest being 52. Higher scores
indicate better adherence to the antihypertensive drug therapy. The
Cronbach’s alpha coefficient of the scale was 0.92, and we found
it as 0.95 for this study.
Arterial blood pressure measurements were performed after letting
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-
sition. After a 5–10 minutes break, a second measurement was per-
formed, and the average of the two measurements was recorded. Care
was taken to prevent the patients from smoking and taking caffeine (cof-
fee, coke) within 30 minutes before the measurements. An ERKA brand
(Perfect Anaroid Model, Serial No: 09008298) sphygmomanometer
was used in all patients for these measurements. Based on Korotkoff
sounds, the systolic blood pressures (SBP) and diastolic blood pressure
(DBP) values were recorded. Controlled blood pressure was defined as
SBP < 150 mm Hg and DBP < 90 mm Hg. Controlled values were taken
as SBP < 140 mm Hg and DBP < 90 mm Hg for the elderly who had
diabetes alongside hypertension.26
Data collection. The study data were collected between May and
September 2014 through face-to-face interviews after a certain
sequence in the waiting rooms of Karaa _ on€
gaç, In€ u, and Mimar Sinan
FHCs during 2–3 days of the weeks in which the investigators were
available. The forms were completed in 20–25 minutes on average.
Statistical analyses
In the analysis of data, the descriptive characteristics were given
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
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Figure 1. Depression statuses and mean scores.
originated from the 80 years and older age group. Furthermore, a
significant correlation was found between depression and gender,
education, marital status, perceived income, perceived health,
and living alone (P < .05; P < .01) (Table 2). The difference in
the educational status originated from the high school/university
graduates, and there was a significant difference in all groups
with respect to the others for income and perceived health.
As seen in Table 2, the depression statuses of the hypertensive
elderly had no significant correlation with receiving social sup-
port, additional disease, and body mass index (BMI) statuses of
them or whether their systolic and diastolic blood pressures
were under control (P > .05).
As seen in Table 3, a significant difference between the edu-
cation, perceived income and health, additional chronic disease,
diastolic blood pressure, and depression statuses of the hyperten-
sive elderly with their medication adherence self-efficacy scores
was found (P < .05; P < .01). According to the result of the
Mann-Whitney U-Test that was carried out to determine from
where the difference in education originated, it originated from
the group which was unable to read and write, whose income
was less than their expenses for the income status, and which
had depression for the depression status, and there was a statisti-
cally significant difference in all groups with respect to the others
for perceived health.
No significant difference was found between the medication
adherence self-efficacy scores of the hypertensive elderly and
their age, gender, marital status, receiving social support, living
alone, and BMI statuses or whether their systolic blood pressures
were under control (P > .05) (Table 3).
No significant correlation was found between GDS and the
year of hypertension diagnosis, duration of treatment, or number
of drugs used daily and between the mean MASES-SF score and
the number of drugs used daily (P > .05). There was a very weak
positive correlation between the mean MASES-SF score and the
year of diagnosis and duration of treatment (P < .01) and a mod-
erate negative correlation between the mean MASES-SF and
GDS scores (P < .001) (Table 4).
DISCUSSION
Some mental problems can be seen in people with a chronic
disease such as hypertension,27 and one of such mental problems
is depression.28 In this study, depression was found at a rate of
57.1% with a mean score of 19.67
4.25 (Figure 1). In a study
- 2018
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
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-
sion, and apart from personal characteristics, the extent to which
individuals take their disease seriously and care about it can be
effective on the outcome.
Being female is one of the risk factors increasing the risk of
depression in the elderly.31 In this study, the prevalence of
depression was found to be considerably higher in women
than in men. Studies carried out with older people have re-
ported that depression occurs more in women,6,28 and study
with hypertensive people reported that the prevalence of
depression is significantly higher in women than in men.30
These results support the results of the present study.
In this study, the prevalence of depression was found to be
significantly lower in the elderly who were graduates of high
school/university than in those who were illiterate and graduates
of primary/secondary school. In a study carried out with hyper-
tensive elderly, the prevalence of depressive symptoms was re-
ported to be significantly higher in the illiterate hypertensive
elderly than in literate ones,32 and in another study carried out
with hypertensive people having a high cardiovascular risk, the
prevalence of depression was found to be significantly higher
in those with a low educational status than in those who had a
moderate and high level of education.33 These results support
the results of the present study, all showing that education and lit-
eracy in health care are important factors in perceiving the seri-
ousness of the disease.
The prevalence of depression was significantly higher in
those who were single/widowed/divorced among the subjects
included in the study than in those who were married. A recent
study has also found that depressive symptoms are seen more
frequently in hypertensive elderly who are not married than in
those who are married.32 The results of the present study suggest
that being married may provide mental support by increased
sharing, but an individuals’ belief in treatment and paying atten-
tion to their health can also be effective regardless of marital
status.
Another result of this study was that the group perceiving to
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-
icant difference among all the groups. In a study carried out with
hypertensive elderly, the prevalence of depressive symptoms was
found to be higher in those having less income than in those hav-
ing more income.32 The result of the reported study supports the
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
effective.
Depression is associated with both lack of health-improving
behaviors and hypertension.34 In this study, it was found that
perceived health was significantly correlated with presence of
depression scores. The correlation was significant in all the
groups with respect to the others, but the group that perceived
their health being poor had the highest depression scores, and
the group that perceived their health being good had the lowest
depression scores. A study carried out with older people found
that the group perceiving their health as being poor had a signif-
icantly higher mean depression score and lower quality of life
score.7 The results of the present study suggest that besides the
sociocultural characteristics of the elderly and the fact that
they may have experienced important life events threatening
their mental or physical health, factors such as lifestyle and belief
in treatment can also be effective.
It was found in the present study that the prevalence of
depression was significantly higher in those living alone. It is
known that loneliness can lead to various mental and physical
disorders.35 In a study carried out with older people, a strong cor-
relation was found between perceived loneliness and presence of
depression.36 The results of the present study suggest whether or
not feeling lonely can be effective alongside perceived disease
and paying attention to it in the elderly.
In this study, no significant correlation of social support, co-
morbid illnesses, BMI, and systolic and diastolic blood pressure
status with GDS score was found. No significant correlation was
reported between high SBP and anxiety or depressive symptoms
in a study carried out with the elderly,37 and no significant corre-
lation was reported between blood-pressure-control status and
presence of depression in another study carried out with hyper-
tensive patients aged 25 years and older.30 The results of the re-
ported study are similar to the results of this study. A study
carried out with individuals with hypertension in China has re-
ported that there is a negative significant correlation between so-
cial support perceived from the family and depression.38 Another
study that examined predictors of depression in black women
with hypertension reported that greater number of comorbidities
was significantly associated with higher depression scores.34 An
another study investigating the relationship between depression
symptoms and obesity in hypertensive people showed that a
high BMI could be a variable associated with depression symp-
toms and hypertension.39 The results of these three presented
studies do not show similarities with the result of the present
study. It is thought that, in addition to difference in individual
and cultural characteristics, how the social support was received
and from whom and how the effects of weight and accompanying
disease are perceived can be effective.
In this study, it was found that those who were illiterate had
the lowest MASES-SF score, whereas those who were graduates
of high school/university had the highest score. Another study
has reported that those with a high level of education use their
medications regularly and has found a significant correlation be-
tween education level and drug use.40 Another study found that
adherence to antihypertensive medication was significantly
higher in graduates of a university.41 The results of the reported
study support the result of this study, which suggests that educa-
tion is an important factor in health literacy and comprehending
seriousness of a disease.
In this study, it was found that those who perceived their in-
come as being satisfactory had significantly higher MASES-SF
scores than those who perceived their income as being poor. It
was found in a meta-analysis that a poor income status was an
important factor in nonadherence to antihypertensive drugs,42
and in another study, it was found that patients with a good eco-
nomic status had significantly higher rates of adherence to anti-
hypertensive drugs.43 The results of the present study suggest
that income level is a major factor in having access to health-
care services and medication, whereas lifestyles, life expecta-
tions, and values of individuals may also play a role.
A significant difference was found in this study between
perceived health and MASES-SF scores. The difference was sig-
nificant in all groups with respect to the others, but the group that
perceived their health being poor had the lowest adherence to
medication scores, and the group that perceived their health be-
ing good had the highest adherence to medication scores. Poor
quality of life is an important factor hindering adherence to anti-
hypertensive medication.44 It has been reported that positive
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
www.jvascnurs.net
spouse and children, with relatives, or living alone was not an
effective factor in making errors in drug use.52
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,
and there was no significant correlation between the number
of medications used daily and the mean MASES-SF score;
but, there was a very weak positive significant correlation
between the year of diagnosis and duration of treatment and
the MASES-SF scores (Table 4). It was reported in a study
that there was no significant correlation between the year
of diagnosing hypertension and the prevalence of depres-
sive symptoms32 and in other studies that adherence to medi-
cation increased significantly as the duration of treatment
lengthened.46,47 Another study carried out with the
population aged 40 years and older showed that there was
no significant correlation between the year of diagnosing
hypertension and adherence to antihypertensive drugs,49 and
one study showed that there was no significant correlation be-
tween the duration of using antihypertensive drugs and adher-
ence to antihypertensive medication in women patients with
and without depression.53 The results of the present study
show that besides personal characteristics, the severity of
the disease, characteristics of the drugs used, average number
of medications being not too many, and many disease-related
factors may play a role in these results. All these results
represent the answers to the first and second questions of
the study.
Depressive symptoms are one of the obstacles among clin-
ical factors influencing adherence to antihypertensive medica-
tion,44 and nonadherence to medication is an important
problem in the elderly.17 In this study, it was found that the
medication adherence self-efficacy scores of the hypertensive
patients with depression were significantly lower than those
of the patients without depression or carrying a possible risk
of depression (Table 3). Moreover, a moderately significant
negative correlation between depression and the mean medica-
tion adherence self-efficacy scores of the participating patients
was found (Table 4). These results explain the third and fourth
questions of the study. A study carried out with women re-
ported that there was a significant correlation between poor
medication adherence and depressive symptoms,34 and another
study reported that depression did not affect medication adher-
ence, but the prevalence of depressive symptoms was higher in
the group not adhering to medication.54 A longitudinal
modeling study reported that onset of depression increased
the risk of nonadherence to medication in hypertensive
males,53 and another study reported that mental functioning
disorder was a major obstacle for taking antihypertensive
medication.55 The results of the reported study support the
result of this study, which suggests that the risk of depression
is an important factor in hindering compliance with
medication.
LIMITATIONS
There are two limitations of the study, first being that the sub-
jects participating in the study were assessed for depression using
only the GDS and were not assessed by a specialist, and the sec-
PAGE 9
ond being that the study was conducted in only 3 FHCs in the
central province.
CONCLUSION AND RECOMMENDATIONS
One of the most striking results of the study was that depres-
sion was found in 57.1% of all the elderly and in 72.6% of those
aged 80 years and older. The major variables increasing the prev-
alence of depression were being aged 80 years and older, being
female, not being a graduate of high school/university, being sin-
gle/widowed/divorced, having less income than expenses, poor
perception of health, and living alone. Being illiterate, having
less income than expenses, poor perception of health, uncon-
trolled diastolic blood pressure, and having depression decreased
the medication adherence self-efficacy score significantly, and
having an additional chronic disease and year of diagnosis and
extended duration of treatment increased the medication adher-
ence self-efficacy score significantly. There was also a moderate
negative correlation between depression and mean medication
adherence self-efficacy scores. Early diagnosis and treatment
of depressive symptoms is an important factor for the treatment
and management of hypertension. In this respect, it is important
for nurses working in primary health-care institutions and other
health professions to monitor the hypertensive elderly especially
for symptoms of depression.
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