Betül Aktaş, PhD, RN; Ayse Berivan Bakan, PhD, RN
Background • The prevalence of chronic diseases increases in old age, and therefore, elderly individuals need to use a large number of medications.
Primary Study Objective • This study was conducted to investigate the relationship between attitudes of elderly individuals with chronic disease toward medication adherence and complementary and alternative medicines.
Methods/Design • This cross-sectional study was conducted between July and September 2018. The participants were 193 elderly individuals who were selected using the sampling method with a known target population. The study data were collected using Descriptive Characteristics Information Form, HCAMQ, and ARMS.
Setting • The study was conducted in Family Health Centres in a city located in the eastern part of Turkey.
Participants • The study involved elderly subjects who had been diagnosed with a chronic disease for at least 6 months that required continuous medication, and who could communicate sufficiently.
Results • The mean ARMS score of elderly individuals was found to be 14.19 ± 3.01, showing moderate adherence to medications. The mean HCAMQ score of individuals was 25.93 ± 6.57, showing positive attitudes of individuals toward CAM. Further, a positive and statistically significant correlation was found between the total scores of ARMS and HCAMQ (P < .01).
Conclusion • It can be suggested that elderly individuals endeavor to maintain medical therapies for their diseases, and they also have positive attitudes toward complementary and alternative treatments. These positive behaviors of the elderly should be supported. Also elderly individuals should be informed about how to take “complementary and alternative treatments” consciously, in a controlled and correct manner. (Altern Ther Health Med. [E-pub ahead of print.])
Betül Aktaş, PhD, RN, Associate Professor, is affiliated with SANKO University Faculty of Health Science, Nursing Department in Gaziantep, Turkey. Ayse Berivan Bakan, PhD, RN, Associate Professor is affiliated with the Department of Nursing, Agri Ibrahim Cecen University School of Health in Agri, Turkey.
Corresponding author: Ayse Berivan Bakan, PhD, RN
E-mail address: [email protected]
Geriatric health problems are gaining more importance today because of increased life span and associated increase in the number of elderly individuals in society.1 The prevalence of chronic diseases increases in old age, and therefore, elderly individuals need to use a large number of medications.2
The presence of multiple chronic diseases in elderly individuals compared to that in younger populations, combined use of different therapies, and decrease in cognitive and functional capacity, create medication adherence issues.1 The factors affecting medication adherence in elderly individuals are multifaceted and present as patient-related, treatment-related, health care system-related, health care professional-related, and socio-demographic factors. Patient-related factors affecting medication adherence include mental status; physical health; demographic characteristics such as age, gender, and educational status; medical history; values; belief; attitude; habit; and education level.3,4,5
In a study conducted on elderly individuals, it was found that the majority of individuals used three or more drugs, one-fourth of elderly individuals did not take their medicines regularly, the majority of the participants needed help in taking the drugs, and forgetfulness was the most common problem they encountered while taking drugs.2 In another study conducted on elderly individuals with chronic diseases, 72.6% of participants were found to be noncompliant with drug therapy.6
In recent years, the use of complementary and alternative treatment (CAT) methods has increased in elderly individuals with the increase in the general population. The majority of CAT use in elderly individuals, either in the form of herbal or nutritional treatments, is observed as a continuation of ethnic and cultural heritage.7
The most common reasons for resorting to CAT methods among elderly individuals are the insufficiency of health insurance systems, side effects caused by drugs or treatments, high treatment and drug costs, lack of control in individuals’ own health care practices, non-individualized general technological medical methods, strengthening the immune system, getting rid of the feeling of hopelessness, and reinforcing healthy behaviors.8 In a study conducted on elderly individuals living in nursing homes, it was found that CAT methods were widely used, and the most common methods were herbal and non-herbal supplements. Further, it was determined that elderly individuals with a chronic disease and receiving regular medical treatment preferred CAT use and generally did not tell healthcare personnel that they used these methods.9
Lack of adherence to medications is a potential cause of hospitalizations, morbidity, and mortality in the elderly. Medication adherence decreases with polypharmacy. Older persons commonly use complementary medicine, therefore complementary medicine use might pose an increase risk of loss of medication adherence with conventional medications.10
In light of this information, the aim of this study was to investigate the relationship between medication adherence and attitudes toward complementary and alternative medicines (CAM) in elderly individuals.
This cross-sectional study was conducted between July and September 2018 at Family Health Centres in a city located in the eastern part of Turkey. The study involved people who had been diagnosed with a chronic disease for at least 6 months11 that required continuous medication, and who could communicate sufficiently. From a known target population, 193 elderly individuals were selected using the sampling method. The target population was comprised of 896 people, who were aged 65 or over, and who applied to Family Health Centres between the specified dates. Individuals who did not meet the criteria and did not want to participate were excluded in the research.
The data was collected using the Descriptive Characteristics Information Form, Holistic Complementary and Alternative Medicine Questionnaire (HCAMQ), and Adherence to Refills and Medications Scale (ARMS). The data were collected at Family Health Centres by the researchers within a period of 10–15 minutes using the face-to face-interview method.
Descriptive Characteristics Information Form. This form prepared by the researchers, consists of seven questions inquiring about the personal characteristics of elderly individuals.
Holistic Complementary and Alternative Medicine Questionnaire (HCAMQ). Developed by Hyland et al.12 in 2003, the validity and reliability of HCAMQ for use in Turkey was evaluated by Erci (2007).13 The questionnaire has two subscales: CAM and Holistic Health. It is a Likert-type scale consisting of 11 questions. The lowest and highest scores that can be obtained from the scale are 11 and 66, respectively. Lower scores indicate a more positive attitude toward CAM. The Cronbach’s alpha coefficient of the scale is 0.72. In this study, Cronbach’s alpha value was found to be 0.71.13
Adherence to Refills and Medications Scale (ARMS). Developed by Kripalani et al.,14 Turkish validity and reliability study was conducted by Gökdoğan and Kes (2017).15 The ARMS has two sub-dimensions: “Adherence to medications” and “Adherence to Refills.” This is a self-evaluation scale calculating medication adherence, and prescribing competencies of individuals with one or more chronic diseases, who are taking medication. It has been reported that the scale can also be used to determine medication adherence of individuals with chronic diseases who have a low literacy. The total score that can be obtained from the scale ranges between 7 and 28. The total score that can be obtained from adherence to medication subscale ranges between 4 and 16, and the total score that can be obtained from adherence to refills subscale ranges between 3 and 12. Lower total score indicates that the patient’s medication adherence is better. In the adaptation study performed by Gökdoğan and Kes (2017),15 the Cronbach’s alpha coefficient of the scale was determined to be 0.75.12 In our study, Cronbach’s alpha value was found as 0.71.
The data analysis was performed by using SPSS 23.0 statistical software. Whether the data distributed normally was tested by using the Kolmogorov–Smirnov Test. The mean score of the scales according to sociodemographic characteristics was compared by using Mann-Whitney U test and Kruskal–Wallis test. Spearman correlation tests were used to show relationship between scale scores.
Prior to the study, University Ethical Committee Approval (document number: 19/07/2018-E.27632) was obtained. Individuals who accepted to participate in the study were informed about the study, and verbal consent was obtained prior to the study.
An analysis of the socio-demographic features of the participating elderly individuals showed the average age was 70.35 ± 6.45 years and 76.2% were between 65 and 74 years of age. Of the participants, 52.8% were male, 84.5% were married, and 48.7% were illiterate. It was also found that 62.2% had an income equal to their expenses, 59.1% lived with their spouse, and 18.7% had more than one chronic disease (Table 1).
Table 1. Descriptive Characteristics of Elderly Individuals (N=193)
|Income less than expenses||57||29.5|
|Income equal to expenses||120||62.2|
|Income more than expenses||16||8.3|
|Lives with spouse||114||59.1|
|Lives with children||51||26.4|
|Existing chronic disease||Hypertension||36||18.7|
|Chronic obstructive pulmonary disease||26||13.5|
|Multiple chronic diseases||36||18.7|
|Age||70.35 ± 6.45||65||96|
According to the findings obtained from the study, it was found that the mean HCAMQ score of participants was 25.93 ± 6.57, with the lowest score of 11 and highest score of 51. The mean ARMS score of participants was 14.19 ± 3.01, with the lowest score of 8 and highest score of 26 (Table 2).
Table 2. HCAMQ and ARMS Total Scores of Elderly Individuals
|HCAMQ||25.93 ± 6.57||11||51|
|ARMS||14.19 ± 3.01||8||26|
The mean ARMS score of participants with an educational status of middle school was found to be significantly higher than that of other participants (P < .05). The mean ARMS score of participants living with their spouse was found to be significantly lower (P < .05). No difference was found between the groups in terms of gender, age, marital status, income status, and existing chronic disease (Table 3).
Table 3. Distribution of Elderly Individuals’ Mean ARMS Scores According to Individual Characteristics (N = 193)
|Test and Significance|
|Gender||Female||91||14.12 ± 2.74||U = 4636.5
P = .99
|Male||102||14.25 ± 3.25|
|Age (years)||65–74||150||14.03 ± 2.95||KW = 2.694
P = .26
|75–84||34||14.41 ± 3.03|
|≥85||9||16.00 ± 3.64|
|Marital status||Married||163||14.13 ± 3.16||U = 2130.5
p = 0.26
|Single/widowed||30||14.50 ± 2.06|
|Illiterate||94||14.68 ± 3.04||KW = 8.262
P = .04
|Literate/elementary school||83||13.55 ± 2.90|
|Middle school||12||15.00 ± 3.13|
|High school/university||4||13.50 ± 2.38|
|Income less than expenses||57||15.05 ± 3.68||KW = 4.252
P = .11
|Income equal to expenses||120||13.91 ± 2.58|
|Income more than expenses||16||13.25 ± 2.86|
|Cohabitants||Lives alone||28||14.93 ± 3.66||KW = 6.174
P = .04
|Lives with spouse||114||13.68 ± 2.68|
|Lives with children||51||14.92 ± 3.15|
|Existing chronic disease||Hypertension||36||14.81 ± 2.63||KW = 5.492
P = .35
|Diabetes||21||13.76 ± 3.06|
|Chronic obstructive pulmonary disease||26||14.73 ± 3.29|
|Heart disease||16||14.81 ± 3.41|
|Multiple chronic diseases||36||14.03 ± 3.40|
|Others||58||13.66 ± 2.69|
The mean HCAMQ score was found to be significantly higher in participants aged ≥85 or (P < .05). The mean HCAMQ score of participants with an income equal to their expenses was found to be significantly lower compared to others (P < .01). No difference was found between the groups in terms of gender, marital status, educational status, cohabitants, existing chronic disease, and the use of nonpharmacological therapies for the disease (Table 4).
Table 4. Distribution of Elderly Individuals’ Mean HCAMQ Scores According to Individual Characteristics (N=193)
|Test and Significance|
|Gender||Female||91||25.86 ± 6.40||U = 4639.0
P = .99
|Male||102||26.00 ± 6.74|
|65–74||150||25.81 ± 6.65||KW = 6.504
P = .03
|75–84||34||25.18 ± 6.58|
|≥85||9||30.44 ± 4.10|
|Marital status||Married||163||26.04 ± 6.79||U = 2259.0
P = .50
|Single/widowed||30||25.33 ± 5.26|
|Educational status||Illiterate||94||25.78 ± 6.66||KW = 1.076
P = .78
|Literate/elementary school||83||25.93 ± 6.56|
|Middle school||12||26.50 ± 7.13|
|High school/university||4||28.00 ± 3.56|
|Income less than expenses||57||28.39 ± 7.05||KW = 22.247
P = .001
|Income equal to expenses||120||24.24 ± 5.77|
|Income more than expenses||16||29.88 ± 6.28|
|Cohabitants||Lives alone||28||28.43 ± 6.82||KW = 4.664
P = .09
|Lives with spouse||114||25.13 ± 6.33|
|Lives with children||51||26.35 ± 6.69|
|Existing chronic disease||Hypertension||36||25.81 ± 5.94||KW = 7.969
P = .15
|Diabetes||21||24.33 ± 6.06|
|Chronic obstructive pulmonary disease||26||26.35 ± 5.83|
|Heart disease||16||30.88 ± 7.78|
|Multiple chronic diseases||36||26.28 ± 6.68|
|Other||58||24.83 ± 6.57|
There was a statistically significant, weak positive correlation between total scores of HCAMQ and ARMS (P < .01) (Table 5).
Table 5. The Relationship Between HCAMQ and ARMS Scores
|HCAMQ total score|
|ARMS total score||r = .196|
|P = .006|
The data obtained in this study examining the relationship between medication adherence and CAM and attitudes of elderly individuals with chronic disease was discussed with respect to the literature.
The mean ARMS score was determined as 14.19 ± 3.01, and considering that a lower score indicates better adherence, it can be suggested that elderly individuals had moderate medication adherence. In the literature, varying results have been obtained in the studies conducted to determine medication adherence of elderly individuals. Akkuş and Karatay2 found that one-fourth of elderly individuals did not use their medicines regularly, the majority needed help in taking medication, and the problem they experienced the most in taking medication was forgetfulness. Furthermore, they also stated that a significant proportion of elderly individuals exhibited behaviors such as not taking drugs when not feeling well, using drugs that were good for their friends, and buying drugs on their own without visiting a doctor.
In another study that evaluated belief in medication and adherence to treatment in elderly patients with chronic diseases, 72.6% of the participants were found to be non-adherent to drug therapy. In the same study, it was also found that the belief in the necessity of drugs in elderly individuals with chronic diseases had a positive effect on medication adherence, whereas the belief of overuse had a negative effect.6 In a study by Demirbağ and Timur,16 it was determined that the majority of elderly individuals did not use their medication regularly. In the same study, 26.1% of individuals aged >65 years reported that they could not repurchase their medication when finished, and therefore, did not use their medication regularly. Sayın Kasar and Kardakovan17 found that the rate of quitting antihypertensive drugs at one’s own discretion was 28.8% in elderly hypertensive patients and almost half of the patients aged >65 years forgot to take antihypertensive medications. In contrast to the negative studies related to medication adherence, Özdemir et al.1 determined that medication adherence of elderly individuals with hypertension was quite good. Turhan et al.18 determined that adherence to treatment was 71.3% in elderly individuals using medications and found that the most important factor in non-adherence to treatment was “forgetting to take the medications,” and participants sometimes did not take their medication when they felt good. According to the results of this study, it was determined that ARMS score of elderly individuals was affected by age, educational status, and cohabitants, but was not affected by gender, marital status, income, and existing chronic diseases. Yılmaz and Yavuz Çolak6 found that non-adherence was the highest among patients with diabetes, and marital status, occupation, health literacy, knowledge on the medications used, taking medications on one’s own, use of over-the-counter medications, and the belief that drugs were necessary were determined as the factors affecting adherence to medication.
According to the results of this study, the mean HCAMQ score of elderly individuals was determined to be 25.93, and based on the maximum score that can be obtained from the scale and the evaluation of the scale, it was concluded that elderly individuals had a positive attitude toward CAM. Similar to our results, Erdoğan et al.9 stated that elderly individuals with a chronic disease who receive regular medical treatment prefer CAM. Schnabel et al.19 stated that older German adults often used CAM, and they perceived it as an effective complement to traditional medicine, however they did not have enough information about the risks and benefits of CAM. Dedeli and Karadakovan20 found that the majority of elderly individuals preferred herbal products and complementary alternative therapies to get healthy and stay healthy. Jasamai et al.21 stated that there was a correlation between CAM use and attitude toward CAM in elderly individuals, and positive attitude increased CAM use. Similarly, Cohen et al.22 found that CAM use was quite common among older adults. Rojas et al.23 stated that CAM practices were accepted and used by the majority of elderly Koreans with mood disorders. Bell et al.24 found that CAM practices were very common in elderly individuals with hypertension. Many elderly patients with arthritis stated that they resorted to CAM providers and used CAT.25
Results of this study, showed that income status and age were influential on attitude toward CAM use, whereas gender, marital status, educational status, cohabitants, and existing chronic disease were not influential. Sharma et al.26 stated that 59% of individuals in the 60–69 age group and 76% of individuals ≥70 years of age used CAT methods; CAM use in elderly individuals was not significantly affected by gender, education, living in rural or urban areas, and distance from modern healthcare systems; and that CAM was the first treatment option for 65.7% of elderly individuals.
In this study, a positive and statistically significant correlation was found between the total scores of HCAMQ and ARMS. Sackett et al.7 reported that a combination of both nontraditional and traditional medical interventions was used by elderly individuals. Krousel Wood et al.27 reported that a significant proportion of older adults combined the use of CAM with traditional medical care in the management of hypertension. Weizman et al. (2012) stated that the use of complementary and alternative therapy is common in individuals with inflammatory bowel disease, but the use of complementary and alternative medicine is not associated with reduced overall compliance with medical therapy.28
A chart review, conducted of 300 patients, at least 65 years of age, who used at least three medications each, and who attended a university geriatrics clinic in Florida, USA to obtain information about medication adherence and complementary medicine use. However, no association found between use of at least one complementary medicine and adherence to conventional medications.10
While maintaining the medication treatment required by modern medicine, elderly individuals resort to CAT methods for the treatment of their diseases because they think that traditional methods, that are in line with their cultural values and beliefs, can also be effective.
In conclusion, it can be suggested that elderly individuals endeavor to maintain medical therapies for their diseases, and they also have positive attitudes toward complementary and alternative treatments. These positive behaviors of the elderly should be supported. Also elderly individuals should be informed about how to take “complementary and alternative treatments” consciously, in a controlled and correct manner.
AUTHOR DISCLOSURE STATEMENT
No financial support was received by any of the authors for the research of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Prior to the study, Agri Ibrahim Cecen University Ethical Committee Approval was obtained with 19/07/2018-E.27632 document number 051 declared on 06/12/2018.
The authors wish to thank all participants for engaging in this study. The authors are grateful to Duygu Ispinar for proofreading the manuscript.
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- Akkuş Y, Karatay G. Knowledge and behaviovur about drug usage of people aged over 60 and live in Kars. Journal of TUBAV Science. 2011; 4: 214-220.
- Yap AF, Thirumoorthy T, Kwan YH, Medication adherence in the elderly. Journal of Clinical Gerontology & Geriatrics. 2016; 7: 64-67.
- Jin H, Kim Y, Rhie SL. Factors affecting medication adherence in elderly people. Patient Preference and Adherence. 2016; 10: 2117-2125.
- Conn VS, Hafdahl AR, Cooper PS, Ruppar TM, Mehr DR, Russell LC. Interventions to ımprove medication adherence among older adults: meta-analysis of adherence outcomes among randomized controlled trials. The Gerontologist. 2009; 49: 447-462.
- Yılmaz F, Yavuz Çolak M. Evaluation of beliefs about medicines and medaication adherence among elderley people vith chronic diseases. Türkiye Klinikleri J Health Sci. 2018; 3: 113-121.
- Sackett K, Carter M, Stanton M. Elders’ use of folk medicine and complementary and alternative therapies. An ıntegrative review with ımplications for case managers. Professional Case Management. 2014; 19: 113-123.
- Sağkal T, Demiral S, Odabaş H, Altunok E. Kırsal Kesimde Yaşayan Yaşlı Bireylerin Tamamlayıcı ve Alternatif Tedavi Yöntemlerini Kullanma Durumları. Ü.Sağ.Bil.Tıp Derg. 2013; 27(1): 19-26.
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- Paul Cherniack, E. Complementary medicine use is not associated with non-adherence toconventional medication in the elderly: A retrospective study. Complementary Therapies in Clinical Practice. 2011; 17:206-208.
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- Hyland ME, Lewith GT, Westoby C. Developing a measure of attitudes: the holistic complementary and alternative medicine questionnaire. Complementary therapies in medicine. 2003; 11(1): 33-38.
- Erci B. Attitudes towards holistic complementary and alternative medicine: a sample of healthy people in Turkey. J Clin Nurs. 2007; 16: 761-768.
- Kripalani S, Risser J, Gatti M, Jacobson T. Development and evaluation of the adherence to refills and medications scale (ARMS) among low‐literacy patients with chronic disease. Value in Health. 2009; 12: 118-123.
- Gökdoğan F, Kes D. Validity and reliability of the Turkish Adherence to Refills and Medications Scale. International of Nursing Practice. 2017; e12566: 1-7.
- Demirbağ BC, Timur M. The Knowledge, attıtude and behavıor related to usıng drugs reflected by the group of elderly. Ankara Journal of Health Services. 2012; 11: 1-8.
- Sayın Kasar K, Karadakovan A. Elderly ındividuals ınvestigation of antihypertensive drugs use error. Journal of Cardiovascular Nursing. 2017; 8: 20-27.
- Turhan Ö, Kibar E, Ekren E, Engin O, Ercan D, Erdal AI, Ergün E Z, Ertop P, Esen B, Geylan DE, Üner S, Bilir N. Medication adherence in elderly: a universıty hospital-based and descriptive study. Nobel Medicus Journal. 2014; 10: 31-38.
- Schnabel K, Binting S, Witt CM, Michael Teut Use of complementary and alternative medicine by older adults-a cross-sectional survey. BMC Geriatrics. 2014; 14: 2-9.
- Dedeli Ö, Karadakovan A. Investigation of complementary and alternative medicine practice and drug use in the elderly. Spatula DD. 2011; 1: 23-32.
- Jasamai M, Islahudin F, Samsuddin NF. Attitudes towards complementary alternative medicine among Malaysian adults. J App Pharm Sci. 2017; 7: 190-193.
- Cohen RJ, Ek C, Pan CX. Complementary and alternative medicine (CAM) use by older adults: a comparison of self-report and physician chart documentation. Journal of Gerontology: Medical Sciences. 2002; 57: 223-227.
- Rojas BY, Richardson E, Ahn DH. Attitudes among elderly towards complementary and alternative medicine use as a suicide prevention program in Korea: a preliminary study. Journal of Traditional Medicine & Clinical Naturopathy. 2017; 6: 1-6.
- Bell RA, Suerken CK, Grzywacz JG, Lang W. CAM use among older adults age 65 or older with hypertension in the United States: general use and disease treatment. The Journal of Alternative and Complementary Medicine. 2006; 12: 903-909.
- Kaboli PJ, Doebbeling BN, Saag KG, Rosenthal GE. Use of complementary and alternative medicineby older patients with arthritis: a population-based study. Arthritis Care & Research. 2001; 45: 398-403.
- Sharma E, Dubey AK, Malhotra S, Manocha S, Handu S. Use of complementary and alternative medicines in Indian elderly patients. Natl J Physiol Pharm Pharmacol. 2017; 7: 929-934.
- Krousel Wood MA, Muntner P, Joyce CJ, İslam T, Stanley E, Holt EW, Morisky DE, He J, Webber LS. Adverse effects of complementary and alternative medicine use on antihypertensive medication adherence: findings from COSMO. J Am Geriart Soc. 2010; 58: 54-61.
- Weizman AV, Ahn E, Thanabalan R, Leung W, Croitoru K, Silverberg, MS, Hillary Steinhart A, Nguyen GC. Characterisation of complementary and alternative medicine use and its impact on medication adherence in inflammatory bowel disease. Alimentary Pharmacology and Therapeutics. 2012; 35: 342–349.