Abstract

This study aimed to investigate factors associated with the treatment adherence of 150 elderly diabetics assisted in gerontogeriatric outpatient service in northeastern Brazil. Full adherence to therapy was self-reported by 27.3% of the elderly. In the bivariate analysis, adherence was associated with self-perceived health, beliefs in the use of medication, understanding explanations about diabetes and professional responsible for treatment guidance. After analysis adjustment, only beliefs in medicine were significant when comparing non-adherence with full adherence (OR = 9.65; CI95% 1.6; 56.6) and non-adherence with partial adherence (OR = 18.15; CI95% 3.5;95.4). It can be concluded that full adherence to diabetes treatment is low and is associated with beliefs in medications for disease control. It is necessary to develop additional studies to better define the role of health beliefs and practices of care among elderly assisted in primary health care.

Adherence to treatment; Elderly; Diabetes Mellitus; Primary health care

Introduction

Diabetes in the elderly is associated with higher rates of premature death, functional disability and coexisting diseases, such as hypertension, coronary disease and stroke. In addition, it contributes to the so-called geriatric syndromes characterized by polypharmacy, cognitive dysfunction, urinary incontinence, falls and persistent pain¹1. American Diabetes Association. Guidelines Source: Standards of Medical Care in Diabetes – 2016. Diabetes Care 2016; 39(Supl. 1):S1-S112.^,22. Mooradian A, Chehade JM. Diabetes Mellitus in Older Adults. Am J Ther 2012; 19(2):145-159..

For metabolic control and prevention of complications of diabetes, a self-care routine involving the use of medication and the adoption of healthy lifestyle habits (balanced diet, regular practice of physical activity, moderate alcohol use and smoking cessation)¹1. American Diabetes Association. Guidelines Source: Standards of Medical Care in Diabetes – 2016. Diabetes Care 2016; 39(Supl. 1):S1-S112.^,33. Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: MS; 2013.. However, behavioral changes are challenging for the diabetic elderly and health services, resulting in non-adherence in more than 80% of individuals with the disease and predisposing to the occurrence of disabilities that negatively affect their quality of life⁴4. Pupko VB, Azzollini S. Actitudes, afrontamiento y autocuidado en pacientes con diabetes tipo 2. Rev Argent Salud Pública 2012; 3(10):15-23..

Adherence is a multidimensional phenomenon⁵5. World Health Organization (WHO). Adherence to long-term therapies: evidence for action. Geneva: WHO; 2003. and, according to Leite and Vasconcelos⁶6. Leite SN, Vasconcellos MPC. Adesão à terapêutica medicamentosa: elementos para a discussão de conceitos e pressupostos adotados na literatura. Cien Saude Colet 2003; 8(3):775-782., it corresponds to the agreement between medical prescription and patient’s own conduct. However, many factors contribute to the lack of adherence among the elderly, such as access to medication, disease and treatment characteristics, social support, professional health-patient relationship, old age, low purchasing power, illiteracy, depression, anxiety, denial or fear of illness, and health-related beliefs⁷7. Almeida HO, Versiani ER, Dias AR, Novaes MRCG, Trindade EMV. Adesão a tratamentos entre idosos. Com Ciências Saúde 2007; 18(1):57-67..

Given the variety and complexity of factors that contribute to non-adherence to treatment, the professional responsible for treatment must implement an individualized approach that considers the singularities of each situation⁷7. Almeida HO, Versiani ER, Dias AR, Novaes MRCG, Trindade EMV. Adesão a tratamentos entre idosos. Com Ciências Saúde 2007; 18(1):57-67.^,88. Tanqueiro MTOS. A gestão do autocuidado nos idosos com diabetes: revisão sistemática da literatura. Rev Enf Ref 2013; serIII(9);151-160.. Thus, studies that identify the prevalence of adherence to different treatment modalities for glycemic control and associated factors are important to guide individual and collective health care actions to the older segment of society. In this context, this study sought to investigate the factors associated with therapeutic adherence in diabetic elderly patients attended in primary health care.

Methods

This is an observational-sectional study developed at the Elderly Care Center (NAI) of the Federal University of Pernambuco (UFPE), a gerontogeriatric service of an outpatient nature. The convenient sample consisted of 244 elderly diabetic patients of both genders, who entered the service from January 2006 to December 2010. Impaired communication and/or cognition recorded in the medical records, elderly individuals with mobility difficulty or impossibility due to muscle weakness, joint problems, pain or neurological conditions that restricted access to the outpatient clinic were adopted as exclusion criteria.

Losses recorded because of death (15), refusal to participate in the study (21) and incorrect record of address and/or telephone number in the medical records (58) contributed to the final sample composition of 150 diabetic elderly.

Data was collected from February to September 2011 through a structured script with closed-ended questions. Interviews were conducted by physiotherapy and nursing students trained to apply the tool and evaluated and recycled throughout the survey period.

The dependent variable corresponded to the referred therapeutic adherence, which corroborates with the Guidelines for the Treatment and Follow-up of Diabetes Mellitus⁹9. Sociedade Brasileira de Diabetes (SBD). Diretrizes da Sociedade Brasileira de Diabetes 2007 - Tratamento e acompanhamento do diabetes mellitus. Rio de Janeiro: SBD; 2007.. In this study, full adherence corresponded to the positive response in questions related to the use of medications (oral hypoglycemic agents and/or insulin) according to medical prescription (except those with no medication prescribed for diabetes), regular aerobic and/or resistance exercise, minimum frequency of three times a week and minimum duration of 30 minutes per session or 150 continuous minutes/week, according to recommendations of the Brazilian Society of Diabetes Guidelines⁹9. Sociedade Brasileira de Diabetes (SBD). Diretrizes da Sociedade Brasileira de Diabetes 2007 - Tratamento e acompanhamento do diabetes mellitus. Rio de Janeiro: SBD; 2007. and food intake control. Regarding elderly who reported not having medication prescribed for diabetes, full adherence was considered regarding the regular practice of physical activity and food intake control. Partial adherence was defined by a positive answer in one of the questions (medication use, regular physical activity and dietary control) and non-adherence defined by negative answers in all three questions.

The independent variables selected for analysis were sociodemographic characteristics (gender, age, schooling, marital status, family arrangement, social security situation, monthly income of the elderly, contribution to the household); health conditions and treatment-related factors (self-perceived health, diabetes diagnosis time, time of treatment, medications prescribed by the physician used for diabetes, means of medication acquisition, side effects, perceived daily use of medicines, use of antidiabetic teas instead of medicines); perception of disease (knowledge about the disease, types of treatment - categorized into none, basic [medication or diet or exercise], moderate [medication and diet or medication and exercise or diet and physical exercise], advanced [medication, diet and physical activity], perception of the occurrence of complications, beliefs in the use of medication, diet follow-up and practice of physical activity to control the disease, beliefs in the measurement of glycemic level and changes in life routine with treatment); social support (social support assessed through the Family’s APGAR¹⁰10. Brasil. Ministério da Saúde (MS). Envelhecimento e saúde da pessoa idosa. Brasília: MS; 2006., whose denomination represents an acronym in English, derived from the following realms: Adaptation, Partnership, Growth, Affection and Resolve, professional relationship/health-patient team investigated through trust in the doctor and in the multi-professional team, understanding explanations about diabetes, clarifying treatment issues at the time of consultation, professional responsible for the guidelines on treatment and participation in educational groups for diabetes).

Statistical Package for Social Sciences (SPSS) for Windows, version 17.0 was used to analyze data. The association between independent variables and therapeutic adherence was examined through bivariate analysis using Pearson’s Chi-square of independence test or Fisher’s exact test, the latter when the results did not meet the requirements for the first test, both with a significance level of 5% and 95% confidence intervals.

In the multivariate analysis, the multinomial regression model was used with the inclusion of all variables with p<0.20 and the variables with p < 0.05 remained in the final model. The results were interpreted in terms of odds ratio and respective confidence intervals (CI), calculated for each statistically significant variable (p < 0.05).

The research protocol was approved by the Ethics and Research Committee of the Health Sciences Center of the Federal University of Pernambuco. Respondents signed or fingerprinted the Informed Consent Form, which explained the research objectives and information requested, ensuring confidentiality of the information obtained.

Results

Of the 150 diabetic elderly interviewed, 73.3% were female, 54.7% were in the 60-69 years age group and only 10.6% were over 80 years old. We verified that 51.3% lived with a partner and 60% with spouse and relatives. With regard to schooling, 58.7% had up to 8 years of schooling. We found that 73.3% were retired, 52.7% received from 1-2 minimum wages and 66% contributed totally to the household’s livelihood (Table 1).

Analyzing the aforementioned adherence, we observed that 78.7% used regular medications for diabetes, followed by 16% who had no indication for medication. Only 38.7% practiced regular physical activity and 60% followed nutritional recommendations prescribed by a physician or nutritionist. When evaluating the therapeutic follow-up of the diabetic elderly, partial adherence was predominant (66.7% of the participants), followed by 27.3% of full-time adherents and 6% of non-adherents (Table 1).

In the bivariate analysis, the variables associated with therapeutic adherence were self-perceived health (p = 0.038), beliefs in the use of medicines to control diabetes (p = 0.001), understanding explanations about diabetes (p = 0.005) treatment guidelines (p = 0.028) (Tables 2, 3 and 4).

In the multinomial analysis, variable “Belief in medication to control diabetes” was significant when comparing non-adherence with full adherence (OR = 9.65, 95%CI 1.6;56.6) and non-adherence with partial adherence (OR = 18.15, 95%CI 3.5;95.4) in the final model adjustment. Thus, elderly diabetics who take and believe that medications control diabetes are 9.65 times more likely to achieve full adherence to treatment when compared to the elderly who do not use medications and do not adhere to treatment. In contrast, elderly diabetics who take and believe that medications control the disease are 18.15 times more likely to achieve partial adherence to treatment when compared to elderly who do not adhere. The likelihood ratio test was significant (p = 0.003), indicating that the proposed model could be used (Table 5).

Discussion

Full adherence to diabetes therapy was low among the diabetic elderly interviewed. A similar result was also observed in a study conducted with people with type 2 diabetes in southeastern Brazil¹¹11. Faria HTG, Rodrigues FFL, Zanetti ML, Araújo MFM, Damasceno MMC. Fatores associados à adesão ao tratamento de pacientes com diabetes mellitus. Acta Paul Enferm 2013; 26(3):231-237. and in the urban and rural areas of the seven states of the Mexican Republic¹²12. Hernandez-Romieu AC, Elnecave-Olaiz A, Huerta-Uribe N, Reynoso-Noveron N. Análisis de una encuesta poblacional para determinar los factores asociados al control de la diabetes mellitus en México. Salud Pública Méx 2011; 53(1):34-39..

Although prevalent, adherence to medication therapy was below the recommended level of 80%⁶6. Leite SN, Vasconcellos MPC. Adesão à terapêutica medicamentosa: elementos para a discussão de conceitos e pressupostos adotados na literatura. Cien Saude Colet 2003; 8(3):775-782.. A systematic review highlights that the low follow-up of drug therapy in the elderly is due to complex drug regimens, coupled with lack of understanding, forgetfulness, decreased visual acuity and manual dexterity¹³13. Gellad WF, Grenard JL, Marcum ZA. A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity. Am J Geriatr Pharmacother 2011; 9(1):11-23.. Similar results were also found in the city of Bagé/RS, where low adherence was associated with age, lack of health plan, purchase of medications, use of more than three medications and instrumental incapacity for daily life¹⁴14. Tavares NUL, Bertoldi AD, Thumé E, Facchini LA, França GVA, Mengue SS. Fatores associados à baixa adesão ao tratamento medicamentoso em idosos. Rev Saude Publica 2013; 47(6):1092-1101..

The regular practice of physical activity and nutritional follow-up were also not adequate. Lifestyle change is part of the treatment for chronic diseases, but habits are social behaviors culturally constructed throughout life, wrapped in symbolic aspects that materialize the tradition in the form of rites and taboos, which are difficult to modify.

Franchi et al.¹⁵15. Franchi KMB, Monteiro LZ, Medeiros AIA, Almeida SB, Pinheiro MHNP, Montenegro RM, Montenegro Júnior RM. Estudo comparativo do conhecimento e prática de atividade física de idosos diabéticos tipo 2 e não diabéticos. Rev Bras Geriatr Gerontol 2008; 11(3):327-339. compared the practice of physical activity in 88 diabetic and non-diabetic elderly subjects and observed that approximately half of the participants of both groups did not practice any physical activity, data that corroborate with that found in this study. Several barriers contribute to physical inactivity among the elderly, with emphasis on health problems and family commitments¹⁶16. Souza DL, Vendrusculo R. Fatores determinantes para a continuidade da participação de idosos em programas de atividade física: a experiência dos participantes do projeto “Sem Fronteiras”. Rev Bras Educ Fís Esporte 2010; 24(1):95-105.. However, it is known that the progressive reduction of physical fitness and muscular strength contributes to the loss of autonomy and functional capacity in this phase of life, making it preventable by regular practice of physical activity¹⁷17. Maciel MG. Atividade física e funcionalidade do idoso. Motriz 2010; 16(4):1024-1032.. Thus, it is necessary to adopt public programs to encourage the practice of physical activity, which consider community spaces, the possibilities and limitations of the elderly to the type of exercise, and clarifications about the contributions of physical activity to the biopsychosocial health of the elderly¹⁶16. Souza DL, Vendrusculo R. Fatores determinantes para a continuidade da participação de idosos em programas de atividade física: a experiência dos participantes do projeto “Sem Fronteiras”. Rev Bras Educ Fís Esporte 2010; 24(1):95-105.^,1818. Knuth AG, Bielemann RM, Silva SG, Borges TT, Duca GFD, Kremer MM, Hallal PC, Rombaldi AJ, Azevedo MR. Conhecimento de adultos sobre o papel da atividade física na prevenção e tratamento de diabetes e hipertensão: estudo de base populacional no Sul do Brasil. Cad Saude Publica 2009; 25(3):513-520..

Besides the practice of physical activity, the follow-up of a food plan is extremely important for glycemic control¹1. American Diabetes Association. Guidelines Source: Standards of Medical Care in Diabetes – 2016. Diabetes Care 2016; 39(Supl. 1):S1-S112.^,33. Brasil. Ministério da Saúde (MS). Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: MS; 2013.. In the evaluation of nutritional follow-up in diabetes, Broadbent et al.¹⁹19. Broadbent E, Donkin L, Stroh JC. Illness and treatment perceptions are associated with adherence to medications, diet, and exercise in diabetic patients. Diabetes Care 2011; 34(2):338-340. identified that adherence was associated with a lower occurrence of complications, greater personal control and treatment, fewer symptoms and emotional disorders. Thus, dietary and therapeutic guidelines must be individualized based on preferences, culture, traditions and metabolic goals, with emphasis on healthy food choices²⁰20. Evert AB, Boucher JL, Cypress M, Dunbar SA, Franz MJ, Mayer-Davis EJ, Neumiller JJ, Nwankwo R, Verdi CL, Urbanski P, Yancy Júnior WS. Nutrition Therapy Recommendations for the Management of Adults with Diabetes. Diabetes Care 2014; 37(Supl. 1):S120-143..

Current self-perceived health was associated with therapeutic adherence in this investigation, in agreement with a study carried out in southeastern Brazil²¹21. avares DMS, Drumond FR, Pereira GA. Condições de saúde de idosos com diabetes no município de Uberaba, Minas Gerais. Texto Contexto Enferm 2008; 17(2):342-349.. This variable represents the way individuals see their state and understand their illness, which is a mortality risk marker. According to Fonseca et al.²²22. Fonseca MGUP, Firmo JOA, Loyola Filho AI, Uchoa E. Papel da autonomia na auto-avaliação da saúde do idoso. Rev Saude Publica 2010; 44(1);159-165. in defining health as good or reasonable, the elderly are not characterized as a disease-free person, but as an autonomous subject capable of acting on the environment. In this study, the elderly who self-perceive their health as fair perform a greater routine of care with the disease in relation to those who self-assess it as bad. A similar result was also found by Luz et al.²³23. Luz TCB, Loyola Filho AI, Lima-Costa MF. Perceptions of social capital and cost-related non-adherence to medication among the elderly. Cad Saude Publica 2011; 27(2):269-276. when identifying that the prevalence of non-adherence was associated with poorer self-perceived health.

The information received and the understanding of the explanations about diabetes influence the behavior of individuals when deciding whether to follow the prescribed therapy for diabetes²⁴24. Mann DM, Ponieman D, Leventhal H, Halm EA. Predictors of adherence to diabetes medications: the role of disease and medication beliefs. J Behav Med 2009; 32(3):278-284.. The lack of knowledge about the disease and the inadequate training and integration of health professionals are associated with non-adherence to treatment, and it is necessary to incorporate new technologies in the health services in order to equip and motivate individuals with diabetes to change their behavior²⁵25. Costa JA, Balga RSM, Alfenas RCG, Cotta RMM. Promoção da saúde e diabetes: discutindo a adesão e a motivação de indivíduos diabéticos participantes de programas de saúde. Cien Saude Colet 2011; 16(3):2001-2009..

The physician was the professional responsible for the diabetes treatment guidelines through individual consultations, but partial adherence was predominant among the respondents. Leite and Vasconcelos⁶6. Leite SN, Vasconcellos MPC. Adesão à terapêutica medicamentosa: elementos para a discussão de conceitos e pressupostos adotados na literatura. Cien Saude Colet 2003; 8(3):775-782. affirm that adherence to treatment is not determined exclusively by the physician’s power to make the client follow the prescription. However, certain prescriber’s attitudes, such as language, time taken for consultation, respect for questions and motivation for therapy compliance may interfere with adherence. However, in this study, we did not evaluate how health professionals transmitted information to the elderly, which is one of the limiting factors.

The belief of the elderly about the use of the medication to control diabetes showed a positive association in both the bivariate and multivariate models, corroborating with the results found by other authors⁵5. World Health Organization (WHO). Adherence to long-term therapies: evidence for action. Geneva: WHO; 2003.^,77. Almeida HO, Versiani ER, Dias AR, Novaes MRCG, Trindade EMV. Adesão a tratamentos entre idosos. Com Ciências Saúde 2007; 18(1):57-67.. Drug adherence to glycemic control involves behavioral, normative and control beliefs that must be considered while evaluating behavioral determinants²⁶26. Jannuzzi FF, Rodrigues RCM, Cornélio ME, São-João TM, Gallani MCBJ. Crenças relacionadas à adesão ao tratamento com antidiabéticos orais segundo a Teoria do Comportamento Planejado. Rev Latino-Am Enfermagem 2014; 22(4):529-537..

A cohort study conducted with type 2 diabetic subjects in the city of Boston, USA, concluded that the belief in medications to improve symptoms and protect health in the future was associated with higher drug adherence rates when compared to those who did not believe²⁷27. Grant RW, Devita NG, Singer DE, Meigs JB. Polypharmacy and medication adherence in patients with type 2 diabetes. Diabetes Care 2003; 26(5):1408-1412.. Thus, the importance of considering the concepts, convictions and attitudes of the elderly related to health and care practices is highlighted.

Limitations of the study were use of a structured script, subject to distortions and bias of the interviewer; adherence analysis performed only from the viewpoint of the elderly diabetics’ report regarding prescribed therapy, which differs from other studies that evaluated adherence through glycemic control¹²12. Hernandez-Romieu AC, Elnecave-Olaiz A, Huerta-Uribe N, Reynoso-Noveron N. Análisis de una encuesta poblacional para determinar los factores asociados al control de la diabetes mellitus en México. Salud Pública Méx 2011; 53(1):34-39.^,1515. Franchi KMB, Monteiro LZ, Medeiros AIA, Almeida SB, Pinheiro MHNP, Montenegro RM, Montenegro Júnior RM. Estudo comparativo do conhecimento e prática de atividade física de idosos diabéticos tipo 2 e não diabéticos. Rev Bras Geriatr Gerontol 2008; 11(3):327-339.; using the odds ratio association measure, considering that cross-sectional studies use the prevalence ratio, but the measurement of adherence under the three aspects (full, partial and non-adherence) was only possible using the multinomial model, opting to work with odds ratio despite the risk of overestimation; a shortage of international and national studies related to adherence of diabetic elderly people under the three aspects studied, hampering comparison with other findings related to this segment, which proved the need for other studies on this subject with the older public.

Findings point to the need for actions that encourage behavioral change towards the adoption of healthy lifestyles and the development of additional studies to better define the role of health beliefs and care practices in this population. In addition, it is inferred that the design of educational practices with active methodologies based on reflection and respect for the autonomy and individuality of the elderly diabetics facilitates the promotion of self-care activities for glycemic control.

References

Publication Dates

History