Evaluation of Adhesion to Pharmacological Treatment in Elderly with Systemic Arterial Hypertension

Systemic arterial hypertension (SAH) is a chronic, asymptomatic and multifactorial disease, characterized by elevated and sustained pressure levels. SAH is the main risk factor for serious cardiovascular complications, such as acute myocardial infarction, chronic renal failure, stroke and heart failure. The objective of this study is to evaluate the adherence to the pharmacological treatment of systemic arterial hypertension in a pharmacy network in a city in the interior of Bahia. This is a descriptive and exploratory quantitative study, performed with 40 elderly patients with systemic arterial hypertension (SAH) in a network pharmacy in Vitória da Conquista, the pharmacy network has three establishments located in different locations in the city, thus covering several carrier profiles. As an instrument for evaluotioning adherence, a structured questionnaire was applied with socioeconomic variables, based on the adherence scales according to the Morisky and Green Test. The prevalence occurred in female representatives, who represented 52.5% of the total sample, the most important age group was among the elderly from 60 to 70 years old, by corresponding to 55% of the 40 hypertensive elderly interviewed, 45% have studied until the current fifth year. In reference to the monthly income of the family group, 65% of the interviewed affirmed that they receive from one to three minimum wages. According to the obtaining of the medicines, 33% of the participants purchase in public pharmacy, 35% in private network and 32% acquires in both parts. The approaching elements demonstrated the importance of implementing health care models that incorporate diverse individual and collective strategies in order to improve the quality of care and adherence to treatment. Keywords— Chronic diseases. Arterial hypertension.


INTRODUCTION
Systemic arterial hypertension (SAH) is a chronic no communicable disease (CDN) of multifactorial origin and is considered a serious public health problem, as it affects many people around the world. It is estimated that a part of the population with arterial hypertension is unaware of its pathology because they are asymptomatic, constituting an important group of risk for other diseases (Araújo et al., 2016; Bonadiman et al., 2012; Gomes et al., 2017).
SAH is the most frequent morbidity in Brazil and is considered a risk factor for the development of serious health complications, such as cardiovascular, cerebrovascular and renal diseases. Approximately 250,000 deaths per year are due to CD in Brazil, about 40% of deaths due to stroke are caused by hypertension, and 25% of deaths due to coronary artery disease are also due to this condition (Lade, Lima, 2014).
The main characteristic of SAH is the elevation of pressure and supporting of pressure values. Currently, established values for hypertension is greater than or equal to 140/90 mmHg for the general population and greater than or equal to 130/80 mmHg for patients who have advanced age associated with cardiovascular risk or underlying disease such as diabetes and chronic kidney disease (Jardim, 2017).
In general, hypertension is asymptomatic, and often its carriers are misdiagnosed or only discover when The elderly are the main carriers of hypertension. This fact can be justified according to the physiological changes of the organism that evidences a decrease in the normal functioning of normal systems, making the patient vulnerable to these chronic dis eases (Medeiros et al., 2014;Campolina et al., 2013, Veras, 2011. Several variables contribute to the development of SAH, such as smoking, alcoholism, stress, family history, obesity, among others (DeVechio et al., 2017). Thus, antihypertensive drugs are used to treat hypertension. The primary objective of this therapy is to reduce the morbidity and mortality of patients who have a high predisposition for CD and other complications resulting from this clinical condition (Corrêaet al., 2005).
Beyond that, no pharmacological treatment should be integral to drug therapy so that the carrier has benefit effects. As a result of this fact, it is of the utmost importance that the patient makes the correct adhesion of the medications to control the blood pressure, in order to avoid possible complications, and the biggest obstacle for health professionals is the lack of blood pressure control (PA) (Freitas, Nielson, Porto, 2015).
The Therapeutic adherence (TA) consists of the commitment and responsibility adopted by the patient in relation to their treatment, established by a qualified health professional. Thus, AT expresses to the carrier the reality and the science of the therapy used to treat its clinical condition. The phenomenon of adhesion comprises several areas that warranty improvements to the health of the patient, such as drug adherence (Rocha et al., 2008).
Therefore, several factors may interfere in TA, among them, the lack acknowledge the patient about the disease and his / her behavior towards drug taking. The difficulty of access to the health system, cost, quantity of drugs and number of daily doses of prescribed medication, besides adverse effects and resistance to treatment, are variables that may impair the course of the treatment established (Freitas; Nielson; Porto 2015).
According to these information, many people carrier with SAH may be resistant to pharmacological treatment and therefore do not adhere to the prescribed therapy. It is estimated that approximately 40 to 60% of patients with this disease do not adhere correctly to therapy. Another essential factor is also important to note that many elderly people are non-adherent, since they have physiological limitations that impede the proper use of the drug (Vancini-Campanharoet al., 2006; Rocha et al., 2008). In this context, the objective of this article is to evaluate adherence to the pharmacological treatment of systemic arterial hypertension in a pharmacy network in a municipality in the interior of Bahia.

II.
MATERIALS AND METHODS This is a descriptive and exploratory quantitative study. The scenario of the study was the city of Vitória da Conquista, that is represented as the third largest city in Bahia. It has a population of 320,129 inhabitants and is a distance of 509 km from Salvador, its capital. The economy of the region is mainly focused on agriculture, livestock and health. And the city as a center of reference in health for more than 70 municipalities (Kochergin; Proietti; César, 2014; Cardoso; Melo; Cesar, 2015). Vitória da Conquista has a local Regional Pharmacy Council (CRF) and according to the information collected by the author, approximately 108 pharmacies are registered. The present research was performed in a pharmacy network that has three establishments located in different locations in the city, thus covering various profiles of carriers. On average, approximately 18,000 people are treated per month in all these three units.
The study population was the elderly carrier with systemic arterial hypertension (SAH) in the city. The classification for the elderly, according to the World Health Organization (WHO), in developing countries focuses on 60 years.
The sample used for developing of the work was configured in 40 elderly people. This number was established according to the flow of the elderly who entered in the pharmacy network between August and October 2018. The elderly included in this research were those ones who were aged 60 years or older and of both sexes, randomly chosen and who are under pharmacological treatment for SAH.
Data collected occurred through a direct interview with the participants. The research instrument was developed based on the work of Elias (2011) that uses adhesion scales according to Moriskt and Green test. The procedure was performed in a reserved place in order to avoid unnecessary exposure of the wearer.
Data obtained were tabulated and organized into spreadsheets, graphs and tables in Microsoft Excel® 2010. Univariate analysis was performed based on absolute frequencies and percentage frequency distribution. In addition, the project was submitted to the Ethics Committee of the Faculdade Independente do Nordeste -FAINOR, and it was authorized through Ordinance no. 2,769,959. The participants involved in the research signed the Informed Consent Term (TCLE). In the sample studied, a higher prevalence was observed in females, that represented 52.5% (n = 21) of the total sample. This data was similar to the one found by Tavares and contributors. (2016), when they evaluated the quality of life and adherence to the pharmacological treatment among hypertensive elderly, so that the predominance was also female.

III. RESULTS AND DISCUSSION
Corroborating with Oliveira et al. (2008), the biological factors and the divergence of exposure to the risk factors of mortality, contribute to this increase be justified in women. David and collaborators (2013) complement this assertion when they approach the climacteric and its consequences in women, especially weight gain and obesity, which are factors that interfere in the emergence of several chronic diseases, such as hypertension.
As to the feminization of old age, it contributes much for obtaining this result, and we can still observe that women are more concerned with health than men, self-care and the search for health services for monitoring, diagnosis and control of certain pathologies, facilitate the identification of SAH in this public (Dias et al., 2019).
In relation to the age group, the highest percentage was in the range of 60 to 70 years, corresponding to 55% (n = 22). The result, however, differed from the study by Aiolfie et al. (2015), since most of the hypertensive elderly present on the study of the authors were older than 71 years (n = 69). The work by Andrade et al. (2014) also had a different result from the present research, and the interval with the highest concentration was between 70 and 79 years (30%). This data may demonstrate that HBP has been increasing by affecting the younger population, requiring medication to control the risk factors associated with the disease.
The relation between the age of the patient and hypertension is quite considerable, since over the years there is a decrease in the integrity of physiolo gical systems and, in contrast, the vascular system is most affected, especially the renin-angiotensin-aldosterone system (RAA), that can suffer a modification and overload the entire organism, by maintaining the systemic blood pressure higher ( In case of physiology, there is still a rigidity in the blood vessels with advancing age, mainly due to the normal dysregulation of the vasodilator and vasoconstricting substances, associated with the genetic factors and the lifestyle of the bearer over the years, which may influence directly into the bloodstream (Barbosa et al., 2016).
Given the above, the physical vulnerability of the elderly and the limitations that arise in this phase of life, interfere directly to the occurrence of chronic diseases. Some examples of these limitations are difficulty for locomotion, the lack of regular physical exercises and the prescription of restricted and specific diets, which can result in a compromising of the quality of life and, consequently, the clinical picture of the individual becomes worse (Campolina; Dini; Ciconelli, 2011).
Concerning to the ethnicity of the interviewees, 57.5% (n = 23) they declared themselves to be of a brown color. However, Massa and collaborators (2016), when they analyze hypertensive elderly in their research, they found a predominance of black skin color. Although this relative difference had been found, the miscegenation is a strong coefficient in Brazil. Thus, self-reported brown individuals are influenced by black skin color, because they are result of mixed breed (Iser, et al., 2015).
Therefore, the work of Serra et al. (2015), this category can be divided into whites and nonwhites (in which it covers brown and black individuals). According to Tavares et al. (2018), THE black race is a risk factor for the development of hypertension and it elucidate the high mortality rates in black individuals who have some cardiovascular disease, in comparison with populations of other races, for example.
Religion was another variable evaluated and the finding was extremely relevant, in which 70% (n = 28) of the elderly say they are Catholic. According to Abdala and contributors. (2015); Silva et al. (2016), older people tend to be more religious as they are compared with individuals of different age groups, by adding that religion provides greater benefits to the quality of life, since this public shows to be more active in religious activities and keep remains the optimistic in relation to the treatment and illness, through prayers.
In relation to schooling, 45% (n = 18) of the 40 hypertensive elderly interviewed studied until the current ATUAL fifth year (formerly known as primary, from the first to fourth grade of primary education). Similar results were found in the work of Aiolfi et al. (2015), in what they evaluated adherence to the medication use among elderly hypertensive patients and they found that the majority of the studied researched population (76%) had low educational level, with some degree of instruction.
The  It was also evaluated the place of residence of the elderly participants, and it identified that 95% (n = 38) reside LIVE in Vitória da Conquista, Bahia. This variant is important, since it can directly impact IN the adherence to the treatment of the patients, since the no displacement of the patient to acquire treatment in another place reflects in its comfort and quality of life (Rêgo et al., 2018).
The subsequent variable was the marital status of the elderly interviewed, and the most frequent data was concentrated around the elderly who were married or lived with a partner with a score of 57.5% (n = 23). Accompanied by the marital situation, it was possible to analyze four other aspects that are complementary to this question: where he/she lives, with whom he/she lives, how many people live in his/her residence, the monthly income of the family group and occupation, which are shown in table 1. In agreement with Muniz and collaborators (2017) it is indispensable that the elderly live with their relatives, because this experience helps, mainly, in the adherence of drug therapy. Warneret al. (2015) supplement this statement as they present a study about aging in Germany and they point out that the social and family support network contributes positively to the quality of the elderly life, especially in mental, by reducing symptoms of anxiety and depression, for example.
In reference to monthly income of the family group, 65% (n = 26) of the interviewed stated that they receive from one to three minimum wages. Santos and Ferreira (2018) and Dias, Souza and Mishima (2016) presented a reality similar to the finding, as they report that the hypertensive elderly in their respective jobs are supported by up to two minimum wages.
Retirement wasthe most marked occupation among the interviewed 65% (n = 26). Similar to the work done by Dias et al. (2015) thatalsoobserved that the elderly hypertensive retired, represent a large part of the sample number used in their research, BY corresponding to 88.46% (n = 23). The income based on retirement provides to the elderly a better adherence to pharmacological treatment, because he can go to the private sector and buys the drug prescribed. While 33% of the elderly (n = 13) warranty the medicines through the public service. The result was directly similar to thatone found in the work of Alvese Ceballos (2018), that obtained a larger number of elderly hypertensive patients, who acquired drugs in the private sector.
The great obstacle that the elderly who buy medicines in the public sector can face is the complexity of the service and the lack of obtaining the medication, that impedes the therapeutic adherence and, consequently, the stability and improvement of the clinical condition The regarding information to the lifestyle of the bearer and habits adopted by them are shown in Table 2. These ones can be configured as modifiable risk factors for the progression of hypertension and possible development of other diseases of the cardiovascular system.

International Journal of Advanced Engineering Research and Science (IJAERS)
[ Vol-6, Issue-5, May-2019]  https://dx.doi.org/10.22161/ijaers.6.5.81  ISSN: 2349-6495(P) | 2456-1908(O) About smoking, 95% (n = 38) of the interviewees do not use tobacco, and 5% (n = 2) use tobacco. These data reveal that most of the elderly individuals interviewed do not use cigarettes or have ever done it in the past. Costa et al. (2007) verified that people who have already smoke have a higher prevalence of hypertension. Girottoet al. (2013), reports that the reduction of alcohol consumption and smoking cessation should be part of the management of the arterial hypertension.
As they evaluate the use of alcoholic beverages, 90% (n = 36) reported that they do not drink, and only 10% (n = 4) use alcoholic drinks. Result similar to those ones of Ramos et al. (2015) that 91.6% said they do not use beverages. It is verified that in this research a very low number of elderly people who consume alcoholic beverages, however the use of the drink can influence the adherence to the drug treatment.
According to the results found, half of the participants, 50% (n = 20) practice some type of physical activity. HAVE showed that most of the elderly have not practiced physical activities. According to Bonadimanet al. (2012) physical activities in general, practiced in a regular way, with lasting from 30 to 45 minutes, with a frequency from three to five sessions per week, have excellent efficacy as an adjunct to antihypertensive treatment. In view of this, it is essential the relation of interventions of the health team to raise awareness and clarify the importance of physical activity in antihypertensive treatment.
In relation to diet, 80% (n = 32) of the patients interviewed refer to follow diet. According to Freire (2016), THE excessive consumption of fats, salt and sedentarism are practices that favor the emergence of hypertension. Therefore, because that, an adequate diet, combined with physical activity, is able to delay the appearance of hypertension. According to Bonadimanet al. (2012) THE obesity is one of the main causes for the development of hypertension, as there is a high prevalence of patients with obesity, since this factor may be related to non-adherence to the antihypertensive treatment. The Morisky and Green test evaluates the adherence to the drug treatment. In this test the answer "Yes" for at least one of the questions means nonadherence, the "No" answer for all the questions means adherence to the treatment. The test can still be used to describe the degree of adherence to the treatment, by classifying as high degree of adherence those people who had all the test answers negative, and with low degree of adherence those ones who had at least one affirmative answer. The delanterones can still be classified as to their behavior that can be intentional or unintentional, or both, as shown in Table 3.
It is noteworthy that in the study 70% (n = 28) administer adequately the drug. In the study, 35% (n = 14) of the participants HAVE reported that they neglected to take the medication, and 65% (n = 26)took the medication at the correct time. Ramos et al., (2015), in their study, 47% of the interviewees forgot to administer the drug, and 54.4% neglect about the time of administering the drug.
The main factors that interfere with adherence to the treatment are sex, old age, health beliefs, life habits, cultural aspects, difficulty to buy the medication, side effects, inadequate orientation of the professional, difficulty in administering the medication, this way a very important aspect for the treatment of SAH is the correct use of medicines (Ramos et al., 2015).

International Journal of Advanced Engineering Research and Science (IJAERS)
[ Regarding failing to take their medication when they feel better, 85% (n = 34) of the interview reported that they do not interrupt their treatment, and 90% (n = 36) do not stop administering the drug even when they felt ill. A similar result was proposed by Ramos et al. (2015). Meanwhile Bonadimanet al. (2012), report in THEIR study that patients discontinue the treatment because they do not feel anything and only return to us e the medication when SOME symptoms reappear.
However, the results presented indicate that 55% (n = 22) of the patients in the study were classified as adherent to the drug treatment, that is, they answered "NO" to all the questions present in the Morisky and Green test. In contrast, 45% (n = 18) of the interviewed answered at least one affirmative question and thus, according to the Morisky and Green test, they have a low degree of adherence. There is also a greater index of "YES" answers in questions one and two of the test, regarding forgetting to take medication and carelessness with the schedule.
Result that differ from that of Ramos et al. (2015), indicate that the majority of the participants (67.3%) were classified as not adherent to the drug treatment. In another study by Dosseet al. (2009) with hypertensive patients who have participated in the Morisky-Green test, has showed that 86.93% of the patients have presented no adherence to the drug treatment.
It is important to draft the factors that may lead to this low adherence to the drug treatment, from the socioeconomic characteristics to the lifestyle of the patient. The majority of the elderly have a polypharmacy, and have a tendency forenoon adherence to the pharmacological treatment.
Most of the participants are over 12 years old with a diagnosis of hypertension, BY representing 37.5% of the sample. In this study, 95% of the participants have no difficulty in administering the medication, that means a positive aspect. Cintra et al. (2010) show that THE elderly patients consume several drugs daily, and may cause errors in their administration.in relation to the undesired symptom in administering the medicament, only 10% reported this discomfort, data similar to that one of Lima et al. (2010). Pharmacovigilance (2008) suggests that unwanted drug symptoms are any unfavorable occurrence or unintended effect while the patient is using the drug.
When evaluated the patients classified with low adherence degree, they may be classified as unintentional, intentional or low adherence with both adherences. Among the 18 patients classified as low adherence, 22.5% (n = 9) presented low unintended adherence, by indicating standards of forgetfulness or carelessness with the time of taking the medication, and 7.5% (n = 3) presented low intentional adherence, in which the patient decides to stop using the medication when he / she feels well, or when he / she feels bad about the use, it is emphasized that in 15% (n = 6) of the cases are classified as low adherence in both types. It is worth noting that 50% (n = 20) of the participants said that "blood pressure always influences", and 27.5% (n = 11) "almost never" have this custom, a result different from that of Lima et al ., (2010), where 84% said they worry about gauging pressure regularly. This way, it is a worrying fact, since because the only way of knowing that there is an effective control of blood pressure is through gauging it , because it is a silent illness and does not usually present signs and symptoms.
In the variable "other diseases" in addition to HAS HBP, 47.5% (n = 19), most the individuals reported by having other health problems. The high level of comorbidity in the elderly population may contribute to poor adherence to the medication treatment of SAH. Freitas et al., (2015) point out that the association of hypertension with other health problems is one of the nonadherence factors.
It should be pointed out that individuals with diseases associated with hypertension suggest the need of taking other medications, which may intensify the side effects and drug interaction, by presenting greater difficulty in acquiring all medications and difficulties in taking care of the dose schedules (Ramos et al., 2015).
The most commonly used drug that was reported by elderly patients was Losartan with 72.5%, followed by Metformin with 27.5%, and Simvastatin and Hydrochlorothiazide with 22.5%. It is noticed that the patient uses on a large-scale Metformin, a medicine used to treat diabetes mellitus type 2, so that the arterial hypertension is most often accompanied with diabetes mellitus. This result is different from the tone found by Lima et al., (2010), and by being that the most used drug was Captopril 34%, followed by Hydrochlorothiazide 29% and Methyldopa 13%. Therefore, this drug treatment is adequate according to the V Brazilian Guidelines for Hypertension.

IV.
FINAL CONSIDERATIONS Arterial hypertension is one of the major public health problems in Brazil and all over the world, with a high prevalence on the Brazilian adult population, especially the elderly. However, it is necessary to monitor all variables related to adherence to the treatment, in order to ensure the effectiveness and efficiency of health care services. By regarding about the pharmacological treatment, it can be affirmed that among the factors that interfere in adherence to the treatment are the symptomatology of the disease and the amount of medication administered daily.
It is able to be emphasized that it is important that the professional advises the ir patients by regarding to the factors involved in abandoning of the treatment or by not complying with therapeutic recommendations. Therefore, it is necessary to plan health promotion activities and disease prevention activities by considering the profile of the elderly hypertensive , such as walking, work gymnastics, educational activities to raise awareness the patient about their illness and the importance of complying with appropriate medical treatment. Beyond that, consultations and home visits should be organized and scheduled.