INVESTIGATION OF THE RELATIONSHIP BETWEEN FRAILTY AND DEPENDENCY IN INDIVIDUALS LIVING IN A NURSING HOME
Year 2024,
Volume: 7 Issue: 1, 29 - 41, 29.05.2024
Hamide Şişman
,
Dudu Alptekin
,
Emir İbrahim Işık
,
Hilal Işık
Abstract
The fragility that occurs with aging increases the risk of dependency. This study was conducted to determine the level of fragility in elderly individuals. The descriptive and cross-sectional study was conducted with 68 elderly people staying in nursing homes between 15.10.2019 and 30.02.2020. Data were collected through face-to-face interviews by the researcher using the Introductory Information Form, Edmonton Frail Scale and Barthel Index. 69.1% of the participants were female and the mean age was 77±10. The number of elderly with severe frailty was 22 (32.4%), and the number of those who were completely dependent was 23 (33.8%), and a statistically significant relationship was found between them (X2=19.55, p=0.00). The incidence of frailty was high in the elderly living in nursing homes. In parallel with the incidence of fragility, dependency levels were also found to be high. It is recommended to evaluate the elderly in terms of fragility in order to reduce their dependency levels.
References
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- Aygor, H. (2013). Investigation of the Validity and Reliability of the Edmonton Frail Scale for Turkish Society [Master's Thesis]. Izmir: Ege University, 1-283. oai:acikerisim.ege.edu.tr:11454/7071.
- Bahrmann, A., Benner, L., Christ, M., Bertsch, T., Sieber, C. C., Katus, H., Bahrmann, P. (2019). The Charlson Comorbidity and Barthel Index predict length of hospital stay, mortality, cardiovascular mortality and rehospitalization in unselected older patients admitted to the emergency department. Aging Clinical and Experimental Research, 31, 1233-1242. https://doi.org/10.1007/s40520-018-1067-x
- Basic, D., and Shanley, C. (2015). Frailty in an older inpatient population: using the clinical frailty scale to predict patient outcomes. Journal of aging and health, 27(4), 670-685. https://doi.org/10.1177/0898264314558202
- Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., Rockwood, K. (2013). Frailty in elderly people. The lancet, 381(9868), 752-762. https://doi.org/10.1016/S0140-6736(12)62167-9
- Chen, C. Y., Gan, P., How, C. H. (2018). Approach to frailty in the elderly in primary care and the community. Singapore medical journal, 59(5), 240–245. https://doi.org/10.11622/smedj.2018052.
- Çilesiz, N., and Behdioğlu, S. (2023). Evaluation of Service Quality with Structural Equality Modeling: The Case of Nursing Home-Nursing Home Elderly Care and Rehabilitation Center. Dumlupınar University Journal of İibf, (10), 82-95. https://dergipark.org.tr/tr/pub/dpuiibf/issue/74200/1208815
- Collard, R. M., Boter, H., Schoevers, R. A., Oude Voshaar, R. C. (2012). Prevalence of frailty in community‐dwelling older persons: a systematic review. Journal of the american geriatrics society, 60(8), 1487-1492. https://doi.org/10.1111/j.1532-5415.2012.04054.x
- Elbi, H., and Özyurt, B. C., (2021). Prevalence of Fragility and Factors Affecting Fragility in Individuals 65 Years and Older. pp.9-17. 9-17. https://www.smyrnatipdergisi.com/dosyalar_upload/belgeler/K%C4%B1r%C4%B1lganl%C4%B1k.pdf
- Göçer, S., and Günay, O. (2018). Daily living activities and depression symptom levels of older people living in a nursing home in Kayseri. Euras Journal Fam Med, 7(3), 116-124. https://search.trdizin.gov.tr/yayin/detay/311167/
- Gökçe, S., Boyraz, S., Adana, F., Demirkıran, F., Kiraz, E. D. E., Aktaş, B., Özvurnaz S., Yıldırım, B. (2020). Living Conditions and Health Conditions of the Elderly Ages 75 and Over. Journal of Public Health Nursing, 2(3), 168-183. https://dergipark.org.tr/en/pub/jphn/issue/58585/799497
- Karen Bandeen-Roche, Christopher L. Seplaki, Jin Huang, Brian Buta, Rita R. Kalyani, Ravi Varadhan, Qian-Li Xue, Jeremy D. Walston, Judith D. Kasper (2015). Frailty in older adults: a nationally representative profile in the United States. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 70(11), 1427-1434. https://doi.org/10.1093/gerona/glv133
- Küçükdeveci, A. A., Yavuzer, G., Tennant, A., Süldür, N., Sonel, B., Arasil, T. (2000). Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scandinavian journal of rehabilitation medicine, 32(2), 87-92. PMID: 10853723
- Kojima, G. (2015). Prevalence of frailty in nursing homes: a systematic review and meta-analysis. Journal of the American Medical Directors Association, 16(11), 940-945. https://doi.org/10.1016/j.jamda.2015.06.025
- Lally, F., Crome, P. (2007). Understanding frailty. Postgraduate medical journal, 83(975), 16-20. http://dx.doi.org/10.1136/pgmj.2006.048587
- Mahoney, F. I., and Barthel, D. W. (1965). Functional evaluation: the Barthel Index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill. Maryland state medical journal, 14:61-65 PMID: 14258950
- Mello, J. L. C., Souza, D. M. T., Tamaki, C. M., Galhardo, V. A. C., Veiga, D. F., Ramos, A. C. B. (2018). Application of an Effective Methodology for Analysis of Fragility and Its Components inthe Elderly. In Information Technology-New Generations: 15th International Conference on Information Technology (pp. 735-739). Springer International Publishing. https://doi.org/10.1007/978-3-319-77028-4_95
- Morley, J. E., Vellas, B., Van Kan, G. A., Anker, S. D., Bauer, J. M., Bernabei, R., Cesari M., Chumlea W.C., Doehner W., Evans J., Fried L. P., Guralnik J. M., Katz P. R., Malmstom T. K., McCarter R. J., Rockwood K., Haehling S.V., Vandewoude M. F., Walston, J. (2013). Frailty consensus: a call to action. Journal of the American Medical Directors Association, 14(6), 392-397. (2013). "Frailty consensus: a call to action." Journal of the American Medical Directors
- Mortazavi, H., Tabatabaeichehr, M., Taherpour, M., Masoumi, M. (2020). Investigating the Status of Daily Life Activities (Basic, Instrumental, Advanced) and Related Factors in the Elderly. Journal of North Khorasan University of Medical Sciences, 12(2), 88-95. URL: http://journal.nkums.ac.ir/article-1-2095-en.html
- Mutlay, F., and Seydi, K. A. (2021). The Relationship Between Frailty and Anemia in Older Adults. Journal of Geriatric Sciences, 4(3), 78-83. https://doi.org/10.47141/geriatrik.1033806
- Rockwood, K., Mitnitski, A., Song, X., Steen, B., Skoog, I. (2006). Long‐term risks of death and institutionalization of elderly people in relation to deficit accumulation at age 70. Journal of the American Geriatrics Society, 54(6), 975-979. https://doi.org/10.1111/j.1532-5415.2006.00738.x
- Rolfson, D. B., Majumdar, S. R., Tsuyuki, R. T., Tahir, A., Rockwood, K. (2006). Validity and reliability of the Edmonton Frail Scale. Age and ageing, 35(5), 526-529. https://doi.org/10.1093/ageing/afl041
- Schoon, Y., Bongers, K., Van Kempen, J., Melis, R., and Olde Rikkert, M. (2014). Gait speed as a test for monitoring frailty in community-dwelling older people has the highest diagnostic value compared to step length and chair rise time. Eur J Phys Rehabil Med, 50(6), 693-701. http://ghdl.handle.net/2066/182826
- Shamliyan, T., Talley, K. M., Ramakrishnan, R., Kane, R. L. (2013). Association of frailty with survival: a systematic literature review. Ageing research reviews, 12(2), 719-736. https://doi.org/10.1016/j.arr.2012.03.001
- Strandberg, T. E., and Pitkälä, K. H. (2007). Frailty in elderly people. The Lancet, 369(9570), 1328-1329. DOI: 10.1016/S0140-6736(07)60613-8
- Pınar, R., and Sert, H. (2009). Hov should the Turkey's national elderly care policy be?[sic]. Turkish Journal of Research and Development in Nursing, 11(2);46-55. https://dergipark.org.tr/en/pub/hemarge/issue/52704/695059
- Porcel-Gálvez, A. M., Barrientos-Trigo, S., Fernández-García, E., Allande-Cussó, R., Quiñoz-Gallardo, M. D., Morales-Asencio, J. M. (2020). Development and external validity of a short-form version of the INICIARE scale to classify nursing care dependency level in acute hospitals. International Journal of Environmental Research and Public Health, 17(22), 8511. DOI: 10.1016/j.enfcli.2020.05.004
- Somrongthong, R., Wongchalee, S., Ramakrishnan, C., Hongthong, D., Yodmai, K., Wongtongkam, N. (2017). Influence of Socioeconomic Factors on Daily Life Activities and Quality of Life of Thai Elderly. Journal of public health research, 6(1);49-55. https://doi.org/10.4081/jphr.2017.862
- OECD, Fertility Rates (indicator). Accesed Date: 18.10.2022. Accessed Address: https://data.oecd.org/ pop/fertility-rates.htm.
- Özdemir, S., Öztürk, Z. A., Turkbeyler, I. H., Şirin, F., Mehmet, G. (2017). Determination of the prevalence of frailty in geriatric patients using different scales. Journal of Kahramanmaraş Sütçü İmam University Faculty of Medicine, 12(3);1-5. https://doi.org/10.17517/ksutfd.338266
- Tavassoli, N., Guyonnet, S., Abellan Van Kan, G., Sourdet, S., Krams, T., Soto, M. E., ... & “Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of disability” Team. (2014). Description of 1,108 older patients referred by their physician to the “Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability” at the gerontopole. The journal of nutrition, health & aging, 18, 457-464. https://doi.org/10.1007/s12603-014-0462-z
- Turner, G., Clegg, A. (2014). Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age and ageing, 43(6), 744-747. https://doi.org/10.1093/ageing/afu138
- TUIK. (2019). Türkiye Population Projections, 2080. Accesed Date: 16.10.2022. Accessed Address: https://tuikweb.tuik.gov.tr/PreTablo.do?alt_id=1027
- Uchmanowicz, I., Lisiak, M., Wontor, R., Łoboz-Grudzień, K. (2015). Frailty in patients with acute coronary syndrome: comparison between tools for comprehensive geriatric assessment and the Tilburg Frailty Indicator. Clinical interventions in aging, 521-529. doi: 10.2147/CIA.S78365
- Van Kan, G. A., Rolland, Y., Bergman, H., Morley, J. E., Kritchevsky, S. B., Vellas, B., Geriatric Advisory Panel. (2008). The IANA Task Force on frailty assessment of older people in clinical practice. The Journal of Nutrition Health and Aging, 12, 29-37. https://doi.org/10.1007/BF02982161
- Xue, Q. L. (2011). The frailty syndrome: definition and natural history. Clinics in geriatric medicine, 27(1), 1-15. DOI:https://doi.org/10.1016/j.cger.2010.08.009
- Yazıcı, S. O., Kalaycı, I. (2015). Evaluatıon Of Daıly Lıvıng Actıvıtıes Of Elderly Patıents. Journal of Engineering Sciences and Design, 3(3), 385-390. https://dergipark.org.tr/en/pub/jesd/issue/20874/224054
- Yönt, G. H. (2023). Review of the Literature on Care Dependency in Chronic Diseases. Journal of Izmir Katip Celebi University Faculty of Health Sciences, 8(2), 575-578. https://dergipark.org.tr/en/pub/ikcusbfd/issue/78150/1167050
HUZUREVİNDE YAŞAYAN BİREYLERİN KIRILGANLIK DÜZEYLERİNİN İNCELENMESİ
Year 2024,
Volume: 7 Issue: 1, 29 - 41, 29.05.2024
Hamide Şişman
,
Dudu Alptekin
,
Emir İbrahim Işık
,
Hilal Işık
Abstract
Yaşlanmayla birlikte ortaya çıkan kırılganlık bağımlılık riskini artırmaktadır. Bu çalışma yaşlı bireylerde kırılganlık düzeyini belirlemek amacıyla yapılmıştır. Tanımlayıcı ve kesitsel nitelikteki çalışma, 15.10.2019-30.02.2020 tarihleri arasında huzurevinde kalan 68 yaşlı ile gerçekleştirildi. Veriler araştırmacı tarafından Tanıtıcı Bilgi Formu, Edmonton Savunmasızlık Ölçeği ve Barthel İndeksi kullanılarak yüz yüze görüşmeler yoluyla toplanmıştır. Katılımcıların %69,1'i kadındı ve yaş ortalaması 77±10 idi. İleri derecede kırılganlığı olan yaşlı sayısı 22 (%32,4), tamamen bağımlı olan yaşlı sayısı ise 23 (%33,8) olup aralarında istatistiksel olarak anlamlı ilişki bulunmuştur (X2=19,55, p=0,00). Huzurevinde yaşayan yaşlılarda kırılganlık görülme sıklığı yüksekti. Kırılganlığın görülme sıklığına paralel olarak bağımlılık düzeyleri de yüksek bulunmuştur. Yaşlıların bağımlılık düzeylerinin azaltılması için kırılganlık açısından değerlendirilmesi önerilmektedir
References
- Aras, S., Varli, M., Atli, T. (2011). Understanding frailty in old age. Journal of Academic Geriatrics, 3, 130-137. www.akadgeriatri.org/managete/fu_folder/.../2011-3-3-130-137.html
- Aygor, H. (2013). Investigation of the Validity and Reliability of the Edmonton Frail Scale for Turkish Society [Master's Thesis]. Izmir: Ege University, 1-283. oai:acikerisim.ege.edu.tr:11454/7071.
- Bahrmann, A., Benner, L., Christ, M., Bertsch, T., Sieber, C. C., Katus, H., Bahrmann, P. (2019). The Charlson Comorbidity and Barthel Index predict length of hospital stay, mortality, cardiovascular mortality and rehospitalization in unselected older patients admitted to the emergency department. Aging Clinical and Experimental Research, 31, 1233-1242. https://doi.org/10.1007/s40520-018-1067-x
- Basic, D., and Shanley, C. (2015). Frailty in an older inpatient population: using the clinical frailty scale to predict patient outcomes. Journal of aging and health, 27(4), 670-685. https://doi.org/10.1177/0898264314558202
- Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., Rockwood, K. (2013). Frailty in elderly people. The lancet, 381(9868), 752-762. https://doi.org/10.1016/S0140-6736(12)62167-9
- Chen, C. Y., Gan, P., How, C. H. (2018). Approach to frailty in the elderly in primary care and the community. Singapore medical journal, 59(5), 240–245. https://doi.org/10.11622/smedj.2018052.
- Çilesiz, N., and Behdioğlu, S. (2023). Evaluation of Service Quality with Structural Equality Modeling: The Case of Nursing Home-Nursing Home Elderly Care and Rehabilitation Center. Dumlupınar University Journal of İibf, (10), 82-95. https://dergipark.org.tr/tr/pub/dpuiibf/issue/74200/1208815
- Collard, R. M., Boter, H., Schoevers, R. A., Oude Voshaar, R. C. (2012). Prevalence of frailty in community‐dwelling older persons: a systematic review. Journal of the american geriatrics society, 60(8), 1487-1492. https://doi.org/10.1111/j.1532-5415.2012.04054.x
- Elbi, H., and Özyurt, B. C., (2021). Prevalence of Fragility and Factors Affecting Fragility in Individuals 65 Years and Older. pp.9-17. 9-17. https://www.smyrnatipdergisi.com/dosyalar_upload/belgeler/K%C4%B1r%C4%B1lganl%C4%B1k.pdf
- Göçer, S., and Günay, O. (2018). Daily living activities and depression symptom levels of older people living in a nursing home in Kayseri. Euras Journal Fam Med, 7(3), 116-124. https://search.trdizin.gov.tr/yayin/detay/311167/
- Gökçe, S., Boyraz, S., Adana, F., Demirkıran, F., Kiraz, E. D. E., Aktaş, B., Özvurnaz S., Yıldırım, B. (2020). Living Conditions and Health Conditions of the Elderly Ages 75 and Over. Journal of Public Health Nursing, 2(3), 168-183. https://dergipark.org.tr/en/pub/jphn/issue/58585/799497
- Karen Bandeen-Roche, Christopher L. Seplaki, Jin Huang, Brian Buta, Rita R. Kalyani, Ravi Varadhan, Qian-Li Xue, Jeremy D. Walston, Judith D. Kasper (2015). Frailty in older adults: a nationally representative profile in the United States. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 70(11), 1427-1434. https://doi.org/10.1093/gerona/glv133
- Küçükdeveci, A. A., Yavuzer, G., Tennant, A., Süldür, N., Sonel, B., Arasil, T. (2000). Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey. Scandinavian journal of rehabilitation medicine, 32(2), 87-92. PMID: 10853723
- Kojima, G. (2015). Prevalence of frailty in nursing homes: a systematic review and meta-analysis. Journal of the American Medical Directors Association, 16(11), 940-945. https://doi.org/10.1016/j.jamda.2015.06.025
- Lally, F., Crome, P. (2007). Understanding frailty. Postgraduate medical journal, 83(975), 16-20. http://dx.doi.org/10.1136/pgmj.2006.048587
- Mahoney, F. I., and Barthel, D. W. (1965). Functional evaluation: the Barthel Index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill. Maryland state medical journal, 14:61-65 PMID: 14258950
- Mello, J. L. C., Souza, D. M. T., Tamaki, C. M., Galhardo, V. A. C., Veiga, D. F., Ramos, A. C. B. (2018). Application of an Effective Methodology for Analysis of Fragility and Its Components inthe Elderly. In Information Technology-New Generations: 15th International Conference on Information Technology (pp. 735-739). Springer International Publishing. https://doi.org/10.1007/978-3-319-77028-4_95
- Morley, J. E., Vellas, B., Van Kan, G. A., Anker, S. D., Bauer, J. M., Bernabei, R., Cesari M., Chumlea W.C., Doehner W., Evans J., Fried L. P., Guralnik J. M., Katz P. R., Malmstom T. K., McCarter R. J., Rockwood K., Haehling S.V., Vandewoude M. F., Walston, J. (2013). Frailty consensus: a call to action. Journal of the American Medical Directors Association, 14(6), 392-397. (2013). "Frailty consensus: a call to action." Journal of the American Medical Directors
- Mortazavi, H., Tabatabaeichehr, M., Taherpour, M., Masoumi, M. (2020). Investigating the Status of Daily Life Activities (Basic, Instrumental, Advanced) and Related Factors in the Elderly. Journal of North Khorasan University of Medical Sciences, 12(2), 88-95. URL: http://journal.nkums.ac.ir/article-1-2095-en.html
- Mutlay, F., and Seydi, K. A. (2021). The Relationship Between Frailty and Anemia in Older Adults. Journal of Geriatric Sciences, 4(3), 78-83. https://doi.org/10.47141/geriatrik.1033806
- Rockwood, K., Mitnitski, A., Song, X., Steen, B., Skoog, I. (2006). Long‐term risks of death and institutionalization of elderly people in relation to deficit accumulation at age 70. Journal of the American Geriatrics Society, 54(6), 975-979. https://doi.org/10.1111/j.1532-5415.2006.00738.x
- Rolfson, D. B., Majumdar, S. R., Tsuyuki, R. T., Tahir, A., Rockwood, K. (2006). Validity and reliability of the Edmonton Frail Scale. Age and ageing, 35(5), 526-529. https://doi.org/10.1093/ageing/afl041
- Schoon, Y., Bongers, K., Van Kempen, J., Melis, R., and Olde Rikkert, M. (2014). Gait speed as a test for monitoring frailty in community-dwelling older people has the highest diagnostic value compared to step length and chair rise time. Eur J Phys Rehabil Med, 50(6), 693-701. http://ghdl.handle.net/2066/182826
- Shamliyan, T., Talley, K. M., Ramakrishnan, R., Kane, R. L. (2013). Association of frailty with survival: a systematic literature review. Ageing research reviews, 12(2), 719-736. https://doi.org/10.1016/j.arr.2012.03.001
- Strandberg, T. E., and Pitkälä, K. H. (2007). Frailty in elderly people. The Lancet, 369(9570), 1328-1329. DOI: 10.1016/S0140-6736(07)60613-8
- Pınar, R., and Sert, H. (2009). Hov should the Turkey's national elderly care policy be?[sic]. Turkish Journal of Research and Development in Nursing, 11(2);46-55. https://dergipark.org.tr/en/pub/hemarge/issue/52704/695059
- Porcel-Gálvez, A. M., Barrientos-Trigo, S., Fernández-García, E., Allande-Cussó, R., Quiñoz-Gallardo, M. D., Morales-Asencio, J. M. (2020). Development and external validity of a short-form version of the INICIARE scale to classify nursing care dependency level in acute hospitals. International Journal of Environmental Research and Public Health, 17(22), 8511. DOI: 10.1016/j.enfcli.2020.05.004
- Somrongthong, R., Wongchalee, S., Ramakrishnan, C., Hongthong, D., Yodmai, K., Wongtongkam, N. (2017). Influence of Socioeconomic Factors on Daily Life Activities and Quality of Life of Thai Elderly. Journal of public health research, 6(1);49-55. https://doi.org/10.4081/jphr.2017.862
- OECD, Fertility Rates (indicator). Accesed Date: 18.10.2022. Accessed Address: https://data.oecd.org/ pop/fertility-rates.htm.
- Özdemir, S., Öztürk, Z. A., Turkbeyler, I. H., Şirin, F., Mehmet, G. (2017). Determination of the prevalence of frailty in geriatric patients using different scales. Journal of Kahramanmaraş Sütçü İmam University Faculty of Medicine, 12(3);1-5. https://doi.org/10.17517/ksutfd.338266
- Tavassoli, N., Guyonnet, S., Abellan Van Kan, G., Sourdet, S., Krams, T., Soto, M. E., ... & “Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of disability” Team. (2014). Description of 1,108 older patients referred by their physician to the “Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability” at the gerontopole. The journal of nutrition, health & aging, 18, 457-464. https://doi.org/10.1007/s12603-014-0462-z
- Turner, G., Clegg, A. (2014). Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age and ageing, 43(6), 744-747. https://doi.org/10.1093/ageing/afu138
- TUIK. (2019). Türkiye Population Projections, 2080. Accesed Date: 16.10.2022. Accessed Address: https://tuikweb.tuik.gov.tr/PreTablo.do?alt_id=1027
- Uchmanowicz, I., Lisiak, M., Wontor, R., Łoboz-Grudzień, K. (2015). Frailty in patients with acute coronary syndrome: comparison between tools for comprehensive geriatric assessment and the Tilburg Frailty Indicator. Clinical interventions in aging, 521-529. doi: 10.2147/CIA.S78365
- Van Kan, G. A., Rolland, Y., Bergman, H., Morley, J. E., Kritchevsky, S. B., Vellas, B., Geriatric Advisory Panel. (2008). The IANA Task Force on frailty assessment of older people in clinical practice. The Journal of Nutrition Health and Aging, 12, 29-37. https://doi.org/10.1007/BF02982161
- Xue, Q. L. (2011). The frailty syndrome: definition and natural history. Clinics in geriatric medicine, 27(1), 1-15. DOI:https://doi.org/10.1016/j.cger.2010.08.009
- Yazıcı, S. O., Kalaycı, I. (2015). Evaluatıon Of Daıly Lıvıng Actıvıtıes Of Elderly Patıents. Journal of Engineering Sciences and Design, 3(3), 385-390. https://dergipark.org.tr/en/pub/jesd/issue/20874/224054
- Yönt, G. H. (2023). Review of the Literature on Care Dependency in Chronic Diseases. Journal of Izmir Katip Celebi University Faculty of Health Sciences, 8(2), 575-578. https://dergipark.org.tr/en/pub/ikcusbfd/issue/78150/1167050