ORIGINAL RESEARCH

Quality of life and factors associated with the health of elderly diabetics

Eliane Leite de Sousa^I; Marino Medeiros Martins^II; Milena Silva Costa^III; Maria Rosilene Cândido Moreira ^IV; Antonia Oliveira Silva^V

^I Nurse. PhD in Nursing from the Federal University of Paraíba. Brazil. E-mail: elianeleitesousa@yahoo.com.br
^II Nurse. Valuation Program for Primary Care. Cajazeiras, Paraíba, Brazil. E-mail: marinomedeiros@hotmail.com
^III Nurse. PhD in Nursing from the Federal University of Paraíba. Professor at the Federal University of Cariri. Juazeiro do Norte, Ceará. Brazil. E-mail: milenascosta2011@hotmail.com
^IV Nurse. PhD in Biotechnology. Professor at the Federal University of Cariri. Juazeiro do Norte, Ceará. Brazil E-mail: rosilenecmoreira@gmail.com
^V Nurse. PhD. Associate Professor at the Federal University of Paraíba. Coordinator of the Nursing Graduate Program. João Pessoa, Paraíba. Brazil. E-mail: alfaleda@hotmail.com

ABSTRACT

Objective : to evaluate the quality of life of elderly people affected by type 2 diabetes mellitus and to identify the associated factors. Methods: this descriptive, cross-sectional study involved 68 elderly diabetics from Cajazeiras, Paraíba State, in 2012, and was approved by the Research Ethics Committee of Campina Grande Federal University (N 20111410-045). Data were analyzed statistically using IBM SPSS 19.0 software. Results: diabetes has significant impact on the lives of younger elderly females with less education and more recent diagnosis. Of the domains studied, pain scored worst, followed by social aspects and general health. Domains with higher values were: mental health, emotional aspects, vitality, physical aspects and functional capacity. Conclusion: although most study participants displayed good quality of life, diabetes entails specificities that vary from individual, characterizing the phenomenon as singular.

Keywords : Quality of Life; Primary Health Care; Type 2 Diabetes; Seniors.

INTRODUCTION

In the last decades, with the epidemiological transition, there has been a significant change in the mortality profile of the Brazilian population, mainly due to the concomitant decline of infectious diseases and increase in chronic-degenerative diseases. The increased longevity of the population associated with lifestyle modifications has significantly contributed to the increase in the occurrence of these diseases, which are responsible for a large number of deaths worldwide ¹. Such a change is a challenge for the health authorities, especially for the implementation of new models and methods for coping with the problem.

Type 2 diabetes mellitus (T2DM) is one of the most common diseases in the classification of chronic-degenerative diseases, whose treatment and control require changes in behavior regarding diet, medication intake and lifestyle. These alterations may compromise the quality of life when there is no adequate orientation regarding the treatment or recognition of the importance of the complications resulting from this pathology^2,3.

Given that chronic diseases significantly affect the health of the elderly, leading to financial, emotional and social impairment, among others, quality of life in elderly people with T2DM is impaired as a result of the disease. The number of pathological conditions associated with Diabetes Mellitus (DM) shows a negative correlation with functional capacity, physical fitness, pain, general health status, vitality and mental health status⁴.

In this context, understanding how the aging process with diabetes occurs, as well as its influence on quality of life (QoL), may contribute to a greater attention to the health of the elderly, enabling health professionals to implement interventions in order to promote the quality of life and well-being of those who grow older.

Thus, the present study aimed to evaluate the QoL of elderly people affected by T2DM and to identify the associated factors in the elderly monitored by the professionals of the family health strategy (FHS) in the city of Cajazeiras, State of Paraíba.

LITERATURE REVIEW

The incidence of DM has increased worldwide. In Brazil, currently, it is estimated that 11% of the population aged 40 years or more have a diagnosis of this pathology, with a tendency to increase, as the age group increases. Thus, there is an increase in the DM mortality coefficient as the age progresses⁴.

The elevation of DM in the elderly can have several causes, among them, the relation of the aging process with the glucose metabolism. Research has shown insulin degradation, as well as the decrease in the removal rate, in the course of the aging process⁵. Hyperglycemia and the main manifestation of the disease cause damage to various organs and body systems, especially the heart, eyes, kidneys and nervous system. Dyslipidemia, often associated with other clinical conditions, may trigger cardiovascular problems such as hypertension, atherosclerosis, angina and myocardial infarction, factors that influence the physical, psychological and social functioning of the individual, impairing their adaptation and productive life⁵.

There has been a high growth in the number of cases of T2DM worldwide. In 1985, it was estimated that there were 30 million people with diabetes. By 1995, this number had already exceeded 150 million. According to statistics from the International Diabetes Federation (IDF), the number is now over 250 million. If no effective prevention approach is taken, the IDF estimates that the total number of people with diabetes will reach 380 million by 2025 ⁴.

Changes in life habits, such as diet and physical activity, regular drug therapy, insulin therapy and glycemic monitoring, are crucial for an adequate response to treatment, but are not always easily understood by the population. Moreover, lack of knowledge about this disease, added to the deficiency of the structure of the public health system for comprehensive and multidisciplinary care directed to these patients, contributes to the increase of the epidemiological indices ^{1, 2}.

Also in this respect, it can be noted that the more associated diseases the diabetic elderly presents, the worse their quality of life is, since the number of chronic diseases associated is an important determinant of the health pattern. Campaigns that seek e early diagnosis, as well as free offer of medications and a rigorous follow-up of the treatment for several chronic diseases that afflict the elderly population, are of fundamental importance for a better quality of life in this population⁶.

METHODOLOGY

This is a descriptive and cross-sectional study, with a quantitative approach, carried out in the municipality of Cajazeiras, State of Paraíba.

The study population consisted of all elderly patients with T2DM monitored by the family health teams of the municipality (962 seniors). This amount was adopted because this is the number of people with diabetes accompanied by FHS teams in the year 2011.

Considering also a population-based study (domiciliary survey) conducted by the Ministry of Health on risk behaviors and referred morbidity of noncommunicable diseases, the prevalence of 5% of diabetes was adopted in the sample calculation (based on the percentages verified in Brazil - 5.2%, and in the city of João Pessoa-PB - 5.3%). Thus, for the sample composition, a sample error of 5% and a 95% confidence interval was considered, resulting in a total of 68 subjects.

Participants were chosen by dividing the total number of subjects to be investigated by the number of family health teams located in the urban area of the municipality (68 ÷ 11 = 6.18 = 6 seniors/family health team), who were selected from the prior consultation of the hypertensive and diabetic follow-up card in the Hypertension and Diabetes Monitoring System (SIS-HiperDia), in which the first six names were chosen.

Data collection was performed from October to December 2012, through the application of an instrument for recording sociodemographic variables and another instrument to evaluate the quality of life, namely the Brazilian version of the Medical Outcomes Study 36-Item Short Form Health Survey (SF -36)⁷.

The SF-36 is a generic instrument for evaluating health-related quality of life (HRQoL) composed of 11 questions and 36 items in eight domains: functional capacity (10 items), physical aspects (four items), pain (two items), general health status (five items), vitality (four items), social aspects (two items), emotional aspects (three items) and mental health (five items). For each domain, the value ranges from 0 to 100, with zero being the worst and 100 being the best health status⁸. In this study, the coefficient of internal consistency (Cronbach's alpha) was 0.85. ⁷

The subjects of the study were informed about the objectives of the research, the guarantee of anonymity, the confidentiality of the data obtained and the absence of damages, as well as the right to withdraw at any time or to refuse participating, without any damages whatsoever. After the explanations, those who agreed to participate signed the free and informed consent, in compliance with that established by Resolution No. 466/2012 of the Ministry of Health⁸.

In order to facilitate the understanding and avoid possible limitations of the participants in relation to not being able to read and/or write, the questionnaires were marked by the researcher, after the appropriate authorization of the respondent as to the item that should be marked.

The data were statistically analyzed through the IBM SPSS 19.0 software, by obtaining absolute, relative frequencies and measures of central tendency (mean and standard deviation). Correlations between SF-36 domain scores were obtained by using the Pearson's coefficient. The project was forwarded for approval and approved by the Research Ethics Committee of the Federal University of Campina Grande - UFCG, Alcides Carneiro University Hospital - HUAC, with protocol No. 20111410-045.

RESULTS AND DISCUSSION

Socio-demographic characteristics of the elderly

A total of 68 diabetic elderly patients were selected based on the follow-up lists of the basic health units. Of these, 75% were female, with ages varying between 60 and 85 years (mean of 68.84; SD ± 6.57).

Still in relation to age, there was a predominance of the age group of 60 to 64 years, in which 34% of the cases were found, followed by the age group of 70 and 74 years (20%). These results suggest that the elderly of this age group may be the ones that most participate in health promotion actions through the adoption of regular measures for the improvement of global health, therefore, being oriented to carry out their examinations and, thus, they reach an early diagnosis.

In this sense, in relation to actions for self-care, health professionals have an essential role in the control of this disease and other comorbidities, given its complications strictly linked to knowledge for adequate daily personal care and healthy lifestyle. The elderly individual, in particular, needs to be encouraged by health professionals to maintain an independent life, seeking to adapt to the changes required by diabetes ⁹.

Regarding schooling, the results showed that 60.3% of the interviewees had only primary education. The survey also showed a considerable rate of illiteracy (32.4%). These findings are higher than those presented by the Primary Care Department (DAB in Portuguese) of the Ministry of Health, through the use of the Chronic Disease Surveillance by Telephone Inquiry (VIGITEL), in which 14.7% of respondents with medical diagnosis of DM in the State of Paraíba in the year 2009 reported having between 0 and 8 years of study^2,4. In contrast, the data from the present study differ from another survey conducted in Uberaba - MG, which found 63.7% of semi-illiterate or illiterate elderly people¹⁰.

Clinical features

The time of diagnosis of diabetes ranged from 1 to 20 years (mean of 6.62; SD ± 4.3 years). The highest prevalence was present in those with a diagnosis time of 5 to 9 years (37%). These data confirm that, in the Brazilian population, a significant number of patients with this pathology is unaware of the diagnosis, which is usually performed only in the presence of complications resulting from the disease. These complications are classified as acute and chronic, such as nephropathy, with possible evolution to renal insufficiency; retinopathy, with the possibility of blindness; neuropathy; appearance of foot ulcers, with evolution to amputations; Charcot's arthropathy; and manifestations of autonomic dysfunction, including sexual dysfunction and impotence ^11,12.

In this context, prevention measures become significant strategies to reduce morbidity and mortality caused by this disease. Rigorous metabolic control and relatively simple preventive and curative measures are able to prevent or delay the onset of chronic complications of DM, resulting in a better quality of life for the diabetic individual.

The use of insulin among diabetic elderly was another aspect investigated in this study. The results showed that a total of 23.5% of the interviewees used insulin, as shown in Figure 1. This is concerning, since diabetes has an evolutionary character and, over the years, almost all patients start to require pharmacological treatment, especially insulin therapy, since beta cells of the pancreas tend to progress to a state of partial or total failure². In addition, these elderly people may be self-administering insulin inadequately, thus requiring the guidance of health professionals and of family members.

FIGURE 1: Distribution of the interviewees regarding the use of insulin. Cajazeiras, Paraíba, 2012. (N = 68)

Health-related quality of life

Quality of life assessment is something that has become important in the last decades. And in order to evaluate the quality of life of the elderly population, scholars have implemented several measuring instruments of biological, psychological and socio-structural nature, classified as generic or specific instruments¹³.

In this study, the SF-36 questionnaire was used to analyze health-related quality of life in general. The SF-36 was translated, adapted and validated for the Brazilian culture. It has 36 items and 8 dimensions, and was used to evaluate the quality of life of both the general population and of the elderly people through negative (illness or injury) and positive health aspects (well-being) of individuals⁷. The dimensions were measured and their respective scores were presented through means and standard deviation, evidencing the general quality of life pattern of the researched diabetic seniors.

In the analysis of the different domains, the greatest impairments (lower scores and averages) occurred in the domains pain, general health status and social aspects, considering the averages less than 50 points.

When evaluating the domain pain, composed of two items, there was an average score of 26.76 (SD ± 20.77), which evidences this condition as the one that most influences the quality of life of the investigated seniors. However, some participants reported that, even with pain, they did not fail to maintain a social life, denoting the relevance of this practice in the life of the human being.

It is worth mentioning that the perception of pain occurs in a unique way for each individual, and it can be considered as a product of past experiences of pain, of values, cultural and emotional expectations, being linked both to physiological and psychological aspects¹¹. It should be noted, however, that pain is among the main limiting factors of the elderly's ability to maintain their daily activities, negatively impacting their quality of life, as well as restricting social life in some situations, leading them to social isolation¹².

The domain general health status, composed of five items, evaluates the elderly's perception of their health. The items that measured such aspect obtained low averages, which resulted in the final mean of 40.81 (SD ± 18.26), thus demonstrating a negative perception of the individuals in relation to their health. This impairment can be attributed to the multiplicity of health problems that affect the elderly, especially chronic conditions, such as arterial hypertension, DM, cardiovascular problems, rheumatic conditions, osteoporosis and others that need, besides financial resources for acquisition of medications and examinations, acceptance and adherence to treatment to control the disease and, consequently, to improve the impact on the quality of life¹⁴.

However, we can mention that the presented results can also be considered positive, and can mean the understanding that a good general health status occurs when the complications due to DM have not yet appeared.

The domain social aspects, composed of two items, analyzes the participation of individuals in social groups and the impairment of this participation due to health problems and identified that, although diabetes has a smaller impact in this dimension, whose average was 42.46 (SD ± 17.96), this result may indicate the difficulty that the elderly person has in adapting to the new requirements imposed by the DM. The results of this research diverge from a study carried out with elderly diabetics enrolled in the FHS of Independência, in the city of Montes Claros, MG, where the domain social aspects presented the highest score of all domains evaluated ¹⁵.

Since the QoL of the elderly depends on the balance between their limitations and potentialities in different degrees of efficiency, with losses that are characteristic of the aging process, the social relations of this individual are a fundamental aspect in this context, and may impair their quality of life. In this regard, and considering that DM imposes new life habits, such as differentiated diet and use of medications, which may lead to difficulties or constraints on the elderly person in exposing their condition, the elderly person can withdraw from activities of the community, reaffirming the influence of DM in their quality of life ¹⁶.

The other SF-36 domains, specifically, mental health, vitality, functional capacity, emotional aspects and physical aspects presented scores above 50, being considered positive for participants' quality of life.

Regarding mental health, the mean was 74.76 (SD ± 18.77). In this case, the presence of anxiety, depression, behavior change and psychological well-being were evaluated. In this aspect, one of the factors that suggest the decrease of the mental domain health, with consequent influence on the quality of life of the elderly with DM, is the progressive cognitive decline, including decline of frontal motor executive function, psychomotor speed, attention, abstract reasoning and decreased ability of visual and verbal memory¹⁷.

In this study, the domain vitality presented an average of 67.50 (SD ± 20.45). This domain is related to daily activities. Thus, when a given population affirms that they feel less vigorous, all their activities will be affected, because the person feels fatigue and discouragement to carry out their activities of daily living¹⁵.

The domain functional capacity presented a mean of 61.18 (SD ± 25.95). It assesses the presence of physical limitations and their influence on the quality of life of individuals. When analyzing the averages of these items, it was observed that the elderly people presented considerable difficulty only in performing activities that require great physical effort. However, aging is understood as a continuous process characterized by the progressive decline of all physiological processes, and it is expected that functional capacity and physical aspects will be reduced, highlighting physical inactivity, mainly, as responsible for contributing to this process¹.

In the domain emotional aspects, the mean obtained was 71.57 (SD ± 42.43). In this perspective, the changes in feelings and attitudes are evaluated, as well as how these changes interfere in the daily activities of the elderly individuals. In this regard, it is important to emphasize that the participants presented many emotional problems, such as anxiety, depression and require a more specific and lasting approach by specialized professionals.

The domain physical aspect presented an average of 66.18 (SD ± 44.63). It assesses the limitations in the form and quantity of work and how these limitations interfere in the daily activities of the patients. This domain shows variation according to the age group, proving to be an important investment target in the evaluation and promotion of health of elderly individuals¹⁵.

Self-assessment of health changes

The SF-36 also has an evaluation item on the elderly's perception regarding their own health condition a year ago. This item, although not used to score any of the aforementioned domains, is important to know and evaluate how the elderly perceive themselves in relation to their current and past (a year ago) health status, and this aspect is also investigated in this study.

In this topic, 32.4% of participants answered that their health was a little worse. This finding may be related to the domains pain, general health status and social aspects. However, 25% of the elderly answered they felt a little better now than a year ago, which may be related to the high scores obtained in the domains functional capacity, physical aspects, emotional aspects, vitality and mental health.

These findings confirm that more subjective aspects, such as those that emphasize independence to perform activities of daily living and those that increase self-esteem and promote general well-being, express the necessary conditions for the improvement of the QoL of the elderly person with diabetes, even though giving attention to their sociability and their pain control is important.

CONCLUSIONS

Living with DM is complex and does not present linearity. It is a process that interacts dynamically with several facets of daily living, influencing and being influenced by numerous relationships. It evidences a dynamic living with multiple possibilities, but one can move towards the maintenance or conquest of life with quality.

This study provided knowledge about the most negative dimensions caused by diabetes, thus enabling the planning of health promotion and prevention actions aimed at the elderly with DM, with a view to healthier choices in their daily life and improvement of QoL.

The present study also allowed the discovery of some relevant points regarding the meaning of QoL for elderly patients with T2DM. Through the analysis, it was evident that QoL is mainly related to pain, general health status and social integration.

From another perspective, this study presents limitations regarding the investigation of QoL of the elderly with diabetes undergoing follow-up in the FHS. One of them is the non-participation of health professionals involved and caregivers, whose interventions could contribute to a better understanding of this phenomenon, highlighting the relational dimensions between health personnel, caregivers and the person being cared.

Therefore, knowing the QoL of individuals with diabetes means a unique moment of understanding and points to the importance of planning and implementing governmental actions based on scientific information, to be developed through public policies with view to improving the quality of life of individuals.

REFERENCES

1.Papaléo Netto M. Tratado de gereontologia. 6. ed. rev. e ampl. São Paulo: Editora Atheneu, 2014.

2.Ministério da Saúde (Br). Secretaria de Atenção à Saúde;Diabetes Mellitus. Brasília(DF): Departamento de Atenção Básica 2010.

3.Barbieri AFS, Chagas IA, Santos MA, Teixeira CRS, Zanetti ML. Consumo alimentar de pessoas com diabetes mellitus tipo 2. Rev. enferm. UERJ. 2012; 20(2):155-60.

4.Ministério da Saúde (Br). Secretaria de Vigilância em Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil. Brasília(DF): Departamento de Análise de Situação de Saúde 2012.

5.Ribeiro J P. Compreendendo o significado de qualidade de vida segundo idosos portadores de diabetes mellitus tipo II. Escola Anna Nery. 2010; 14(4)765-71.

6.Ribeiro JP, Rocha AS, Popim RC. Compreendendo o significado de qualidade de vida segundo idosos portadores de diabetes mellitus tipo II. Esc. Anna Nery [online]. 2012 [citado em 12 fev 2016]; 14(4): 765-71. Disponível em: http://www.scielo.br/scielo.php?script=sci_pdf&pid=S1414-81452010000400016&lng=en&nrm=iso&tlng=pt .

7.Ciconelli RM. Tradução para o português e validação do questionário genérico de avaliação de qualidade de vida Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) [tese doutorado]. São Paulo: Escola Paulista de Medicina, Universidade Federal de São Paulo; 1997.

8.Ministério da Saúde (Br). Conselho Nacional de Saúde. Resolução 466/2012. Dispõe sobre as diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Brasília( DF): CNS; 2012.

9.Santos IS, Guerra RG, Silva LA. Características individuais e clínicas de pessoas idosas com diabetes: investigação temática em oficina sociopoética. Rev. enferm. UERJ. 2013; 21(1):34-40.

10.Tavares DMS, Rodrigues RAP. Educação conscientizadora do idoso diabético: uma proposta de intervenção do enfermeiro. Rev esc enferm USP [online]. 2008; [citado em 12 dez 2015]. 36(1): 88-6. Disponível em: http://www.scielo.br/pdf/reeusp/v36n1/v36n1a12.

11.Cunha LL, Mayrink WC. Influência da dor crônica na qualidade de vida em idosos. Rev Dor. .2011; 12(2): 120-4.

12.Miranzi SSC, Ferreira FS, Iwamoto HH, Pereira GA, Miranzi MAS. Qualidade de vida de indivíduos com diabetes mellitus e hipertensão acompanhados por uma equipe de saúde da família. Texto contexto - enferm. 2008; 17(4):672-9.

13.Gontijo EEL, Silva MG, Lourenço AFE, Inocente NJ. A qualidade de vida de idosos atendidos no ambulatório do centro universitário unirg na cidade de Gurupi, Tocantins. Rev ciênc biol saúde. 2012; 7(2): 39-52.

14.Franco Junior AJA, Heleno MGV, Lopes AP.Qualidade de vida e controle glicêmico do paciente portador de Diabetes Mellitus tipo 2. Rev Psicol Saúde [online]. 2013; [citado em 15 fev 2015]. 5(2): 102-108. Disponível em: http://pepsic.bvsalud.org/pdf/rpsaude/v5n2/v5n2a05.pdf .

15.Miranda LP, Gomes LMX, Prado PF, Barbosa TLA, Teles MAB. Qualidade de vida de idosos com diabetes mellitus cadastrados na estratégia saúde da família. Rev Min Educ Fís. 2010; 5(5): 125-35.

16.Santos EA, Tavares DMS, Rodrigues LR, Dias FA, Ferreira PCS. Morbidity and quality of life of elderly individuals with diabetes mellitus living in urban and rural areas. Rev esc enferm. USP [online]. 2013; [cited in 10 2016 feb].47(2): 393-400. Disponível em: http://www.scielo.br/pdf/reeusp/v47n2/en_17.pdf .

17.figura American Diabetes Association. Standards of Medical Care in Diabetes. Position statement. Diabetes Care. 2014; [cited in 13 2016 feb]. Disponível em: http://care.diabetesjournals.org/content/37/Supplement_1/S14.full .