PREVENTING CARDIOVASCULAR COMPLICATIONS BEHAVIORS
IN ELDERLY WITH POORLY CONTROLLED TYPE 2 DIABETES
MELLITUS IN INDONESIA
Dayan Hisni, S.Kep., Ns1, Tippamas Chinnawong, RN.,Ph.D2., Ploenpit Thaniwattananon,
RN.,Ph.D3
1
Master of Nursing Science Student, Faculty of Nursing, Prince of Songkla University, Thailand
2
Assistant Professor, Department of Medical Nursing, Faculty of Nursing, Prince of Songkla
University, Thailand
3
Assistant Professor, Department of Medical Nursing, Faculty of Nursing, Prince of Songkla
University, Thailand
ABSTRACT
Background: Preventing cardiovascular complications behaviors is the cornerstone in Elderly with
poorly controlled type 2 DM to prevent CVD complications. Purpose: To describe the prevention
cardiovascular complications behaviors in the Elderly with poorly controlled type 2 DM in Cilegon City,
Indonesia. Methods: A quantitative descriptive study to describe the preventing cardiovascular
complications behaviors of 60 Elderly with poorly controlled type 2 DM who met inclusion criteria.
These patients were selected by using random sampling assignment from Elderly Health Care Unit,
Public Health Center, Cilegon City, Indonesia. Preventing cardiovascular complications behaviors was
measured by using the preventing cardiovascular complications behaviors questionnaire (PCCBQ). The
PCCBQ was modified from a previous study and with adequate reliability (Chronbach’s alpha was .88).
Results: The subjects who participated in this study were Elderly more than 60 years. More than half of
the subjects were female (75%) who had been studied in the elementary school (51.7%). The majority
of the patients had no experience of any previous structural educational program or counseling program
related to the preventing cardiovascular complications behaviors (96.7%). The result showed a moderate
level of preventing cardiovascular complications behaviors in the Elderly with poorly controlled type 2
DM (Min-Max= 24-91, M= 58.43, SD= 13.68). Discussion: CVD complications are common DM
complications in the Elderly with poorly controlled type 2 DM. The level of preventing cardiovascular
complications behaviors in the Elderly with poorly controlled type 2 DM is moderate. This is due to
some of Elderly have experience related to health behaviors including unstructured educational program
at the Eldery Health Care Unit, self-learning, family support, belief and perceptions. Conclusion: The
level of preventing cardiovascular complications behaviors in the Elderly with poorly controlled type 2
DM was moderate level. Two subscales of preventing cardiovascular complications behaviors including
physical exercise and taking medications regularly were at a low level, whereas the DM diet and heart
healthy diet and smoking cessation were at a moderate level.
Key words: preventing cardiovascular complications behaviors, elderly, poorly controlled type 2 DM,
Indonesia.
INTRODUCTION
Background
Diabetes mellitus (DM) is a worldwide
health problem. The prevalence of type 2 DM in
the elderly was increase each year and will
reach 2 billion people in 2050 (Kowal et al.,
2012; Michalakis, Goulis, Vazaiou, Mintziori,
Plymeris, & Abrahamian, 2013). The high
prevalence of diabetes is associated with poor
glycemic control in elderly with type 2 DM
(Omar & San, 2014). Poorly controlled type 2
DM in the Elderly is defined when HbA1c level
> 7 % (Otiniano, AlSnih, Goodwin, Alghatrif,
& Markides (2012) or equal to fasting blood
glucose (FBG) level ≥ 154 mg/dL (Inzucchi,
2012).
Patient with type 2 DM who have HbA1c
> 7 % is increased to DM complications
including CVD complications (Imran, RabasaLhoret, & Ross, 2013). A study conducted by
Al-Nozha, Mojadadi, Mosaad, and El-Bab
(2012) reported that prevalence of CVD
complications in patient with type 2 DM was 5.5
% in Kingdom of Saudi Arabia. Another study
conducted by Bonakdaran, Ebrahimzadeh, and
Noghabi (2011) reported that 21.8 % in
Republic of Iran, 72 % in Rusia and 21 % in
China. Currently, in Cilegon Indonesia there
was 48 % of elderly with diabetes who have
CVD complications (Arriadna, 2015).
CVD complications in the Elderly with
poorly controlled type 2 DM occurred due to
Elderly are more common to develop
endothelial dysfunction, oxidative stress, and
inflammation (De Tata, 2014). Furthermore,
endothelial dysfunction can influence on
increasing FBG and lipid profiles (e.g., totalcholesterol, HDL-cholesterol, and LDLcholesterol). Therefore, Elderly with poorly
controlled type 2 DM should manage their life
style
by
preventing
cardiovascular
complications behaviors including DM diet and
heart healthy diet, physical exercise, taking
medications regularly, and smoking cessation
(Sung, 2015) and they have to control their
blood glucose and lipid profiles routinely to
prevent CVD complications.
Various studies related to DM and
chronic complications in Elderly in Indonesia
have been conducted (Nazir, 2009; Rosyada and
Trihandini, 2013; Yuliani, Oenzil, & Iryani,
2014). However, these studies were focused on
DM complications generally, not specific in
preventing CVD complications and it was not
specific in Elderly population with poorly
controlled type 2 DM, so the results may not be
generalized to other settings in Indonesia.
Therefore, the researcher needs to describe the
preventing
cardiovascular
complications
behaviors in the Elderly with poorly controlled
type 2 DM in Cilegon, Indonesia.
Objective
The objective of this study was to
describe the prevention cardiovascular
complications behaviors in the Elderly with
poorly controlled type 2 DM.
METHOD
Setting
The patients of this study have been
selected from two Elderly Health Care Units at
Public Health Center in Cilegon City, Banten
Province, Indonesia during January December
2015 to January 2016.
Sample
Sixty Elderly with poorly controlled type
2 DM were recruited by random sampling
assignment based on inclusion criteria. The
inclusion criteria was Elderly with age ≥ 60
years, fasting blood glucose ≥ 154 mg/dL in the
past 3 months after fasting at least 8 hours or
HbA1c level > 7 % with the duration of diabetes
at least 1 year, be able to communicate in
Indonesian language both verbal and written,
have no hearing impairment, have family
member who stay together with elderly, have no
mental health problems as recorded in in the
Elderly medical record.
Data collection instruments
Demographic Data Questionnaire and
Health Information (DDQHI). This DDQHI
was completed by filling in the blank form. The
demographic data was consisted of 10 items
including patient’s age, gender, occupation,
education level, family income, family member,
education
experience,
patients’
belief,
performing exercise, and taking medication
history, whereas the health information consists
of 9 items including BMI status, the last of totalcholesterol levels, HDL-cholesterol levels,
LDL-cholesterol levels, FBG levels, blood
pressure levels, duration of diabetes, smoking
status, and current medications.
The
Preventing
Cardiovascular
Complications
Behaviors
Questionnaire
(PCCBQ). This instrument was modified based
on existing tools by Pamungkas (2015). It was
used to measure preventing cardiovascular
complications behaviors which consists of 4
dimensions, including DM diet and heart
healthy diet (9 items), physical exercise (7
items), taking medications regularly (4 items),
and smoking cessation (5 items). Each item was
measured by using a six point (0-5) Likert scale
in which:
0 = not applicable (NA) (only for smoking
cessation items for elderly who do not
have experience with smoking),
1 = Never
2 = Seldom
3 = Occasionally
4 = Often
5 = Repeatedly
The total score is from 20 – 125. The
scoring system is divided into three categories:
low behavior scores (score 20-54), moderate
behavior scores (score 55-89), high behavior
scores (core 90-125) with the highest score
indicating better for preventing cardiovascular
complications behaviors.
Ethical consideration
This study has been approved by the IRB
of the Faculty of Nursing, Prince of Songkla
University, Thailand. Permission letters were
also obtained from the Head of Health
Departement and the Head of Cilegon Public
Health Center, Banten Province, Indonesia. The
researcher explained the purposes of the study,
procedures, risks, and benefits of the study.
Furthermore, they had been assured that they
had the right to refuse to participate in this study
at anytime without any negative consequences.
They were given a brief explanation about the
study and informed consent form before they
determine to participate in the study. The
confidentiality and anonymity of the patients
were maintained throughout the study.
Data Analysis
Descriptive statistics were used in this
study to describe the subjects’ demographic,
health information related to characteristics, and
preventing
cardiovascular
complications
behaviors in terms of frequency, percentage,
mean, and standard deviation.
RESULTS
Demographic Characteristics
A total of sixty patients were selected in
the study. The demographic characteristics of
the Elderly with poorly controlled type 2 DM
are presented in Table 1. According to the data,
the subjects who participated in this study were
Elderly with age of 60-65 years (83.3%). More
than half of the subjects in this study were
female (75%). Most of the subjects in this study
were housewife (66.7%). In terms of education
levels, more than half of the subjects had an
education level of elementary school (51.7%).
More than one third of subjects had family
income less than IDR 1,700,000 per month
(46.7%). More than half of the subjects had
children who taken care the Elderly (68.3%).
The subjects had no experience with any
previous educational programs or counseling
programs related to prevention cardiovascular
complications behaviors (96.7%). The subjects
had no belief regarding DM diet in their daily
life (75%). More than half of the subjects never
perform physical exercise regularly in a week
(71.3%), and most of the subjects had history of
taking medications regularly (60%).
Table 1: Demographic characteristics of the Elderly with poorly controlled type 2 DM in Cilegon,
Indonesia (N=60)
Characteristics
M (SD)
N
%
60-65
50
83.3
66-70
8
13.3
> 70
2
3.3
Male
15
25
Female
45
75
Do not have experience in formal school
6
10
Elementary school
31
51.7
Junior high school
6
10
Senior high school
13
21.7
Diploma degree
3
5
Bachelor degree
1
1.7
Age (Elderly)
Gender
Education levels
Family income
IDR < 1,700,000 per month
28
46.7
IDR 1,700,000 per month
11
18.3
IDR >1,700,000 per month
21
35
Husband or wife
15
25
Children
41
68.3
Husband or wife and children
4
6.7
2
3.3
58
96.7
36
60
24
40
43
71.7
8
13.3
8
13.3
1
1
36
60
24
40
Family member who taking care Elderly
Education experience about preventing cardiovascular
complications behaviors
Yes
No
Belief regarding DM diet
Yes
No
Performing exercise
Never exercise in a week
1 time a week
2 times a week
More than 2 times a week
Taking medications
Regularly
Sometimes (if remember)
According to the clinical characteristics
of the Elderly with poorly controlled type 2 DM
in Cilegon, Indonesia (N=60) as shown in Table
2, the findings of this study reported that the
average of last total-cholesterol level was
188.77 mg/dL (SD = 23.56), the last HDL level
was close to normal level 47.88 mg/dL (SD =
7.07), the last LDL-cholesterol level was 79.12
mg/dL (18.58%), and the average of the last
FBG level was high 191.90 mg/dL (SD =
32.59). Nearly a half of the patients had the last
blood pressure < 150/90 mmHg (40%). The
duration of the Elderly being diagnosed with
diabetes mellitus was more than one year
(100%). Most of the subjects in this study were
never smoking (76.7%). More than half of
current medications of patients were metformin,
simvastatin, and amlodipine (38.3%).
Table 2: Clinical characteristics of the Elderly with poorly controlled type 2 DM in Cilegon, Indonesia
(N=60)
Characteristics
M (SD)
N
%
< 150/90 mmHg
24
40
150/90 mmHg
18
30
> 150/90 mmHg
18
30
> 1 year – 5 years
45
75
> 5 years – 10 years
10
16.7
> 10 years
5
8.3
Never smoking
46
76.7
Stop smoking < 1 year ago
1
1.7
Stop smoking 1-2 years ago
0
0
Stop smoking > 2 years ago
7
11.7
Active smoking
6
10
Metformin
17
28.3
Metformin and amlodipine
15
25
Metformin and simvastatin
5
8.3
Metformin, amlodipine, and simvastatin
23
38.3
The last total-cholesterol level (Min-Max = 120-233 mg/dL)
188.77 (SD = 23.56)
The last HDL-cholesterol level (Min-Max = 31-67 mg/dL)
47.88 (SD = 7.07)
The last LDL-cholesterol level (Min-Max = 45-120 mg/dL)
79.12 (SD = 18.58)
The last FBG level (Min-Max = 154-248 mg/dL)
191.90 (SD = 32.59)
The last blood pressure level
Duration of diabetes mellitus
Smoking status
Current medications
Preventing Cardiovascular Complications
Behaviors
Table 3 shows the mean, standard
deviation (SD), and the levels of preventing
cardiovascular
complications
behaviors
(N=60). Regarding the data, the total level of
preventing
cardiovascular
complications
behaviors of the subjects were at moderate
levels (M = 58.43, SD = 13.68). DM diet and
heart healthy diet and smoking cessation were
at the moderate level. However, physical
exercise and taking medications regularly were
at the low level.
Table 3. Mean, standard deviation (SD), and the levels of preventing cardiovascular complications
behaviors
Characteristics
Possible
score
Min-Max
score
Mean
SD
Level
1.
DM diet and heart healthy diet
9-45
24-44
32.88
4.51
Moderate
2.
Physical exercise
7-35
7-35
15.28
8.13
Low
3.
Taking medications regularly
4-20
4-20
8.92
3.18
Low
4.
Smoking cessation
0-25
0-25
1.68
5.21
Moderate
5.
Total of preventing
cardiovascular complications
behaviors
20-125
24-91
58.43
13.68
Moderate
No
DISCUSSION
The findings of this study revealed that
the level of preventing cardiovascular
complications behaviors was a moderate level.
The subscale of DM diet and heart healthy diet
and smoking cessation are at moderate level.
These are occurred due to most of Elderly in this
study are female, it is associated with cultural
aspect in Cilegon City where most of people in
Cilegon City have belief that females who
smoking are not good and have bad attitude,
whereas the subscales of physical exercise and
taking medications regularly are at low level.
These are associated with physical and
cognitive dysfunction in the Elderly. It is
consistent with study was conducted by Gates
and Walker (2014) reported that Elderly with
diabetes mellitus are associated with functional
changes.
The improvement of preventing
cardiovascular complications behaviors was
due to several reasons such as: The first reason
related to informal and unstructured educational
program in the Elderly Health Care unit at
Public Health Center. Elderly Health Care unit
at Public Health Center in Cilegon, Indonesia
provides brief information regarding DM
complications generally. It might improve the
patients’ knowledge. Therefore, the Elderly can
determine on the best management to prevent
DM complications behaviors. However, Elderly
Health Care unit did not provide some materials
regarding how to prevent specific DM
complications including CVD complications
such as a book, leaflet, and flipchart. This
finding was consistent with Nazir (2009) stated
that the increasing of knowledge was associated
with
management
to
prevent
DM
complications.
The second reason is the Elderly have
been diagnosed with diabetes more than 1 year.
It might develop their self-learning and they
have more experience to manage their disease
including
preventing
cardiovascular
complications. Therefore, after the Elderly had
been diagnosed with diabetes mellitus for
enough long time, they can manage their
behaviors to prevent CVD complications by
performing DM diet and heart healthy diet,
physical exercise, taking medication regularly,
and smoking cessation. This finding was
consistent with Omar & San (2014) stated that
long duration of diabetes was associated with
improving knowledge and more experience
regarding DM management.
The third reason may relate to the social
support especially from family support. The
family provides direct support to the patient and
has benefit to the self-management (Xu,
Toobert, Savage, Pan, & Whitmer, 2008). Most
theories of health and behavior change suggest
a need for social support as a crucial component,
family members are the most significant source
of that support (Kang et al., 2010). Support from
family member to the Elderly, for instance to
encourage the Elderly to eat healthy food by
helping to prepare foods, remind the Elderly to
eat in proper time, accompany the Elderly to
perform physical exercise, assist and remind the
Elderly to take medicines properly, and
motivate to perform health behaviors.
Therefore, Elderly who have family support is
strongly associated in term of diabetes mellitus
treatment to prevent its complications,
including cardiovascular disease (Nicklett, &
Liang, 2010).
The fourth reason is related to the belief
and perception regarding the management for
preventing
cardiovascular
complications
behaviors. Health Belief Model Theory stated
that the behaviors of the patients were
associated with the seriousness of their disease,
perception of the advantages and barriers of
behavioral change (Rosenstock, Strecher, &
Becker, 1998). The result of this study showed
that the majority of the patients understand
regarding the preventing cardiovascular
complications behaviors especially in DM diet.
In contrast, the result showed that
patients had low levels of physical exercise and
taking medications regularly. These findings
might be due to the Elderly have special need to
perform physical exercise, it was associated
with functional changes caused by aging (Choi,
Jang, & Nam, 2008) and it will impact on
limitation of movement. Also, diabetes in
Elderly is metabolically different from diabetes
in younger patient populations. Therefore,
approach to therapy needs to be different in this
age group (5). Elderly with diabetes has been
linked with cognitive dysfunction (Gates &
Walker, 2014). These conditions might be
influence to medication adherence in the
Elderly.
CONCLUSION AND
RECOMMENDATION
Conclusion
The
preventing
cardiovascular
complications behaviors in the Elderly with
poorly controlled type 2 DM in Cilegon,
Indonesia were at moderate level. Regarding the
subscales of the preventing cardiovascular
complications behaviors, DM diet and heart
healthy diet and smoking cessation were at
moderate level. These are happened related to
unstructured educational program, patients’
self-learning, family support, and patients’
beliefs. However, physical exercise and taking
medications were at low level which might
relate to the functional changes including
physical and cognitive dysfunction.
Recommendations
CVD complications are a common DM
complications in the elderly with poorly
controlled type 2 DM. To prevent CVD
complications in the Elderly with poorly
controlled type 2 DM, health care persons need
to pay more attention on promoting exercise and
adherence to taking medications and several
factors should be considered in order to further
research was needed to establish an intervention
approach related to preventing cardiovascular
complications behaviors to prevent CVD
complications in the Elderly with poorly
controlled type 2 DM.
ACKNOWLEDGEMENT
We thankful all the staff at the Cilegon
Public Health Center for their assistance and
great appreciation is offered to the Graduate
School Prince of Songkla University for
providing and giving me research funding and
full scholarship to continue my Master Degree,
International Program, Faculty of Nursing,
Prince of Songkla University Thailand.
REFERENCES
Al-Nozha, Mojadadi, M., Mosaad, M., & ElBab, M. F. (2012). Assessment of
coronary heart diseases in diabetics in
al-Madinah al-Munawarah.
International Journal of General
Medicine, 5, 143 – 149. doi.
10.2147/IJGM.S27373
Arriadna. 2015. “Pemkot Cilegon Resmikan
Public Health Center”. Radar Banten.
Tuesday, 14 July 2015.
Bonakdaran, S., Ebrahimzadeh, S., & Noghabi,
S. H. (2011). Cardiovascular disease and
risk factors in patients with type 2
diabetes mellitus in Mashhad, Islamic
Republic of Iran. Eastern Mediterranean
Health Journal, 17(9), 640-6. Retrieved
from
http://www.ncbi.nlm.nih.gov/pubmed/22
259913
Choi, G., Jang, S. M., & Nam, H. W. (2008).
Current status of self-management and
barriers in elderly diabetic
patient. Korean Diabetes Journal, 32(3),
280-289. doi: 10.4093/kdj.2008.32.3.280
De Tata, V. (2014). Age-related impairment of
pancreatic beta-cell function:
pathophysiological and cellular
mechanisms. Frontiers in
Endocrinology, 5.
doi:10.3389/fendo.2014.00138
Gates, B. J., & Walker, K. M. (2014).
Physiological changes in older adults
and their effect on diabetes
treatment. Diabetes Spectrum, 27(1), 2029. doi:10.2337/diaspect.27.1.20
Kang, C. M., Chang, S. C., Chen, P. L., Liu, P.
F., Liu, W. C., Chang, C. C., & Chang,
W. Y. (2010). Comparison of family
partnership intervention care vs.
conventional care in adult patients with
poorly controlled type 2 diabetes in a
community hospital: a randomized
controlled trial. International Journal of
Nursing Studies, 47(11), 1363-1373.
doi:10.1016/j.ijnurstu.2010.03.009
Kowal, P., Chatterji, S., Naidoo, N., Biritwum,
R., Fan, W., Ridaura, R. L., & Boerma,
J. T. (2012). Data resource profile: the
World Health Organization Study on
global AGEing and adult health
(SAGE). International Journal of
Epidemiology, 41(6), 1639-1649.
doi:10.1093/ije/dys210
Michalakis, K., Goulis, D. G., Vazaiou, A.,
Mintziori, G., Polymeris, A., &
Abrahamian-Michalakis, A. (2013).
Obesity in the ageing
man. Metabolism,62(10), 1341-1349.
doi: 10.1016/j.metabol.2013.05.019
Nazir, Y, H. (2009). The effect of health belief
model based education program to
prevent diabetes complications on
dietary behaviors of Indonesian adult
with type 2 diabetes mellitus.
Unpublished master’s thesis of Faculty
of Nursing, prince of Songkla
University, Thailand.
Nicklett, E. J., & Liang, J. (2010). Diabetesrelated support, regimen adherence, and
health decline among older adults. The
Journals of Gerontology Series B:
Psychological Sciences and Social
Sciences, 65(3), 390-399.
doi:10.1093/geronb/gbp050
Omar, M. S., & San, K. L. (2014). Diabetes
knowledge and medication adherence
among geriatric patient with type 2
diabetes mellitus. International Journal
of Pharmacy and Pharmaceutical
Science, 6(3), 103-106. Retrieved from
http://www.ijppsjournal.com/Vol6Issue3
/8838.pdf
Otiniano, M. E., Al Snih, S., Goodwin, J. S.,
Ray, L., AlGhatrif, M., & Markides, K.
S. (2012). Factors associated with poor
glycemic control in older Mexican
American diabetics aged 75 years and
older. Journal of Diabetes and Its
Complications, 26(3), 181-186. doi:
10.1016/j.jdiacomp.2012.03.010
Pamungkas, R. A., Chinnawong, T., &
Kritpracha, C. (2015). The effect of
dietary behaviors among muslim
patients with poorly controlled type 2
diabetes mellitus in community setting
in Indonesia. International Journal of
Medical and Pharmaceutical
Sciences, 5(10), 08-13. Retrieved from
http://www.scopemed.org/?jft=47&ft=4
7-1434634526
Rosenstock, I. M., Strecher, V. J., & Becker,
M. H. (1988). Social learning theory and
the health belief model. Health
Education & Behavior, 15(2), 175-183.
Rosyada, A., & Trihandini, I. (2013).
Determinan Komplikasi Kronik
Diabetes Melitus pada Lanjut
Usia. Kesmas: Jurnal Kesehatan
Masyarakat Nasional,7(9), 395-402.
Retrieved from
http://www.jurnalkesehatannasional.fkm
.ui.ac.id
Sung, K. (2015). The Effects of Elderly
Diabetes Mellitus Patients' Self-care
Behavior and Health Conservation on
Cardiovascular Risk Factors. Journal of
Korean Academy of Community Health
Nursing, 26(2), 150-159. doi:
10.12799/jkachn.2015.26.2.150
Xu, Y., Toobert, D., Savage, C., Pan, W., &
Whitmer, K. (2008). Factors influencing
diabetes self‐management in Chinese
people with type 2 diabetes. Research in
Nursing & Health, 31(6), 613-625. doi:
10.1002/nur.20293
Yuliani, F., Oenzil, F., & Iryani, D. (2014).
Hubungan Berbagai Faktor Risiko
Terhadap Kejadian Penyakit Jantung
Koroner Pada Penderita Diabetes
Melitus Tipe 2. Jurnal Kesehatan
Andalas, 3(1), 37-40. Retrieved from
http://jurnal.fk.andalas.ac.id
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