Comparison of Health-Related Quality of Life of Elderly With Hypertension Living in Long-Term Facility vs. Community

COMPARISON OF HEALTH-RELATED QUALITY…
1.0 ABSTRACT
Hypertension can impair the Health-Related Quality of Life (HRQoL) of the elderly because
of its complications and comorbidities. The objective of this study is to compare the Health-
Related Quality of Life (HRQoL) of Elderly with Hypertension living in Long-Term Facility
versus Community. The study will use quantitative, descriptive, comparative research design.
MINICHAL Questionnaire will be used to assess the subject’s HRQoL. Chi-Square, Pearson
and Spearman rho correlations will be used to determine the relationship between HRQoL and
Hypertension prognosticators while T-test will be used to test the main hypothesis.
Keywords: Hypertension, Long-Term Facility Elderly, Community-Dwelling Elderly, Health-

Related Quality of Life (HRQoL), Physical Therapy
OUR LADY OF FATIMA UNIVERSITY COLLEGE OF PHYSICAL THERAPY

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2.0 INTRODUCTION
Hypertension cases worldwide are present in 1.13 billion people that are mostly living in
low and middle-income countries or third world countries (World Health Organization [WHO],
2019). Elderly aging 75 years and above has a prevalence rate of 70% of developing
hypertension while those aging 65 years old has a 90% chance of developing hypertension as
they reach the age of 80 (Boateng, Luginaah, & Taabazuing, 2016). 75 million people or 1 out
of 3 U.S. adult has hypertension and is said to be a common risk for stroke and heart disease
which are the leading causes of death (Center for Disease Control and Prevention [CDC],
2019). According to De Leon (2014), 3.3% of the population are elderly and is expected to
increase to 10.25% in 2025. In a study of National Nutrition Council ([NNC], 2018), Food
Nutrition Research Institute (FNRI) stated that the prevalence of Filipinos, aging 20 years and
older, to hypertension increased from 22.3% in 2013 to 23.9% in 2015. The Department of
Health states that hypertension is said to be the leading cause of illness in the Philippines
(National Nutrition Council [NNC], 2018). Incidence of hypertension is higher in men than in
women but reciprocates when women reaches their menopausal stage at the age of 50- 55 years
old (Babatsikou, Zavitsanou, 2014). In a study of Moore, Boscardin, Steinman, and Schwartz
(2014), hypertension is one of the most prevalent comorbid conditions present in nursing homes
residents.
Having hypertension (HTN) increases the risk of developing cardiovascular diseases such
as coronary heart disease (CHD), congestive heart failure (CHF), stroke, renal failure and
peripheral arterial diseases (Awoke, A., Awoke, T., Alemu, & Megabiaw, 2012). Korhonen,
Kivela, Kautiainen, Jarvenpaa & Kantola, (2011) stated in their study that decrease in health-
related quality of life is not the direct result of people having hypertension but of knowing that
they have hypertension. In the study of Soni et al., (2010) they listed the HRQOL in terms of
HTN with CVD, HTN with Diabetes and HTN with chronic kidney disease (CKD), wherein,
HTN with CVD patients rate themselves as having poor HRQOL if they present a number of
CVD risk factors; in HTN with CKD, it is said that HTN is both a cause and complication of
CKD which causes the 26.8% of end-stage renal disease cases while in HTN with Diabetes
patients have a better HRQOL than those who doesn’t have Diabetes. Wang, Zhao, He, Ma,
Yan and Sun et al., (2009) indicated in their study that previous conducted studies are saying

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that hypertension affects vitality, social functioning, mental health mood and psychological
functioning.
Benetos, Petrovic, and Strandberg (2019) stated that hypertension is highly prevalent in
the elderly, with arterial hypertension particularly systolic hypertension is constantly rising
worldwide, due to arterial stiffening as a result of the population’s aging. Several
epidemiological surveys conducted in the USA and Europe conclude that hypertension
prevalence in the elderly ranges between 53% and 72%, high blood pressure values in the
presence of several risk factors (obesity, diabetes mellitus, increased salt intake,
hyperlipidemia, smoking, lack of physical activity, psychological factors, advanced age, sex)
lead to a further increase of cardiovascular disease risk. (Babatsikou & Zavitsanou, 2010).
According to National Nutrition Council (2018) High blood pressure or also known as
hypertension is a major risk factor of many cardiovascular and kidney diseases and often leads
to stroke when uncontrolled and unmanaged in Philippines. Arterial hypertension is a common
health problem in older nursing home residents (NHR)/Long-term care residents (Könner et
al., 2014; Welsh, Gladman, & Gordon, 2014) and associated with cardiovascular risk factors,
and a substantial degree of associated clinical conditions (Baranera et al., 2006). Chronic
elevation in blood pressure represents a major risk factor not only for cardiovascular morbidity
and mortality but also for cognitive decline and loss of autonomy later in life of community
dwelling elderly (Benetos et al., 2019). According to Luz (2016) that age, occupation, and
waist to hip ratio to be associated with hypertension. In addition, that the aforementioned
demographic changes concomitantly lead to a greater number of older people in Philippines
need of both home and institutionalized care because of cognitive and functional decline,
frailty, multimorbidity, polypharmacy, as well as partial or complete loss of autonomy
(Benetos et al., 2019). Major Predictors of Hypertension Among Adults 30 and Older in
Philippines are Age, Family history of hypertension and BMI (Reyes-Gibby & Aday, 2000).
There are several risk factors of Health-Related Quality of Life (HRQoL) among Elderly
living in Long-Term Facilities and Community such as Falls (Gangavati et al., 2011;
Robinovitch et al., 2013), Frailty (Ricci, Pessoa, Ferrioli, Dias, & Perracini, 2014), Depression
(Ma et al., 2015; Seitz, Purandare, & Conn, 2010), Stroke (Divani, Majidi, Barrett,

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Noorbaloochi, & Luft, (2011) and Dementia (Ogunniyi et al., 2011; Seitz, Purandare, & Conn,
2010).
Welsh, Gladman, Gordon (2014) concluded that there is no guarantee of improvement of

blood pressure control of hypertensive elderly living in long term care facilities regardless of
how many antihypertensive drugs they use, therefore increasing their vulnerability to side
effects like polypharmacy without much benefits from antihypertensive drugs. Borowiak,
Kostka (2004) suggests than polypharmacy and cardiovascular disease may contribute to
lower QOL in institutionalized elderly more than those who are community-dwelling. Burack,
Weiner, Reinhardt, & Annunziato (2012) suggested that Health related quality of life of
institutionalized elderly people is significantly related to happiness and satisfaction with their
caretakers in long term care facilities like Nursing Homes. Gallegos-Carrillo et al. (2009)
stated that community-dwelling adults who have hypertension are more likely to have lower
health related quality of life when they also have depressive symptoms such as loneliness. In
terms of Diet and Nutrition, Abizanda, Sinclair, Barcons, Lizán, & Rodríguez-Mañas (2016)
stated that community-dwelling elderly have better nutrition than institutionlized elderly,
leading to a decrease in Health related quality of life of Elderly individuals.Rodrigues et al.
(2015)presented how both community-dwelling and institutionalized individuals may have a
lower quality of life if they are not well hydrated.Bunn, Jimoh, Wilsher, & Hooper (2015)
compared the susceptibility of community-dwelling and institutionalized edlerly to
dehydration and found that institutionalized elderly are more susceptible, putting them in
higher risk of having a lower Helth Related Quality of Life. Cucato et al. (2016) looked into
the predictors of lower Health Related Quality of life of Community-dwelling and
Institutionalized Elderly according to their age and found that in Community-dwelling elderly,
women have higher prevalence of depression and Institutionalized elderly men have higher
prevalence of cardiovascular diseases.
As a human body ages, there is a need for increased physical activity to lower the risk of
cardiovascular diseases as the previous studies suggested (Vagetti, Barbosa, Moreira, Oliveira,
Mazzardo, Campos, 2014). Studies show that health related quality of life decrease because of
the presence of hypertension along with ageing (Lee, Kim, & Han, 2015; Mulasso, Roppolo,
& Rabaglietti, 2014). Community participation is said to be an important factor to improve

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quality of life (Chui, 2018). Meanwhile for the elderly residing at long term care facilities
there are conflicting studies regarding HRQOL, one study state that older adults living in
institutions shows lower HRQOL than those who reside at their homes (Luque-Reca, 2015)
but according to Smit, de Lange, Willemse, Twisk, and Pot (2016) elderly living in long term
care facilities demonstrates higher health related quality of life due to the protection, care, and
social support that they are receiving, being comfortable at a home-like environment. Here in
the Philippines there is a lack of study that tackles about the comparison between the HRQOL
of community dwelling elderly and those who are living in institutions.
2.1 Literature Review

In 2013, World Health Organization [WHO] stated that Hypertension is responsible for
death caused by heart disease at approximately 45% and 51% of deaths due to stroke. WHO
(2014) referred to Hypertension as the “silent killer” as it usually manifests minimal to no
symptoms but can lead to cardiovascular diseases that are detrimental to one’s health like
cardiovascular disease, Diabetes, and chronic kidney disease (Arija et al., 2018). WHO(2017)
published a guideline for Diagnosis and Management of Hypertension, which states that
Hypertension can be diagnosed if the average Blood Pressure taken on two or more separate
days has a Systolic pressure of 140-159 mmHg and Diastolic pressure of 90-99 mmHg for
Stage 1, a Systolic blood pressure equal to or more than 160mmHg and a Diastolic pressure
equal to or more than 100mmHg for Stage 2. Secondary Hypertension is caused by other
diseases such as Hyperaldosteronism, Cushing syndrome, Pheochromocytoma, Thyroid
diseases, Renal parenchymal diseases, Renal artery stenosis, and Sleep apnea (Jordan,
Kurschat, & Reuter, 2018). Although Hypertension usually have no other symptoms other than
elevated blood pressure, some individuals exhibit symptoms such as headache, palpitation,
and excess sweating. In the Philippines, almost one-third of the population is Hypertensive
(Castillo et. al 2019).
2.1.1 Risk Factors of Hypertension among Elderly in Long-Term Facility and Community
2.1.1.1 Age.
According to Sun (2015), more than two-thirds of individuals after 65 years of age
experiences hypertension and are doubled as to compare with young population. Hypertension
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accounts for about one-third of deaths due to Cardiovascular Diseases at ages 35-79 years old
(Huang et al., 2017). With increasing age, the aorta and arterial walls will be stiffened, and this
contributes to the high prevalence of hypertension in older age groups (Singh, Shankar, &
Singh, 2017).
2.1.1.2 Family History of Hypertension
A family history of HTN was also a strong predictor of HTN in this population, supporting
similar findings in different populations (Reyes-Gibby & Aday, 2000). Family history is an
important non-modifiable risk factor for hypertension. The present study aims to describe the
influence of family history (FH) on hypertension prevalence and associated metabolic risk
factors in a large cohort of South Asian adults (Ranasinghe, Cooray, Jayawardena and
Katulanda, 2015).
2.1.1.3 Body Mass Index
Obesity, which is generally determined by body mass index (BMI), and respondents with
an overweight was defined as BM>25 and obesity was defined as BM>30 kg/m2 in adults 60
and older had more than double and is one of the leading the risk for HTN (Tabrizi et al,
2016), suggesting the need for behavior modification programs pertaining to weight control
(Jayedi et al., 2018; Reyes-Gibby & Aday, 2000) and the prevalence of hypertension increases
with increasing BMI (Landi et al., 2018).
2.1.1.4 Waist to Hip Ratio
Waist to Hip Ratio was associated with 37% higher risk of HTN (Jayedi et al., 2018). WHtR
and WC are strong risk factors for hypertension and cardiovascular events (Luz, 2016) and
WHtR was found to be significantly better than WC for hypertension, CVD and all outcomes
in both men and women (Tawfik, 2018).

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2.1.1.5 Knee Osteoarthritis Pain

Study of Korean community dwelling Kim et al (2010) elderly showed the 37.3% and
24.2% prevalence of knee osteoarthritis, they also showed that it is significantly associated
with presence of hypertension. Perception of pain is influence by age, thus prevalence of pain
among elderly population ranges approximately from 45% to 80% in elderly population and
increase as high as 83% in long-term care facility residents, this high prevalence were
contributed by age related disabilities like osteoarthritis (Leone, Standoli, & Hirth, 2009).
Pain and its intensity independent of age, race, ethnicity and familial history is associated with
increased risk of hypertension (Saccò et al., 2013). A study of community-dwelling elderly in
Taiwan Tsai, Liu, & Chung (2010) reported a 50% chronic pain prevalence and those
participants that reported with pain had a significant prevalence of chronic diseases in which
hypertension is the most prevalent.
2.1.1.6 Diabetes
According to Nshisso, Reese, Gelaye, Lemma, Berhane and Williams (2012), people with
diabetes has the highest prevalence of developing hypertension. In the study of Naresh et al.
(2012) participants who are hypertensive has a comorbidity condition of diabetes mellitus
(DM). Huang et al (2017) stated in their study that hypertensive people who have a comorbid
of DM has more control of their blood pressure than those who do not have DM. They
explained that those who have DM receive a more intensive antihypertensive therapy than
those who do not have DM. 66% of participants in the study of Awoke et al (2012) reported
that they have diabetes. They also indicated that diabetes and hypetension are two
interconnected conditions that may cause each other. Gao et al (2013) said that diabetes is one
of the risk factors of hypertension. Boateng, Luginaah and Taabuzing (2015) mentioned in
their study that elderly Ghanaians who are diagnosed with diabetes have a higher possibility
of being hypertensive. Babatsikou and Zavitsanou stated that those who presents with DM 2
are likely to also be hypertensive. They also indicated that it is more common in men and those
who are in low-socioeconomic level.

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2.1.1.7 Loneliness
A study of older population Momtaz et al. (2012) reported a 39% overall prevalence of
hypertension among old individual with high level of loneliness and concluded that loneliness
is a major risk for developing hypertension and should be considered in health care of older
individuals. Prevalence of loneliness in community-dwelling person aged 60 and older
increased from 52.72% in 2008 to 56.63% in 2012 and projected to increase as older
population increases (Gerst-Emerson & Jayawardhana, 2015).
2.1.1.8 Poor sleep quality

As a normal part of ageing, changes sleep quality and quality affect most of the elderly
population, accompanied by other factors of ageing which leads to poor sleeping pattern
(Roepke & Ancoli-Israel, 2010). A systematic review (Palagini et al., 2013) indicated that vast
amount of evidence support that sleep loss independent of other health-related condition
increase BP this increasing the risk of hypertension in elderly population both male and
female. Poor sleep habits and sleep disorders leading to poor sleep quality adversely affect BP
control and should be considered an important factor in preventing or controlling hypertension
(Pepin et al., 2014).
2.1.1.9 Occupation
Individuals who value occupation than giving importance to their health tend to have
common abnormal conditions; these are usually workers in a third world country like the
Philippines (Banaag, Dayrit, & Mendoza, 2019; Blattman & Dercon, 2016). Studies suggested
that occupation is one of the risk factors for hypertension, which is considered as an important
public health problem (Kishore, Gupta, Kohli, Kumar, 2016; Howitt, Humbleton, Rose,
Hennis, Samuels, George, Unwin , 2015) According to a study conducted by Gao, Xie, Wang,
Li, Tang, Zang, Yao (2017) sedentary behavior is associated with having hypertension, most
civil servants who's suffering from hypertension have a sedentary occupation. Also, studies
showed that hypertension can be seen in pregnant women and a new finding was concluded in
the research conducted by Jacobs, Vreeburg, Dekker, Heard, Priest and Chan (2003),
according to them, unemployed pregnant women have higher risk of having hypertension than
those who are engaged in home duties which is considered as their occupation.

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2.1.1.10 Gender
Cohort studies and other studies are saying that there are gender differences in blood
pressure that occurs from an early age but becomes higher in men than in women before the
age of 50 years old (Reckelhoff, 2018). Di Giosa, Giorgini, Stamerra, Petrarca, Ferri and
Sahebkar (2018) explained that women who are not yet in their menopausal stage are less
likely to develop hypertension but their prevalence to hypertension increases at the age of 65
to 74 years old and is higher than men. in women. Hu, Huang, You, Li, Hong, Li, et al (2017)
also stated that females aging ≥65 years old has a higher hypertension prevalence than men
and is also similar to other studies. They also discussed that this higher prevalence of women
is because of hormonal changes that menopausal period brings to them. But in the study of
Fang, Song, Ma, Zhang, Jing and Chen (2014), 56 studies have reported that hypertension is
still higher in men than in women. Fang et al. (2014) also explained in their study that higher
prevalence of men in hypertension might be a result of difference in physiological structure
and the higher rate of men being alcoholic and smoker.
2.1.1.12 Physical Activity

Dumurgier, Elbaz, Dufouil, Tavernier, & Tzourio (2010) investigated the association of
walking speed and hypertension in elderly and found that risk of hypertension is associated
with low walking speed and low physical activity. A study of physical activity and HRQOL
in community-dwelling elderly Halaweh, Willen, Grimby-Ekman, & Svantesson (2015)
concluded an increase to the prevalence of comorbid condition such as hypertension in elderly
with low physical activity.
2.1.1.13 Polypharmacy
In the elderly, use of medications is common to improve their quality of life, reduce
comorbidities or extend their life expectancies (Akazawa & Sato, 2013). In a systematic
review of Masnoon, Shakib, Kalisch-Ellett, & Caughey (2017), 12 studies defined
polypharmacy as multiple medications used concurrently by the same individual. Mukete &
Ferdinand (2016) stated that it is more likely in elderly with hypertension to have medications
of greater than two and is more susceptible to risks of adverse events such as fall injury, hyper
or hypokalemia, heart failure, etc that may greatly affect their health-related quality of life. In
a study of Benetos et al. (2015), those who presents with SBP of less than 130mmHg and is
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taking more than two medications are associated with higher mortality rates. In a systematic
review of Gellad, Grenard, & Marcum (2011), they stated that non-adherence to medications
can cause negative effects on the health of the elderly. Hacihasanoglu and Gozum (2011)
stated in their systematic review that non-adherence is an important factor to those who have
uncontrolled HTN and the incidence of hypertensive complications. In a systematic review
and meta-analysis of Leelakanok, Holcombe, Lund, Gu and Schweizer (2017),
institutionalized people who has excessive polypharmacy are at a less risk of impact on
mortality than those living in the community.
2.1.1.13 Smoking
A meta-analysis by Guo et al., (2011) stated that the effects of smoking on Hypertension
is unclear with different contradicting studies. Sun et al. (2007) associated smoking with
prehypertension while Agyemang, Valkengoed, Born, & Stronks(2007) said that
prehypertensive and hypertensive subjects smoked less than those normotensive subjects.
However,smoking and hypertension was correlated by Dikalov et al. (2019), linking oxidative
stress caused by gmoking to developing Hypertension in the long run. Gupta, McGlone,
Greenway, & Johnson (2010) compared the risk of prehypertension between current smokers
and ex-smokers, and only found a slight variation. Erem, Hacihasanoglu, Kocak, Deger, &
Topbas (2008) correlated smoking with prehypertension and hypertension, emphasizing that
history of smoking is more prevalent in Hypertensive subjects than in prehypertensive
subjects.
2.1.2 Risk Factors of Health-Related Quality of Life (HRQoL) among Elderly with Hypertension
living in Long-Term Facility and Community
2.1.2.1 Falls
According to Gangavati et al. (2011), elderly living in the community with uncontrolled
hypertension and a drop of systolic blood pressure (SBP) upon standing are at greater risk of
falls. They also discussed that acute orthostatic drops in blood pressure in people with
hypertension when standing may lead to transient cerebral ischemia from diminished blood
flow to the brain that may exacerbate a chronic decrease in cerebral blood flow and
subsequently lead to falls. The study of Robinovitch et al., (2013) enumerated the causes of

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falls in elderly living in a long-term facility such as incorrect transfer or shifting of bodyweight
which is the most common. Tripping or stumble is the next most common cause, and slipping
being the least common. They also discussed the most common activity that leads to fall was
walking forward.
2.1.2.2 Frailty
According to Ricci, Pessoa, Ferrioli, Dias, & Perracini (2014), hypertension and frailty
syndrome adversely affect health and decreases the quality of life of people living in the
community. The same study also discussed having cardiovascular diseases (CVD) risk factors
such as hypertension is prevalent on being frail. Frailty and hypertension share risk factors
such as physical inactivity and inadequate nutritional status.
2.1.2.3 Depression
The study of Ma et al. (2015) regarding adults living in the community said that
hypertension has psychosomatic aspects and has been associated with depression which can
increase the risk of sudden cardiac death in subjects. People living in rural areas are mostly
people with little education and low income and rarely have medical insurance which they
cannot receive a prompt diagnosis which having poor health and mental status makes them
more prone to depression. Elderly who are divorced or widowed often feel lonely and does
not have any will to communicate with other people which exacerbates depression. Life events
which are unfortunate, poor sleep and loss of mental and physical activities increases the
loneliness, anxiety and depression in the elderly. Seitz, Purandare, & Conn (2010) described
the elderly in the long-term facilities that major depressive disorder and symptoms are
common to them.
2.1.1.4. Stroke
The study of Divani, Majidi, Barrett, Noorbaloochi, & Luft (2011) states that stroke is the
most frequent cause of adult disability and can cause a reduced quality of life that is frequent
in elderly with stroke. They also explained that having stroke can cause comorbidities such as
falling, urinary incontinence, sleep disturbances, depression, gait impairment and cognitive
deficits. They may worsen after stroke or develop over time.

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2.1.1.5 Dementia
Both hypertension and dementia are age-associated conditions and are responsible for
disability in community-dwelling adults (Ogunniyi et al., 2011). The same study also
discussed that having an increased risk of dementia that is associated with hypertension means
that more individuals are at risk of developing dementia as they age because blood pressure
increases with age. In addition, they explained that hypertension results in dementia and
cognitive decline through the promotion of arteriosclerosis and lipohyalinosis of small cerebral
vessels that results in ischemic lesions and increased volume of white matter hyperintensitites
in later life. Seitz, Purandare, & Conn (2010) stated that dementia are the most common
psychiatric disorders inside the Long-term facility, and it is a precipitant of Long-Term Care
admission.
2.1.2 Comparison of Health -Related Quality of Life (HRQoL) among elderly with hypertension
living in long-term facility and community
There is a lack of study comparing elderly with hypertension who is residing in long term
care facilities and elderly with hypertension who are community dwelling. However, there are
studies describing the health-related quality of life of old people residing in institutions same
with those who are still staying in their community. In Philippines, there’s only few studies
which describes the HRQOL of old people but not specifically have a hypertension.
According to Vanleerberghe, De Witte, Claes, Schalock, and Verté (2017) quality of life
was defined by Quality of Life Group of the World Health Organization as ‘‘individual’s
perception of his or her position in life in the context of the culture and value system where
they live, and in relation to their goals, expectations, standards and concerns’’. Health related
quality of life (HRQOL) is said to be a description of a person’s general health perception
which considers individual’s physical, mental and social aspect. Assessment of HRQOL is
very important particularly to patients dealing with chronic diseases such as hypertension
(Vanleerberghe et al., 2017; Lee, Kim, & Han, 2015; Halaweh, Willen, Grimby-Ekman, &
Svantesson, 2015)
Kostka and Jachimowicz (2010) claimed that elderly people have the fastest portion in the
growing population. It is also stated that demographic reports show that the segment of old

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people will continue to grow, and segment of very old individuals will grow faster
(Vanleerberghe et al., 2017). There is an inverse relation between the age and quality of life;
meaning as an individual age and acquired diseases such as hypertension, quality of life
decreases (Vagetti et al., 2014). A study by Mulasso, Roppolo and Rabaglietti (2014) stated
that chronic diseases have a negative effect on the HRQOL; these include hypertension,
osteoarthritis, diabetes, depression, and asthma. Poor health-related quality of life is more
expected on individuals with hypertension than those without hypertension, likewise, elderly
individuals with hypertension tends to have poorer HRQOL than those without hypertension
(Lee, Kim, & Han, 2015; Mulasso, Roppolo, & Rabaglietti, 2014; Lin et al., 2011)
There are lot of studies about Health-related Quality of Life of elderly but only few
discussed about community dwelling elderly. Studies have shown that engaging in physical
activities and self-efficacy promotes healthy aging and significantly improves quality of life
of elderly (Chui, 2018; Halaweh et al., 2015; Kostka & Jachimowicz, 2010). Good health and
participating in physical activities as well as interaction in the community is important in
improving quality of life (Chui, 2018). Previous researches have indicated that the older people
prefer to stay in a familiar environment, their household and community. They emphasized
that these have a significant effect on obtaining good quality of life (Chui, 2018;
Vanleerberghe et al., 2017). Some studies focused on elderly living on institutions but there
is an emphasis on a very common disease which is dementia.
Long term care facilities primarily give importance on improving and maintaining the
quality of life of the residents in terms of social, psychological and functional aspect of life, it
similar with home environment providing security, social support and physiological needs of
elderly (Roberts & Ishler, 2018; Klapwijk, Caljouw, Pieper, van der Steen, & Achterberg,
2016; Naylor et al., 2016; Luque-Reca, Pulido-Martos, Lopez-Zafra, & Augusto-Landa,
2015). It was stated by Luque-Reca (2015) that institutionalized older adults shows lower
HRQOL than those who reside at their homes, however according to Smit, de Lange,
Willemse, Twisk, and Pot (2016), those who are engaged in long term care facilities who are
receiving physical care and comfort in a cleaner environment demonstrates improved quality
of life. In the Philippines, there are very limited studies regarding the comparison between the
HRQOL of community dwelling elderly and those who live in long-term care facilities.

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2.2 Purpose of the Study

The objective of this study is to compare the HRQoL of elderly with hypertension living
in long-term facility vs. community. This study will benefit the following:
2.2.1 Physical Therapist

The Physical Therapist will benefit from this study by contributing to an Evidence Based
Practice by comparing the health-related quality of life among elderly with hypertension living
in long-term facility and community. If the study is successful, they will be able to share
knowledge and be able to prevent future comorbidities in terms in treating patients who are at
risk for hypertension. They will also be aware of the situations inside a community or a long-
term facility in which they can give attention and give immediate management.
2.2.2 Community-Dwelling Elderly
Community dwelling elderly with hypertension will benefit from this study. Prevention
and educational program should target hypertensive and non-hypertensive community dwell
elderly. It will help to improve their health quality of life as they live. Perhaps to also open
them to possibilities of having long term facility option.
2.2.3 Long Term Care Facility Elderly

Elderly living in long-term care facility can use this study to evaluate the effectiveness of
long-term care facilities on managing the impact of hypertension in their health-related quality
of life. This study also present different factors which help them on their decision-making on
choosing a long-term care facility suited for the current status of their disease.
2.2.4 Family/ Caregivers

Caregivers of the elderly with hypertension living in long-term care facility will benefit
from this study by having an appropriate and cost efficient assessment for the elderly with
hypertension and their quality of life, thus will have the ability to provide a more holistic
approach in caring for the subjects health and well-being. Family of the elderly with
hypertension who are community-dwelling will have a basis for assessing the subjects’ quality
of life in the community, will be able to compare it with the quality of life of hypertensive

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subjects living in long term care facilities, and decide what would be the best situation and
care for the subjects’ health and well being
2.2.5 Administrators of Long-Term Care Facility
The admins of long-term care facilities will benefit from this study by improving their
services and provide activities that will accommodate the problem regarding the hypertension
of the elders residing in their institution. Preventing the aggravation of the symptoms of
hypertension of the elderly is way more cost effective than treating hypertension that is already
in chronic phase. Better relationship with their clients and employees might also be established
due to the activities that they will provide.
2.2.6 Local Officials of Community

Local Officials of the Community can use the information in this study to develop a health
education program regarding the awareness of how hypertension can affect their lives
especially those who are elderly. They can also promote healthy habits to prevent or decrease
the risk of having hypertension and start a weekly exercise program to increase the quality of
life of people in the community. The local officials may also open the possibility of building
a facility that will be specially made to cater the elderly in the community.
2.3 Problem Statement

2.3.1 What are the characteristics of elderly in terms of:
2.3.1.1 Age
2.3.1.2 Sex
2.3.1.3 BMI
2.3.1.4 Hip-Waist Ratio
2.3.1.5 Diet
2.3.1.6 Family Hx of HTN
2.3.1.7 Diabetes
2.3.1.8 Loneliness
2.3.1.9 Smoking
2.3.1.10 Sleep Quality
2.3.1.11Chronic pain

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2.3.1.12 Occupation
2.3.1.13 Physical Activity
2.3.2 What is the subject’s level of Health-Related Quality of Life?
2.3.3 What is the relationship between Hypertension’s prognosticating factors and HrQoL?
2.3.4 What is the difference between the HrQoL of elderly with hypertension living in institutions
and elderly with hypertension living in community?
2.4 Hypothesis
This study hypothesizes that:
H1: Risk factors of Hypertension have no significant relationship with Health-Related quality of
life.
H2: Hypertension has no significant effect on Health-Related Quality of Life of Elderly living in
the Community and in Long Term Care Facilities.
2.5 Theoretical Framework

2.5.1 Age
In the Wear and Tear Theory as discussed by Jin, (2010), cells and tissues have vital parts
that will wear out resulting in aging. According to Sun (2015), aging in hypertension has a
decline in physiological function essential for survival and fertility. In correlation with Health-
Related Quality of Life (HRQoL), Buford (2016) stated health risks among adults with
hypertension are critical in having (1) cognitive decline and dementia, (2) functional decline
and physical disability, and (3) falls and fractures in which in the study of Carvalho, Siqueira,
Sousa, & Jardim, (2013) concluded that hypertensive people had a poorer HRQoL having
presence of comorbidities, target-organ damage, high heart rate and are old.

17
2.5.2 Diabetes
Cheung & Li (2012) discussed that insulin plays a role in development of hypertension
having the insulin secretion suppressed. Further explanation by Vanstone, Rewegan, Brundisini,
Dejean, & Giacomini, (2015) that physically people with diabetes often feel ill, experience
cognitive dysfunction, having difficulty maintaining their weight at a desired level and
experience flunctuating moods. Emotionally, people may feel anxious about their long-term
consequences of having diabetes and may also experience frustration, guilt and powerlessness
in their capability to control diabetes. Socially, they also experience several negative impacts
on their well-being including alienation, embarrassment and stigmatization.
2.5.3 Sleep Quality
The theory of the seasonal expression of the thrifty genotype is theorized to have evolved
to be expressed during seasons of high food availability to facilitate the deposition of fat reserves
through insulin resistance and other metabolic changes to prepare for later seasons of relative
food scarcity (Gangwisch, 2014). The authors discussed that poor sleep quality is positively
associated with hypertension having decreased Health-Related Quality of Life (Lo, Woo, Wong,
& Tam, 2018). They hypothesized that the connection of poor sleep quality to hypertension is
that having alterations in sleep quality/quantity leads to the loss of the nocturnal dip in BP which
is the first step toward the hypertension disease that is mainly attributable to an increase in
nocturnal sympathetic activity that leads to a permanent increase in sympathetic tone.
2.5.4 Gender
It is said that as the woman ages, and reaches the age of menopausal period, their risk for
developing hypertension increases because of hormonal changes and it’ll cause a decrease in
their health-related quality of life (Babatsikou, Zavitsanou, 2014). This can be correlated to the
mathematical principle of direct proportion wherein as something increases, another amount
increases at the same rate. According to Isiaho (2014), the Health Belief Model (HBM) gives
insights of the health outcomes of hypertensive patients on how the demographic factors such
as gender can affect whether they can control their hypertension or suffer its complications such

18
as increased heart rate, increased risk to developing comorbidities that can affect their quality
of life.
2.5.5 Polypharmacy
Leventhal’s Self-Regulation Model was used to improve the adherence to prescribed

medications for hypertensive elderly by blood-pressure monitoring and medication-taking
behavior that caused in a better quality of life and adherence to medication taken (Patton,
Hughes, Cadogan, Ryan, 2017).
2.5.6 Evolutionary Theories and Men’s Preferences for Women’s Waist-to-Hip Ratio
The ratio between the waist and the hips circumferences (Waist-to-Hip Ratio, or WHR) is
a physical characteristic often used as an example to show that evolution shaped human mate
preferences (Bovet, 2019). According to Koscinski (2014) waist-to-hip ratio (WHR) is
negatively related to the level of estradiol and positively related to the level of
testosterone, which is why WHR is clearly lower in women than men. High WHR values
in women are associated with mortality and many medical conditions, such as
cardiovascular diseases, type 2 diabetes, gall bladder disease, lung function impairment,
carcinomas, menstrual irregularity, anovulatory cycles, and subfertility (Singh &
Singh, 2011; WHO, 2011).
2.5.7 FMHx of HTN
The theory of polygenic inheritance refers to a single phenotypic trait which is controlled
by two or more genes. It also encompasses the polygenic threshold model which is considered
realistic based from acquired evidences and it generally acknowledges the assumption on
disease characteristics (Ott, 2015). Hypertension is considered as a polygenic disease, it can be
acquired genetically (Lindpaintner, 1993; Miyao 1978; Platt, 1963)
2.5.8 Occupation
Workaholic individuals tend to oversee and sacrificed their health because income is more
valuable than health especially for those who lived in a third world country including Philippines
(Banaag, Dayrit, & Mendoza, 2019; Blattman & Dercon, 2016). One of the components of the

19
Health Belief Model (HBM) is the demographic and socioeconomic variables which include
age, race, ethnicity, education, occupation and income, taking consideration of the
characteristics of the worker, job being performed, organizational structure and the total work
environment (Taylor, Bury, Campling, Carter, Garfied, Newbould, & Rennie, 2006; DeJoy,
1996). In the perspective of HBM, hypertension is included in the list of sick role behaviors that
should be monitored (Conner & Norman, 2007). It is the researchers’ opinionated statement that
unhealthy work habit and environment contributes to the aggravation of symptoms of the
individuals with hypertension.
2.5.9 Model of relationships between physical activity, self-efficacy, physical self-worth, disability
limitations, and quality of life
In the study of White, Wójcicki, & McAuley (2009) presented an expanded model in which
they show to relationship between QOL and physical activity which operates through self-
efficacy. The model indicates the relationship between physical activity driven by self-efficacy
reflects to its role as an indicator of QOL (White et al., 2009). The model presented in the study
supports the relationship between physical activity and QOL.
2.5.10 Item response theory model of HRQOL

The study Jiang & Hesserv (2009) of combined multiple results of different HRQOL model
and used Item response theory (IRT) to assess the association between each variable. IRT is
a special type of structural equation model that has been applied in educational measurement
with great success, it uses responses to a set of discrete items (indicators) to estimate latent
traits or latent variables that cannot be measured directly (Jiang & Hesser, 2009). The study
developed a model for overall HRQOL by using IRT and one of the strongest predictor for
poor HRQOL was obesity (Jiang & Hesser, 2009). The model in the study supports that obesity
is a strong predictor to a poor HRQOL.
2.5.11 Loneliness:
Vendegodt, Merrick, & Andersen (2003) correlated quality of life with self- actualization,
characterized by Health, happiness, and ability to function according to Maslow’s Heirarchy

20
of Needs published in his book Towards a Psychology of Being Maslow (1960). Following
the heirarchy of needs by Maslow, health, hapiness and ability to function would only be
achieved when one independently accomplishes the most basic needs first such as
physiological needs,The need of a safe residence, for peace of mind,the need to belong to
someone assurance of love the need for respect or to be acknowledged (Vendegodt, Merrick,
& Andersen, 2003).
2.5.12 Smoking
According to Newton’s third law (Hall, 2015), for every action, there is an equal and
opposite reaction. So if you are a chronic smoker, it’ll affect your body especially the heart
wherein, according to Leone (2015), nicotine and carbon monoxide gives a harmful effect on
the heart and blood vessels which cause the heart rate to increase as well as the systolic blood
pressure that will result in decreased health-related quality of life and increased hypertension.
2.5.13 Health-Related Quality of Life of Elderly in Long-Term Facility
According to an article in the webpage of Positive Psychology Center, University of

Pennsylvania, Quality of life is often associated with life satisfaction and happiness. One of
the most popular models is the PERMA model developed by Martin Seligman. PERMA
stands for the 5 building blocks that flourish life according to him, Positive emotion,
Engagement, Relationships, Meaning, and Accomplishment. Each of these building blocks
said to have a contribution to the well-being of a person.

21
2.5 Simulacrum
Age
Sex
BMI
Family history of
HTN
Diabetes
Loneliness Community-
Smoking Health-Related dwelling elderly
Quality of Life and Long-term care
Sleep quality R (+) D (-) facility elderly with
Chronic pain H1 H2 HTN
Occupation
Physical activity
Polypharmacy
Waist to Hip Ratio
Figure 1: Simulacrum
3.0 METHODS
2.2 Research Design
This study will use a Quantitative, Descriptive, Comparative, Research Design. The
purpose of descriptive research is to document the nature of a phenomenon through the
systematic collection of data, in which the data are collected by having participants complete
questionnaires or respond to interview queries (Carter, Lubinsky & Domholdt, 2011).
2.3 Site and Sampling
This study will be conducted in a nursing home and in a local community in Valenzuela
City. The sites were chosen because of availability and accessibility of the subjects.
A total of 42 Filipino adults with hypertension will be recruited to participate in the study.
The sample size was based on the 23.9% incidence rate (National Nutrition Council, 2015) of
hypertension among elderly at 95% confidence interval plus a 10% attrition rate using the EPI-
info formula.

22
The subjects will be selected purposively. To be included are elderly who are male or
female, ages 60-80 with hypertension living in a Long-Term Facility and Community for 5
years and above, should be clinically diagnosed or met the World Health Organization’s criteria
of Pre Hypertension (120-139/80-89 mmHg), Stage I (140-159/90-99 mmHg), and Stage II
(160mmHg/100mmHg or higher), must have an 25-30 score for Mini-Mental State Exam
(MMSE) which indicates normal, must be able to comprehend simple questions, able to follow
instructions and an informed consent to participate. Those with Mental Illness, Mild to Severe
Dementia (MMSE score of 24 or lower), not able to follow instructions and simple questions
will be excluded.
2.4 Research Instruments

2.4.1 Pittsburg Sleep Quality Index (PSQI) (Appendix C)
The Pittsburg Sleep Quality Index (PSQI) consists of 19 self-rated questions and five
questions rated by the bedpartner or roommate. The latter five questions are used for clinical
information only, are not tabulated in the scoring of the PSQI. The 19 self-rated questions
assess a wide variety of factors relating to sleep quality, including estimates of sleep duration
and latency and of the frequency and severity of specific sleep-related problems. These 19
items are grouped into seven component scores, each weighted equally on an O-3 scale. The
seven component scores are then summed to yield a global PSQI score, which has a range of
O-2 I; higher scores indicate worse sleep quality. A Systematic Review by Mollayeva et al.,
(2016) indicated that this test is the most valid, reliable and responsive measure of Sleep
Quality among elderly people.
2.4.2 Personal Demographic Sheet (Appendix B)

The Personal Demographic Sheet (PDS) is a valid and reliable tool to gather the subject’s
age and other risk factors of Hypertension. The confounding variables are based on the
Systematic Review by Bosu, Reilly, Aheto, & Zucchelli, (2019), Elperin et al., (2013),
Anchala et al., (2014), Naing & Aung (2014), Essouma et al., and Bosu et al., (2017).
2.4.3 Mini-Mental State Exam (MMSE) (Appendix D)

23
The Mini-Mental State Exam (MMSE) is a 30-item assessment of global cognitive status
that taps into domains such as orientation, concentration, attention, verbal learning (without
delayed recall), naming, and visuoconstruction having a score of 20-24 suggests mild
dementia, 13-20 suggest moderate dementia and less than 12 indicates severe dementia
(Chapman et al., 2016). A systematic review by Tsoi, Chan, Hirai, Wong, & Kwok, (2015),
indicated that this is the most frequent, reliable and responsive measure of dementia among
elderly people.
3.3.4 Verbal Descriptor Scales (VDS) (Appendix E)
Presence of knee OA pain will be measured by VDS. Verbal Descriptor Scales is derived
from the Present Pain Index, from the McGill Pain Questionnaire, patients choose the word
that best describes their pain from ‘‘no pain” to ‘‘extreme pain” (Chanques et al., 2010). A
systematic review Karcioglu, Topacoglu, Dikme, & Dikme (2018) stated that Verbal
Descriptor Scales (VDS) is reliable and valid appropriate tool for measuring pain intensity of
elderly.
3.3.5 International Physical Activity Questionnaire (IPAQ) (Appendix F)

IPAQ (short form) will be used to assess physical activity of the subjects. International
Physical Activity Questionnaire – Short form (IPAQ) is a self-reported questionnaire for
assessing physical activity and a useful tool for assessing physical activity among elderly
(Tomioka, Iwamoto, Saeki, & Okamoto, 2011). A systematic review Helmerhorst, Brage,
Warren, Besson, & Ekelund (2012) stated that IPAQ is a valid and reliable tool in measuring
physical activity of elderly.
3.3.6 UCLA Loneliness Scale (Appendix G)

The UCLA Loneliness Scale is a 20-item scale designed to measure one’s subjective
feelings of loneliness as well as feelings of social isolation. Participants rate each item as either
O (“I often feel this way”), S (“I sometimes feel this way”), R (“I rarely feel this way”), N (“I
never feel this way”) (Russell, 1996). A systematic review and meta-analysis Deckx, van den
Akker, & Buntinx, (2014) 8 of 13 used UCLA Loneliness scale, it is also stated that a
Crobach’s alpha was reported and all were > 0.70, which dictates to a good internal

24
consistency. It was also one of the most commonly used loneliness scales and they have been
proven to be reliable in a wide variety of populations, including older persons in good health,
with varying self-reported health, disabled and opiate dependent person and to be considered
as one of the strength of the study (Deckx et al., 2014). Russell, Peplau, and Cutrona (1980)
concluded that UCLA Loneliness Scale has high internal consistency Discriminant validity
and found to correlate more highly with other measures of loneliness.
3.3.7 MINNICHAL Questionnaire (Appendix H)

Mini Cuestionario de Calidad de Vida en Hipertensión Arterial (MINICHAL) (Soutello et
al., 2015; Oza, Patel, Malhotra, & Patel, 2014; Carvalho et al., 2012; Schulz, Rossignoli,
Correr, Fernández-Llimós, & de Toni, 2008) is a valid and reliable measure of Health related
quality of life (HrQoL) among hypertensive individuals. MINICHAL contains 17 item
questions and was developed in Spain in 2001. It consists of 2 domains mental (nine items)
and somatic (seven items). The mental domain includes questions one to nine and score ranges
from 0 to 27 points. The somatic domain includes questions 10 to 16 and score ranges from 0
to 21 points. Last question is related to the overall impact of hypertension on the QOL. The
score scale is Likert scale with four possible answers (0 = No, not at all; 1 = yes, somewhat; 2
= yes, a lot; 3 = yes, very much). Total points range from 0 (best level of health) to 51 (worst
level of health). A systematic review by Vagetti et al. (2014) and Schulz et al. (2008) indicated
that this test is the most valid, reliable and responsive measure of HrQoL specific to
hypertensive individuals.
2.5 Conduct of the Study

3.4.1 Preparation Phase
The objective of the preparation phase is to formulate a sound and feasible thesis
proposal. A review of literature was conducted to serve as background for the study.
Legitimate sources like PubMed, Ebscohost, and Google Scholar were searched using the
keywords Elderly, Hypertension, Community-dwelling, Long term care, and Health-related
quality of Life. The thesis proposal will then be drafted and revised based on the panel’s
feedback. The identification of prospective subjects and sites for the study including the

25
formulation of ICF (Appendix A), permission letters, and questionnaires will be done during
this phase.
3.4.2 Pilot Testing

The purpose of the pilot testing is to determine the conceptual equivalence of the Filipino
version of the MINICHAL Questionnaire, VDS, PSQI, UCLA Loneliness Scale, MMSE and
IPAQ. The researcher will translate the MINICHAL Q uestionnaire, VDS, PSQI, UCLA
Loneliness Scale, MMSE and IPAQ to English. A linguist without prior knowledge of
MINICHAL Questionnaire, VDS, PSQI, UCLA Loneliness Scale, MMSE and IPAQ will
translate Filipino Version of MINICHAL Questionnaire, VDS, PSQI, UCLA Loneliness
Scale, MMSE and IPAQ back to English. Another linguist also without prior knowledge of
MINICHAL Questionnaire, VDS, PSQI, UCLA Loneliness Scale, MMSE and IPAQ will
verify the accuracy of the translation.
The purpose of the pilot testing is to determine the clarity and understandability of Filipino
version of MINICHAL Questionnaire, VDS, PSQI, UCLA Loneliness Scale, MMSE and
IPAQ. 5 pilot test subjects meeting the study’s criteria will be asked to answer Filipino version
of MINICHAL Questionnaire, VDS, PSQI, UCLA Loneliness Scale, MMSE and IPAQ
individually. After the test, each will be asked to the feedbacks or comments on the
questionnaires. The objective of the pilot testing is to determine the reliability of the study’s
assessors.
3.4.3 Implementation Phase
The objective of the implementation is to identify prospective subjects. A letter asking

permission to conduct the study (Appendix I) will be sent personally by the researcher. The
request will be followed up after a week. Upon approval, all subjects will be briefed about
the purpose of the study. Those who will consent to participate will be asked to sign an ICF.
Those who will pre-qualify and consent to participate in the study will be asked to answer
MINICHAL Questionnaire.

26
2.6 Data Analysis

Descriptive statistics like mean, median and mode including statistical deviation will be
used to describe the subject’s characteristics. Correlational statistics like chi-square, pearson
and spearman rho will be used to determine the relationship between disease, risk factors and
quality of life. Levene’s test will be used to determine homogeneity of the subjects while
Kolmogorov-Smirnov test for normality. T- Test will be used to compare the health-related
quality of life of community-dwelling and long-term care facility elderly with hypertension.
All statistical levels of significance will be set at p <.05. Statistical Package for Social
Sciences (SPSS) version 21 will be used to analyze the data (International Business Machine
[IBM], 2019).
2.7 Potential Ethical Considerations

3.6.1 Beneficence
The researcher will ensure that the study will promote the welfare of other people and
maximum benefits of the participants while decreasing the possible risk that cause harm or
discomfort to the researcher’s subject. The significant of this study is not to bring harm or
discomfort to anyone but to contribute to the further improvement knowledge and learnings.
3.6.2 Non-Maleficence
This study will be done with well-established policies for the safety and protection of the
subjects in a way that the researcher will provide appropriate care to avoid further harm to the
subjects in order to have no doubt during the conduct of the study.
3.6.3 Veracity
The researchers should be truthful during the whole process of the study. The subjects will
be given informed consent and must have the knowledge regarding the nature of the study.
Information must be understandable and clear, not false, misleading, deceptive and unfair.
3.6.4 Justice

27
The subjects will be selected fairly to avoid inappropriate inclusion based on subjects’
attributes such as gender, age, race, language, ethnicity, social status and disability. The
researchers shall take into consideration fairness in terms of recruitment of research subjects
and the ideal location to conduct trials to eliminate issues who will benefit from the research
and the ones who are at risk. Subjects who are included in the study must not only be included
due to easy access, subject’s availability or subject’s vulnerability and lesser chances of
withdrawal to the study. Researchers shall ensure that trials are safe for potential subjects in
the study.
3.6.5 Autonomy
The autonomy of the subjects must be taken into consideration in the research study to be
made. In order to accumulate information from the subjects, an informed consent must be
made by the researcher such as written consent form. It should be an ongoing, interactive
dialogue between the researcher and the subjects. Disclosure of the information to the subjects
about the study and its effects before they confirm their voluntariness to the study and
agreement to the informed consent should be made. The researchers must ensure the
voluntariness of the subjects and no coercion was done to acquire the consent.
All subjects will sign an informed consent form (ICF) at the start of the study (Appendix
A). This study will undergo Ethics Review by the Institutional Ethics Review Committee.
OPERATIONAL DEFINITION OF TERMS
1. Community-Dwelling Elderly
Hypertension adversely affect health and decrease the quality of life of older people
(Ricci et al., 2014). It is an important risk factor for cardiovascular morbidity and mortality in
the elderly which requires an optimal control and persistent adherence to prescribed
medication to reduce the risks of cardiovascular, cerebrovascular and renal disease (Lionakis,
2012). To be included in this study are community-dwelling elderly who resides for 5 years
and above, should be clinically diagnosed or met the World Health Organization’s criteria of
Pre Hypertension (120-139/80-89 mmHg), Stage I (140-159/90-99 mmHg), and Stage II
(160mmHg/100mmHg or higher), must have an 25-30 score for Mini-Mental State Exam

28
(MMSE) which indicates normal, must be able to comprehend simple questions, able to follow
instructions and an informed consent to participate. Those with Mental Illness, Mild to Severe
Dementia (MMSE score of 24 or lower), not able to follow instructions and simple questions
will be excluded.
2. Long-Term Facility Elderly

Subjects who are living in a nursing home or long-term care facility for 5 years or older
and is clinically diagnosed with hypertension that are in the category of prehypertension (120-
139mmHg SBP and 80-89mmHg DBP), Stage 1 (140-159mmHg SBP and 90-99mmHg DBP),
and Stage 2 (≥160mmHg SBP and ≥100mmHg DBP). These elderly people are aging 65 and
above, msut have an MMSE score of 25-30 as normal, able to comprehend simple questions,
able to follow instructions and has an informed consent to participate. They should not be
diagnosed with any mental illness or mild to severe dementia (MMSE score of ≤24).
3. Hypertension
Hypertension can be diagnosed if the average Blood Pressure taken on two or more
separate days has a Systolic blood pressure 120–139 mmHg and a Diastolic blood pressure of
80–89 mmHg for Prehypertension, Systolic pressure of 140-159 mmHg and Diastolic pressure
of 90-99 mmHg for Stage 1, a Systolic blood pressure equal to or more than 160mmHg and a
Diastolic pressure equal to or more than 100mmHg for Stage 2(WHO 2017). WHO (2017)
emphasized that although Hypertension usually have no other symptoms other than elevated
blood pressure, some individuals exhibit symptoms such as headache, palpitation, and excess
sweating. Secondary Hypertension is caused by other diseases such as Hyperaldosteronism,
Cushing syndrome, Pheochromocytoma, Thyroid diseases,Renal parenchymal diseases, Renal
artery stenosis, and Sleep apnea(Jordan, Kurschat, & Reuter, 2018).
4. Health-Related Quality of Life

There are disease specific instruments that were designed to assess and measure the HrQoL
in well-defined populations (Makai, Brouwer, Koopmanschap, Stolk, & Nieboer, 2014).

29
HrQoL was operationally defined by using the MINICHAL Questionnaire. The MINICHAL
is a multiple-choice questionnaire used to assess subjects’ perception of how hypertension and
its treatment affect his/her quality of life (Schulz, Rossignoli, Correr, Fernández-Llimós, & de
Toni, 2008). There are two domains, domain total scores are inversely proportional to the
HrQoL which means higher scores denotes lower health related quality of life (Oza, Patel,
Malhotra, & Patel, 2014).
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APPENDIX A

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51

52

53

54

55

56
APPENDIX B

57
APPENDIX C

58

59

60

61

62

63

64
APPENDIX D

65
APPENDIX E

66
APPENDIX F

67

68

69

70

71

APPENDIX G

APPENDIX H

APPENDIX E
ASSESSMENT TOOL CRITIQUE FORM
GENERAL INFORMATION
Title of Tool  MINICHAL – Mini-questionnaire of Quality of Life
in Hypertension (Brazilian Version)
Author  Schulz et al.
Time Required  5 to 10 minutes
to administer the test
Materials Required  Pen and Questionnaire
Cost  Free Cost

TEST DESCRIPTION
Purpose of the Test
 To evaluate the impairment of the quality of life of
persons with hypertension in their somatic and
mental domains
 Measure of health-related quality of life (HRQoL) is
relevant for the investigation and evaluation of the
health of individuals
 The instruments used to measure quality of life are
useful methods of transforming subjective
measurements into objective data that can be
quantified and analyzed, and are also important for
assessing the impact of health care interventions on
patients’ HRQoL
Target Population People with hypertension.
Domains Measured  Mental Status dimension
 Somatic Manifestation dimension
Item Description MINICHAL Brazil contains seventeen items grouped into
two domains.
 Mental state (items 1-9)
-the maximum scoring is 27 points.

 Somatic manifestations (items 10 to 16)
-with a maximum scoring of 21 points.
-The original version in Spanish and the Brazilian version

include an additional item, number 17, concerning the
overall impact of hypertension in the QOL of the patient.
-This item, as it contains a general qualitative question, does
not enter the sum of the scores in the CTT (Borges et al.,
2017).
PRACTICAL ASSESSMENT
Ease of administration Administration are easy since the questions can be easily
understood by the patient and their answers can be written
or orally answered. The answers are based on self-report of
the patient.
The MINICHAL has been originally developed to be a self-

administered questionnaire.
-because of the low educational level of the patients, the

instrument was administered by means of a structured
interview (Melchoirs et al., 2009)
Clarity of directions Patients are asked to answer questions through:
 Self-administered paper questionnaire (PQ)

 In-person interview
This application had no negative impacts; on the contrary, it
allowed the use of the instrument by persons with low
schooling.
Scoring & Interpretation Scoring
The answers in the domains are distributed on a Likert-type

frequency scale (0 = no, absolutely; 1 = yes, a little; 2 = yes,

enough; 3 = yes, a lot) (Schulz, 2008)
Thus, using the CTT, the domain of mental status has a

score between zero (best quality of life) and 27 (worst
quality of life) points, while the domain of somatic
manifestations has a score between zero (best quality of life)
and 18 (worst quality of life) points.
Interpretation
-According to this scale, the closer the result is to 0 (zero),

the better the quality of life.
Examiner qualifications & training No need
PSYCHOMETRIC PROPERTIES
Validity  Construct Validity
The construct validity of the Brazilian version of

MINICHAL was verified by means of the assessment of
known groups.
It has been hypothesized that hypertensive patients with

symptoms (dyspnea, chest pain, presyncope, palpitations
and headache), TOD and high risk for cardiovascular events
would have a significantly higher HRQoL score than
hypertensive patients with no complications, i.e., with no
symptoms, no TOD, and at a low risk for cardiovascular
events, according to international guidelines.
Significantly higher HRQoL scores were observed among

those with renal damage in comparison to hypertensive
patients with preserved renal function, as regards the
Somatic Manifestations dimension and total MINICHAL
score. However, no significant difference was observed in

the comparison of HRQoL scores between patients with or

without LVH, as well as between those with and without
diastolic dysfunction and/or hypertensive retinopathy
(Soutello et al., 2015).
Reliability  Internal Consistency Reliabity
The analysis of the internal consistency of MINICHAL –

BRASIL revealed an alpha value of 0.88 for Mental Status
and 0.86 for Somatic Manifestations, a result very close to
that of the original SPANISH MINICHAL in which the α
value for Mental Status was 0.87 and the α value for
Somatic Manifestations was 0.75. (Schulz et al., 2008)
 Test-retest Reliablity
The reliability of the MINICHAL (Brasil) instrument was

tested using Cronbach’s alpha coefficient for internal
consistency analysis. This coefficient ranges from 0 to 1 and
the greater the value, the better the reliability. The analysis
was carried out for both factors (Mental Status and Somatic
Manifestations)
Responsiveness This study allowed us to conclude that the reliability and
validity aspects of the portuguese version of MINICHAL
are adequate for its utilization as a quality of life
assessment instrument in hypertensive adults. This
instrument can be used both for population-based studies
and clinical trials to assess a patient’s quality of life
OTHER CONSIDERATIONS
Culture-Fair Evaluation Language has to be culturally and conceptually adapted
so as to bring it as close as possible to the context of

the population of interest. Particularly in the case of

Brazil, regional, social and cultural differences, low
level of schooling, and high prevalence of functional
illiterates make this task even more difficult (Schulz et
al.,2008)
Disability-Fair Evaluation This application had no negative impacts; on the
contrary, it allowed the use of the instrument by
persons with low schooling (Borges et al., 2017)
Strengths
- The major strengths of the MINICHAL are this
measurement instrument has been well validated,
has good reliability
-The translation into brazilian portuguese and

validation of a specific questionnaire such as
MINICHAL make it a feasible instrument that can be
used not only in research, but also in clinical practice
to assess quality of life in hypertension.
Weaknesses
Relation to limitations, the MINICHAL did not provide

information that qualified persons with very high quality of
life. In addition, there is the need to create a digital platform
so that it can be used in future research studies (Borges et al.,
The construction of an interpretation for each level of the

scale seems to fill the gap in studies that measure health
behavior, which goes beyond the responses commonly
provided by instruments of quality


APPENDIX I

APPENDIX J
(Letters)

APPENDIX K
(Curriculum vitaes)

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COMPARISON OF HEALTH-RELATED QUALITY…

Keywords: Hypertension, Long-Term Facility Elderly, Community-Dwelling Elderly, Health-

OUR LADY OF FATIMA UNIVERSITY COLLEGE OF PHYSICAL THERAPY

OUR LADY OF FATIMA UNIVERSITY COLLEGE OF PHYSICAL THERAPY

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Welsh, Gladman, Gordon (2014) concluded that there is no guarantee of improvement of

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2.1 Literature Review

2.1.1.2 Family History of Hypertension

2.1.1.3 Body Mass Index

2.1.1.4 Waist to Hip Ratio

OUR LADY OF FATIMA UNIVERSITY COLLEGE OF PHYSICAL THERAPY

2.1.1.5 Knee Osteoarthritis Pain

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2.1.1.8 Poor sleep quality

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2.1.1.12 Physical Activity

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2.2 Purpose of the Study

2.2.1 Physical Therapist

2.2.2 Community-Dwelling Elderly

2.2.3 Long Term Care Facility Elderly

2.2.4 Family/ Caregivers

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2.2.5 Administrators of Long-Term Care Facility

2.2.6 Local Officials of Community

2.3 Problem Statement

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This study hypothesizes that:

2.5 Theoretical Framework

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2.5.3 Sleep Quality

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Leventhal’s Self-Regulation Model was used to improve the adherence to prescribed

2.5.7 FMHx of HTN

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2.5.10 Item response theory model of HRQOL

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2.5.13 Health-Related Quality of Life of Elderly in Long-Term Facility

According to an article in the webpage of Positive Psychology Center, University of

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2.3 Site and Sampling

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2.4 Research Instruments

2.4.2 Personal Demographic Sheet (Appendix B)

2.4.3 Mini-Mental State Exam (MMSE) (Appendix D)

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3.3.4 Verbal Descriptor Scales (VDS) (Appendix E)

3.3.5 International Physical Activity Questionnaire (IPAQ) (Appendix F)

3.3.6 UCLA Loneliness Scale (Appendix G)

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3.3.7 MINNICHAL Questionnaire (Appendix H)

2.5 Conduct of the Study

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3.4.2 Pilot Testing

3.4.3 Implementation Phase

The objective of the implementation is to identify prospective subjects. A letter asking

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2.6 Data Analysis

2.7 Potential Ethical Considerations