ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL
Mental health of the elderly: perceptions related to aging
Salud mental del anciano: percepciones relacionadas con el envejecimiento
Saúde mental do Idoso: percepções relacionadas ao envelhecimento
Lais Soares Vello1; Maria Alice Ornellas Pereira2; Regina Célia Popim3
1RN. UNIMED, Piracicaba/SP. Brazil. email: firstname.lastname@example.org.
2RN, Specialist. Professor, Universidade Estadual Paulista UNESP, Brazil. email: email@example.com.
3RN, Ph.D. Professor, UNESP, Brazil. email: firstname.lastname@example.org.
Receipt date: Aug 9, 2012. Approval date: Oct 7, 2013
Article linked to research: Mental Health of the Elderly: perceptions related to aging at the interface with primary healthcare.
Conflicts of interest: none.
How to cite this article: Vello LS, Pereira MAO, Popim RC. Mental health of the elderly: perceptions related to aging. Invest Educ Enferm. 2014;32(1): 60-68.
Objective. To understand the elderly's perception of their current condition. Methodology. Study undertaken in 2012 using the qualitative method of Minayo and the thematic analysis according to Bardin's suggestions. Data were collected through semi-structured interviews that took place in the homes of the elderly people. The guiding question was: At this point in your life, how do you feel? Tell me. Results. The elderly who were satisfied stated that this was due to the good relationship with their family, spouse, to the fact of having autonomy and respect from the society. Those who were shown to be dissatisfied reported lack of family support, physical limitations imposed by age and the presence of illnesses as the main causes. Conclusion. The adult population requires the use of care technologies that cover all the stages of life, including old age. Nursing professionals should be prepared for the increasing care demand of these people.
Key words: aged; mental health; primary health care; qualitative research.
Objetivo. Comprender cómo el anciano percibe su condición en ese momento de su vida. Metodología. En 2012 se realizó un estudio en el que se empleó el método cualitativo, según Minayo, y se hizo análisis temático de acuerdo las indicaciones sugeridas por Bardin. La información fue recolectada de entrevistas semiestruturadas realizadas en las viviendas de los ancianos. La pregunta orientadora fue: ¿cómo se siente en este momento de su vida? Cuénteme. Resultados. Los ancianos satisfechos atribuyeron ese sentimiento a la buena convivencia con la familia, con el cónyuge, al hecho de tener autonomía y respeto por parte de la sociedad. Los que se mostraron insatisfechos, relataron falta de apoyo de la familia, limitaciones físicas propias de la edad y la presencia de enfermedades. Conclusión. La población adulta exige para su atención la utilización de tecnologías de cuidado que contemple todas las etapas de la vida, incluyendo la vejez. Los profesionales de enfermería deben estar preparados para la creciente demanda de cuidado de estas personas.
Palabras clave: anciano; salud mental; atención primaria de salud; investigación cualitativa.
Objetivo. Compreender como o ancião percebe sua condição nesse momento da sua vida. Metodologia. Em 2012 se realizou um estudo no que se empregou o método qualitativo segundo Minayo e se fez análise temática segundo as indicações sugeridas por Bardin. A informação foi coletada de entrevistas semiestruturadas realizadas nas moradias dos anciãos. A pergunta orientadora foi: Neste momento da sua vida, como se sente? Conte-me. Resultados. Os anciãos satisfeitos atribuíram esse sentimento à boa convivência com a família, com o cônjuge, ao fato de ter autonomia e respeito da sociedade. Os que se mostraram insatisfeitos relataram falta de apoio da família, limitações físicas próprias da idade e a presença de doenças como principais queixas. Conclusão. A população adulta exige para seu atendimento a utilização de tecnologias de cuidado que contemple todas as etapas da vida, incluindo a velhice. Os profissionais de enfermagem devem estar preparados para a crescente demanda de cuidado destas pessoas.
Palavras chaves: idoso; saúde mental; atenção primária à saúde; pesquisa qualitativa.
The Brazilian population is going through a deep socioeconomic transformation resulting from demographic changes. Between 1940 and 2010, mortality rates started to fall, especially among young adults and children, and life expectancy at birth rose from 50 to approximately 73 years of age. The speed of population aging in Brazil will be significantly faster than that in the most developed societies in the last century.1 The aging process in the developed countries is connected to the services in the healthcare system, housing conditions, sanitation, work and food; in Brazil, this happens rapidly and in a context of social inequalities, weak economy, increasing poverty levels, with precarious access to healthcare services and reduced financial resources.2
This rapid growth of the Brazilian elderly population has required the development of strategies and policies aimed at the promotion of healthy aging and guarantee of human rights, since the population aging makes the problems that were considered "silent" more apparent, such as violence against the elderly. The aging of the population increases the size of this violence and makes it necessary to adjust the public services to the healthcare of this population group, in order to add dignity and quality of life to the years experienced.3 From the collective healthcare perspective, violence is not inherent; it is a complex social event that can be prevented and its approach requires a systemic-ecologic focus, covering the individual, family, community and society scopes as a whole, with public policies and specific coping strategies for each level of approach.4
Taking into consideration the execution of the necessary Health Policies since 1994 in Brazil, laws directed to the elderly population have been developed, emphasizing the particularities of the healthcare and social inclusion in the Elderly National Policy and the Elderly Statute; the concern with the violence problem in the Elderly National Healthcare Policy, in the National Policy for Reduction of Morbidity and Mortality from Accidents and Violence and in the Health Pact; these policies recommend integral healthcare to the elderly in all levels of care, the rehabilitation and social, family and community integration, the human resources training in the areas more directly related to the elderly and the support to studies and researches.3
The increasing demand for healthcare systems on the part of the elderly indicates the need for restructuring primary healthcare, being the government's responsibility to develop policies and make decisions to follow up healthcare actions and meeting the needs of the population. These epidemiological studies are essential to identity priority issues with the purpose of guiding decision related to the definition of priority, thus allowing to better direct healthcare initiatives and avoiding unnecessary expenses.5 It is a challenge for the training schools to educate healthcare professionals taking into account the aging of the population and the focus should be the development of specific healthcare skills for the elderly in a systematic way, in order to achieve care integrality, interdisciplinary and inter-sectorality.6
The nursing professional, as a member of the multiprofessional team, must be aware of the healthcare needs of the population. They should be the guide to healthcare actions, being required to master the instruments for assessing needs. When reaching old age, the elderly may be independent or weak, being the community therapy highlighted as a time for sharing and promote the mental health of the elderly.7 Some people may present psychiatric conditions that are common in this age group. Generally, such mental damages include dementia, depressive states or psychotic disorders that have a late start. However, there are also cases in which the disorder started in a young age and the person got to old age with it, for example, schizophrenia, affective bipolar disorder, dysthymia and anxiety disorders.7
The elderly who are victims of violence can present a mental illness condition, most often in a residual stage and thus they are also part of the group that is more vulnerable to violence due to their dependence on their caregivers. Several authors have highlighted the association between violence and the occurrence of psychiatric conditions, especially depression.3 It is evident that the shared care of the elderly should be mainly based on the family and the primary healthcare through the Primary Healthcare Units (PHU), particularly under the family health strategy, which must ideally represent to the elderly the link with the healthcare system.7 For public health, the population aging is one of the biggest challenges, however, it is important to emphasize that this demographic transition reflects improvements for the state and for society, since this population aging is the result of fertility reduction, childhood mortality and elderly mortality.2 This requires the formation of professionals based on the care to the needs of the elderly as a whole. On the other hand, a study undertaken in Sao Paulo city showed the great difficulty of healthcare professionals working in primary healthcare resulting from the lack of standardized instruments for assessing healthcare needs applicable in the Family Health Strategy.8
There are six priorities in the Life Defense Pact, but three of them stand out in relation to the health of the population over 60 years of age. These priorities involve the health of the elderly, the promotion of health and the strengthening of the Primary Healthcare (PH). In this context, Elderly National Healthcare Policy reinforces that the primary healthcare should be the avenue for initial insertion of the elderly into the healthcare services of the Unified Health System (SUS) and can rely on the specialized healthcare services network involving medium and high complexity.9 On the other hand, the National Policy for Health Promotion has implementation strategies that should guide the actions planned by the PH professionals with the purpose of better assisting the elderly, in particular. Above all, the PH National Policy informs that the actions can be developed through democratic and participative management and sanitation practices based on teamwork.6 The professionals working in primary healthcare, in particular nurses as members of the healthcare team, need to clearly see the importance of keeping the elderly within the family daily life and within the life in the community as essential factors for keeping their physical and mental balance.
Viewing and defending the presence of the elderly within the family and the society in a happy way as essential is one of the important missions for those who embrace the proposal of a resolute, integral and humanized primary care. They should not accept only the longevity of the human being as the main achievement of modern society, but that this human being have guaranteed a quality life, happiness and active participation in their environment. Therefore, the "things of the age" should not be seen as a determination but as possibility.9 The healthcare initiatives developed by the professionals working in the Family Health Strategy (FHS) need to overcome the old proposition exclusively centered in the disease, using democratic and participative management and sanitation practices directed at defined populations for which they are responsible. This requires that the family healthcare professionals are prepared to deal with the aging in order to stop the fragmentation of work processes and establish a relationship with the elderly whilst recognizing their experience and wisdom.6 Without a doubt, Brazil is about to face great challenges, in which public policies should prioritize the maintenance of the elderly's functional capacity, monitoring their health conditions through preventive and differentiated health and education actions based on qualified and integral care. Issues related to the exclusion of these people, often from the family context, are present in the daily life of communities and healthcare services. Based on these considerations, this research was aimed at understanding the elderly's perception of their current condition.
The research has a qualitative nature which is, according to Minayo,10 understood as that one which is capable of incorporating the meaning and intentionality issues as part of the acts, relationships and social structures. This study was carried out in a Family Health Strategy unit located in the outskirts of a country town in the state of Sao Paulo. The suburb where this unit is located has a low income population with complex family networks. It could be observed that a large number of elderly people use psychiatric drugs, with a high depression rate. The unit has three healthcare teams. Each team is composed of a doctor, a nurse, three nursing assistants, four health community agents (HCA), a dentist, a dental assistant, an administrative assistant and a cleaning assistant. The unit counts with the matrix support of the mental healthcare team.
The choice of subjects was conducted through a contact made by the researcher with the professionals working at the Family Health Strategy. Thirteen subjects were interviewed, aged 70 years or over, assisted at the service, with a diagnosis related to mental health and who, at the time of the interview, had conditions to answer the proposed questions. The saturation criteria established by Minayo10 was used. After the positive evaluation of the Research Ethics Committee of the School of Medicine, number 3555-2010, the interviews were conducted through home visits (HV), based on indications from the Health Community Agents and other professionals of the unit. After this stage, semi structured interviews were conducted. In these, after the identification information (gender, age, marital status, number of children, who they live with, if they receive any government payments), a recording device was used with the following guiding question: At this point in your life, how do you feel? Tell me. Initially, a test interview was conducted in order to test the instrument and perform the necessary changes. Thus, the interviews were conducted in September 2011 at the subjects' homes and, for such, the researcher was accompanied by the Community Agent. The interviews lasted from 10 to 20 minutes in average, and the researcher was welcomed by the subjects and their family members and/or caregiver in all the homes.
Data collected in the interviews were transcribed by the researcher. Next, the Floating Attention10 was used; in this, the researcher reads the text obtained several times with the purpose of establishing the best possible contact with the material, being impregnated by its contents. In the next stage, the thematic analysis proposed by BARDIN was used. This author states that the thematic analysis involves discovering the core meaning that composes the communication and which presence or frequency may mean something for the chosen analytical objective.11 From this perspective, the thematic analysis follows the following organizational stages: pre-analysis, exploration of material, handling of results, conclusion and interpretation.
For data collection, thirteen subjects were interviewed, among them nine women and four men. The age ranged from seventy to ninety years and, among them, eight subjects were between seventy and seventy nine. Concerning marital status, eight are married and five were widowed. In relation to living arrangements, two live alone, eight live with their partners, one lives with a niece, and only two with their children. The interviews resulted in reports rich of meanings, allowing the capture of the themes Satisfaction resulting from Well-being and Dissatisfaction resulting from Losses and Neglect, as per the descriptions below.
Satisfaction with life
The satisfaction, the Well-Being is evidenced by a family reunion, exchange of affections and feeling of belonging to a group: Then, we are proud, the family is gathered, when it is someone's birthday, everyone comes… there is nothing that gets in the way (E9). There is expression of pride for having built, throughout life, their own family units: I had a block of land here that I sold to pay my son's debts,… We have been living here for 40 years, there is nothing to complain about (E7). The subjects put into words the celebration of life, honoring the time experienced, and they remind other times that are past: Ah, I think it is happy to reach this age, because I have a brother who is eighteen years younger than me and he has already died (E10), the well-being is expressed for having the company of their children, the leisure and the condition of being able to come and go, move around. All these factors are listed as important: I go out and around, go out with my children, from one place to another… (E12). We did what we could, we fought in life, because I raised seven children… (E9).
The feeling of well-being is also related to the religiosity of the elderly, and the religious practices and beliefs decisively contribute to well-being in old age: Well, thank God (E12), because my life is not bad, life is good, isn't it? Thank God. There is always a little problem but it goes away, doesn't it? Being satisfied with life, being inserted into a family unit, exchanging affections with others, contribute for the elderly to overcome the difficult moments, and to deal with the losses imposed by life itself better: Yes, thank God. God is good (E2), God took him (the husband), didn't he? My children, thank God, are well. Each one has their own jobs (E6).
Dissatisfaction with life
The losses and abandonment experienced are shown as factors of dissatisfaction with life: I don't feel very well, I'm always sick, always sick, laughs (E3). The clear expression of the limitations imposed by age and aggravated by pathologies in old age: It is bad, I was not bad like this (E5), until here, what mostly kills me, apart from the death of the man, is diabetes, because I cannot eat for the fear of being eating this, eating that, and pain in the joint that burns here in the ribs (E13). The elderly reveal to suffer with the losses throughout chronologic life but, at the same time, reveal to face the limitations with a large range of coping strategies: Because we get sad, and we worked, always got out and now got retired and stay more at home. And also I can no longer work (E1). We have a father, a mother, a father-in-law, a mother-in-law; and then, when we reach this age, we have nothing else (E2).
Many people state that they are bothered by the physical limitations imposed by age: I'm upset, because I cannot do anything anymore, I don't do anything anymore, I depend for everything, even food they give me like this, hold like this, give in my hands, I cannot bear standing up next to a sink to clean up the kitchen… (E6). They remember with nostalgia a time they lived, a better time than the current one: What is missing is when the children were all together, it was nicer, all little ones. Now, the concerns are different (E10). There is also the comparison between the young body and the old one, the latter in a worse situation, uglier and with more limitations: because the good thing about our life, I think, it is when we are young, to get out, isn't it, to have a boyfriend…(E13).
Some of the elderly report feeling abandoned by the family, revealing a feeling of not belonging, of rupture with the family unit: …they [grandchildren] do not care about me, I have them but it is the same as not having them, who don't come to see me, don't show up (E5). There is a disappointment expression in relation to the family they built, the lack of relationship and exchange of affection with its members: The worse in the story is this, because until now, I will tell you the truth, nobody from my family came to bring me anything (E13). You start alone, you end up alone (E11).
In relation to the theme Satisfaction with Life, Well-Being, it can be observed that in the Hispanic literature, any reference to concepts of quality of life such as happiness, well-being and health, are necessarily linked with social and economic well-being.12 The subjects heard, while referring to quality of life, expressed the feeling of well-being with their own current life situation, showing satisfaction in having the family together, the exchange of affections, and the feeling of belonging to the group.
The correlation between social health and family structure expresses that the family represents both a social support for the elderly and a concern of well-being with the members of the family, that is, they tend to define healthy aging as the ability to envisage a broad well-being of their children and relatives, observing emotional, physical and financial aspects,13 which is represented when the interviewee expresses that the family unit is their pride among the constructions built in the course of their lives. It is within the family environment that the ethical and humanitarian values are incorporated, and where the solidarity relationships are deepened. It is also within the family that the marks are built across generations and the cultural values are found.14
In our daily lives, the meaning of family seems clear, taking into account that most people are part of a family unit. However, the family is presented under the most varied types of support.15 It could be noted that some subjects reported the importance of celebrating life, honored past experiences and remembered the others who had already gone. And once again, the subjects expressed how much their children's company, the search for leisure and the condition of being able to move are important for the preservation of the well-being. A positive attitude of the family in relation to the elderly is essential: firstly, it is necessary to note that many elderly people do not have a family or even if they have it, they do not have much contact with them; in this case, the whole society is responsible for the elderly.14 On the other hand, the importance of social interaction through groups which promote recreational and sociocultural activities in the community contribute to the insertion, socialization, learning and mutual exchanges, enabling elderly people to expand their own lifestyle.
In the field of Public Policies, another basic social protection developed by the Social Assistance policy, and which indirectly benefits the elderly, is the Integral Care for Families Program (ICFP), undertaken in cities and called Family Homes, with the purpose of supporting, interacting, socializing and stimulating the social participation of the families and their members. The Social Assistance, for dealing with issues related to violence against the elderly, includes community centers, homes, shelters, day and night care centers, home visits, articulating the other public policies.16 The feeling of well-being may result from the religiosity/spirituality of the elderly. In Brazil, 99% of adults declared to believe in God.14 Religiosity has a central place in the lives of a large number of elderly people, since the increase of spirituality with age is an important source of emotional support, with repercussions in the physical and mental health areas. Religious practices and beliefs seem to crucially contribute to well-being in old age,16-17 as observed in many statements.
Belonging to a group brings psychosocial support that can promote health. Religion may provide social cohesion and a sense of belonging to a group. The exchange of affection and continuity in the relationship between friends, family members and support groups, bring satisfaction to the elderly with advancing of age.18 A person with religious orientation is spiritually more confident and has more comfort and distraction.19 It could be noted that higher levels of religious involvement are positively associated with indicators of psychological well-being (satisfaction with life, happiness, positive affection and higher moral) and less depression, suicidal thoughts and behaviors, use/abuse of alcohol/drugs. Thus, there is sufficient evidence available to affirm that religious involvement is usually associated with better mental health.18,19
It can also be noted that, after difficult times, the elderly were able to cope with the losses imposed by life, holding on to a bigger force. Old age is a complex social and vital event, determined by the course of life and by the experiences and sociocultural and historical opportunities gathered throughout life. Old age and aging are not synonyms of sickness, inactivity and development contraction.20 In regards to to the theme dissatisfaction with life, the losses and abandonment were related. It could be noted that loneliness causes a feeling of inner emptiness that can be present in the human being in different stages of life and tends to be more frequent with aging. The past experiences, the passing of time and with it, the restrictions imposed, contributed to some reports which point out dissatisfaction with the situation experienced, bringing feelings of loss or abandonment.18
The situations that lead to abandonment are caused by the fragile condition of the elderly, who may depend on other people due to the loss of autonomy and independence, the extinction of affective connections and the conduct of the relationship group or its absence, which prevents the person to live and fully interact and remain within the family, the group and the culture. This situation breaks up the vital contact with the world, promotes the body inertia and takes away the possibility of being and knowing.20 It could be noted in some of the statements the unhappiness with the limitations resulting from old age.
Quality of life and satisfaction in old age have often been associated with the issues of dependence and autonomy, being important to distinguish the "age effects". Some people have their health conditions and their cognitive abilities precociously worsen, while others live a healthy life until very advanced ages, as seeing in some previous reports the dissatisfaction with acquired diseases. The elderly deal very well with the stress caused by losses, that is, the elderly are generally more efficient than younger adults in relation to coping with stress. The explanation for this fact is that, in aging, the elderly have a larger number of coping mechanisms they experienced in the course of their lives, and also these become more effective over the years.20,21
However, this does not guarantee that the elderly do not suffer, which may explain their susceptibility to depression. There are also those who are bothered by the limitations imposed by age, the difficulty in readapting and the acceptance of the new conditions of life, and they miss what they lived. The society expects eternal youth, because we live in a time in which the growth of the services in the body care industry, that goes from cosmetics to plastic surgery, from food supplements to physical exercise, promise to delay the effects of time or, at least, some of the most notorious brands. As a consequence, the dissatisfaction felt by some older people in relation to their own bodies may be related to certain restrictions and the reduction of body functions, as well as to the concept that an old body is an ugly body. Some people complain that their bodies are no longer attractive, leaving only sadness and memories of a seductive time.20
Some of them report feeling abandoned by their families. The family is the human being's natural way of insertion. When there is absence or disruption of this insertion, the elderly experience a situation of not belonging, they feel ignored, unvalued and excluded. The abandonment is felt as being lonely among others, it is not being well, not having anyone's help, walking from one side to the other. It is to have a family and not being protected by them, forgotten, isolated, indifferent, not being valued and noted.19 When domestic violence is considered, it is common to think about physical aggressions, but violence can be defined as the actions or omissions that affect the emotional and physical integrity of the victim. Many family members abandon, neglect, commit psychological violence, but do not allow the elderly to leave their homes because they become an extra income for the family, thus the family explore their financial resources and the human beings themselves.21 The fact of having formed a family did not guarantee to the elderly the family company at the present time and the disappointment they currently feel can be noted through their statements. For many of them, death is the biggest loss. Accepting the limit imposed by death as a daily experience requires accepting the rules of existence, given that death imposes a break up with everything that is known and loved and is part of the human condition.21
To conclude, the study showed the need for investments in resources for social and health policies directed to this population and training of professionals to understand the new family structure and provide them with support, creation of new urban equipment, services and inclusion programs for the elderly. In particular, the chances of the professional nurses, as members of the interdisciplinary team, to meet this demand and provide extensive care for this population.
Promoting the easy access and mobility, with policies that ensure the autonomy of this population and independence with functional capacity, is the required attribute and it is directly related to the quality of life in old age. This study does not allow generalizations, since it has a restricted population; however, it was possible to understand some guiding principles concerning primary healthcare services in the daily life of Brazilian elderly people who live within the community. The importance of educational institutions to maintain an eye open to the education of future healthcare professionals concerning human aging issues, in particular the nurses, as essential parts of the interdisciplinary teams, is highlighted. Therefore, as a challenge for the society, it could be stated that it is our responsibility, as students of the higher education, and resource providers, to view the elderly beyond their limitations, recognizing that they are human beings with great experience who socially contributed in their environment and have social rights and benefits. Although in our country the elderly have more diseases and incapacities and, as a consequence, use healthcare services more often, the current models of healthcare directed to the elderly are inefficient and highly expensive. It is necessary to promptly think about implementing models such as the Community Centers, which provide evaluation and maintenance of the physical and mental condition of the elderly and interdisciplinary, integral and qualified healthcare.
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