Senescence and senility: the new paradigm in primary health care

Abstracts

A senescência e a senilidade são temas cada vez mais explorados, considerando o crescente aumento da população idosa no mundo, principalmente no Brasil. A assistência ao idoso deve prezar pela manutenção da qualidade de vida, considerando o processo de perdas próprias do envelhecimento e as possibilidades de prevenção, manutenção e reabilitação do seu estado de saúde. Conhecer o cotidiano dos idosos tem sido um desafio para os profissionais de saúde para implementar programas e ações que visem alcançar a manutenção do equilíbrio no processo saúde-doença, e é nessa busca que temos envidado esforços para contribuir, de forma efetiva, nas estratégias de fortalecimento dos idosos e seus familiares, de forma a tornar possível o desencadeamento de ações na promoção da saúde, principalmente considerando que o desafio para este milênio é construir uma consciência coletiva para alcançar uma sociedade para todas as idades, com justiça e garantia plena de direitos.

Idoso; Envelhecimento; Saúde do idoso; Atenção Primária à Saúde; Necessidades e demandas de serviços de saúde

THEORETICAL STUDIES

Senescence and senility: a new paradigm in primary health care

Suely Itsuko Ciosak^I; Elizabeth Braz^II; Maria Fernanda Baeta Neves A. Costa^III; Nelize Gonçalves Rosa Nakano^IV; Juliana Rodrigues^V; Rubia Aguiar Alencar^VI; Ana Carolina A. Leandro da Rocha ^VII

^IRN. Associate Professor, Collective Health Nursing Department, School of Nursing, University of São Paulo. Head of the Research Group Senescência e a Senilidade: Desafios no Cuidar, enrolled with the CNPq. São Paulo, SP, Brazil. [e-mail]

IIRN. Ph.D., Professor, Nursing Department, Universidade Oeste do Paraná. Cascavel, PR, Brazil

^IIIRN. Ph.D., Professor, Nursing Department, Federal University of Santa Catarina. Florianópolis, SC, Brazil

^IVRN, graduated by the Unviersity of São Paulo School of Nursing. CNPq fellow. São Paulo, SP, Brazil

^VRN. Ph.D., Professor, Universidade Positivo. Curitiba, PR, Brazil

^VIRN. Doctoral student of the Graduate Studies Program, School of Nursing, University of São Paulo. São Paulo, SP, Brazil

^VIIRN. Masters student of the Graduate Studies Program, School of Nursing, University of São Paulo. São Paulo, SP, Brazil

ABSTRACT

Senescence and senility are themes of growing interest, considering the inxrease of the elderly population in the wrold, particularly in Brazil. Health care for the edlery should value to maintain quality of life, considering the loss process particular of aging and the possiblities to prevent, maintenain and rehabilitate their health condition. Knowing the everyday lives of the elderly has been a challenge for health care professsionals regardint the implementation of programs and actions that aim to maintain the balance of the health-disease process, and it is in this search that we have made efforts to constibute, effectively, with the strategies to strengthen the edlerly and their relatives so it becomes possible to trigger health promotion actions, especially considering that the challenge for the millenium is to build collective awareness to achieve a society for all ages, with justice and the guarantee of full rights.

Descriptors: Aged; Aging; Health of the elderly; Primary Health Care; Health services needs and demand

RESUMEN

La senectud y senilidad constituyen temas ampliamente investigados, considerando el aumento de la población anciana en el mundo, principalmente en Brasil. La atención al anciano debe velar por el mantenimiento de su calidad de vida, estimando el proceso de pérdidas propias del envejecimiento y las posibilidades de prevención, mantenimiento y rehabilitación de su salud. Conocer la rutina del anciano se ha tornado un desafío para los profesionales de salud en lo que atañe a implementar programas y acciones que apunten a alcanzar el equilibrio del proceso salud-enfermedad, y en tal búsqueda hemos efectuado esfuerzos para contribuir efectivamente en las estrategias de mejoramiento integral del anciano y sus familiares, a fin de hacer posible el desencadenamiento de acciones promotoras de salud, considerando principalmente que el desafío para este milenio es construir una conciencia colectiva que alcance a una sociedad para todas las edades, con justicia y plena garantía de derechos.

Descriptores: Anciano; Envejecimiento; Salud del anciano; Atención Primaria de Salud; Necesidades y demandas de servicios de salud

INTRODUCTION

Becoming old is a natural process that involves gradual and inevitable changes related to aging and occurs despite the individuals' good health or healthy and active life style. In humans, this progressive phenomenon, in addition to triggering an organic wearing down of the body, causes alterations in the cultural, social and emotional aspects affecting an individual's life.

The World Health Organization (WHO) considers aging a

sequential, individual, cumulative, irreversible, universal, and non-pathologic process of a mature organism's deterioration, occurring to all members of a certain species, in such a way that time makes them less capable of facing environmental stress

and, therefore, introduces the possibility of death. In addition, the WHO states that the age delineating an adult individual and a senior citizen is 65 years in developed nations and 60 years in developing countries. Therefore, population aging is a consequence of development⁽¹⁾.

The proportional growth in the population of senior citizens, added to a decrease in birth rates and the technological and therapeutic developments in the treatment of disease, especially chronic diseases (NCDs), influence the aging trend. This has resulted in a change in the age structure of the population, especially in Brazil, with the consequent increase in the number of individuals older than 60 years, as a result of the population aging that occurred within a short period of time, highly impacting the health system.

Aging is something that occurs gradually over a lifetime, considering that individuals start aging as soon as they are born⁽²⁾. However, when bio-functional aspects are considered, aging starts within the second decade of life, although the effects may not yet be perceived. At the end of the third decade the first functional and structural alterations appear, and after the fourth decade, there is a loss of approximately 1% of function/year, in different organic systems⁽³⁾.

Normal aging is connected to the ability of individuals to adjust to environmental stressors. Therefore, every individual ages differently, depending on variables such as gender, origin, the place in which he/she lives, size of the family and abilities and experiences in life. Exposure to stress or tobacco, lack of exercise and appropriate nutrition are other contributing factors that determine the quality and speed of the aging process⁽⁴⁾.

Aging and illness cannot be seen as intimately dependent or connected factors; however, there is a higher vulnerability to becoming ill, or in other words, a predisposition to illness⁽⁵⁾.

Senior citizens' health and quality of life, more than other age groups, are influenced by multiple factors: physical, psychological, social and cultural. Evaluating and promoting the health of senior citizens means considering variables from distinct knowledge fields using interdisciplinary and multidimensional interventions.

Health care for senior citizens must strive to maintain quality of life, considering the common and frequently lost functions in aging and the preventive, maintenance and rehabilitation processes involved, dependent upon the individual's health status.

Considering that the health-illness process is a complex phenomenon, socially determined and guided by biologic, psychological, cultural, economic, and political conditionings, the health needs of senior citizens reflect multiple dimensions of reality and regard the singularity of health or illness phenomena affecting individuals and their families^(6-7).

As with other human needs, health needs are socially and historically determined and lie between nature and culture; in other words, they not only regard the conservation of life, but also the implementation of a project in which individuals, standing between the private and the generic, are progressively humanized⁽⁸⁾.

Despite these considerations, in western society, concern regarding aging in the population and its psychological, social and economic consequences are recent and care has been guided and limited to meeting biological needs for food, physical health and housing.

Health care, as a social practice, is organized to provide for health needs; however, it may or may not correspond to the real needs of social groups, since the relationship between health needs and care practices may not be connected, learned from economic, political and ideological meanings, captured in its history and in real societies. Interventions may be reinforced by the results they produce, or by the ability to produce positive changes in the health-illness profile of a certain population. This second perspective refers to the understanding and evaluation of characteristics and the practices resulting in health due to their utility, viability, accuracy and ethics.

Since health advances and technology have made it possible for people to reach more advanced ages in better relative health, active and healthy aging is the great objective in this process. If health is broadly considered, changes that produce a more favorable social and cultural environment in the current context of the elderly population are needed⁽⁹⁾.

The idea that age is dominated by illness is not always the reality. Even though the elderly population is faced with physical, economic, social and psychological changes and losses, maintaining activities, social belonging and family commitment favor a healthy aging process.

In the search for better conditions to assist senior citizens and concerned with the increase in this population within the Brazilian society, the Senior Citizen Statute (Law No. 10.741, of October 2003) represents a great progress in legislation, although there is still a great gap between what is needed and the reality⁽¹⁰⁾.

Acknowledging and dealing with the health needs of seniors are strictly connected to the primary principles of the National Health System (Sistema Único de Saúde - SUS), especially regarding the concepts of integrality and equity, as they require efforts to provide care to meet these needs from the health teams, requiring articulated and complementary actions in the care provided by each professional, from each team and the health services network⁽¹¹⁾. This network depends on the updated, concrete and specific information from various segments of the community.

Facilitating the access of the elderly population to health services, mainly through Primary Care, and considering their limitations, must be the health professionals' concern^(12-13).

Striving to learn about the senior citizens' daily life

Regarding senior citizens' health, there are many aspects to be considered. On the one hand is aging as a progressive process of decreasing functional resources – senescence – and on the other hand, the development of a pathologic condition due to emotional stress, accident or illness – senility⁽¹⁾. Both require interventions from health professionals, with focused actions for this population segment.

The greatest challenge in the care of senior citizens is to contribute to rediscovering possibilities of living their lives with the highest possible quality, despite progressive limitations. The possibility of accomplishing it increases as society considers the social and family context and is able to acknowledge the potential and value of these senior citizens, since part of their difficulties are related to a culture that diminishes and limits their potentialities.

The importance of this research Senescence and Senility: Challenges in Health Care lies in the search for daily interactions with senior citizens who come to the health units, or remain in their home, enabling the development of programs and interventions for health professionals with a view to reaching an understanding regarding the caring experience, striving for balance in the health-illness process. Therefore, many themes have been elected as research subjects; among these, integrality in health care for senior citizens, health grievances, coping with chronic diseases and home care services stand out.

Since the organization of the health system is connected to political, administrative, managerial, socio-economic and cultural factors, among others, the implementation and consolidation of SUS has revealed difficulties in how the health services and practices are organized locally for providing care to meet the health needs of the population. This makes difficult confirming its primary principles, as universal access, equity, integrality, problem-solving, decentralization, and social control⁽¹⁴⁾ are all desired principles which can be difficult to judge regarding the senior citizen population⁽¹²⁾.

With a view to understanding these dynamics and the mechanisms involved in the processes of care for senior citizens, and knowing that evaluating local health systems functioning was intended, with its concrete experiences in management, including managers and workers of Family Health Teams (FHT), this study set forth to examine this population through integrality, especially where the growth of this population stands out, as is the case in the city of Santos, SP. We observed that, despite the difficulties of deploying SUS and, consequently, programs that provide for the senior citizens' needs, the intentions of managers and all FHTs are aimed at meeting these needs, with an effort made to provide care to this population segment⁽¹³⁾.

An increase in trauma affecting senior citizens is a situation that attracts the attention of health care mangers, since, apart from the resulting injury, they are added to common degenerative diseases in this age bracket that compromise seniors' recovery and reinsertion back into society. Searching for preventive measures for trauma, especially trauma related to falls, very common among senior citizens, was the objective of another investigation that pointed out gender, continuous use of medications, vision and hearing problems, and the presence (or absence) of a caretaker as risk factors for falls⁽¹⁵⁾. Indicators such as the increase in sexually transmitted diseases (STD/AIDS) in senior citizens is another challenging factor that Primary Care (PC) faces, since sexuality in this population segment is neglected. Little is invested in prevention and control of STDs in seniors, resulting in an increase not only in the occurrences of these health conditions, but also in late diagnoses^(16-17). Our investigations have observed the unpreparedness of health professionals in approaching the subject with seniors, and little investment in education and prevention has been made, indicating that the stigma regarding STDs and the mechanisms for prevention⁽¹⁶⁾ still exist.

Many senior citizens have chronic health conditions that require constant attention. These chronic conditions tend to appear more commonly in old age and are frequently associated with other conditions (comorbidities). Although not fatal, they tend to significantly compromise the senior citizens' quality of life⁽⁹⁾. Identifying ways of dealing with them is another theme that interests us.

We observed that, although health professionals do not broadly use this approach, spirituality, religiousness and faith positively affect how individuals cope with a chronic disease and its impact, strengthening senior citizens' resilience and improving their quality of life⁽¹⁸⁾.

Avoiding hospital care and turning to non-institutionalized care has become a common practice. Since there is a policy for senior citizens, but no governmental program aimed at assisting individuals caring for senior citizens, and also due to the bankruptcy of the pensions and benefits system, the family is gradually becoming one of the only resources for caring for dependent senior citizens.

At home, the family is already physically, emotionally and spiritually developed; where interpersonal relations are established, there may be crisis and conflicts. In coping with illness, the family requires support, with a view to overcoming, adjusting and increasing self-help and care relations⁽¹⁹⁾. Thus, some authors⁽²⁰⁾ state that, in each family and for each individual, the meanings for their experiences are unique; hence, their individuality and specific needs must be respected.

For the group of senior citizens who receive care at home, there may be another problem related to the caretaker. The role of caretaker, whether a family member or not, is fundamentally important in the care of the individual, particularly at home. In general, care responsibilities lay on the caretaker, rather than on other entities.

This challenging context was investigated, demonstrating that home care provided to an elder experiencing a health problem or condition, whether physical or mental, exposes the family to a series of significant challenges, especially due to the alterations in the family dynamics. As meeting the financial needs of the family is becoming more difficult with one income, women are leaving the home to enter the work force. This phenomenon is demonstrated by the increase in families composed only of senior citizens, women and small children. This new role in the life of females guides the family life towards senior citizens who have the responsibility of performing domestic tasks and caring for ill individuals⁽²¹⁾.

The existence and magnitude of these problems, considered to be natural in the eyes of society, are triggered by unplanned situations or may even be planned among family members, resulting in the responsibility lying in the hands of a certain family member chosen by the others. The chosen member is not always given a choice in this responsibility, but may be forced into it due to the current situations of the other family members. Within this new situation, the family structure and routine changes, organized up until this point within certain patterns, mainly due to the limitations and dependency of the ill senior citizen. Therefore, the illness process does not affect only one person, but interferes in the whole dynamic of the family, especially when there are senior citizens taking care of other senior citizens, exposing them to a series of significant challenges⁽²¹⁾.

It is becoming apparent that the need for support services for these families is now urgent. Studies emphasize human resources training in the area of health care for the purpose of developing population studies, mainly regarding the elderly population, pointing at the needs of family members for information regarding the illness, the elements required for caring for the ill individual and a social support network⁽²²⁾.

In the search for a reduction in health problems resulting from the care of the elderly, strategies that can be implemented as training courses for caretakers and redirecting public health services in a way to support home care must be included, associated with an academic educational review for health professionals highly focused on the growing elderly population^(23-24).

CONCLUSION

It is the duty of health policies to contribute towards more people reaching advanced ages in the best possible health condition. Healthy and active aging is the great objective of this process. If health is broadly considered, changes in the current context of health care producing a more favorable social and cultural environment for the elderly population are needed.

As observed, there are many ways to search for knowledge and strengthen the care of senior citizens. Acknowledging these factors, involving values, beliefs, behaviors and practices of the population and health professionals, is essential to understanding the way in which health systems, more specifically the health work processes, are structured in order to acknowledge and deal with the health needs of this population.

Considering the shortage of available public resources in the health sector, strategies must be used to understand the weakening and strengthening processes affecting senior citizens, the family and the caretaker family member, with a view to making possible the health promotion and prevention of the health/illness balance process of these groups.

The health professional, in order to provide for the health needs of senior citizens, must be open to understanding them within their social-cultural context, strengthening their responsibility and acknowledge their limits, as well as their potentials.

The great challenge for this millennium is to build a collective conscience in such a way as to build a society for all ages, fully ensuring rights and justice for all, including senior citizens.

REFERENCES

• ¹
  Brasil. Ministério da Saúde; Secretaria de Atenção à Saúde; Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. Brasília; 2006. (Cadernos de Atenção Básica, n. 19).
• 2. Segun E. O idoso aqui e agora. Rio de Janeiro: Júris; 2001.
• 3. Jacob Filho W. Envelhecimento e atendimento domiciliário. In: Duarte YAO, Diogo MJD'E. Atendimento domiciliar: um enfoque gerotológico. São Paulo: Atheneu; 2000. p. 19-26.
• 4. Braz E, Ciosak SI. O perfil do envelhecimento. In: Braz E, Segranfredo KU, Ciosak SI. O paradigma da 3Ş idade. Cascavel (PR): Coluna do Saber; 2006.
• 5. Rodrigues RAP. Mulheres em mudança no processo da vida e envelhecer [tese livre-docência] Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 1997.
• 6. Breilh J, Granda E. Investigação da saúde na sociedade: guia pedagógico sobre um novo enfoque do método epidemiológico. Rio de Janeiro: Instituto da Saúde/ABRASCO; 1986.
• 7. Laurell AC. A saúde-doença como processo social. In: Nunes ED, organizador. Textos de medicina social: aspectos históricos e teóricos. São Paulo: Global; 1983. p. 133-58.
• 8. Melo Filho DA. Repensando os desafios de Ulisses e Fausto: a saúde, o indivíduo e a história. Cad Saúde Pública. 1995;11(1):5-33.
• 9. Temporão JG. Apresentação. In: Brasil. Ministério da Saúde; Secretaria de Atenção à Saúde; Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. Brasília; 2006. (Cadernos de Atenção Básica, n.19).
• ¹⁰
  Brasil. Lei n. 10.741, de 1º de outubro de 2003. Aprova o Estatuto do Idoso e dá outras providências [Internet]. Brasília; 2003 [citado 2011 out. 14]. Disponível em: http://www.receita.fazenda.gov.br/legislacao/leis/2003/lei10741.htm
• 11. Cecílio LCO. As necessidades de saúde como conceito estruturante. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ; 2001. p. 113-26.
• 12. Amendola F, Oliveira MAC, Alvarenga MRM. Influence of social support on the quality of life of family caregivers while caring for people with dependence. Rev Esc Enferm USP [Internet]. 2011 [cited 2011 Oct 25];45(4):884-9. Available from: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a13.pdf
• 13. Costa MFBNA, Ciosak SI. Comprehensive health care of the elderly in the Family Health Program: vision of health professionals. Rev Esc Enferm USP [Internet]. 2010 [cited 2010 Oct 13];44(2):433-40. Available from: http://www.scielo.br/pdf/reeusp/v44n2/en_28.pdf
• 14. Egry EY, Chiesa AM, Barrientos DMS, Fraccolli LA, Nichiata LY, Oliveira MAC, et all. Necessidades de salud de la poblacion & posibilidades de afrontar-las en la Atención Básica. In: Egry EY, Hino P, organizadoras. Las necesidades en salud en la perspectiva de la Atención Básica: guia para investigadores. São Paulo: Dedone; 2009.
• 15. Rodrigues J. Idosos vítimas de trauma: uma proposta de predição de riscos [tese doutorado]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2011
• 16. Nakano NGR, Ciosak SI. Desafios na senescência: doenças sexualmente transmissíveis em usuários de um centro de saúde. In: XI Mostra de Monografias da Escola de Enfermagem da Universidade de São Paulo; 2008.
• 17. Alencar RA, Ciosak SI, A transmissão e prevenção das DST/Aids na perspectiva do idoso. São Paulo. In: Resumos do 2o Simpósio Internacional de Aids e Saúde Mental; 2010 abr. 21-23; São Paulo, SP, Brasil. São Paulo: FMUSP; 2010.
• 18. Rocha ACAL. A espiritualidade no manejo da doença crônica do idoso [dissertação]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2011.
• 19. Sena RR, Leite JCA, Costa FM, Santos FCO, Gonzaga RL. O cuidado no domicílio: um desafio em construção. Cogitare Enferm. 1999;4(2):58-62.
• 20. Marques SM, Ferraz AF. A vivência do cuidado domiciliar durante o processo de morrer: a perspectiva de familiares cuidadores. REME Rev Min Enferm. 2004; 8(1):182-90.
• 21. Braz E. Entre o visível e o invisível: as representações sociais no cotidiano do senescente cuidador de idosos dependentes [tese doutorado]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2009.
• 22. Alvarenga MRM, Oliveira MAC, Domingues MAR, Amendola F, Faccenda O. Rede de suporte social do idoso atendido por equipes de Saúde da Família. Ciênc Saúde Coletiva. 2011;16(5):2603-11.
• 23. Mazza MMR. O cuidar em família: análise da representação social da relação do cuidador familiar com o idoso [dissertação]. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2002.
• 24. Sportello EF. Caracterização das formas de vida e trabalho de cuidadores familiares do Programa de Assistência Domiciliária do Hospital Universitário da Universidade de São Paulo [tese doutorado]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2001.

^*

Senectud y senilidad: nuevo paradigma en la atención básica de salud

Correspondence addressed to

Publication Dates

• Publication in this collection
  04 May 2012
• Date of issue
  Dec 2011

History

• Accepted
  29 Nov 2011
• Received
  11 Nov 2011