Cognitive and functional assessment about elderly people users of health public servicea

Objective: To evaluate the functional capacity, cognition and mood in three different care models for older adults. Method: A cross-sectional study conducted in 2014 with 140 older adults (37 institutionalized, 53 hospitalized and 50 outpatients). The MMSE, Clock Drawing Test (CDT), Activities of Daily Living Scale ADLs (Katz, Lawton) and the Geriatric Depression Scale (GDS) were applied. Results: Of those institutionalized, the majority were totally dependent for ADLs and 100% presented cognitive decline. Of those hospitalized and the outpatients, the majority were independent for ADLs, with 62.3% and 48.0% presenting cognitive decline, respectively. The minority presented depressive symptoms. The results indicated that age was a predictor of cognitive decline and the likelihood of prevalence in hospitalized and outpatient older adults increased by 8.7% for each year of life. Conclusion: It is important to pay attention to the cognitive and functional performance of older adults with the aim of preventing their decline, which is so frequent in the public health services in Brazil.


INTRODUCTION
For decades, population aging has been a reality for both developed and developing countries. 1In Brazil, reducing fertility rates have resulted in declining population growth, and declining infant and child mortality rates.The increase in life expectancy has also favored the increase in the population contingent of older adults. 2 The Brazilian age group pyramid has, for many years, evidenced the ascendancy of children and young people, showing a broad base and narrow top.Currently, it shows characteristics of balance between the age groups, with a tendency for the enlargement of the top.Concomitantly with the demographic transition, there is a change in the epidemiological landscape. 3In this sense, it is important to highlight the high prevalence of chronic noncommunicable diseases, cognitive losses, sensorial decline and social isolation.These factors may cause deterioration in the functional capacity of older adults, making them dependent on other people for their daily care. 4unctional dependence can be defined as the inability to maintain the physical and mental skills necessary for independent and autonomous living.Persons affected by incapacitating processes may suffer limitations in the performance of activities related to self-care -Basic Activities of Daily Living (BADLs) and in the performance of activities related to the organization of the daily routine -Instrumental Activities of Daily Living (IADLs). 5s provided by law, health actions directed toward older adults aim for the maximum maintenance of autonomy and independence, however, there are factors that configure complications to achieve these goals.Among these factors, cognitive decline is given more emphasis. 6ognitive decline consists of a slight slowing of mental abilities that evolves with advancing age and may be associated with various factors, such as: dementia, medication use (mainly benzodiazepines, neuroleptics and antidepressants) and mood alterations, particularly depression, among others. 7n view of the above, it is essential to evaluate the cognitive and functional capacity of older adults.Through a broad geriatric evaluation, these aspects will be addressed by health professionals, who will be able to identify the demands of each older adult evaluated and establish an individualized care plan that promotes active aging and improves quality of life.An in-depth evaluation provides subsidies for health decision-making and for the design of strategic actions aimed at the particularities of each older adult, in order to provide them with integral health care, as recommended by the National Policy for Older Adult Health. 8ne of the aspects highlighted by this Policy is the promotion of active and healthy aging, which can be accomplished through the optimization of health, participation and safety opportunities, with the aim of improving the quality of life as people age.One of the aspects addressed in active aging is good functional capacity. 9pport for the older adult population still represents a challenge for the Brazilian Health System, especially regarding the knowledge of the health needs of this population.This context seems to have allowed an increase of specialists in different areas of professional activity, interested in developing actions related to the older adult public and, in the health area, focusing on the preservation of the functional and cognitive capacity.
Thus, studies that address this issue are essential to support the health policies aimed at older adults.Although the current literature indicates the multiple characteristics of older adults in institutional, hospital and outpatient settings, there is still a need to further explore knowledge, considering that these characteristics may vary according to the specificities of each context.Thus, the present study aimed to evaluate the functional capacity, cognition and mood of the older adults of three different older adult care models in São Carlos -SP, favoring the implementation and improvement of the planning of integrated health actions for these people.

METHODS
This was an observational, cross-sectional, comparative, quantitative study to verify the sociodemographic and health profile and the functional and cognitive capacity of the older adults of the municipality of São Carlos-SP.
The target population consisted of older adults, aged 60 years or older, that were users of three different types of public healthcare in the municipality of São Carlos.They were studied simultaneously in three groups.The first included older adults undergoing medical care at the University Health Unit (UHU) of the Federal University of São Carlos/UFSCar, considered a medium complexity outpatient clinic that attends users referred by the public health network of São Carlos and region.The second group consisted of older adults treated at the University Hospital (UH) of the Federal University of São Carlos/UFSCar, which is integrated into the Network (Primary and Secondary Care Units) offering healthcare, and provides observation/hospitalization services and emergency care for the population.The third group was represented by older adults from the Cantinho Fraterno Dona Maria Jacinta Long-Stay Institution for Older Adults (LSIOA), this being a philanthropic institution, located in the urban environment of the city of São Carlos, founded in 1922.At the time of the study it was home to approximately 37 elderly people.
The total sample consisted of 140 older adults (37 institutionalized, 53 hospitalized and 50 outpatients) and the analysis of the sample power, using the Power Analysis and Sample Size (PASS) application, 2002, for a significance level of Α = 0.05 and a sample size of n = 140, revealed an a priori statistical power of 1 -β = 99.8%.
Data collection was performed in the first half of 2014 and only started after approval from the Research Ethics Committee of the Federal University of São Carlos.Individual interviews were conducted, with the consent of the study participants, who all signed the consent form.
For the characterization of the older adults, an instrument was applied that included the following information: gender, age group, education level, marital status, nationality, place of origin, with whom they live, self-reported diseases and life habits.
Cognitive performance was evaluated through the Mini Mental State Examination (MMSE).This instrument was translated and validated for Brazil by Bertolucci 10 and tracks possible cognitive deficits in individuals at risk of developing dementia syndrome.The score can range from 0 to 30 points.The cut-off score was calculated with the median values presented by age group and a standard deviation subtracted. 7he cut-off points adopted were: 18 points for illiterate people; 21 points for those with one to three years of schooling; 24 points for four to seven years of schooling and 26 points for eight years of schooling or more.
The Clock Drawing Test (CDT) is a cognitive evaluation tool validated in Brazil, 11 which consists of a scoring scale of 0 (totally incorrect or non-existent clock) to 10 points (fully correct clock).
The depressive symptomatology was evaluated using the 15-item version of the Geriatric Depression Scale (GDS), validated in Brazil by Almeida and Almeida. 12A score of 5 points indicates absence of depressive symptoms, 6 to 10 points: mild depressive symptoms and 11 to 15 points: severe depressive symptoms.
Limitations in the Basic Activities of Daily Living (BADLs) were assessed using the Katz Index of Independence in Activities of Daily Living.This instrument investigates self-care activities, such as: bathing, dressing, going to the bathroom, lying down and getting out of bed, eating and controlling urination and/or evacuation functions.This scale was adapted for use in Brazil by Lino et al. 13 Shelkey and Wallace 14 proposed a point for each activity that the evaluated person does without help.This score varies from 0 to 6 points, with individuals that obtain from 0 to 2 points being considered totally dependent, 3 to 5 points partially dependent and individuals that obtain 6 points considered independent.
Limitations in the Instrumental Activities of Daily Life (IADLs) were evaluated through the Lawton and Brody Instrumental Activities of Daily Living Scale, adapted to the Brazilian context by Santos and Virtuoso Junior in 2008. 15Examples of IADLs are: using the telephone, using some means of transportation, shopping, preparing meals, cleaning and tidying up the house, taking medications and dealing with finances.The score varies from 7 to 21 points, with a score of 7 points being considered total dependence, 8 to 20 points partial dependence and 21 points independence.
Descriptive and univariate data analysis was performed using the Statistical Package for the Social Science (SPSS), version 20.0, program, for both the categorical variables (frequency tables) and the quantitative variables (measures of central tendency and variability).Pearson's correlation calculation was also performed between the quantitative variables.The correlations were considered weak (r < 0.3), moderate (0.3 ≤ r < 0.7) or strong (r ≥ 0.7).The midpoints of the functional capacity measures (Katz Index of Independence in Activities of Daily Living and Lawton and Brody Instrumental Activities of Daily Living Scale) were statistically analyzed through the non-parametric Mann-Whitney test with Bonferroni correction.In order to adjust the prevalence ratios of cognitive decline to the institutions, according to the variables gender, age, presence of depressive symptoms and morbidities, a multiple logistic regression model was constructed with the simultaneous input of predictors, or saturated model, method.The level of significance was α = 0.05. All

RESULTS
A total of 140 older adults were interviewed, 37 of whom were evaluated in the LSIOA, 53 in the UH and 50 in the UHU.The sociodemographic and health characteristics of the older adults were presented considering the three care modalities and the main differences related to the items: to have or not cognitive decline, functional capacity and the presence or not of depressive symptoms.
Table 1 shows the distribution of the older adults in the three care modes according to gender, marital status, health profile, mood and cognition.

Cognitive and functional evaluation of older adults
Melo BRS, Diniz MAA, Casemiro FG, Figueiredo LC, Santos-Orlandi AA, Haas VJ, Orlandi FS, Gratão ACM   Table 3 presents the three care profiles and the main differences related to the item "to have or not cognitive decline".
There was an association between the place of residence of the older adults and the proportion or prevalence of cognitive decline, with 100.0% in the LSIOA, 62.3% in the UH and 48.0% in the UHU (χ 2 = 26.29,p < 0.001).
Table 4 shows the multiple logistic regression analysis, having cognitive decline as the outcome and the institution as the preferential predictor, adjusting for gender, age, presence of depressive symptoms and number of morbidities.
Only age was considered a predictor of cognitive decline.Adjusting for the other variables, the chances of prevalence of cognitive decline increase 8.7% for each additional year of life.The chances of prevalence for the LSIOA could not be calculated as all the older adults presented cognitive decline.This variable was also not statistically significant, indicating that there were no differences between the institutions studied when adjusted for gender, age, depression and number of morbidities.
Table 5 presents the differences in having functional capacity in the three care modes for the older adults.
The overall or omnibus test indicated that there was a statistically significant difference between the mean scores of the two scales among the three institutions (p < 0.001).To determine between which institutions the differences were statistically significant, a multiple comparison analysis, using Mann-Whitney for the pairs, was performed.For this, αCP = α/3 = 0.017 was considered to adjust the multiple comparisons by Bonferroni, revealing statistically significant differences in    functional capacity, both for the BADLs and IADLs, between the LSIOA and UH (p < 0.001) and the LSIOA and UHU (p < 0.001).Regarding the performance in the BADLs and IADLs, the older adults of the LSIOA were more dependent.There was no statistically significant difference between the UH and UHU.

DISCUSSION
In the present study, the participants presented low levels of schooling in all care models.During the childhood of these older adults, education was not seen as a priority, reflecting today in older adults with low levels of education. 16Faced with this, health professionals should evaluate the interpretation and understanding of actions directed toward health education, taking into consideration that low levels of schooling may hinder the understanding of guidelines. 17lder adults with lower levels of education have little or no knowledge of the need for access to the services for health promotion actions and are less likely to seek continuity of care for the prevention of illness and complications, and at the same time more often choose a emergency service. 18Authors highlight that low levels of schooling are strongly related to the cognitive impairment and functional incapacity of older adults. 6,19mong the institutionalized participants, there was a predominance of dependence in the basic and instrumental activities of daily living.Similar data were found in a study conducted in Marília (SP), with the aim of studying depressive symptoms and cognitive and functional decline in older adults residing in an LSIOA.The authors found that the performance of activities of daily living in the institutional context becomes impaired, considering the limitations that the environment itself imposes in relation to the social functions.Furthermore, situations that involve decision making are practically non-existent, considering the organization, rules and routine of the LSIOAs. 6onversely, the finding of high dependence in older adults can highlight the risk factor for institutionalization. 20 The demand for institutionalization has increased in recent years, reflecting the  changes in family and social dynamics, accompanied by the difficulty for family members to find people capable of being responsible for the care of the older adult. 21In this context, the demand increases for LSIOAs that provide the care necessary for dependent older adults, overcoming the lack of family and social support.
Regarding outpatient and inpatient settings, the majority of the older adults were independent for BADLs and IADLs.These data were partially corroborated by the literature.A crosssectional study carried out at the Geriatric Outpatient Clinic of the Clinical Hospital of UNICAMP analyzed the profile of the older adults regarding mood and loss of functional and cognitive capacity.The authors found that the majority of the participants reported independence for BADLs (63%) and dependence for IADLs (68.3%). 22 study carried out with 94 older adult patients admitted to a university hospital in Belém indicated that there was some degree of dependency in the BADLs (61.7%) and in the IADLs (52.1%).The authors stated that hospitalization is a known risk factor for the functional decline of older adults, who lose their autonomy in this context.In addition, an already existing functional impairment may be potentiated, due to excessive time in bed, sleep deprivation and the use of multiple medications.23 The literature shows a hierarchy of functional capacity loss in older adults, when thinking about care models for the older adult.In the outpatient model, the older adults are more independent when compared to those in the hospital and institution contexts.A gradual increase in the severity of functional dependence is observed when hospital services are sought, which culminates in severe dependence in those who seek or even reside in longstay institutions.
The study of functional capacity provides subsidies for the planning and systematization of the care provided by the health professional, in relation to older adults.Strategies developed in the context of a multidisciplinary team aiming to assist or restore their functional capacity may be necessary.In addition, emphasis can be given to maintaining/strengthening activities in which the older adults do not present difficulties. 17he evaluation of the mental state in this study showed that 100% of the older adults of the LSIOA presented cognitive alterations, with a low mean in the MMSE (6.6 points).A study carried out in Belo Horizonte -MG with 47 institutionalized older adults revealed that the cognitive decline was highly prevalent in the older adults of LSIOAs, with 93.3% presenting cognitive impairment. 21he evaluation of the cognitive performance of the older adults in the hospital showed that 62.3% presented cognitive decline, with an mean of 17.3 points.These data are in agreement with the literature.Hospitalized older adult patients presented a mean of 18.14 points in the MMSE, in a study conducted in Belém. 23f the older adult outpatients, 48% presented cognitive decline, obtaining a mean score of 19 points in the MMSE.Other national studies found that cognitive deficits were present in 29% of the older adults evaluated. 22,24esearchers have indicated that institutionalized older adults present lower cognitive performance and less functional activity when compared to non-institutionalized older adults. 25he results of this study demonstrated that the different health service modalities have a strong influence on the cognitive performance of older adults.Incapacitating chronic diseases, such as dementia, are a major risk factor for institutionalization, therefore it is common to have many older adults with cognitive decline in these institutions.However, social isolation, withdrawal of the older adult from the community, the sedentary lifestyle imposed by the LSIOA and the lack of intellectual stimulation in this context can be important factors for the development and/or aggravation of cognitive changes. 26,27Cognitive repercussions over time should be monitored from the first day of institutionalization.
Age was considered a predictive factor for cognitive alterations.Organic changes occur throughout the aging process, which can result in a reduced ability to maintain homeostasis and in health complications that compromise different areas, such as a progressive decline in cognitive functions. 28Memory losses are the most frequent complaints among older adults. 29With the advance of age, there is a greater predisposition to chronic diseases and, in senility, impairments occur with greater intensity, and there may be changes in the nervous system, culminating in cognitive deficits and, often, in the impairment of the performance of activities of daily living. 26hese data demonstrate that it is necessary to apply screening instruments for cognitive function as soon as the patients are admitted to the different models of healthcare for the older adult.This evaluation, as part of the health services routine, will provide subsidies for health professionals to work in the preventive and rehabilitation programs in a more effective way. 23ognitive and functional evaluation of older adults Melo BRS, Diniz MAA, Casemiro FG, Figueiredo LC, Santos-Orlandi AA, Haas VJ, Orlandi FS, Gratão ACM In the evaluation of mood, 29.7% of the institutionalized older adults, 41.5% of those hospitalized and 36% of those in the clinic presented depressive symptoms.A national study found that 32% of the participants presented depressive symptoms, being more prevalent among those that were younger, female, less educated and had lower scores in the MMSE. 22Depression is not directly related to aging, however, the onset of aging presents some atypical characteristics or particularities that predispose the person to the development of depressive symptoms, such as retirement and the reduction of the possibility of fulfilling a productive role, which generally leads to demoralization and loss of status. 30lthough the older adults with depressive symptoms were in the minority in the different services, special attention should be paid to these individuals.Strategies such as leisure, social and cultural activities can be carried out by the multidisciplinary team.
The following limitations were verified in the present study: 1) the transversal sample did not allow causality to be attributed among the variables; 2) the lack of studies comparing the three care modalities for older adults, outpatient, hospital and long-stay, hampered the discussion of some findings; 3) the use of questionnaires may have underestimated or overestimated some information found; 4) the various research instruments and parameters used to classify the functional capacity of the older adults, as well as the cut-off point, make it difficult to compare the results with the other studies.
Further longitudinal studies that consider the relationship between functional capacity, cognition and depressive symptoms for older adults in different care contexts are suggested, considering the lack of these in the literature.

CONCLUSION
The presence of debilitated and totally dependent older adults, with severe cognitive impairments was more prevalent in the LSIOA context.The hospital and the outpatient clinic were similar in terms of the functional capacity of the older adults, however, in the hospital the older adults presented greater cognitive impairment and a higher prevalence of depressive symptoms, this being in agreement with the profile and complexity of each older adult care model.
The likelihood of prevalence of cognitive decline increased with age when related to the hospital and outpatient mode, which reveals the association between the place of residence of the older adult and the prevalence of cognitive decline.
Considering the above, it is important to compare the three care models for older adults, since the planning of the actions is carried out in an appropriate, real and particular way for each scenario, providing the health team with the capacity to tailor the interventions to the older adults involved.
Cognitive and functional evaluation of older adultsMelo BRS, Diniz MAA, Casemiro FG, Figueiredo LC, Santos-Orlandi AA, Haas VJ, Orlandi FS, Gratão ACM Cognitive and functional evaluation of older adultsMelo BRS, Diniz MAA, Casemiro FG, Figueiredo LC, Santos-Orlandi AA, Haas VJ, Orlandi FS, Gratão ACM the ethical guidelines that govern research with human subjects were observed and respected, according to Resolution 466/2012, regulated by the National Health Council.This study was approved by the Research Ethics Committee of the Federal University of São Carlos, under authorization number 416.459, on 10/6/2013, CAAE 21522513.8.0000.5504.

Table 1 .
Distribution of the older adults in the three care modes according to gender, marital status, health profile, mood and cognition.São Carlos -SP, 2014.

Table 2
shows the means, standard deviations and minimum and maximum values for the variables age, schooling, CDT, gross values of the MMSE, Index of Independence in Activities of Daily Living (BADLs), the Instrumental Activities of Daily Living Scale (IADLs) and GDS of the older adults in the different care modalities.The older adults of the LSIOA presented a mean of 74.4 years of age (sd = 9.8), 1.

Table 2 .
Distribution of the older adults in the different care modalities according to the variables age, schooling, CDT, cognitive decline, IADLs, BADLs and GDS.São Carlos -SP, 2014.

Table 3 .
Distribution of the older adults in relation to the presence of cognitive decline, according to the three care modes (LSIOA, UH and UHU).São Carlos -SP, 2014.

Table 4 .
Multiple logistic regression analysis having cognitive decline as the outcome.São Carlos -SP, 2014.

Table 5 .
Distribution of the means, medians and p-value in the three care modalities, related to the performance of the older adults in BADLs and IADLs.São Carlos -SP, 2014.