Interdisciplinarity of care to the elderly with Alzheimer’s disease: reflection to the light of the theories of Leininger and Heller

Objective: to reflect on the integration of Leininger's Transcultural and Heller's daily life theories in the support of the care of the elderly with Alzheimer's disease. Method: reflection study guided by the researchers' perceptions, when understanding, in the development of actions, the convergence between the theories. As the procedures, studies about the theme in the fields of nursing and social work were analyzed. Results: text organized in two parts: "Cultural Care of the elderly with Alzheimer's Disease" and "The Daily Care of the elderly with Alzheimer's Disease". The respect for cultural aspects and immediate problems resolution of the elderly with Alzheimer's Disease are interdisciplinary actions integrated in the context of care, from the assumptions of Leininger and Heller, in this scenario used as a foundation for improving the care of patients. Conclusions and implications for practice: the interdisciplinarity of care in Heller and Leininger is explained by the approximation to the social context, with common elements. Together, these theories provide the best response in promoting the well-being of the elderly with Alzheimer's Disease and its related surrounding. The theories congruence implies an integral and solid care, involves concrete action, based on different assumptions, which strengthen when they come together, benefiting patient and caregivers, with an individualized and differentiated care. Cultural


INTRODUCTION
The Alzheimer's Disease is characterized as a neurodegenerative disease, of unknown cause, with specific neurochemical and pathological elements, which go beyond the physiological course of ageing and modify the patient's culturally established social follow-up, with interference at individual and family level. This condition changes in an impacting way the autonomy and independence levels, leading to important changes and serious limitations in the carrying out of daily life activities. Therefore, caring of a family member with this disease involves responsibility and challenge of multidimensional nature, a little explored context that raises new social requests and the adoption of different tools to deal with the situation, both by the affected family, and by the service providers 1 .
In this sense, care models of people with dementia in primary health care have been developed over the last decade: the collaborative care or patient-centered care, to assist the complex patients' health needs and caregivers, providing opportunities for multidisciplinary care. For a successful collaboration, it is essential the interdisciplinary integration, as the collaborative care focuses on systematic long-term approaches, to improve the disease management and not only treating acute symptoms 2 .
Among the needs of persons with dementia, especially those with Alzheimer Disease, are those related to biological and psychosocial health. In this domain, the prevention of risk of social vulnerability highlights. To address this problem, the users can use the actions of social assistance policy, inserted in the social welfare system of Brazil that, along with the social security and the right to health, comprise the named tripod of the social security in the country. In accordance with the National Plan of Social Assistance (PNAS), the social assistance should be provided to those who need it 3 . Moreover, among its objectives, is the protection of the family, from childhood to aging 4 . In considering that in the elderly, naturally, occurs losses resultant from physiological and organic changes inherent to the aging process, the individual begins to live with the reduction of some skills 5 . Such conditions can make them fragile and susceptible to vulnerable situations, and when affected by some comorbidity, such as the Alzheimer's Disease, the risk increases, demanding attention network mobilization, both to address biological, social and behavioral issues that occur with the patient, as for the protection of the caregiver who is, in general, at advanced age 6 .
The efforts of governmental and non-governmental bodies to develop health promotion policies and the population's welfare are evident. With regard to the elderly's health, the 1988 Constitution stands out, with the Brazilian Unified Health System (SUS), assuring the free access and equity to all actions and services in order to protect, promote and recover the health, ensuring the integrality of care, in the different environments and problems of the community and individuals 7 .
In this process, among other pillars, the Brazilian National Health Policy for Elderly Persons was created with the aim at rescuing, conserving and propitiating the Independence and autonomy of persons aged 60 or older, directing collective and individual health measures for this purpose 7 .
At the same time, the Primary Care Book was elaborated, with mention in the Pact for Life 2006 and the National Policies, which comprehends a range of actions and educational instruments that include from primary care, elderly's health, humanization program in SUS and health promotion, considering the population's aging reality. These instruments have the intention of making available technological subsidies addressed to the elderly's health, in order to qualify and better train workers from the more varied professions who work in Primary Care 8 .
Specifically, with regard to the Alzheimer Disease, the Ministry of Health of Brazil (MH) created, in the SUS scope in 2002 the Healthcare Program for Alzheimer's Disease Carriers that regulates, mainly, the free distribution of medication used for the treatment 9 . In 2013, the clinical protocol with the AD therapeutic guidelines was launched by the MH, which presents basic concepts of the disease and drugs indicated for drug treatment 10 . And, more recently, in 2016, the MH distributed free rivastigmine patches for this therapeutic resource 11 . Drug that attaches to the skin gradually releases the active ingredient, with the advantage of entering directly into the bloodstream, reducing side effects caused by ingestion 11 .
Among the services that provide care of the elderly, especially those with the Alzheimer's Disease, are the nursing and the social service, which although are different fields, interact and complement each other in the provision of care. When considering that the elderly, regardless of their clinical condition is inserted in a cultural context of the daily, the consolidation of professional actions should be based on a philosophical theoretical framework, that is, the practice based on theories. 12 One considers the Transcultural Theory of Madeleine Leininger as appropriate in the fields of Nursing and the Daily Theory of Agnes Heller, in the Social Service. The complementarity of interventions raises reflections from the referred theories as a foundation for the professional doing of nurses and social workers, in the scope of care of elderly with Alzheimer's Disease and respective surroundings.
This reflection idea emerged from the experience in the care practice, while pursuing the doctorate course at the State University of Maringá, carried out in an institution that provides care of elderly with Alzheimer's Disease, Organization of Civil Society (OCS -Law 13019/2012) that provides ongoing, permanent and planned orientation and monitoring in the health and social areas, with coverage at home 13 .
To meet the demand for services, the said institution count on social service professionals, of psychology and pedagogy, thus characterizing the reference tripod in the Basic Social Protection service, in accordance with the NOB/RH/SUAS 13 .
Interdisciplinary care in Alzheimer: theoretical reflections Barbosa MEM, Corso ER, Scolari GAS, Carreira L Due to the characteristics marked by specific health demands, the institution adapted the professional staff, including nursing, physiotherapy and nutrition professionals, forming an interdisciplinary team, that work in an integrated way. Interdisciplinarity is characterized as an interception point among the operations of disciplines and among them, with different meaning, is related to the search for harmony between the fragmentation and synthetic fusion, requires balance between the gaze marked by the nexus of the reason, subjective and instrumental and, not only with teamwork, as well as individual work. The role of the interdisciplinarity in Nursing and its openness to other disciplines make caring something more than a profession 14 .
This reciprocal integration process among disciplines is an intermediate point between the trans and the multidisciplinarity, in which changes and reciprocal improvements among the disciplines take place. All strive far from their area and specific technical vocabulary, to risk in a specialty that it is not exclusive owner. In this way, it seeks to stimulate a new understanding of the reality, by articulating elements that pass between, beyond and through the professions, seeking to understand the complexity of the real world 15 .
This interdisciplinary context, with different professions, based on specific theoretical frameworks that support the praxis, led to the elaboration of this article that aimed to reflect on the integration of Leininger' s Transcultural and Heller's Daily Life theories, in the support of the care of elderly people with Alzheimer's Disease and respective caregivers.
As procedures, we sought to bring studies in the fields of Nursing and Social Work that addressed the issue related to cultural and daily care, similarities and integration in the practice. The text was organized in two parts, focusing on the themes: Cultural Care of the Elderly with Alzheimer's Disease and the Daily Care of the Elderly with Alzheimer's Disease".

Cultural Care of the Elderly with Alzheimer's Disease
The Nursing, as a Science in stabilization process, calls for a definition of its own knowledge framework, as well as specific vocabulary that can base the daily know-how and guide the work method with components that symbolize the professional identity, by developing the expertise. 16 In this way, nurses anchor the actions from the theoretical framework to consolidate the care object and professional profile. The nursing theory facilitates the strengthening of the scientific guided professional practice, by enabling it to improve the holistic and human care of the person, family and community. This integration configures itself in the cultural care 17 .
Most of the population's health problems have sociocultural etiology. Faced with the demographic changes and of the persons' mobility, cultural diversity is increased as well as modifying social relationships. From this perspective, the anthropological perception has repercussions as a plausible resource.
Anthropology and Nursing form a "natural alliance", with common elements. While the former is more focused on human beings, nursing is more dedicated to the person. From this alliance, arises the Transcultural Theory proposed by Leininger, who has the cultural care as its basis 17 .
Leininger states that the nursing needs to know the cultural scope of the person to better enable the care, respecting the different ways of thinking, knowledges and health practices, aware that each culture influences in caring, without, however, losing the affection essence and love in the actions of this care. In this process, the coexistence of nurses in the living environment of persons and the participant observation are fundamental. 18 .
Madeleine Leininger presented, in 1970, implicit and respectful precept to the Nursing profession, when adding the Anthropology to its doing. She graduated in Nursing in 1948, earned his bachelor's degree in Sciences in 1950 and, concluded her Doctorate in Anthropology in 1965, in the University of Washington. In her thesis, by observing children and their respective parents, proved that these presented differences of behavior according to origin, by attributing them to an axis of cultural basis. From then on, she devoted herself to its new area of Nursing, that is, the transcultural Nursing, being the first nurse in the world to obtain a doctorate in Anthropology. When considering the anthropological basis, the Transcultural Theory presents great amplitude 19 .
The professional performance of nurses alongside the elderly with Alzheimer' s Disease encompasses the care of the person itself, of the caregiver who, many times, is also in old age, and the family, so is a disease that affects the whole family's structure, impelling them to new arrangements. Persons who, regardless of origin, class or social condition, are part of the society, with certain culture, customs and traditions 20 .
The patient care involves its surrounding, the neighborhood. The cultural care, the proximity is essential value. It's impossible not to bother about the distance, since the care is interrelated with the cared person 17 .
The culture defines the affective relationships belief systems, of healing, well-being and death. It determines what type of treatment will be given, who should provide the treatment and who could make decisions. The prejudices and the lacks of awareness and cultural understanding of the caregiver contributes to the patient's lack of trust and respect, resulting in poor communication, non-adherence, negative outcomes and health disparities. For health professionals, understanding the culture is an active and constant learning process that requires long-term commitment 21 .
The cultural care, understood as the act of helping, supports and facilitates a cultural sense, focuses on the actual or anticipated needs for the person's health and well-being, with the aim to face the situations 22 .
Interdisciplinary care in Alzheimer: theoretical reflections Barbosa MEM, Corso ER, Scolari GAS, Carreira L Madeleine Leininger explored the concept of caring in the Cultural Care Theory: Diversity and Universality, highlighting the apprehension of diversity (inequalities) and universalities (equivalence) within and among cultures, related to care. The culture is essential to the discernment into the health and the care of the patient should be adapted to it. The care provided should not only be congruent with the culture, as well as useful to help achieve the desired results. The nurse's role is essential to help the patient search for its well-being. So that, it is important to construct reliable and therapeutic bonds, which are better promoted from cultural awareness and knowledge 23 .
The theorist reiterates that there are three constructs to be considered by professionals: adaptation of care, which helps the patient to achieve the desired results, preserving the culture: accommodation or negotiation and restructuration of cultural care. Concerning the care cultural, this is a recognition that the patient has cultural practices that do not influence negatively the health. The nurse's role is to help it maintain the cultural values and the life style regarding its own health concerns. The restructuration of cultural care should be applied, when better health and well-being results are required 19 .
The merit of cultural competence in each space of nursing practice, in the current sphere, cannot be underestimated 16 . The nursing actions should support patients, whatever their culture, to adapt or mediate with the health community to obtain better results. At last, the nurses' role in reformulating the cultural care is to provide the persons with awareness, enabling them to make informed decisions, welcoming cultural values. This can help them transform negative behaviors to achieve benefits 19 .
It's worth highlighting that offering culturally competent care does not mean that the person is the authority over the values and beliefs of all cultures or that always accept the beliefs of a patient or a family. The culturally competent care expresses that one should be respect for the cultural differences and understand the effects of the care provided to the person and its culture. The culturally competent care denotes to be willing to admit that there are many ways of seeing the world and that no route can be considered the right way 1 That way, in the Alzheimer's Disease, Leininger points out that one of the ways of achieving this is to provide culturally congruent care, in other words, considering the context, values, beliefs, life style and usual practices of the elderly and their families 24 .
In practice, the cultural care is applied by the way they address patient and caregiver, as well as in developing interventions, from the educational process to a more complex procedure. For example, elderly people have beliefs and customs that distinguish them as personalities, in developing the Alzheimer's Disease, the recent memory is initially affected, but the past is preserved longer, thus the adherence to care will be better, as far as habits and customs are respected. Among the care, one of the most relevant is to avoid changes, that is, not to remove the elderly from their residence place.
The cultural care consists of technology that uses the dialogue and the other's world acceptance as a basis to promote well-being implies respect for the ill person and its family, in the sociocultural and daily context in which emerge the social demands, characteristics of the daily.

Daily life of the care of the elderly with Alzheimer's Disease
The Social Work is a relatively new area of knowledge and, as other disciplines, request adequate definition of theoretical and methodological domain. In this context, the Agnes Heller's ideas arose, in 1990s, as the premise of a theoreticalmethodological framework, in the scope of the social worker's training and professional actuation, with the daily life theory. The author starts from the concept that the daily life is the scenario where the events of the social life occur and there is an evolution of the life of every human being 25 .
It is also stressed that, in the daily routine of the professional intervention, it is of crucial importance the professionals' interdisciplinarity immersed into this field, working in a way to integrate the elements present in the Heller's Daily Life Theory, which are spontaneity, immediacy and analogy.
Heller's Daily Life Theory seeks to understand the elements that permeate the daily life, the interaction with the common sense and the uncommon rescue within the daily life, is to discover that the essence of the daily life is in the non-daily life. The daily life is the life of the whole man, in other words, the one who participates in life, of the every day, with all aspects of the individuality and personality. In the daily life, the senses, the intellectual faculties, the persuasive skills, the feelings, the passions, the thoughts and the convictions are set "in motion" 26 .
Heller's philosophical conjectures understand the daily life, immediacy, historicity, social roles, science of values, ethical/moral behavior, provisory judgements, objectivity and subjectivity, particularity, individuality, that is, the ontological foundations of the social being, pattern of analysis of Hellerian thought, through daily life experiences.
Interdisciplinary care in Alzheimer: theoretical reflections Barbosa MEM, Corso ER, Scolari GAS, Carreira L The daily life is the "life world" where one creates and recreates through the dialogue, in permanent movement. The concept of the daily is related to the one that is lived and to the social life of the social individuals. One and other relate to each other 27 .
The applicability of the Daily Life Theory along with elderly with Alzheimer's Disease is perceived when facing with situations of social vulnerability (low income) and family conflicts, that must be immediately alleviated (immediacy), to enable the patient and its family the support. The course of re-socializing is not limited to the access of the citizenship, work and social rights. Citizenship positions the person to basic conditions of social inclusion however, the life purposes of each individual shows a way to be followed so that the inclusion can occur. Therefore, it is necessary to be aware to individual desires and needs and help them to life from their singularities in the social context, in which they are inserted 25 .
In the health care, it is important to search for the completeness of the existence and way to enable offering meaning and sense not only to health, but to the own life project, which re-signifies everything, the care of yourself 25 .
According to Heller´s Theory, each man lives the daily life existence, with its experiences, skills, affections, passions, thoughts and ideologies. The global is included in every men. It is specific and, simultaneously, a generic creature, since it is a consequence of its social bonds, inheritor and conservative of the human development; it is not only, but always integrated with other men, in a sociocultural sphere. The men´s daily life makes it possible, in general terms, the model of how the society where this citizenship lives presents itself 25 . Therefore, when analyzing the interviewed persons´ daily life, one perceives the orientation with regard to the organization and reproduction of the society in which they are inserted.
The approach of the knowledge basis marked by Heller´s daily life, as an essential way of care, as a cultural axis of attention, according to Leininger´ s presuppositions occur by using the same field and in the joint action in the same patient/space. Nurses and social workers carry out the situational diagnosis of health and social, then, the interdisciplinary planning of interventions, in specific moments of each area, which fuse, later, into a single context, the resolution of social problems, addressing the cultural values of the individual and its family.
In the context of elderly with Alzheimer´s Disease, it is common to meet unstructured families, both financial and emotionally, in a threatened condition, not necessarily of damage, but at risk of weakness. Certain elderly persons with the disease have a greater risk of grievances because of tight economic conditions, therefore, are susceptible to other comorbidities. They are elderly in social vulnerability, with an unfavorable condition of deprivation in daily life 28 , a scenario that requires vigorous and immediate social intervention, aiming at the protection and well-being of the patient and its family, according to the immediate presuppositions of Heller´s daily life.
Another condition of the daily life in the Alzheimer´s Disease that generates wear in the social relationships that require interventions of the social assistance, are the related to communication. Communication difficulties mostly are resulting from the lack of knowledge of the disease 27 . That, many times, entails conflicts. In this sense, the daily life of cultural care points out the dialogue, in constant movement, as the best strategy for solving problems of patients and caregivers. The factor communication is also a potential basis in cultural care.
The daily life care is represented by the problem-solving attitude when emerge from the social organization, having as a premise the conflict resolution and meeting the needs experienced by the elderly with Alzheimer´s Disease and respective families, as early as possible. It is within the family, in the daily of relationships that result from it, that life happens. That way, the problems resulting within the family are social diagnoses 29 .
The daily is a kind of study composed of factors of organization of the personal life, of the work, of the entertainment space and of the collectivity as a whole, configuring themselves in hierarchical and heterogeneous place, rooted in the present time, in that the individual places itself integrally, with all elements of singularity and personality. In this universe, knowledges, communicative skills, passions, feelings, conceptions and values are used. To analyze persons is, therefore, stop the paradigm that biological man is the center in matter of importance and value, and to rethink it as integrant of historical-social follow-up, that permeates objective and subjective demands of the context in that it is 30 .
In this process of understanding of Heller´s presuppositions, with emphasis on the theoretical-practice dimension, applied to elderly with Alzheimer´s Disease and its surroundings, it is necessary to clarify about the main characteristics of the disease, that requires the prompt intervention of the social worker: depersonalization (progressive loss of memory), social exclusion, family conflicts in confronting the disease, financial imbalance for treatment, among other factors, requiring family adjustments, need to hire professionals, among others. Therefore, the interventions need to be based on meeting immediate social needs, with support to families, followed by inclusion processes in the cultural scope, offering means for the elderly, caregiver and family are reinserted in society.

Congruence of the Cultural Care and of the Daily Life of Care
Conceive the elderly person with Alzheimer's Disease and the social and cultural expressions that result from it means to think about immediate answers for every situation that emerges.
Interdisciplinary care in Alzheimer: theoretical reflections Barbosa MEM, Corso ER, Scolari GAS, Carreira L The compliance of the daily and cultural care is configured in a new technology of care, with interdisciplinary comprehensiveness, which allows a greater effectiveness in solving problems that affect the elderly with Alzheimer's Disease. In this process, one prioritizes the care in acute situations of health and/or social (spontaneousness) and invests in the prevention of grievances and health promotion of these elderly and their caregivers, by means of actions based on the respect to cultural aspects and in the daily life of these persons.
In this respect to the culture of the families involved in this situation, strongly marked by the patriarchal society, from the not-so-distant past, in which women were destined to family care in a private environment, and to men, the care in providing the support, in other words, women in the private, men in the public 19 , is the Nursing and the Social Work, for the disposition of distinct interventions, with regard to family values, and the society, in that these elderly one day were active subjects at the wheel of life of the birth, working, falling ill and needing someone else that care him, must be present.
Taking into account that most caregivers of elderly persons with Alzheimer's Disease are male, to the same extent, we must enter into this family daily, without prejudice and personal values and, able to act with respect to these women who even knowing that they are banished from social life, of rights that are inherent to them as an human being, are willing to abnegation of caring of elderly persons with Alzheimer's Disease. This care includes referral, when necessary for the public and/or private of care services, as well as requesting eventual benefit, arisen from the Organic Law of Social Assistance (such as the basic food), among others 3 . Therefore, the interdisciplinary actuation in this context would be to prepare the caregiver to exercise care with more property.
Only the care is not enough, it is necessary to visualize apart from the apparent, to unveil the reality of each family, respecting values and beliefs, having the sensitivity and social responsibility of knowing how to intervene in each case, as effectively as possible, with a view to emancipation and autonomy.
The joint actions of nursing and social work confer a character of congruence of the theoretical framework of Leininger and Heller. Among the frequent requests of families for the services of these professionals, is conflict resolution. For example, it is common, mainly in large families the care falls to only one family member, due to the numerous demands for the care of the elderly with Alzheimer's Disease, that is, which makes it overloaded. Solution that involves the need to know the sociocultural context of this family and the communication as a support tool.
So, the conflicts resolution involves respect for culture, in addition to consider the family context of the elderly for providing care, in the role of mediator, orient the family members about the disease characteristics, in that the maintenance of the routine in the environment of the elderly with Alzheimer's Disease, for example, promotes its well-being.
Thus, also sensitize the family members as to the overloaded caregiver's needs, because they need to have moments to take care of themselves, meet personal commitments, have moments of leisure, to maintain its own health and, jointly, find the best solution 22,27 .
In other interventions of care, the compliance between the theories is also perceived. In the scope of the health promotion, group physical activities aimed to stimulate the memory, improve the mobility of the elderly/caregivers and promote socialization. These are carried out in external environment (such as a park), enabling close contact with nature, motivating elderly with Alzheimer's Disease and caregivers to feel wellbeing, perceived by the expression of joy and satisfaction of participants. Such activity integrates the daily care, in the aspect of socialization, and the fact of being carried out in open space, while promoting health, stimulates reminiscences, mainly of those who are from rural regions, revisit the past, with customs and traditions 24,19 .

CONCLUSION AND IMPLICATIONS FOR PRACTICE
The interdisciplinarity of care in Heller and Leininger, originated in the Anthropology, can be explained by the presence of elements in common, both theoretical and practical. Concepts such as holism, environment, basic needs, bond, support and daily are analogous.
In Anthropology, human groups are concentrated, where the person's understanding of the cultural universe come from. So, the Social Work is concerned with the population at risk of social vulnerability; and, the Nursing, with the person as a whole. Regarding interdisciplinary actions, in the context of the elderly with Alzheimer's Disease, one understands as family disease, requiring dialogical relationship, of the respect for differences and the search for promoting the involved persons' s well-being.
Similarities also occur in the methodological aspects. Monitoring in the field is the attribute in common to all disciplines, as well as the participant observation is the instrument that bring the professional closer to the persons' s universe, an indispensable resource for understanding reality, both in the health-disease processes and sociocultural, in order to enable the therapeutic approach with the creation of bond, essential in working alongside the family, whose elderly presents the Alzheimer's Disease.
The congruence of the theories implies solid, integral care, involves concrete actions, based on different presuppositions, which strengthen each other when they come together, by benefiting elderly and caregivers, with individualized and differentiated care. This integration, marked by the sum of efforts, on the one hand the respect for culture, and on the other hand, the immediacy in solving problems, improve the qualified care carried out.
Interdisciplinary care in Alzheimer: theoretical reflections Barbosa MEM, Corso ER, Scolari GAS, Carreira L Moreover, it involves objective behaviors, based in the specific demands where, separately, neither the nursing nor the social work would be able to solve carried out with focus on the care of elderly with Alzheimer's Disease.
This reflection made possible the immersion in the theoretical basis universe that guide the praxis of nurses and social workers. Also, enabled a better understanding of the actions of others and its interaction in the care process of the elderly with Alzheimer's Disease, in multidimensionality, contributing, among other factors, to the team's harmony. The knowledge of the philosophical basis regarding the doing of the other strengthen the interdisciplinarity, resulting in higher quality of care.