Concept of family insuffi ciency in the aged : critical literature analysis

Objective: to identify the attributes of the “family insuffi ciency” concept of the aged in the literature. Method: critical literature analysis. Results: family insuffi ciency is characterized as a complex process of psychosocial interaction, founded mainly on low social support of the aged and impaired family ties. Its antecedents are found in contemporary transformations within the family system, intergenerational confl icts, impaired family relationships and social vulnerability of the family. The consequences of family insuffi ciency include social vulnerability of the aged, decline of psychological and functional health, lower quality of life and unsuccessful aging. An original theoretical proposal was elaborated for the concept of family insuffi ciency in the elderly, with the identifi cation of its attributes, antecedents and consequences. Conclusion: the fi ndings of this study constitute a theoretical advancement in the Family Insuffi ciency Syndrome in elderly people and provide data for future fi eld research in developing the concept.


INTRODUCTION
In recent years, life expectancy has risen for different reasons, in particular due to the development of new technologies, especially in the area of health.By 2050, the population over 60 will exceed the population under 15, and 80% of the world's elderly will be living in emerging countries such as Brazil, according to the United Nations Population Fund (1) .
The increase of the elderly population, both in Brazil and worldwide, has resulted in a wide range of transformations, economic, social, in health, in leisure, and also in affective relationships, inside or outside the family.Similarly, the transition from adulthood to old age is a process that has generated new demands.Noticeable among them is the need for greater family support, with the main role of guaranteeing a reliable and safe environment in which the elderly can lead autonomous, independent and active lives (2) .
Family can be defined as a group of people linked by kinship, household dependence or rules of social interaction, living in the same household unit or alone (3) .It can also be viewed as an interpersonal system composed of people who interact for different reasons, such as affection or reproduction, within a historical life process, despite not sharing the same living space (4) .It can therefore facilitate the development of healthy, emotionally stable, happy and balanced people (5) .
Thus, a family constitutes a space of social protection, to the extent that it is a place that provides its members with support, solidarity, social reproduction and care (6) .
Sociodemographic and cultural changes, such as increase in human lifespan, reduction of fertility rates, larger female participation in the work market, valorization of individualism and intergenerational conflicts, have, over the years, affected the family structure and weakened family support.This has jeopardized the family's role of protecting less autonomous people who have historically depended on family support and care (7) .
When the family lacks the necessary psychological and social conditions, or the financial and human resources to care for its elderly members, they are exposed to situations of morbidity.This creates a fertile ground for family insufficiency, which can impair the life conditions of elderly people, commonly leading to institutionalization (8) and separation from their families.Currently, the concept of family insufficiency is seen as a Geriatric Syndrome and considered one of the seven giants of Geriatrics (9) .Thus, a new concept emerges in the specific literature, that of family insufficiency, which is still adapting itself to its actual meaning; hence the importance of exploring it with the aim of raising the awareness of nurses, health professionals and society, especially the family, to their role in opposing this risk, inasmuch as family insufficiency is directly linked to human relationships.This context gives rise to the research questions: What is family insufficiency?What does the literature contribute to this concept?What precedes family insufficiency?What are the implications of family insufficiency for the aged?
In this perspective, this study aimed to identify in the literature the attributes of the concept of family insufficiency in the aged and reveal what the authors mean by family insufficiency.This research is justified by the fact that investigating, characterizing and illustrating the concept of family insufficiency will potentially contribute to the practice, research and training of nurses and other health professionals in the context of elderly care.

METHOD
This study corresponds to a Critical Literature Analysis (10)(11) of the concept of family insufficiency in the aged.Concept is identified as "cognitive representations" of a perceived reality, formed by direct and indirect experience based on situations, events or actual behavior (12) .In this sense, a concept does not arise out of the blue, but from multiple situations, influenced by intrinsic and extrinsic factors which expand, refine and characterize it.It acquires meaning through its use and application in individual situations (13) .Owing to their abstract nature, concepts are verified by determining their components, normally referred to as attributes (12) .
A concept can be understood by exploring its attributes identified as antecedents, defining attributes and consequences (14) .Defining attributes are words and/or expressions employed to outline the properties that determine the given concept, differentiating it from other analogous or related concepts (15) .The antecedents and consequences of the concept are assessed as situations, events or incidents happening before and after the given phenomenon, respectively (16) , and may or not coincide with the defining attributes.Antecedents help us to understand the social context of the concept under study and allow us to refine its defining attributes and identify its underlying premises (15) .

Databases and descriptors
The theoretical exploration of the abstract components and descriptors of the concept of family insufficiency was carried out by the authors (AS, TSP, JHSR, DSP, MAM) in September 2013.
the CINAHL and APA PsycNET search resources were "aged" [DeCS] and "family relations" [DeCS] and "social support", which resulted in 43 and 35 citations, respectively, and a combined total of 353 potential references for this research.

Selection process
Publications presenting defining elements of the concept of family insufficiency, published in Portuguese, English or Spanish, were included in the study, regardless of publishing date.The titles of the 353 references resulting from the strategies employed in the bibliographical searches were read in order to select articles that were relevant to the study, as well as any existing abstracts.In case of doubt, or when the extract was not conclusive, the publication was saved for the following phase of full text reading.
The selected papers were read in full and analytically in order to identify those outlining possible elements of family insufficiency, whether antecedents, attributes or consequences.Most of the excluded references focused on the role of the elderly caretaker in the family, others alluded to the process of institutionalizing elderly individuals in the family, many referred to geriatric pathologies and therapies, among others.This phase led to a new selection of texts, resulting in the final set to be analyzed.

Data extraction and analysis process
This process started out with a close reading and critical analysis of the content of the publications brought up by the search.Those publications indicating possible contributions to the study of the concept of family insufficiency were set apart.These small texts were analyzed, within their respective contexts, to identify which elements they addressed, whether attributes, antecedents or consequences.Identification codes where then assigned to their content and inserted in a Microsoft Excel 2010 spreadsheet.The codes on the spreadsheet were constantly compared in order to identify the conceptual limits of family insufficiency (10) .And, consequently, they were grouped according to similarity of meaning, resulting in categories and subcategories which were individually named.The categories referring to the same approach of the concept of family insufficiency were grouped, which generated a new organization.During the analysis of the categories, some of them were renamed until the attribute meaning was adequately represented by a definite designation.This analysis was carried out by the authors (AS, TSP, JHMR) and validated by the researchers (DPS, MAM).

RESULTS
The theoretical exploration of the literature to analyze the concept of family insufficiency resulted in 23 publications.Box 1 summarizes the main characteristics of the studied publications: author/year, country of origin, impact factor, study type and objective.The critical literature analysis allowed the identification of the elements of the family insufficiency concept, namely, defining attributes, antecedents and consequences, which are presented in analysis categories and subcategories in Box 2. The findings of the analysis of the family insufficiency concept will be described in three parts, starting with the defining attributes, then the antecedents and finally the consequences, plus their respective synthesis tables, Box 3, 4 and 5. Also part of the result is a conceptual theoretical formulation of family insufficiency in the aged.
Defining or critical attributes of the concept of family insufficiency in the aged Family insufficiency in the aged is characterized as a complex psychosocial interaction process (17) founded on two defining elements: low social support and impaired family ties.
Family support is important for individual well-being throughout life; however, it can be particularly relevant in later life, when occupational, economic, functional and health challenges tend to increase (17) .
Therefore, social, emotional and/or instrumental support, such as financial aid, transportation, help with household chores and illness treatment, may have different links to the well-being of elderly people (17)(18)(19) .After all, an inadequate social network added to financial difficulties or poor physical health may result in a tense life situation, contributing to the psychological suffering experienced by elderly people (20) .
The main social integration networks, responsible for providing a broad base of support, are composed by relatives, friends and neighbors, besides those resulting from the involvement of elderly people with the community through neighborhood ties, religious groups, clubs or non-governmental organizations (21) .Such networks are distinct in structure, type and number of social ties, reciprocity, social engagement, relationship closeness and function, such as frequency of contact with the elderly and their participation (22) .
The various sources of support may have different impacts on the well-being of the elderly (23) .The most obvious way to offer total social support to elderly people is through an equally total social network combining offspring, relatives and friends, considered the best social network (24) .The family, on the other hand, is the source of information, counseling and instrumental help (18,25) ; however, family members provide instrumental rather than emotional support (19) .
Low total social support stands out as a basic element of family insufficiency in the aged, which in turn is composed of low family support and low social support.
Family relations have a mandatory nature, sustained by the institutionalized family structure and approved by prescribed social rules and roles (26)(27) .Therefore, the network focused on the family is characterized by close links among spouses, children and siblings, but low contact with friends and controlled organizational participation (21) .Owing to physical, mental, emotional and social changes, the elderly require greater care and help from family members (28) .Consequently, the family is the main source of support for the elderly, and each family provides all help possible within its means to improve the life conditions of its elders, especially in times of "extreme need" (29) .Given the closeness, the family is able to detect swiftly and precisely any changes in its elderly members, such as the ability to perform daily tasks independently.Moreover, it To examine and associate potential effects of social support on illness burden, functional impairment and depressive symptoms in elderly people.
can identity their physical conditions or notify them of health changes and difficulties, down to the most discreet depressive symptoms, and thus help them manage or deal with potential health problems (30) .In particular, elders suffering from diseases benefit greatly from family support (23) .Within this context, low social support to elders by the family has a negative impact on interdependence, personal affection, emotional intimacy and reciprocity, in both physical and psychological care (27) .In this research, the social integration network is marked by frequent contact with friends and neighbors, but low contact with relatives or even no family ties whatsoever.Such a network can become more restricted due to rare social activities and low organizational participation (21) .And low social support to elders is one of the psychosocial factors with potential impact on individual health promoting practices (31) .
The family is the source of information and counseling; impaired family ties can harm its capacity to provide elders with comfort, support and company, for example, when few family members take an active interest in the health care of their elders, being thus unable to follow medical instructions and understand the effects of the clinical procedures they are undergoing (19) .Impaired family ties can be reinforced by a sense of poor involvement and perceived incompetence of relatives (22) .Finally, impaired family ties can foster social isolation among elderly people (6) .

Antecedents of the concept of family insufficiency in the aged
The antecedents of the concept of family insufficiency in the aged are determining elements that somehow collaborate to establishing family insufficiency among elderly people.They are composed of the following analysis categories: Contemporary transformations in the family system; Intergenerational conflicts; Impairment of family relations; and, finally, Social vulnerability of the family.
Given the recent demographic, economic and social changes undergone by society, numerous modifications can be observed in the patriarchal family system (34) .Noteworthy among contemporary transformations are the decreasing number of extended family members (20) , the emergence of the empty nest and the inversion of roles among family members, with Role inversion and Empty nest constituting analysis subcategories in this study.
With role inversion, support becomes unidirectional, i.e., elderly people offer care and support, whereas they should receive the same from their relatives (29) , helping to alleviate their vulnerability.Thanks to wider access to pensions, elders have become an important source of financial support within the family, taking on, to a certain extent, the role of family provider (29) .Many elders have become heads of their families, being financially responsible for providing for their children and grandchildren.Thus, the elderly person supports the household, supplying basic needs such as clothing, footwear, Box 2 -Synthesis of the analysis categories and subcategories of antecedents, defining attributes and consequences of family insufficiency in the aged, Alfenas, Minas Gerais, Brazil, 2014 Low social support (17)(18)23) ; Low instrumental support (17)(18) ; Inadequate source of instrumental aid (19) ; Low emotional support (17) ; Inadequate social network (20) ; Long-term institutionalization (24) ; Low social integration (22) .
Impaired family ties Impaired family contact (22) ; Sense of impaired family involvement (22) ; Inadequate source of family information (19) ; Inadequate counseling source (19) ; Perceived incompetence of family members (22) ; Social isolation (6) .medication and food.Pensions have commonly become crucial to family survival and finances, and in many cases are the main, if not sole, source of income (29) .On the other hand, owing to the natural evolution of life, to the resulting changes in the family system and to globalization, adult children are increasingly living far from their parents (20) , given the economic and social opportunities available away from home (34) , thus leading to the emergence of the empty nest condition.Added to role inversion, this can contribute to trigger family insufficiency in the aged.
Intergenerational relationships within the family are governed by strong rules of filial piety (34) .These incorporate emotions, including respect and intimacy between older adults and their children (19) .In addition, providing support to parents is marked as a moral and social obligation in which children should be obedient and subservient, respecting their parents throughout their whole lives (34) .However, some families stand out as sources of intergenerational conflicts, sustained by relationships of violence, negligence, disrespect, abandonment, domination, power and force (6) .Such a family context fails to fulfill its important supporting role in intergenerational relationships, with their cultural expectations of love, closeness and solidarity, thus leading to the impairment of family unity (17) .What stands out in this situation, added to the stress of modern life problems, is the loss of the cultural value of authority and respect among family members, leading to the potential weakening of ties with elders or social isolation (6) .
In the category of impaired family relations, the absence of family members can have a negative impact on elders' personal affection, emotional intimacy or even physical and/ or psychological care (27) .Moreover, impaired family relations contribute to reduce the sense of self-esteem of elderly people.Likewise, family members can assume a critical attitude in situations of health problems, disapproving of or rejecting the elder's behaviors and decisions, which can lead to further functional decline, adaptive health behaviors, increased negative affection or even depression (35) .
Finally, social vulnerability of the family is also characterized as an a priori condition of family insufficiency in the aged.Such family vulnerability can be caused by unemployment, alcohol and drug dependence, family ties or stressed relations due to modern life problems such as overvalued materialism, increased individualism among family members, loss of the values of authority and respect (6,27) , among others.In addition, negative social interaction can aggravate the effects of poor health conditions and emotional decline in elders.Depending on the living conditions, the family can drive its elders to social isolation (35) .Therefore, social isolation of elderly people emerges as the main antecedent of the family insufficiency concept.

Consequences of the concept of family insufficiency in the aged
The consequences of the concept of family insufficiency are defined as situations, events or incidents resulting from the application of the concept, that is, implications of family insufficiency in the aged.The analysis categories of the consequences are described in Box 5, to wit: Social vulnerability of the elderly; Decline of psychological health; Functional decline; Lower quality of life; and Unsuccessful aging.
Social interaction of elders with their relatives provides greater support for their affective ties to preserve interpersonal relationships (6) , among other considerations.Therefore, social vulnerability of elders, generally occurring within the family, happens when the aged face potential threats to their needs and health, and lack the necessary personal, social and legal Box 4 -Analysis categories and subcategories of antecedents of family insufficiency in the aged, Alfenas, Minas Gerais, Brazil, 2014

Categories/ subcategories Main codes and references
Contemporary transformations in the family system Non-patriarchal family system (34) ; Diminishing family size (20) .

Role inversion
Unidirectional support (29) ; Source of financial support to the family (29) .

Empty nest
Social and economic opportunities away from home (34) ; Married children living far from their parents (20) ; Distant family (21) .

Social vulnerability of the family
Negative social interaction (35) ; Unemployment in the family (6) ; Alcohol and drug dependence in the family; Stressed family ties due to modern life problems (6) ; Individualism in the family (27) ; Overvalue of material goods (6) ; Isolation (35) .
resources to avoid violation of their human rights (33) .The absence of resources, evidenced by counterproductive social exchange, may increase poor health conditions and emotional decline (35) .Similarly, the negative impact of life stress factors on elders can the alleviated by an effective social network (20) .Consequently, among the multiple social networks available to elderly people, the total social network, composed of all children, relatives, friends and confidants, plays an important role in protecting against residency in Long-Term Care Institutions (24) .On the other hand, with the impairment of this type of network, allied to loneliness, elderly people become vulnerable to institutionalization (37) and separation from the family.
A further consequence of family insufficiency in the aged is the decline of psychological health.When elders are neither integrated into their families nor into the communities to which they belong, sustaining fragile relationships, they normally present negative feelings towards life (37) , low selfesteem (28) , and increased negative affection (35) .Therefore, loneliness, isolation and negative social interaction aggravate poor emotional functioning (35) , create stressful situations (6) and result in inadequate psychological care to the elderly (27) .In addition, lack of affection and aid to elderly people can weaken their defense against health-related stressors and hinder their capacity to adapt to crises (30) .
The consequences of insufficient social support to the elderly in the family are also linked to impaired health-promoting behavior and reduced psychological well-being (31) , potentially contributing to psychological suffering in elders.Such suffering can be especially aggravated when combined with stressful life situations, such as poor physical health and financial difficulties (20) .Moreover, a deficient or limited family network can trigger low mood, with depressive symptoms (6) , or actual depression (6,35,38) , which can be aggravated when combined with common old-age chronic diseases (35) .In this perspective, low family support is decisively linked to psychological health decline in elders, which can obviously lead to their social isolation.
Alongside decline in psychological health, functional decline in elders is a further consequence of the family insufficiency concept.It is equally characterized by the impairment of health-promoting behavior, as well as inappropriate health behavior in the context of health disorders (35) .Therefore, limited or poor interaction with family members, such as in widowhood, is related to greater dependency (38) and vulnerability to health problems among elders (27) , resulting in impaired physical health (23) and its potential complications (38) .Elders in a restricted social network, i.e., with little help from and social interaction with relatives, also present a greater decline in daily life activities, since they have less help to perform daily tasks, including physical care (27) .
Once the most important source of well-being for the elderly -the family -is scarce, lower quality of life or impaired well-being (31) emerges as a logical consequence of the social isolation of elders in a situation of family insufficiency (6) .Lack of family support can hinder the preservation of health and cause the reduction or loss of life satisfaction (3,6,34) or even of quality of life (30)(31) .
Social vulnerability of elders, decline of psychological and functional health, and lower quality of life culminate in the major consequence of the concept of family insufficiency in the aged, namely, unsuccessful aging.This occurs since, through psychological, behavioral and physiological processes, elders with few or fragile family ties tend to undergo greater cognitive decline, which impacts physical aging (22,37) .
The analysis of the defining attributes, antecedents and consequences of the family insufficiency concept through Literature Critical Analysis (10,39) allowed the formulation of the original theoretical proposal of the concept of family insufficiency in the aged: Family insufficiency in the aged is characterized as a complex psychosocial process founded on impaired family ties and, above all, low social support, the latter being mainly determined by poor family support, both emotional and in terms of instrumental help.Contemporary transformations in the family system, among them the inversion of the role Box 5 -Analysis categories of the consequences of the concept of family insufficiency in the aged, Alfenas, Minas Gerais, Brazil, 2014
of elders and their empty nest, combined with intergenerational conflicts and impaired family relations, may trigger or strengthen the social vulnerability of the family.As to the social vulnerability of elders, the decline of their psychological and functional health, with loss of quality of life, in short, their unsuccessful aging, these are consequences of family insufficiency in the aged.

DISCUSSION
The growth of the elderly population has produced numerous transformations, especially in family relations.For elders to continue leading autonomous and active lives, they must live in a reliable and safe environment, chiefly provided by family support (2) .Alongside the perception of nurses and other health professionals of the inadequacy or even lack of family support, this study aimed to research in the literature elements that constitute family insufficiency in the aged in order to formulate a proposal of that concept.
Family insufficiency in the aged is understood as a psychosocial process.It is a process since it exists in an updated, continuous and permanent movement.It is psychological for being founded on internal constructions and on meanings, and it is social for happening in the interaction of elders with the family, with the context in which they live and also with themselves.Given that the family is a complex construction (17) , the experience of family insufficiency is an equally complex process of interactions, symbolically constituted by non-linear events occurring simultaneously and influencing each other, such as impaired family relations, contemporary transformations in the family system, intergenerational conflicts, decline of psychological and functional health, among others.The process of family insufficiency in the aged evidences links existing between the causal conditions leading to the increase of family insufficiency, to the experience itself, founded on impaired family ties and low social support, and to the consequences of or responses to the experience of family insufficiency.
In the literature analysis, the attributes that define family insufficiency in the aged are characterized by low total social support, which is composed of family and social support, besides impaired family ties of elders.The sources of social support in the consulted literature, in turn, also lack a better conceptual differentiation concerning its nature, role and underlying mechanisms, indicated the need for further research.
The family stands out as the main source of support for elderly people (29) .Among the family relationships of elders, those established with children are identified as the most important to the physical well-being of elderly individuals (23) .Likewise, the support of the family youth predict greater wellbeing of old-age members (17) .Therefore, low family support, whether of adults, youths or children, is fully linked to the development of family insufficiency in the aged.Support must be bidirectional so that elders receive support from family and friends and at the same time contribute by caring for grandchildren, performing simple household chores or doing informal work to increase the family income (33) .However, in the context of family insufficiency, support is mainly unidirectional, that is, from the elder to the family.
The aging process demands greater care and support, which must be provided by the main source of support to elders -their family.Therefore, family interaction is beneficial for elders (22) and, when scarce, family ties are naturally impaired so that when support is not provided, the process of social isolation of elders begins.Likewise, the studied literature does not outline the concept of family ties and its distinction from family relations, once more suggesting further research questions.
The antecedents, which contribute to reinforce the family insufficiency concept, can be explained by the contemporary transformations affecting the family system, such as the empty nest.These cultural transformations also tend to increase the value of individualism, independence and autonomy among family members, as well as socioeconomic conditions, as in the search for higher income and better health conditions, triggering greater estrangement in family relations (6,34) .The context of low social exchange within the vertical family gives rise to the concept of distant family, characterized by a high exchange of support with the family extended horizontally, i.e., with non-family members, neighbors, friends, institutions, religious groups, among others (21) .
The reduced social contact of elders, whether through physical separation, social barriers or even psychological mechanisms, has wide repercussions for elderly people.When applied, the concept of family insufficiency makes elders vulnerable and promotes the decline of their psychological health, ranging from negative feelings towards life, low self-esteem and low mood to actual depression symptoms.Moreover, it triggers their functional decline, especially by reducing health-promoting behavior, compromising their general health conditions and, consequently, their quality of life.
In the analysis of the family insufficiency concept, social isolation of elders was characterized as a major attribute, since it appears as an antecedent, as a defining attribute and, lastly, as a consequence.Therefore, social isolation of elders is an important factor in the onset of family insufficiency, as well as in its establishment, after which social isolation tends to increase among elderly people.

CONCLUSION
The findings of the research on the family insufficiency concept in the literature, through Critical Literature Analysis (10)(11) , provide relevant theoretical material to formulate such a concept.The theoretical proposal of the concept of family insufficiency in the aged represents innovative evidence on the topic, providing data for future field research on the development of the concept in order to understand how it occurs and is structured in the daily life of elders.The findings also further the development and expansion of the conceptual components identified to date and indicate the need for a deeper understanding of the family insufficiency concept.
As for the practical implications, this study exposes a set of defining or critical attributes pointing to the concept of family insufficiency in the aged.The clear outlining of these attributes for nurses and other health professionals favors the assessment and identification of family insufficiency and, consequently, supports clinical decision-making and the design of effective strategies within the family and community, aiming at improving the well-being of elderly people.Finally, this study provides a theoretical framework for both health professionals and the family to support the elderly in their aging process.
In addition, the conceptual theoretical proposal of family insufficiency in the aged can be used as a tool to support improvement in learning to diagnose this Geriatric Syndrome.A further possibility is carrying out additional research to validate family insufficiency as a nursing diagnosis.

Box 1 -
Characteristics of the researched publications, Alfenas, Minas Gerais, Brazil, 2014 Analysis categories and subcategories of the defining attributes of family insufficiency in the aged, Alfenas, Minas Gerais, 2014