DEPENDÊNCIA FUNCIONAL DE IDOSOS E A SOBRECARGA DO CUIDADOR DEPENDENCIA FUNCIONAL DE ANCIANOS Y LA SOBRECARGA DEL CUIDADOR

A finalidade deste estudo foi identificar a dependencia funcional de idosos e a sobrecarga do cuidador. Trata-se de estudo epidemiologico e transversal realizado em 2009 com 574 idosos e 124 cuidadores em Ribeirao Preto-SP, por meio dos instrumentos MIF e Escala de Sobrecarga de Zarit. Entre os idosos, a maioria era do sexo feminino (67,8%), com media de 76,6 anos, baixa escolaridade (54,7%) e renda individual mensal de R$ 942,20. Apenas 15,7% foram identificados como dependentes. Dos cuidadores, 85,6% era do sexo feminino, com media de 56,5 anos e 90,3% eram familiares (filhas ou esposas). A media de sobrecarga dos cuidadores foi de 27,8 (±17,5). A dependencia do idoso foi fator de risco para sobrecarga do cuidador (p<0,05). A abordagem preventiva e a intervencao precoce devem ser prioritarias para essa populacao. Sao necessarias a vigilância de uma equipe multidisciplinar de saude, a aplicacao de instrumentos de avaliacao do comprometimento da funcionalidade e a intervencao para prevencao da sobrecarga dos cuidadores.


ABSTRACT
This study inves gated the func onal dependency of older individuals and caregiver burden. This epidemiological and cross-seconal study was conducted in 2009 with 574 older people and 124 caregivers in Ribeirão Preto, SP, Brazil, using the following instruments: Func onal Independency Measure (FIM) and Zarit Burden Interview. Among the elderly, 67.8% were women with an average age of 76.6 years old; 54.7% had a low level of educa on and a monthly per capita income of R$ 942,20, and only 15.7% were iden fi ed as dependents. A total of 85.6% of the caregivers were women with an average age of 56.5 years; 90.3% were family caregivers (daughters, wives), and the average burden was 27.8 (±17.5). The older individuals' dependency was a risk factor for caregiver burden (p˂0.05). Preven ve ac ons and early interven on should be priori es for this popula on. Surveillance from a mul disciplinary health team is required, as well as the applica on of instruments to assess the extent to which func onality is compromised and interven ons to prevent caregiver burden.

INTRODUCTION
One of humanity's greatest triumphs has been to dras cally increase life expectancy; however, this increased longevity has resulted in major challenges for healthcare workers.
In Brazil, the number of seniors aged 60 and over has risen from 14.8 million in 1999 to approximately 20.6 million in 2010 (11% of the popula on) according to the Brazilian Ins tute of Geography and Sta s cs (IBGE). The increase has been even greater among older age groups. In 1999, Brazil recorded 6.4 million people over the age of 70 (3.9% of the total popula on); however, by 2010, this age group had reached 9.3 million, accoun ng for 5.1% of all Brazilians (1) .
In addi on to this demographic transi on, Brazil is also undergoing an epidemiological transi on as a result of its aging popula on. This transi on has led to a higher prevalence of chronic diseases, cogni ve impairment, sensory decline, accidents and social isola on, all of which can result in func onal dependence in the elderly (2) Func onal dependence is the inability to maintain the physical and mental skills necessary to live independently and autonomously (3) . It is generally measured by the inability to perform the ac vi es of daily living (ADLs), either basic ac vi es (BADLs), which are o en described as self-care ac vi es, or instrumental ac vi es (IADLs), which involve the organiza on of one's daily rou ne.
A major challenge we face with regard to aging is to reach old age without suff ering from one or more of the diseases or medical condi ons that limit daily life and render us dependent on others. However, when a person is impaired for any reason, it is most o en the family who assumes the task of daily care, o en without adequate prepara on or knowledge for such a role or the support necessary to perform it (4)(5) .
The complexity of the task o en makes caregivers forget about themselves, their own needs and interests. Mixed feelings, psychological confl icts, grief, fear and insecurity are common throughout the caregiving experience (6) . Such confl icts are o en the result of con nuous caregiving and are considered symptoms of the caregiver being overburdened by the task of assis ng a senior in basic ac vi es, such as bathing, dressing, oral hygiene, feeding or helping an elderly person to move around or be transferred or posi oned. These ac vi es are considered the most stressful tasks in the daily rou ne (7) .
In this context, the role of the nurse is cri cal. As an educator, a nurse is in a posi on to suggest strategies and give advice that can transform the lives of both individuals and the wider community.
Further research on this topic is required because the challenge of how best to provide support for caregivers is a rela vely new ques on for the Brazilian healthcare system. Analyzing the reasons why caregivers o en fall ill themselves is par cularly per nent. Such data would help to improve the health care system's ability to address the health needs of this popula on.
The loss of an elderly person's func onal independence is an important public health issue. Studies that address this issue are therefore essen al because they can inform and guide public health policies for both the elderly and those who take care of them.
Although current literature has highlighted numerous characteris cs of family caregivers in the home environment, a need to explore this issue further remains because such features take on diff erent contours according to the country's regional peculiari es.
With this in mind, we set out to answer the following ques on: Are the caregivers of func onally dependent seniors in Ribeirão Preto, SP, Brazil, feeling overburdened by their caregiving ac vi es? The main objec ve of this study is thus twofold: to determine the level of func onal dependence of the elderly living in the community and to evaluate whether their family caregivers were being overburdened by the job.

METHODS
We conducted an epidemiological study that was descrip ve and cross-sec onal in nature. The study was performed in the urban community of Ribeirão Preto, SP, Brazil.
Our target popula on comprised seniors aged 65 and older and their caregivers who lived in the local community (inclusion criteria). We used two-stage cluster sampling to arrive at the number of seniors in the sample. A er a random selec on of sectors, at least 110 households in each sector were visited. We went on to iden fy these sectors on the map of Ribeirão Preto and mark the neighborhoods and streets that were visited.
We registered 733 elderly people using this method but interviewed only 574. This 22% reduc on was because of deaths, changes of address, and those who did not agree to par cipate in the study.
During each home visit, the elderly individuals and their caregivers were invited to par cipate in the study, and those who accepted and met the inclusion criteria were asked to sign a consent form in duplicate. The study was approved by the Ethics Research Commi ee at the University of São Paulo at Ribeirão Preto, College of Nursing.
Data were collected between January and July, 2009. We used an instrument that addressed the Functional dependence is the inability to maintain the physical and mental skills necessary to live independently and autonomously. following variables and scales to obtain data on senior citizens in the area: Socio-demographic profi les: These included the following variables: age, gender, marital status, personal and family income, source of income, years in re rement, educa on level and living arrangements.
Func onal Independence Measure (FIM): This instrument was developed to assess the level of dependency in pa ents with func onal restric ons of various origins (8) . Its primary objec ve is to quan ta vely evaluate the burden of care required for a person to perform a series of everyday cogni ve and motor tasks. The scale consists of two areas and six dimensions. The area of motor FIM (including the dimensions of self-care, sphincter control, mobility and locomo on) is assigned a score of 13-91 points. The area of cogni ve FIM (including the dimensions of communica on and social cogni on) is scored between 5-35 points. Two or more ac vi es are evaluated in each dimension for a total of 18 func onal categories of which 13 are motor and fi ve are cogni ve. These categories are evaluated in terms of how independently they can be performed. For this evalua on, we used a seven-point scale wherein each category was given a score of one (total dependence) to seven (complete independence). This yields a minimum score of 18 and a maximum of 126 (9) . For data analysis, we considered the global average, motor and cogni ve FIM scores. In Brazil, the scale was translated into Portuguese and validated in 2004 (9) .
To evaluate the caregivers, we used the following tools: Caregiver profi les: These allowed us to create a picture of caregivers looking a er seniors with cogni ve defi cits. The profi les included the following: gender, age, marital status, kinship, knowledge of the disease, degree of formal training in caregiving, number of hours devoted to care, types of caregiving tasks performed, and support they received. (10) : This scale was translated and validated in 2002 for Brazil (11) . It consists of 22 items and seeks to assess the extent to which the caregivers believe the ac vi es of caring aff ect their physical and emoonal health, social ac vi es and fi nancial situa on. The responses to the 22 items should be on a fi ve-point scale that describes how each statement aff ects the person. The total score is obtained by totaling all the items and can range from 0 to 88. The higher the score, the greater the perceived care burden.

Socio-demographic profi les and func onal independence measures (FIM scores) of the elderly living in the community
It is interes ng to note that the most signifi cant age range (33.4% of par cipants) was that of 80+ (minimum age of 65 and maximum of 103 years) and that the great majority of seniors who par cipated in the study were female (67.8%). The mean age of all par cipants was 76.6 years (± 7.6) with mean ages of 76.5 (+ 7.7 years) and 74.9 (± 7.3) for women and men, respec vely. Of the 574 seniors, 326 (56.8%) reported not having a partner, being either widowed, single or divorced. Analyzing only those par cipants who had been widowed, we found that 54.5% of women were in this situa on whereas only 15.7% of men categorized themselves as such. With regard to educa on, 314 (54.7%) par cipants had studied for between 1-4 years, followed by 116 (20.2%) who categorized themselves as illiterate.
Regarding the economic situa on of the elderly, 363 (63.2%) were re red, and 188 (32.8%) were receiving alimony, most of whom were women (179 or 46%). Only a minority (62 or 10.8%) reported themselves as working. As for personal income, the average was R$947.20, with the men receiving approximately R$300.00 more than their female counterparts. The average total household income (including that of the elderly person) was R$1,460.00. Table 1 shows the correla on between func onality levels (FIM scores) and the socio-demographic variables of age, educa on, personal income and family income. The posi ve correla on among global, cogni ve and motor FIM scores and the par cipant's age, although significant, was weak. However, we found a sta s cally significant nega ve correla on of moderate strength between func onality and educa on, i.e., in this popula on, parcipants with higher levels of educa on had lower levels of func onal impairment. Table 2 shows data on mean FIM scores related to the variable "with/without caregiver," indica ng whether they had help in their daily rou nes. Our data suggests that seniors who were assisted by a caregiver had lower than average FIM scores. In other words, we observed that those seniors were generally the most func onally dependent. The diff erences were sta s cally signifi cant, revealing that the higher the func onal dependence of the senior, the greater the need for caregiver support.

Socio-demographic profi les and func onal independence measures (FIM scores) of the elderly living in the community
We found a predominance of women and older seniors in the local community. The overall mean age of the seniors in our study was 76.6 years, which is similar to the average life expectancy data reported by some Brazilian and interna onal studies (12)(13)(14)(15) .
The seniors in our study were classifi ed according to marital status, as having or not having a partner. Those who had a partner were either married or lived with a partner, whereas those classifi ed as having no companion were widowed, divorced or single. It is noteworthy that the majority of women were widowed, whereas the majority of men were married. The diff erence between these variables was sta s cally signifi cant.
Similar fi ndings were reported in another study (16) , in which women were shown to be more likely than men to remain unmarried a er widowhood. The same study (16)

Socio-demographic profi les and burden levels of caregivers assis ng seniors living in the community
We interviewed 124 caregivers, of whom 107 (85.6%) were female and 17 (14.4%) were male. The average age of the caregivers was 56.6 (± 13.4), with male caregivers having a higher average age (61.8, ± 18) than their female counterparts (55.7, 55.7 ± ). This diff erence is sta s cally signifi cant (p <0.05).
For the variable having a partner, we included caregivers who were either married or in a stable civil union. Single, widowed, separated or divorced caregivers were categorized as not having a partner. Most female caregivers reported having a partner (71 or 66.4%), whereas among male caregivers, the majority did not have a partner (12 or 70.6%).
With regard to educa on, most of the caregivers, both females (40 or 37.4%) and males (7 or 41.25%), had studied for between one and four years. Few were illiterate, and few had studied for more than 13 years.
Regarding the degree of kinship to the senior, most caregivers fell into the category of daughter/son or son-in--law/daughter-in-law (69 or 55.6%), followed by spouses (22 or 17.7%). For female caregivers, 62 (57.95%) were daughters or daughters-in-law, and 18 (16.8%) were spouses. A similar trend was evident for male caregivers, of whom seven (41.2%) were sons or sons-in-law and four (23.5%) were spouses. The great majority of caregivers reported living with the senior (99 or 79.8%) and having knowledge of how to provide care (115 or 92.7%). Table 3 shows the socio-demographic aspects of seniors with caregivers and how they aff ect caregiver burden scores. The average score of our par cipants on the caregiver burden scale was 27.8 (± 17.5), with caregivers who assisted seniors aged between 65 and 69 years repor ng a higher average burden than those of other age groups. Similarly, caregivers of seniors with the following profi les also showed higher than average burdens: male (28.1, ± 16.3), divorced/separated (39; ± 19.9) and those who had studied for between fi ve and eight years (38.8; ± 13.9). These results, however, were not sta s cally signifi cant.
We analyzed the data using linear regression with the total score on the Zarit burden scale as the outcome and the global FIM as the explanatory variable and found a sta s cally signifi cant correla on (= -0.179, p = 0.046). These fi ndings indicate that the level of a senior's dependence is a possible risk factor for a caregiver's becoming overburdened, i.e., the more dependent the senior, the greater the chance of caregiver burden.  showed that social isola on is a risk factor for disabili es because unmarried people are signifi cantly more likely to need a caregiver than those with a partner.
When considering the per capita income of the senior, the vast majority reported receiving a pension or alimony, whereas only a small minority categorized themselves as working. The overall average personal monthly income, in Brazilian reais, was R$947.20, approximately 2.1 mes the minimum wage (in 2009, the minimum wage was R$450.00). This fi gure was higher than that reported by other Brazilian studies (13,(17)(18) .
With regard to educa on, the data show that the popula on we chose to study had li le access to educa on; most of the studied seniors were either illiterate or had studied for between one and four years. A lack of access to educa on was a strong variable and was nega vely and independently correlated with the need for a caregiver. Conversely, higher educa onal levels were associated with both a higher func onal status and a lower risk of cogni ve impairment among the elderly (19) .
In the distribu on of living arrangements, most respondents reported living only with a spouse. Another study (2) showed that only a minority of older people lived alone, whereas the vast majority cohabited in mul genera onal households (two or three genera ons).
In assessing the popula on aged 80 or over in the city of Ribeirão Preto, SP, Brazil, a study (17) showed that many older par cipants (26.5%) lived only with a spouse, especially those aged between 80 and 84 years old, a percentage that decreased with age. This diff erence can be explained by the interval of seven years between the surveys because, during this me, the Brazilian family structure has been migra ng from mul genera onal extended families to predominantly nuclear families.
In our study, the majority of seniors who had a caregiver lived in mul genera onal households with their spouses, their children and their daughters and sons-in-law. These fi ndings are consistent with those of another study that showed that this type of arrangement is more than a sociocultural choice; it is a means of survival. This is because living alone is independently and nega vely correlated with a person's need to have a caregiver (16) . This trend may refl ect the rela vely be er condi ons of those who are able to live alone compared with those who cohabit with other genera ons.
According to the values found in our study, our participants presented an average FIM of 113.9 (± 20.6). Our findings are similar to those of another study (20) that evaluated 125 elderly people in a city in the state of São Paulo to verify the relation between subjective well-being, independence and the functional performance of the lower limbs (muscle strength, speed of gait and balance) of elderly outpatients. This study found average global FIM scores of 112.9 (± 12.86), motor FIM scores of 82.07 (± 9.69) and cognitive FIM scores of 30.87 (± 4.81).
By analyzing FIM scores against socio-demographic variables, such as age, gender, educa on and income, we observed that educa on was posi vely correlated with the funconal performance of the elderly. Seniors with lower levels of educa on were fi ve mes more likely to be dependent on others in their daily rou ne (18) . In contrast to other studies (18,21) , we found no signifi cant correla ons between funconality and the variables of personal or family income.
We found a nega ve correla on between age and func onal performance, which suggests that the older the par cipants, the lower their FIM scores will be. In other words, older seniors tend to have lower func onal independence. This correla on was, however, not considered to be sta s cally signifi cant. Two large studies of the elderly community in São Paulo found that the diffi culty in performing the basic ac vi es of daily living is associated with both advancing age and gender (2) .
The independence of the elderly is directly related to maintaining their ability to carry out the ac vi es of daily living without assistance and the autonomy and freedom to make their own decisions and to manage their own lives. Seniors may be dependent, requiring help for self-care, but nevertheless preserve their autonomy. Func onal capacity indicates not only the ability to perform everyday tasks but also the preserva on of mental ac vi es and the ability to integrate socially (21) .
Studies on the func onality of the elderly show that the basic ac vi es of daily living are the last to be compromised as a result of aging or health problems. In a hierarchy of complexity, it is ini ally the ability to perform the advanced ac vi es of daily living that is compromised, followed by the instrumental and, fi nally, the basic ac vies of daily living. These basic ac vi es are those that are closely related to self-care (21) .
Thus, it is important to associate FIM with other instruments that assess the diff erent levels of complexity of ac vi es, par cularly those related to instrumental and advanced ac vi es of daily living. This analysis is vital because early interven on is necessary to prevent dependency and promote the recovery of func onal independence in the elderly.
When a senior's independence and autonomy are impaired, the need for a caregiver arises. In the present study, caregivers were associated with lower average FIM scores. This correla on is consistent with the fi ndings of other Brazilian and interna onal studies [12][13][14][15] .
Researchers in this line of study are o en mo vated by the recogni on that caregivers play an essen al role in public health care, especially when chronic physical disabili es are present.

Socio-demographic profi les and burden levels of caregivers assis ng seniors living in the community
Our data show that 86.4% of caregivers surveyed were female, which is consistent with extensive Brazilian (12)(13)19) and interna onal (15) literature. These fi ndings reinforce the historical role of women, which a ributes to them the social func on of caring for the house, the children and the spouse. Moreover, the historical fact that women did not perform du es outside the home meant that they were more apt than men to undertake this role.
The mean age of the caregivers in our study was 56.6 (± 13.4), which is similar to Brazilian studies (13,19) but lower than other interna onal studies (15) . In developed countries, life expectancy is higher than in developing countries, perhaps explaining the higher mean age of caregivers in developed countries when compared with Brazilian data.
A survey of caregivers in the Programa de Assistência ao Idoso no Domicílio [Assistance for the Elderly at Home Program] (USP) found that 24.1% of caregivers were spouses and 39.8% were their children, many of whom were over 60 years of age themselves (22) . In contrast, some interna onal studies on caregivers report that a majority of caregivers are spouses (15) . Social and cultural norms in developed countries o en result in an elderly spouse assuming the role of caregiver because most families are nuclear with few or no children. In developing countries, however, the elderly generally have more than one child, making it more likely that children take responsibility for the care of their elderly parents.
The majority of caregivers in our study reported living with the person they care for. This fi nding is in keeping with the majority of Brazilian and interna onal studies (12)(13)15,19) . This situa on can be perceived as favorable to the senior who is receiving care because their care demands can be met promptly. However, it can be nega ve for the caregiver, whose constant exposure to the task of caregiving can generate high levels of stress.
With regard to the educa onal level of the caregivers, most had studied for between one and four years. Their rela ve lack of educa on may contribute to the likelihood of their becoming a caregiver because society increasingly demands higher levels of educa on in the formal labor market, making it more diffi cult for individuals with less educa on. Consequently, it is more likely that these people will devote themselves to housework and the task of caregiving.
When considering the age of the caregivers, 31.8% were over 60 years of age and had therefore had been brought up when access to schools in Brazil was par cularly diffi cult. Moreover, at that me, families o en gave their children responsibility for many household ac vi es, especially in rural environments. Nevertheless, 68.2% of caregivers were less than 60 years old. Despite these caregivers' being younger and, therefore, products of a diff erent era, low educa on levels were also prevalent among them, revealing an underlying social issue.
The data showed a posi ve correla on between educa on levels and the income of the caregivers surveyed. The average household income (including that of the senior) was R$1,460.00, which is 3.2 mes the minimum wage (the minimum wage in 2009 was R$450.00), indica ng that 66.7% had a monthly family income equivalent to one to three mes the minimum wage, 20% received four to six mes the minimum wage and 13.3% were earning more than six mes the minimum wage. These fi ndings are consistent with those of other Brazilian studies (13) . It is noteworthy that when caregiving occurs under economically diffi cult condi ons, the caregiver tends to see caregiving as a duty or does not see any alterna ve to the arrangement, making the task even more stressful.
In analyzing the profi les of the seniors being cared for in terms of caregiver burden, we found that caregivers who assist seniors aged between 65 and 69 showed higher levels of burden than those caring for older seniors, although this rela on cannot be considered sta s cally signifi cant. Some research suggests that burden levels decrease over me, possibly as a result of the caregivers' adap ng to their new role. In one study, caregivers reported increased confi dence as the years went by as a result of their experience and subsequently reported decreased feelings of burden (12) .
In the current study, which was conducted in Ribeirão Preto / SP, the func onal capacity of the senior was the only variable that proved to be sta s cally signifi cant in rela on to caregiver burden with inversely propor onal averages, i.e., the lower the average FIM, the higher the average burden. These fi ndings suggest that the greater the dependence of the elderly, the higher the level of caregiver burden, suppor ng the conclusions of other Brazilian studies (12)(13) . Support groups play an important role in helping caregivers develop coping mechanisms and in decreasing caregiver burden. As a global and mul dimensional phenomenon, caregiver burden requires coordinated interven ons rather than the isolated and random ac ons that are most commonly the case (5) .
Nursing has a vital role to play, and ac on should be taken in the area of health educa on to improve geriatric care and caregiver support, especially in situa ons of func onal dependence. This ac on should include providing guidance on posi oning the bed, bathing, feeding, and transfer, among other daily necessi es. Counseling and psychoeduca on can prepare caregivers and families for the feelings of guilt, frustra on, anger, sadness, depression, etc., that come with the responsibility of caring for a sick family member at home, even with the help of health professionals.
To provide such support, it is essen al that caregivers receive planned interven ons, such as regular home visits from health professionals (nurses, doctors, psychologists, etc.), as well as other forms of supervision and training. This type of support should be considered a basic and essen al requirement to meet the needs of caregivers and the elderly (16) .

CONCLUSION
Caregiving, when associated with a senior's lack of ability to perform the basic ac vi es of daily living, results in caregiver burden. The level of dependence of the senior was an important predictor of elevated burden levels.
In most cases, a senior is already incapable of many self-care ac vi es when a caregiver begins the task of assis ng him or her. O en, caregivers take on this role without any prior training and are urged to learn from experience. They o en lack the informa on and guidance on the specifi cs of geriatric care that should be supplied by health professionals. Where there is evidence of caregiver burden, which is o en accompanied by psychosoma c symptoms, it is even more important to take specifi c measures to prevent caregiver burden, provide counseling and even treat informal caregivers.
We suggest further studies to address this issue, as well as the development of public policies targe ng the elderly and their caregivers residing in the community. The use of assessment tools that address func onal capacity in terms of the instrumental and advanced ac vi es of daily living are par cularly important because research in this area has mainly been focused on the evalua on of the basic ac vi es of daily living of the elderly. Such a change in focus would lead to results that would benefi t not only the elderly in preven ng dependency but also their caregivers in lowering their level of burden.