Transition of care for the elderly after cerebrovascular accidents – from hospital to the home

OBJECTIVE
to examine the transition of care in families caring for elderly persons who suffered the first episode of a cerebrovascular accident.


METHODOLOGY
an instrumental ethnographic case study was used. The sample comprised 20 subjects: 10 caregivers and 10 elderly persons aged 65 or over, of both sexes, with diagnoses of first episode of cerebrovascular accident, capable of communicating, and requiring care from a main carer in their family. The data was collected through interviews, observation, existing documentation and field notes. Qualitative analysis techniques were used to codify and classify the data and to formulate significant categories, which generated typologies of care.


RESULTS AND DISCUSSION
The central idea was the Transition of Care and showed the context in three typologies: The care process for the dependent elderly person, Strategies for the care process and Impact and acceptance of the limitations.


CONCLUSION
The data indicates that caring for an elderly person after a cerebrovascular accident is a challenge for the family. The data permitted it possible to elaborate a proposal for a model for the organization of the work, with a view to holistic care delivery in the health services, forming a care network, which constitutes an advance for the area of nursing.

Around 16 million people suffered an episode of CVA, for the first time, in 2005, with an estimated prevalence of 6.2 million survivors (2)(3) .
In Brazil, in the period 2008 to 2011, there were 424,859 hospitalizations of elderly persons aged 60 years old or more due to CVA, with a mortality rate of 18.32. In the state of São Paulo 69,722 hospitalizations occurred, with a mortality rate of 18.57. In the same period, within the state of São Paulo in the municipality of Ribeirão Preto, it was ascertained that 1,645 elderly persons were hospitalized (820 women and 817 men), with an average period of hospitalization of 7.1 days and a mortality rate of 16.41 (4) . This data reaffirms the seriousness of the problem in this age range and the need for special attention to the issue, because it is the most prevalent cerebrovascular illness in the elderly population. Its incidence increases exponentially as age advances, and it is considered one of the major causes of disability in this population (5)(6)(7) .

Functional incapacity can create difficulties for
the elderly in carrying out daily activities which may be transcient or permanent, depending on the region of the brain affected, the level of the lesion and the individual capacity for recuperation following the CVA.
These difficulties can lead to reduction in quality of life with an impact on the everyday routine of the elderly persons and their families (8) . The degree of the patient's incapacities determine the levels of dependency on care and, consequently, the challenge to the family caregiver (8)(9) , because the elderly person will need prolonged care. After discharge from hospital, the elderly person may have a series of limitations, including behavioral changes and changes in roles to be developed in the family, in society and in the self itself.
Once the patient has returned home, the care's perspective differs from in hospital; it is in this moment that the transition from the 'cure phase' to the 'case process' at home takes place. Authors report that the transition is the passage from one phase of life to another, in the face of various conditions or status, in a particular social context (10) . It is in this moment of transition in the elderly person's health -towards recuperation and selfcare -that the family, as a social institution, deals with the changes, both in functional abilities and in the body image of the CVA survivor (11) . It is observed that in this transition, the process of caring for the elderly person depends on the society's culture and on the family itself.
Each family devises this care, which was constructed over time with its knowledge, habits, customs, language, beliefs, family environment and network of relationships constructed with the elderly person.
The interpretation of a culture of which one is part must be deduced (12) . By nature, humans have the potential to care for themselves and for others within their cultural universe (13) . This care has always existed and is a challenge society faces in caring for family members. Even with the availabiliy of lighter technology, the family's difficulties in dealing with the condition of dependency arising from an illness remain. These difficulties affect the entire family dynamic.
One of the strategies for responding to the challenges to health care in the population of persons who have suffered CVA is to investigate -in partnership with the elderly persons and their families -the description, in depth, of this caring process, so as to implement a care plan. Furthermore, it becomes necessary to refer the elderly person so that the health team may act in partnership with the family in this process.
It is worth emphasizing the scarcity of the literature on this issue, which justifies the need for undertaking research to deepen knowledge of the topic and, also, the need to support the nurse on the subject of the requirements of caring for the elderly following CVA and, consequently, to support the nurse by developing a care plan which is integrated with the family.
In the face of the above considerations, this study aims to examine the transition of the care for the elderly person and the families which care for elderly persons who have suffered the first episode of CVA, from the perspective of the culture constructed by the family.

Method
An instrumental ethnographic case study was used, because the objective was to examine the transition of care in families caring for 10 elderly persons who had suffered the first episode of CVA, attended in the Emergency Department of a hospital in Ribeirão Preto in the state of São Paulo, Brazil. The case study describes the contemporaneous experience and the historical events, and both are used to narrate, represent and to examine situations which emerge from the people's lives and which must be taken into account from the perspective of the ethnographic method (14) . The focus of interest was on knowing and interpreting how the process of caring for the elderly person after a stroke worked out, following discharge from hospital. The interviews were transcribed on a word processing program for data encoding and inductive thematic analysis (15) ; the ALCESTE (Lexical analysis by context of a set of segments of text) program was used for the search for the topics, refining and final production of the main categories derived from the data extracted from the study.  on activities of daily living, principally on mobility. It is in this context that the role of the clinical nurse must be to find out about the family's culture of care, so that in this process of transition, the experience with this may foster interaction, so that this process of caring for elderly persons in a more vulnerable condition may occur.

Characterization of the Elderly Person
The experience of the dependence allows the elderly person to unveil the context that he or she was experiencing, that is, the need for care after the CVA.
The first issue which emerged was the dependence that the elderly had in the face of difficulties in self-care, and also, which the caregivers themelves had in providing this care, as in the following account ...she used to be an Human beings, by nature, have the potential to care for themselves and for others within their cultural universe. Although this caregiving has always existed, it is a challenge for a family to care for a person whose dependency has been imposed by an illness, even with the aid of a wide range of technology; which ends up affecting the family dynamics (13) .
While the elderly person is hospitalized, the care is given by the nursing team. When the elderly person returns home, however, the transition of care occurs, that is, the family assumes responsibility for the care, as part of the dynamic which goes from "curing the illness" to "caring for the elderly person", in a more global context, with a view to recuperation. This care, "hidden", interwoven with easy and/or complex tasks, In the process of implanting the Unified Health Service (SUS), the work of the nurse in Primary Care involves administration, the organization of the work of health and nursing, but clinical actions for system users still need to be discussed and implemented, there being a need for formal spaces for the work of the nurse for carrying out these actions (18) .

Typology 2: Strategies for the care process
One of the aspects observed in the present study is that the socio-familial contexts are diverse, and that the relationship and care histories were reconstructed over the period of their formation. Thus, one must consider not only the care given after the CVA, but also the context into which the families are inserted. In the process of caring for an elderly person with difficulties in self-caring, the family learns with the patient, organizing itself, and new ways of caring appear, as was related: ...I think that this experience is difficult…an adult knows how to care for themselves, but with the illness, the family needs to learn… it's an obligation and a test for us. We are learning to provide care, as the family teaches (Caregiver 5).
A study with stroke survivors showed that in the period of transition from hospital to home, the following stood out: changes in the sense of self and body experiences, changes in the relationship with others and in one's integration in the community (17) , which In the period of transition, there may occur a phase of changes in family relationships, very often followed by a reorganization of the family system to manage this care (19) .
The literature describes few experiences of how the family manages the care for the elderly person after the CVA ( The transition is a process which occurs over time, that is, it involves the interruption of a given situation in a person's life, while the second phase involves the changes which occur as a result of this transition (20) .
Particularly in this study, the elderly persons who suffered CVA are subject to a series of interruptions which entail the implementation of new strategies for reorganizing the care, in the face of functional and emotional losses, irrespective of how the care was learnt.
The caregivers' experiences in caring for patients who had suffered CVA, in the phase of transition from hospital home, show the need for important training so that they can manage this process. The strategies may be divided into: aspects involving society, the system of care, and the person involved in this process (21) .
The aspects of society involve the allocation of financial resources for this transition of care, principally because of the health problems appearing with the CVA.
In Brazil, this discussion still needs effective debates for its implementation; in the care system the work of the multidisciplinary team, including the nurse, must  The health services for elderly people being cared for at home remain inefficient, a fact confirmed in the present study on the elderly. Thus, the family itself, without preparation, "tries" to reorganize so as to deal with this process, as Caregiver 2 reports ...the impact on the family as a whole, because of the fact that he had a stroke, Discharge from hospital should be considered a special moment for producing continuity of the treatment and care, thus establishing the system of conter-referral, constructing in this way the care pathway, with the family's participation in this network (16) . After discharge from hospital, the primary care system proposed by the Unified Health System, still does not function effectively, although the integrality of care can only be obtained in a network (16) which must be woven in the practice, involving the family. Integrality requires that the work of the primary care team recognizes the elderly person's needs and the family's care practices, as well as the resources available for this care, within the cultural context with its beliefs and values, which were constructed socially, both because of the ageing process and because of an illness which produces incapacities. It is, moreover, worth emphasizing the importance of the care's integrality, that is, the variety of services and their reach (22) ; in addition, support for education for the family to provide this care at home has to be considered a necessary practice. In the specific case of the elderly person after a CVA, the hospitalization is emergency treatment, but the care provided after discharge is more prolonged, the elderly persons' needs diverge in each situation, the families have distinct contexts and relationships, and the continuity and the integrality are compromised by the absence of the continuity of care.
According to the epidemiological data on CVA, both in developed countries and developing countries, there is an urgent need to study the evidence for the provision of care, in isolation from the social context of the health system. Hence, knowledge is needed on how this care process takes place, through a case study, that is, what "it interprets is the flow of social discourse and interpretation; thus, the interpretation involved means trying to save what was said in that discourse from a possible extinction and fixing it in researchable form" (12) .
Considering this collocation, the application of

Final considerations
The elderly person who has suffered a CVA passes through stages, from treatment at the hospital level to care at home. The transition of this care is a time which