INTRODUCTION

The growing population of older people worldwide makes chronic disease management and the improvement of life of this age group new challenges to global public health. However, for the United Nations (UN), older people differ in developed and developing countries, according to the context and the conditions of each region, regarding the establishment of public policies^(1-2).

In Brazil, the population aging has occurred rapidly in recent years, as a result of the demographic development. In the 1940s, older people accounted for 4.1% of the total Brazilian population and, in 2011, amounted to 20.5 million, equivalent to 10.8% of the total. By 2020, older people are expected to be around 30.9 million, about 14% of the total population, which puts Brazil in the sixth place in the world classification⁽³⁾.

With advancing age there are morphological, functional and biological changes that trigger the progressive loss of the individual’s ability to adapt to the environment and cause greater fragility and decreased functional capacity as well as the potential for performing personal care, basic and more complex everyday life activities⁽⁴⁾.

Functional capacity can be defined as “a construct that indicates the maximum amount of functionality that a person can achieve in a given moment.” Studies show that this issue is a new paradigm on old people’s health, being autonomy one of the main factors considered regarding health policies – namely, the ability to choose for themselves as a result of the relationship between physical and mental health, functional independence, social integration, family support and financial self-sufficiency⁽⁵⁾.

However, in urban areas, especially in peripheral regions, many problems can negatively affect the well-being of a person, including, for example, poverty, illiteracy, overcrowding and poor sanitation. Thus, old people are more vulnerable to these difficulties and, consequently, to numerous noncommunicable diseases and their complications because of the absence of basic facilities, precarious health services and stress due to the lack of social support ^(6-7).

OBJECTIVE

This study aimed to verify the socioeconomic profile and functional status of older people living in the state of Paraíba, Brazil, from a temporal perspective. Results will allow to rethink the current intervention strategies, aiming to delay the losses caused by the aging process and the potential diseases associated with it.

METHOD

RESULTS

Between 2000 and 2010, the total older people population in the state of Paraíba increased from 10.17% to 11.98%. Analyzing some of the main determinants and risk factors for functional incapacity, we noted a growth of older women, people aged 85 years or older, older people who live in urban areas, alone and who are not responsible for the household (Table 1). The research considers the household responsible concept used by IBGE, based on the answer of the residents regarding the person responsible for maintaining the household (or the family).

Regarding the socioeconomic profile over the considered time, there was also a decrease of illiterate older people, with monthly income of up to one minimum wage and in poverty.

Regarding functional state, between 2000 and 2010, the older people’s health conditions worsened in the state of Paraíba, due to an increase in the proportion of those who reported any permanent mental disability, motor (completely unable, with small or major difficulty walking or climbing stairs), visual or hearing impairments (Table 2). These indicators influence the ability of older people to perform daily activities. When associated with conditions of lesser physical agility and performance, this shortfall in capacity can be a big risk factor for isolation, loss of motivation and lack of interest in the participation of social life.

Table 3 shows data related to the functional state of the investigated age group. We should point out that the year evaluated was 2013, the only one available in SISAP-Idoso, concerning basic and instrumental activities of daily living. Thus, 7.86% of the older people considered reported inability or great difficulty in: (1) eating alone with a plate placed before them, which involves holding a fork, cutting food and drinking from a glass; (2) showering alone, including going in and out of the shower or tub; or (3) going to the bathroom alone, as well as sitting down and lifting the toilet. Furthermore, 11.22% of older people reported not being able or having great difficulty in walking alone around the house, from one room to another.

Regarding the Activities of Daily Living (ADLs), 10.24% reported inability or great difficulty to perform at least one of the following activities: (1) eating, (2) showering and (3) going to the bathroom alone; (4) dressing alone, including putting on socks and shoes, zipping up and opening and closing buttons; (5) walking around the house alone; (6) getting in or out of bed alone. Moreover, 25.96% pointed out inability or great difficulty to perform at least one of the following Instrumental Activities of Daily Living (IADLs): (1) shopping alone, i.e., for food, clothing or medicines; (2) managing finances alone (taking care of their own money); (3) taking their medication alone; (4) going out alone and using buses, subway, taxi, car, etc.

DISCUSSION

The proportion of older women has increased between 2000 and 2010. The feminization of old age is related to the increased survival of women when compared to men, since they take better care of themselves and easily adapt to new functions⁽¹²⁾.

Concerning functionality, women have a higher level of disability than men. Female old age is associated with a higher prevalence of chronic diseases. In short, older women have a lower socioeconomic condition than men, because many did not attended school and did not have formal jobs⁽¹³⁾.

People aged 85 years or older also grew in number in the investigated interval. It is known that the advance of age is considered one of the most important risk factors for the deterioration of the functional capacity because of the increase in physiological changes (sensory, neurological and musculoskeletal systems) and the prevalence of chronic diseases⁽¹⁴⁾.

A possible explanation for the increase of older people living in urban areas could be the need for more frequent medical care in this age group. In addition, in the event of widowhood, older people often take to reside with their descendants (children and grandchildren) for greater security and quality of life⁽¹⁵⁾.

Thus, the growing transition of older people from rural to urban areas can be explained because of the search for better conditions of access and use of health care services and new sources of income. After all, because of the precarious conditions of life and the lack of opportunities in the countryside, it is possible that these old people have been deprived of schools and health care, which highlights the need for an integral attention to prevention and maintenance of their functionality^(16-17).

In the state of Paraíba, despite the decrease of the levels of illiteracy among older people between 2000 and 2010, monthly income below one minimum wage and poverty rates remain high. Over recent decades, Brazilian educational alternatives were imposed for the “out-of-school” population, as the Youth and Adults Education (EJA – Educação de Jovens e Adultos) and Literate Brazil Program (PBA – Programa Brasil Alfabetizado), aimed at youth, adults and older people literacy, especially in municipalities with illiteracy rates higher than 25% – 90% of them located in the Northeastern Region of the country. However, despite national efforts, the problem persists^(18-19).

Low levels of education and income are distinctive of this generation of older Brazilians, who had restricted access to education and, therefore, few job opportunities⁽²⁰⁾. This negatively affects their health aspects by making them more vulnerable to diseases, in addition to poor life conditions, lack of basic sanitation, poor access to health care services, consumer goods, healthy nutrition and adequate housing, which creates greater social inequality that culminates in the decrease of life quality and difficulties for self-care^(21-22).

A research conducted in the city of Montes Claros (MG) showed that older people with fewer years of schooling and monthly income of up to two minimum wages showed higher percentage of inadequate functional capacity. The low per capita income of this age group, associated with low schooling, causes them to be deprived of adequate health care as well as purchasing medicines or paying health care plans, with direct repercussions on their functional performance, since income is an essential element to preserve the autonomy and maintenance or recovery of health⁽²³⁾.

Differences in results – increase in the number of old people who live alone and decrease of those not responsible for the household – can be explained by the double relation of age with household arrangement. The years can cause older people to stay alone because of the loss of a spouse, but also increases the chances of living with relatives because of greater physical dependence. A higher percentage of older adults who live alone shows, on the one hand, that they have successfully experienced the aging process. On the other hand, it is a concerning matter, as they may find some impasses when using health services as well as hardships in performing everyday tasks, which can be aggravated by the absence of a family member⁽²⁴⁾.

Regarding health conditions, visual and hearing capabilities are key aspects of functioning among old people. Therefore, the increase of these disabilities tends to compromise the performance of ADLs by creating greater dependency. Vision and hearing problems are risk factors for falls, depressive symptoms, reduced health-related quality of life and are directly related to aging and chronic diseases as they directly affect the functional capacity and mobility of older people⁽²⁵⁾.

Since most sensory deficiencies belong to the old population, they hinder the rehabilitation process. Factors such as low pay and living alone play an important role, since the living conditions of these people are determined by variables such as marital and health status, financial dependency, family relationships and social support⁽²⁶⁾.

In the studied period, the growth of mental illnesses should also be noted. In Brazil, the relative increase of the old people population contributed to change the profile of morbidity and mortality, which results in the higher prevalence of chronic-degenerative and disabling diseases such as those related to cognitive decline, with higher incidence of Alzheimer’s disease (AD). Cognitive losses are more frequent in women – because of a higher disposition for AD and longer life expectancy – and in individuals with low education levels, who are not physically active, who have low economic conditions, and who are older and frail. Other risk factors such as chronic diseases (hypertension, diabetes mellitus, among others), depression and the institutionalization status increase the exposure to cognitive losses. In short, these are all variables to which preventive actions can be taken^(27-28).

Among them, we highlight the level of education, which is inversely proportional to cognitive losses. Schooling leads the individual to improve basic knowledge in search of diversification of activities and intellectualization, which, in turn, enhances their performance in tests of cognitive abilities during old age⁽²⁷⁾.

There was a higher frequency of functional impairment to perform IADLs (25.96%) than basic ADLs (10.24%) in 2013. Hierarchically, losses occur from IADLs to basic ADLs because IADLs require greater cognitive and physical integrity when compared to basic ADLs⁽⁴⁾, which raises the chance that this difference is also associated with the increase in mental and motor impairment among the old people of Paraíba in the 2000-2010 period.

Another point that also supports this hypothesis is that IADLs connect community and residence. Thus, the lack of schooling, which is high in this population and its consequent low purchasing power can influence buying options, finance control and other IADLs⁽²⁹⁾.

However, this hierarchy in functional decline with subsequent loss to independently perform basic ADLs reflects more dependency. In this case, it is a responsibility to be shared between older people, caregivers and professionals through coordinated and continuous care to provide the basic conditions for a suitable performance⁽³⁰⁾.

Maintaining functional capacity has important implications for the quality of life of older people, since it involves working until more advanced ages. Therefore, is essential to plan specific intervention programs to eliminate risk factors related to the loss of autonomy and independence – with emphasis on visual problems, hypertension and mental illness, variables that can be acted upon. Such a program must permeate activities that stimulate social and healthy living in groups, with recreational, cultural and physical pastimes⁽³¹⁾.

Aging populations have more chronic diseases and disabilities, which strongly reflect in the increased demand for health care and impose challenges such as reducing inequalities. After all, poorer old people have lower access to health care plans and require more attention, yet rarely use health services, which ultimately worsens social inequality. There is some endogeneity in the equation of individuals’ income, i.e., worst income generates poorer health, and worse health, lower income. That is why public health care policies are also policies to combat poverty and inequality⁽³²⁾.

Over the last three decades, poverty rates in Brazil dropped by more than five times. Between 1991 and 2008, the Gini coefficient fell 15%, although it remains one of the largest in the world (0.54 in 2009). Policies to reduce inequality have shown the way to reduce poverty, largely represented by income transfer programs (mainly the Bolsa Família), the minimum wage policy and the expansion of the non-contributory social security system^(33-34).

However, social inequalities regarding the health of old Brazilians are still noteworthy. Those whose household income per capita lies in the bottom quintile have worse health perception, functional capacity and attend fewer medical appointments. In a study conducted on social health inequalities among old Brazilians (1998-2008), there were no changes in the magnitude of disparities by income in their self-assessment of health and functional capacity⁽³³⁾.

In this case, differences by income in the current functional capacity of older people can be explained by factors related to health services, since, despite obvious improvements, there are still differences when using services, in addition to the underfunding of the Brazilian health system⁽³³⁾.

CONCLUSION

The use of temporal analysis allowed us to register the evolution of phenomena and identify trends that converge to indicators such as women, and, among them, being 85 years of age or older, living alone, increase of disabilities and impairments, and decrease of poverty and illiteracy. Thus, the study suggests that the actions to be taken should not be directed only to the functional state. Actual effective measures need to be directed towards higher levels of this matrix, aiming at a good functional state and thus interfering with the determinants of environmental change, such as illiteracy, low income and disabilities, which can become risk factors and need to be overcome.

Results show the need to take actions to monitor and control factors that interfere with functional capacity. For the nursing field, it is relevant to identify the performance of old people during basic and instrumental activities of daily living, since the results can help rethinking intervention strategies used in the services to delay the losses caused by the aging process and possible diseases.