versão impressa ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.2 São Paulo abr. 2012
Cognitive alterations of the elderly in home settings and the attitudes of children towards aging*
Alteraciones cognitivas del anciano en contexto domiciliario y actitudes de infantes en relación a la vejez
Bruna Moretti LuchesiI; Sofia Cristina Iost PavariniII; Aline Silveira VianaIII
IRN. Master's student, Federal University of São Carlos, Nursing Graduate Program. Member of the Health and Aging Research Group/CNPq. São Carlos, SP, Brazil. email@example.com
IIRN. Doctoral student in Education, State University of Campinas. Associate professor, Federal University of São Carlos, Nursing Department. Director of the Health and Aging Research Group/CNPq. São Carlos, SP, Brazil firstname.lastname@example.org
IIIUndergraduate student in Gerontology, Federal University of São Carlos. Member of the Heath and Aging Research Group/CNPq. São Carlos, SP, Brazil. email@example.com
Children develop attitudes towards aging from birth and are influenced by everyday factors. The objective of this study was to evaluate attitudes towards aging of children living with elderly individuals with and without cognitive changes. Home interviews were performed with 54 children from five Family Health Units, 25 of whom lived with seniors with cognitive changes (group 1), and 29 living with seniors without cognitive changes (group 2). All ethical precautions were observed. The Scale for Children's Attitudes Towards Aging was used. The mean scores obtained were 1.66 (group 1) and 1.52 (group 2). One point represented the most positive possible score, and three points the most negative. The comparison between groups, cognition domains, and social relationships presented significant rates, showing that children living with seniors with cognitive changes have more negative attitudes in these domains. Primary healthcare professionals should pay close attention to multigenerational families and invest in their education.
Descriptors: Aged; Child; Intergenerational relations; Attitude; Family nursing
Los niños desarrollan actitudes relacionadas a la vejez desde el nacimiento, influenciadas por factores cotidianos. Se objetivó evaluar y comparar la actitud relacionada a la vejez de niños viviendo con ancianos con y sin alteraciones cognitivas. Se realizaron entrevistas domiciliarias con 54 infantes de cinco USF, 25 viviendo con ancianos con alteraciones cognitivas (grupo 1) y 29 con ancianos sin alteraciones (grupo 2). Se observaron los cuidados éticos. Se aplicó Escala de Actitudes Relacionadas a la Vejez para Infantes; el puntaje promedio fue 1,66 (grupo 1) y 1,52 (grupo 2). Un punto representa el score más positivo, tres puntos, el score más negativo. Comparando los grupos, los dominios cognición y relación social presentaron índices significativos, indicando que infantes conviviendo con ancianos con alteraciones cognitivas tienen actitudes más negativas en estos dominios. Profesionales de salud en atención básica deberían alentar a las familias multigeneracionales a invertir en la educación del infante.
Descriptores: Anciano; Niño; Relaciones Intergeneracionales; Actitud; Enfermería de la familia
In Brazil, in addition to being a legal duty, it is also a tradition that the family be responsible for providing care to any dependent elderly individual in the family. According to Article 230 of the Brazilian Federal Constitution "the family, society and the State have the duty to support elderly individuals ensuring their participation in the community, defending their dignity and well being and guaranteeing their right to life"(1).
Families are aging together with elderly individuals, since the number of families with an elderly individual living in the same house has increased. Another common situation is various generations living at the same time, whether sharing a residence or not(2).
There are two types of families with elderly individuals in their configuration: an elderly family in which the head of the family or spouse is an elderly individual and families with elderly individuals, in which an elderly individual is related to the head of the house. The average size of elderly families in 2003 was 3.3 people and the average size of families with elderly individuals was five people. Residences of elderly families are the ones that grow the most, which may indicate other family members have increasingly come to depend on the elderly head of the family(2-3).
The predominant type of family in Brazil is still composed of elderly couples with children, which is a bi-generational arrangement; 43.3% of households are inhabited by elderly families. This configuration still predominates but is in decline and the number of elderly individuals living by themselves, childless couples, and households with co-habiting individuals and three generations is increasing(2).
In 2000, 14% of the family members living within elderly families were grandchildren while grandchildren represented 2.2% of family members living with families with elderly individuals. On average, 12% of families with elderly individuals also have grandchildren and most are aged up to 14 years of age (72.5% of grandchildren living in elderly families are aged up to 14 years old and 94.6% of grandchildren living in families with elderly individuals are up to 14 years old)(2).
The fact that children reside together with elderly individuals, regardless of kinship or any other bond, may influence the attitudes of children in relation to elderly individuals and themes related to aging.
(...) attitudes are predispositions learned and relatively stable to respond to an object and comprise three components: cognitive, emotional, and a tendency to action. The cognitive component includes evaluative beliefs concerning a given object and reflects, in part, social norms. The emotional component refers to feelings experienced by the individual in relation to the object. Tendency to action refers to the individual's willingness to interact with the object(4).
Attitudes synthetically evaluate an object, and even though they are non-observable bipolar attributes, they can be inferred and evaluated. Additionally, attitudes have a guiding role that integrate and control people's behavior(5-7). Attitudes derive from common learning processes and even though they are relatively stable, they are subject to change. Education is a crucial tool in the attempt to promote change(6,8).
Attitudes have two dimensions: direction, which is expressed as antagonistic qualities such as positive-negative and intensity, expressed in different degrees(9). They can represent evaluations concerning diverse objects and the interest in studying attitudes began when the political impact of authoritarianism and intolerance where evaluated in various nations. These evaluations clarified some mass phenomena and improved statistical techniques, which enabled other social objects to be studied, among them aging(5).
The first studies addressing attitudes related to aging date from the 1940s, though the most important mark was a study that investigated, through a questionnaire, the attitudes of 147 young American adults toward aging(10).
There are many ways to evaluate attitudes concerning aging. In Brazil, one of the most used scales, called the Neri Scale, was developed. It is composed of 40 pairs of bipolar adjectives with seven degrees of intensity for each pair and was applied to a sample of 4,300 non-elderly Brazilians(11). Other studies were conducted and the initial scale was refined and currently has 30 pairs of adjectives and five degrees of intensity(12).
The Neri Scale(11-12) is divided into four domains: cognition, agency, social relationships and persona. Cognition refers to one's problem-solving capacity and the ability to process information, which in turn reflects on social adaptation; agency refers to autonomy and tools used to perform actions; the domain of social relationships refers to affective-emotional aspects, which reflect on social interaction; while persona refers to social labels commonly used to designate and discriminate elderly individuals(8,11,13).
There are few studies evaluating the attitudes of children in relation to aging. At the international level, these studies date from the 1970s, on though these are more recent in Brazil. Studying the attitudes of children toward aging is important because many significant attitudes are formed early on in life and may persist later into life(14).
In Brazil, a scale according to semantic differential models was developed based on the initial Neri Scale(11-12) and adapted for school age children(15). The final version was called the Todaro Scale for Assessing Attitudes of Children Toward the Elderly and contains 14 bipolar items with three degrees of intensity. On this scale children choose the best alternative for Elderly individuals are:(15). The items are divided into the four domains previously mentioned(11-12): cognition, agency, social relationships and persona. The scale's internal consistency was tested and considered satisfactory for children from seven to ten years old.
Attitudes toward aging accrue from common learning processes, hence context of life may play a role. One of the contexts children currently experience is the presence of elderly individuals, who may have cognitive disorders, in the family. Given the previous discussion, the following question was asked: does the presence of elderly individuals with cognitive disorders living together with children influence the children's attitudes toward aging?
Considering that as the elderly population grows the number of individuals with cognitive disorders and the number of children living with them also increases, this study evaluates and compares attitudes toward aging of children living with elderly individuals with and without cognitive disorders.
This cross-sectional, descriptive and quantitative study was conducted in a medium-sized city in the interior of São Paulo, Brazil. Children aged seven to ten years old enrolled in five different Family Health Units (FHU), who lived with at least one elderly individual (older than 60 years of age) in the same residence participated in the study. The children were selected through the files of families registered in the FHU, which contained the name and age of all those living in the house.
All the children who met the inclusion criteria (n=103) were visited and all those who were not located after two visits in alternate days (n=21), had moved of residence or no longer belonged to the FHU's coverage area (n=27), or those whose elderly resident had died (n=1) were excluded from the study, totaling 54 children. The elderly individuals (n=46) living with the children were also interviewed so children could be divided into two groups: Group 1 (children living with elderly individuals with cognitive disorders) and Group 2 (children living with elderly individuals without cognitive disorders).
Ethical guidelines according to Resolution 196/96 concerning research with human subjects were complied with. The project was approved by the Ethics Research Committee at the university (Process nº 486/2008) and data collection was initiated after the children's legal guardians and elderly individuals read and signed free and informed consent forms.
Interviews were held at the residences and previously scheduled according to the availability of children, their parents or legal guardians and the elderly individuals living with them. Collection was conducted from June to August 2009 and comprised two steps performed in the same day, one after other.
Step I Interview with the elderly individual
- A socio-demographic questionnaire addressing name, age, gender, schooling, religion, race and health plan was applied.
- The Mini Mental State Examination (MMSE) was applied. This instrument was chosen because it is one of the most frequently used worldwide to screen for cognitive deficit. It shows whether the individual is likely to have some cognitive deficit and in which area(16-17). Cut-off scores followed the recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology and were adapted based on the elderly individual's educational level. They were: score of 18 for the illiterate, 21 for those with one to three years of schooling, 24 for those with four to seven years of schooling, and 26 for those with eight years of schooling or more. After the MMSE was applied, the group to which the elderly individual belonged was noted (1 with cognitive disorders and 2 without cognitive disorders).
When there was more then one elderly individual living in the same house, the one present at the time, or who was more available to answer the questions at the time, was interviewed. When there was more than one child in the house, the elderly individual was interviewed only once and all the children were interviewed once. For this reason, there is a greater number of interviewed children than interviewed elderly individuals. Interviews were held separately when there was more than one child in the house.
Step II – Interview with children
- Socio-demographic characterization of children including name, address, FHU, gender, age, schooling, family income, number of people in the house, religion, race, health plan, gender and kinship of the elderly person living together with them and for how long the children have lived with the elderly individual.
- Sensitization of children in relation to the object they would evaluate, that is, in relation to aging. For that, an initial question was asked: Do you know what an elderly individual is? If children answered yes, they were asked to explain the concept and the researcher would correct the concept if necessary. If the children were not able to answer, the concept was explained and only after this explanation would the interview proceed.
- Application of the Scale of Attitudes Toward Aging for Children(15). On the Todaro Scale, the items with positive poles that were not located in the position corresponding to score ONE were recoded to remain in this position.
Of the 46 studied elderly individuals, 63% were women and 37% were men. The most frequent age group was 60 to 64 years old (43.5%), with an average of 67.04 years old (SD=6.08). In relation to education, 95.6% of the elderly individuals were either illiterate (34.8%) or had not completed primary school (60.8%). Catholicism predominated (78.2%) followed by Protestant Christianity (10.9%). In relation to race, 60.9% of the elderly individuals reported to be Caucasian, 21.7% to be of mixed race, and 17.4% to be Afro-Brazilian. A total of 6.5% had a health plan.
The MMES was applied to 45 of the 46 visited elderly individuals. One individual did not answer the test because he was already diagnosed with dementia by a specialist and had cognitive problems also accruing from other diseases. The child living with this elderly individual was included in Group 1, that is, children living with elderly individuals with cognitive disorders, since the elderly individual was considered to have cognitive impairment given the diagnosis of dementia.
The MMSE application resulted in: 39.1% of the elderly individuals scored below the cut-off point, 58.7% scored above and one elderly individual did not take the test (2.2%). The average score was 20.4 (SD=5.55). Of those with cognitive impairment (n=18), 61% were women and 39% were men, a plurality were aged between 60 and 64 years old (37%), were either illiterate (53%) or did not complete primary school (47%).
In relation to the 54 children interviewed, most were male (57%). The most frequent ages were nine years old (29.63%) and ten years old (27.78%). The greatest number of children attended the 4th grade (42.6%). Only one child was in the 5th grade; 24% was in the 3rd grade; 20.4% was in the 2nd grade, and 11.1% was in the 1st grade.
There was an average of six people (SD=2.34) living in the house, including the children; the number varied from two to 12 people. Family income ranged from half to five times the minimum wage, that is, an average of R$ 260.00 to R$ 2,620.00 (equivalent to USD 144.50 to USD 1,455.60) and the average salary was 2.04 times the minimum wage, corresponding to R$ 1,071.00 (equivalent to USD 595.00).
A little more than half of children or their legal guardians (when children were not able to answer or did not want to answer the question) reported being Caucasian (53.7%), 27.8% mixed and 18.5% Afro-Brazilian. Most children were Catholic (64.8%) followed by 20.4% Protestant Christians, 11.1% reported no religion and 3.7% did not want to provide this information. None of the interviewed children had a health plan.
Most children were grandchildren of the elderly individual they lived with (85.2%), 7.4% were children of the elderly individuals, great-grandchildren (3.7%) and great-nephews (3.7%). There were children living with elderly individuals of both genders in 39% of the cases, only with a female elderly individual in 37% of cases, and only with a male elderly individual in 24% of cases. Most children lived with the elderly individuals for more than five years (75.9%), followed by children had lived with their elderly relative between three and four years (11.1%), between four and five years (7.4%) and less than three years (5.6%).
After the MMSE was applied, the children were distributed into Group 1 (n=25, 46.3%) or Group 2 (n=29, 53.7%). The average score in the Attitude Scale obtained by children in Group 1 was 1.66 (SD=0.3) and that of children in Group 2 was 1.52 (SD=0,38), as shown in Figure 1, in which the average score that each group obtained in each domain is also shown.
As shown in Table 1, the comparison between Groups 1 and 2 presented levels considered significant for the domains cognition (p=0.025) and social relationships (p=0.049) and presented a tendency to be significant for the scale's overall score (p=0.053). Figure 2 presents the average rank, according to the Mann-Whitney test, for the general scale and the domains cognition and social relationships'.
Children living with elderly individuals with cognitive disorders obtained higher rank averages than children living with elderly individuals without cognitive disorders, which means they present worse attitudes in the domains cognition and 'social relationships' and a tendency to present worse attitudes on the general scale.
The results enable drawing a profile of elderly individuals living with children aged seven to ten years old. Most children live with elderly individuals of both genders and when there is only one elderly individual, it is female. They are mostly young elderly individuals with no or little education. Family income is low if we consider that there were an average of six people per household.
A study conducted in São Paulo, SP, Brazil in 2000 with a representative sample of the elderly population in the city revealed that 32% were between 60 and 64 years of age, 46% were between 65 and 74 years old and 22% were older than 75 years of age(18). Younger elderly individuals predominated in this study, more prevalent that what is found in the literature. This finding may be explained by the fact that children were 10 years old, at most. Since all pairs of child-elderly individual were from the same family, we assume that for a elderly individual to live with a child this age, s/he would have to be either a parent or grandparent, that is, s/he would be younger, what was in fact confirmed.
According to data provided by IBGE expressed in the profile of the elderly individuals head of families in Brazil in 2001, 54.4% of the elderly individuals had three years of schooling at most(19), which confirms the low level of education of Brazilian elderly individuals.
Families with children and elderly individuals had six people on average. One study conducted with elderly individuals living in seven countries in Latin American and the Caribbean (including Brazil) reveals that more than half of the interviewed elderly individuals lived with three or four people and 25% with five or more people. Data from Brazil only show that 37% live with three or four people, 19% with five or more people and only 13% live by themselves(18). The average number of people living in residences in which elderly individuals are the family head in Brazil was 3.2 people(19). The National Household Sample Survey by IBGE of 2008 reported an average of 3.3 people by household(20).
The literature shows that the average number of people living in a household with elderly individuals varies according to region and the individuals' characteristics. Factors influencing this variation depend on the needs of family members, the elderly individual's number of children, gender, age, degree of dependency, marital status, and even physical and financial viability, and health conditions(18).
Most elderly individuals were grandparents of the interviewed children, which shows there are households gathering three generations. Additionally, elderly individuals who are parents of children from seven to ten years old were also identified, which may indicate increased quality of life and productive life in old age. A large part of these children had lived with the interviewed elderly individual for more than five years, hence, they must know each other well and the children's attitudes may have been influenced by the elderly individuals' behavior.
Even though the interviewed individuals were comparatively young, the percentage of individuals with cognitive impairment was expressive. The average score was low, though this is not a very relevant indicator since the score indicating cognitive deficit depends on a cut-off point, which is adapted to the level of schooling.
The evaluation of the children's attitudes toward aging reveals that the average score of the children, both in Group 1 and Group 2, was close to score one, indicating more positive attitudes toward aging since children could score one at a minimum and three at most. The most negative attitude presented by the two groups was in the domain cognition and the most positive in the domain persona, results that corroborate another study conducted in Brazil using the same scale, which evaluated 258 children, though most did not live with their grandparents(15).
Even though the attitudes of children from the two groups toward aging was positive, there were differences in the comparison between the group living with elderly individuals with cognitive disorders (Group 1) and the group living with elderly individuals without cognitive disorders (Group 2). Children from Group 1 had a negative view of wisdom, creativity, speed, attention, security and clarity of elderly individuals (domain of cognition). This may be a reflex of the condition of the elderly individuals they live with who present cognitive impairment.
Children from Group 1 also presented more negative attitudes concerning the domain social relationships, which is linked to affective-emotional aspects (valorization, acceptance and mood) and reflects social interaction. Children from Group 1 also presented the most negative attitudes., also having a tendency to present more negative attitudes on the scale's general score.
Therefore, the children living with elderly individuals having cognitive disorders tended to present more negative attitudes toward aging in general, more significantly negative in the domains cognition and social relationships. The other domains did not present significant differences in the comparison between groups 1 and 2.
Due to the specificities of the aging process, it is important that children become involved in the process of caring for the elderly(21), so they can learn the qualities and limitations they have and improve their attitudes toward elderly individuals, especially children living with elderly individuals with cognitive impairment.
This study enabled the evaluation of attitudes toward aging of children living with elderly individuals with and without cognitive impairment. The children were seven to ten years old and more frequently lived with young elderly individuals of both genders, with a low level of education, who were their grandparents, living together for more than five years. Family income was low considering the average number of people (six) per household.
Most elderly individuals (58.7%) scored above the cut-off point, adapted to their level of schooling, on the MMSE. Most of those considered to have cognitive deficit were women, younger elderly, with little or no education.
Children were divided into Groups 1 and 2 according to the score obtained in the MMSE by the elderly individual with whom they lived. Hence, children living with elderly individuals who presented cognitive impairment were assigned to Group 1 (46.3%) and those living with elderly individuals who did not present cognitive impairment were assigned to Group 2 (53.7%).
The average score of children from Group 1 was 1.66 and from Group 2 was 1.52. The comparison between the two groups showed significant differences in the domains cognition and social relationships and a tendency to present differences in the scale's general score.
Therefore, children living with elderly individuals with cognitive disorders present more negative attitudes toward aging in the domains cognition and social relationships than children living with elderly individuals without cognitive impairment.
It is worth noting that even though significant differences were found when the score on the scales of the children's attitudes and cognition of elderly individuals were compared, other variables may have influenced these results, such as in cases when the child lived with more than one elderly individual in the same house. Nevertheless, the differences found should be taken into account in care delivery and in the planning of actions directed to children living with elderly individuals with cognitive disorders.
Health professionals working in the Family Health Strategy are faced everyday with the most diverse family configurations. Usually, when the family's child does not have a disease, s/he does not receive proper attention. Elderly individuals with chronic diseases are frequently visited and assessed and caregivers pay increased attention to them. The remaining family members, including children, are often left aside in care delivery, and the care provided is minimum. Children should, in addition to having an individual care plan, be included in the care plan of elderly individuals to understand the process these are experiencing and help in the best way possible.
This study reveals that children are influenced by situations occurring with the people around them and have worse attitudes toward aging when elderly individuals with whom they live have cognitive disorders. Therefore, children should be included in the care plans of elderly individuals to understand these individuals' diseases and know how to help them, without however keeping information from them.
Other actions such as inter-generational groups in the FHU's scope can play an important role in integrating generations and exchanging experiences. It is the duty of health professionals to encourage and make partnerships with entities in the unit's coverage area, such as schools and community centers, implementing actions that involve gerontology education and inter-generational aspects to help children to better understand the aging process.
Additionally, the education of health professionals should focus on gerontology due to the growing number of elderly individuals in the population and the diseases affecting them. The importance of the family and children in this context should also be the target of programs training professionals who care for them.
Research in this field is important because children of today will be the elderly of tomorrow.
Appreciation to the São Paulo Research Foundation (FAPESP) for financial support.
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* Extracted from the thesis "Crianças que convivem com idosos: atitudes em relação à velhice e percepção sobre demência", Federal University of São Carlos, 2011.