Intervention of occupational therapists with frail elderly¹

Abstract

Introduction

Occupational therapists make up the teams that provide assistance to frail elderly people in different care contexts, including health, social assistance and culture.

Objective

To identify the role of occupational therapists who work with frail elderly people.

Method

Qualitative and exploratory study. Interviews were carried out with occupational therapists who work with frail elderly people in the city of São Paulo, SP, Brazil, using a semi-structured script of questions. “Snowball sampling” was used. The results were analyzed using thematic-categorical content analysis.

Results

Nine occupational therapists working in health, social care and culture were interviewed. The categories found were: I) actions developed by occupational therapists in assisting frail elderly people; II) teamwork and articulation of knowledge, contributions and challenges; III) articulation of networks and intersectoriality; IV) relevant aspects in comprehensive care for frail elderly people. The interviewees perform diversified actions, considering the cultural and social insertion of the elderly and public policies; shared with team professionals and with services from the sectorial and intersectorial network; included caregivers in the assistance provided to the frail elderly.

Conclusion

Among the challenges faced by occupational therapists in working with frail elderly people, there is the incorporation of the premises of integrality, intersectoriality and teamwork. The different actions taken are supported by public policies for aging, and seek unique care based on biopsychosocial complexity and contextual aspects that influence aging. The results indicate the need to expand the insertion of occupational therapists in teams that offer care to frail elderly people in different care contexts.

Keywords:
Occupational Therapy; Elderly; Professional Practice

Resumo

Introdução

Terapeutas ocupacionais compõem as equipes que prestam assistência a idosos frágeis em diferentes contextos de atenção, dentre eles saúde, assistência social e cultura.

Objetivo

Identificar a atuação de terapeutas ocupacionais com idosos frágeis.

Método

Estudo qualitativo e exploratório. Realizaram-se entrevistas com terapeutas ocupacionais que atuam com idosos frágeis na cidade de São Paulo, SP, Brasil, utilizando roteiro semiestruturado de questões. Empregou-se a técnica “bola de neve”. Os resultados foram analisados por meio da análise de conteúdo temático-categorial.

Resultados

Foram entrevistadas nove terapeutas ocupacionais atuantes na saúde, assistência social e cultura. As categorias encontradas foram: I) ações desenvolvidas por terapeutas ocupacionais na assistência a idosos frágeis; II) trabalho em equipe e articulação de saberes, contribuições e desafios; III) articulação de redes e intersetorialidade; IV) aspectos relevantes na assistência integral a idosos frágeis. As entrevistadas realizam ações diversificadas, considerando a inserção cultural e social do idoso e as políticas públicas; compartilhadas com profissionais da equipe e com serviços da rede setorial e intersetorial; além de incluírem cuidadores na assistência prestada aos idosos frágeis.

Conclusão

Dentre os desafios encontrados pelas terapeutas ocupacionais na atuação com idosos frágeis, encontra-se a incorporação das premissas da integralidade, intersetorialidade e trabalho em equipe. As diferentes ações realizadas estão amparadas nas políticas públicas para o envelhecimento, e buscam o cuidado singular baseado na complexidade biopsicossocial e nos aspectos contextuais que influenciam o envelhecimento. Os resultados indicam a necessidade de ampliação da inserção de terapeutas ocupacionais em equipes que ofertam cuidados para idosos frágeis em diferentes contextos de atenção.

Palavras-chave:
Terapia Ocupacional; Idoso; Prática Profissional

Introduction

Aging, despite being a heterogeneous process experienced in a unique way by each elder, gradually leads to loss of physiological reserves, increased chances of contracting diseases and a general decline in the individual's intrinsic capacity (Organização Mundial da Saúde, 2015). Furthermore, aging brings changes in social roles and the need to deal with affective absences and the finiteness of life (Organização Mundial da Saúde, 2015). Thus, the advance of age often predisposes the individual to frailty.

The National Health Policy for the Elderly (PNSPI) (Brasil, 2006) considers an elderly person to be frail or in frail conditions a person who: resides in a Long-Term Institution (ILPI), is bedridden, has been hospitalized recently, has diseases that result in functional incapacity, has at least one basic functional incapacity, and who lives in a situation of domestic violence. In addition, the Policy states that elderly people who have difficulties in performing Instrumental Activities of Daily Living (IADL) have the potential to develop frailty.

Accordingly, it is argued that frailty in the elderly should not be considered only in the dimension of functional abilities. This way of understanding frailty is restricted, because, despite the decline in functionality being a predictor of disabilities for Activities of Daily Living (ADL) - and some frail elderly people actually present decreased functionality - the terms frailty and disability do not refer to the same phenomenon (Fritz et al., 2019).

In this perspective, the presence of disabilities is not a determinant of frailty, in the same way that the frail elderly may not have disabilities. Thus, the assessment of frail elderly people should be guided by a broader gerontological conception, that is, should consider, in addition to functionality, environmental aspects and those related to psychosocial well-being and social participation (Fritz et al., 2019). This broader understanding allows the early identification of elderly people who are at risk of developing frailty, in addition to favoring environmental assessment and intervention and the use of assistive technologies that can help prevent and/or reduce the severity of conditions that predispose to frailty (Fritz et al., 2019).

Therefore, intervention with frail elderly people is complex and must include different professionals. Among the professionals who provide assistance to the frail elderly, the occupational therapists stand out (Neves & Macedo, 2015). They configure actions in different contexts, such as: health, culture and social assistance.

In the context of health, the occupational therapist is fundamentally guided by the concept of functional capacity to operationalize and equip the care of the elderly population, which refers to the preservation and/or increase of physical and mental skills required for an independent and autonomous life (Almeida, 2003). In dialogue with this, the National Health Policy for the Eldery (PNSPI) (Brasil, 2006) recognizes that the maintenance of functional capacity constitutes the basis for the promotion of active aging, in addition to being a relevant goal in health actions aimed at this population.

Considering that the aging process is multidimensional, the occupational therapist should develop their performance based on the diversity of needs of the elderly assisted. In the field of health, the complexity inherent to this process implies the use of approaches aimed at health needs and their social determinants by occupational therapists, which include mental health care in the face of daily disruptions, combating social isolation, attention to issues relating to grief and finitude of life, as well as approaches to reduce impacts on occupational performance and occupational roles. Thus, the health care offered to this population should also privilege actions that encourage social participation and self-care, the resumption and discovery of significant activities, insertion in socialization spaces and the construction of life projects (Almeida et al., 2016).

With regard to the role of the occupational therapist in social assistance, the resolution of the Federal Council of Physiotherapy and Occupational Therapy (COFFITO) (Brasil, 2010b) number 383 of 2010 - which defines the competences of the occupational therapist in social contexts - points out that this professional has competence and specificity to act at different levels of complexity of social assistance policy, socioeconomic, cultural and socio-environmental development (Brasil, 2010a). According to Neves & Macedo (2015), occupational therapists inserted in social assistance services must include, among their attributions, the monitoring of families and the provision of support to the elderly and caregivers in order to avoid conflicts arising from overload and violation of rights.

With regard to culture, the occupational therapist prioritizes, in this context, the care of population groups in situations of vulnerability and who are marked by experiences of disruptions in social and support networks (Inforsato et al., 2017). In this way, it seeks to favor the access and agency of cultural facilities, services and collectives that promote unique experiences and foster subjectivities, in addition to confronting institutionalization processes (Inforsato et al., 2017). Therefore, the relevance of this field for the work of the occupational therapist with frail elderly is identified, considering the vulnerability in which this population is often found.

Based on the above considerations, it is necessary to identify the actions taken by occupational therapists in the assistance offered to the elderly in situations of vulnerability and disability in different scenarios, in order to understand the professional practice and its contributions. Therefore, this study aims to identify the role of occupational therapists with this population.

Methods

This is a qualitative and exploratory study. The target population was captured using the methodological technique of non-probabilistic sampling called “snowball sampling” (Baldin & Munhoz, 2011).

The research participants made up the network of collaborators of the Laboratory of Studies and Actions in Gerontology and Occupational Therapy of the Occupational Therapy undergraduate course at the Faculty of Medicine of the University of São Paulo, and were contacted with the consent of the professor responsible for the laboratory. According to the “snowball sampling” methodological technique adopted in this study, the first participants indicated other potential participants to the researchers.

The criteria for inclusion in the research were: a) occupational therapists who care for frail elderly people; b) residents and working in the city of São Paulo.

Data collection took place between April and August of 2017. Occupational therapists who agreed to participate in the study were invited to an individual interview. To conduct the interview, the researchers prepared a semi-structured script corresponding to the study objectives, which included closed questions that dealt with the professional characterization of the participants (year of graduation, continuing education, degrees and professional insertion); and open questions that covered actions developed with frail elderly people, partnerships and articulations with sectorial and intersectorial network services and the understanding of their performance as an occupational therapist with this population in different care contexts, with regard to the contributions resulting from these actions and challenges for their development.

A pilot interview was carried out to assess the need for possible adjustments to the semi-structured question script. However, as this proved to be adequate for data collection, the pilot interview participant was included as the target population of the study. The interviews lasted an average of 1 hour and were carried out in a place of convenience for the participants. They were recorded and later transcribed for analysis. The results obtained were analyzed from the thematic-category content analysis, which constitutes a set of techniques for the interpretation of qualitative data (Bardin, 2004).

According to Bardin (2004), the thematic-category content analysis aims to describe the content emitted in the communication process through systematic procedures that provide the survey of indicators, allowing the realization of knowledge inference.

In this context, the information collected during the interviews was grouped by similarity of content, covering the stages of prior exploration of the material, selection of analysis units and categorization and subcategorization process (Bardin, 2004).

This study was approved by the Research Ethics Committee of the Faculty of Medicine of the University of São Paulo, under opinion number 2.178.750 of July 19, 2017. All participants signed the Informed Consent Form.

Results

Next, the characterization of the study participants will be presented, as well as thematic categories identified through the analysis of interviews and illustrative speeches. The author of the speeches will be designated by the letter I (interviewed), followed by the number corresponding to the interview. The categories found were: I) actions developed by occupational therapists in the care of frail elderly people; II) teamwork and articulation of knowledge, contributions and challenges; III) articulation of networks and intersectoriality; IV) relevant aspects in comprehensive care for frail elderly people.

These categories, as a whole, comprised specific interventions, shared with other professionals and with services from the sectorial and intersectorial network; contributions and challenges for the development of actions. Furthermore, the interviewees were encouraged to identify relevant aspects in the construction and development of actions in the care of frail elderly people.

Population characterization

9 (100%) occupational therapists participated in the study. All completed postgraduate studies, while 5 (55.5%) specialized in the area of ​​aging. Furthermore, the interviewees had between 1 and 20 years of training. Table 1 presents the sociodemographic profile, while Table 2 presents the professional profile of the interviewees.

Table 1
Sociodemographic profile of the intervewees, according to gender and age group. São Paulo, 2017.

Sex	No.	%
Female	9	100
Male	0	0
Total	9	100
Age group	No.	%
>20 years	4	44.4
>30 years	3	44.4
≥ 40 years	2	22.2
Total	9	100

• Source: Data collected for the research. São Paulo, 2017.

Table 2
Professional profile of the intervewees, according to time since graduation, city of graduation, continuing graduation and degree. São Paulo, 2017.

Time since graduation	No.	(%)
1 - 5 years	4	44.4
8 - 11 years	3	33.3
19 - 20 years	2	22.2%
Total	9	100
Graduation completion city	No.	(%)
São Paulo - SP	4	44.4
Ribeirão Preto – SP	2	22.2
São Carlos - SP	1	11.1
Santos – SP	1	11.1
Campinas – SP	1	11.1
Total	9	100
Continuing qualification and education	No.	(%)
Multiprofessional residency	4	44.4
Master’s degree	2	22.2
Doctorate degree	2	22.2
Professional enhancement	1	11.1
Total	9	100

• Source: Data collected for the research. São Paulo, 2017.

Among the interviewees, 8 (88.8%) mentioned being part of teams in the area of ​​health care or social assistance. Only the interviewee who was part of the culture context claimed not to be part of teams, despite performing non-systematic shared actions with other professionals from the network's services, in case of the needs of the frail elderly.

Regarding professional practice, 6 (66.6%) participants had a direct link to services and 3 (33.3%) were linked to universities, performing the role of tutors, among other functions.

The Table 3 indicates the professional insertion of the interviewees. Furthermore, it is noteworthy that 3 (33.3%) respondents mentioned more than one professional insertion at the time of the research.

Table 3
Professional insertion of the interviewees (contexts of work and services) in the city of São Paulo, 2017.

Contexts of work	Services
Healthcare	Elderly Companion Program (PAI)
	Health Center
	Psychossocial Care Center (CAPS)
	Hospitals: outpatient clinics (specific for the elderly, specific on falls and general occupational therapy) and wards (geriatric and psychogeriatric)
	Integrated Rehabilitation Center (CIR)
	Elderly Health Reference Unit (URSI)
	Therapeutic Residencial Service (SRT)
Social assistance	Long-stay Institution for the Elderly (ILPI)
	Specialized Reference Center in Social Assistence (CREAS)
Culture	Cultural center
	Theater Company
	Solidarity Economy Point

Actions developed by occupational therapists in assisting frail elderly

The interviewees identified, in the context of health, the development of actions with frail elderly people aimed at: preserving their functional capacity, independence and autonomy; promotion of social participation; technical and matrix support:

The actions I develop are related to the increase or maintenance of the elderly’s functionality (I.1).

Occupational therapy in the ward usually performs cognitive and motor stimulation actions, we also teach energy conservation techniques for the elderly who have difficulty performing daily activities due to health issues (I.2).

In the context of social assistance, the professionals mentioned actions aimed at social protection and promoting social participation. Finally, in culture, interventions were identified with the objective of guaranteeing access to culture.

Generally, in different contexts of action, occupational therapists reported: the development of therapeutic groups and activities; rescue of significant activities; home, individual and family care; use of artistic and expressive practices:

We often use artistic resources to enable the elderly to express their emotions (I.9).

Occupational therapy has an important role in the rescue of significant activities. We seek to understand the reason for abandoning activities, and we build strategies so that the elderly can perform them again. This is very important, as it helps to rescue the subject’s life story and identity (I.4).

In the outpatient clinic and infirmiry, we carry out therapeutic groups and family care (I.2).

The actions mentioned differed according to the context of care. Specifically in health, most actions consisted of training in activities of daily living (ADL), prescription and preparation of assistive technology and fall prevention:

At the outpatient clinic, we provide guidelines for preventing falls, and ADL training with the elderly who are dependent for self-care and eating (I.1).

In social assistance, interventions in situations of social vulnerability, violation of rights and in situations of institutionalization were highlighted, with the aim of guaranteeing rights:

In social assistance, all the actions we develop aim to guarantee the rights of the elderly. We carry out interventions with different network services when we identify that the elderly person is in a vulnerable situation (I.7).

In the culture context, the following were reported: organization of cultural activities; mapping and agency of cultural and leisure spaces; stimulus and facilitation of territorial circulation; and urban mobility and dialogue with different institutions, all aiming to favor the social participation of the elderly:

Our main objective is to guarantee the social participation of the elderly. We encourage and monitor access to cultural facilities and organize artistic experiences in the community (I.9).

Occupational therapists reported the development of shared actions with other team members, such as: team matrix; technical support to formal elderly caregivers hired by the elderly and/or institutions for the qualification of assistance; assistance and discussion of cases with other services, seeking articulation of sectorial and intersectorial networks; therapeutic and psychoeducational groups for the elderly; assistance to family members; physical and cognitive rehabilitation; fall prevention; bed mobilization; support network mapping and development of therapeutic projects:

The multiprofessional team performs the matrix support of primary care teams, as well as the caregivers’ of the elderly (I.3).

We carry out therapeutic and psychoeducational groups with institutionalized elderly people, always along the nursing and psychology team (I.8).

We discuss the cases with the health and social care services, and plan the therapeutic projects according to that subject’s needs (I.4).

Teamwork and knowledge articulation: contributions and challenges

Eight interviewees considered that teamwork qualifies care for the frail elderly, as it favors actions centered on the subject's needs, as well as greater articulation between different types of knowledge.

Occupational therapists emphasized that the complexity of caring for frail elderly people demands actions that go beyond the specificities of each professional. They also reported that effective communication between team members favors the singularization of care, contextualized in the life story of the elderly and their environment and centered on their needs:

When working as a team, there are more people reflecting on the needs of that subject, thus the sum and articulation of knowledge provides qualified care (I.1).

In this work logic, it is possible to see the contribution of each field of knowledge. Something that would go unnoticed by one professional is perceived by the other, which broadens the team’s view of the elderly (I.2).

Each professional has specific skills and knowledge that help with care. It is necessary to identify as demands and needs the cultural and social insertion of the elderly. Only one professional is not able to handle this complexity, so teamwork is essential (I.4).

One interviewee points out that the sharing of knowledge increases her repertoire of knowledge for working with frail elderly people, as it allows the joint construction of therapeutic actions. They consider that teamwork is an intrinsic part of their practice, and that it seeks interprofessional articulation, especially in situations where the needs of the elderly go beyond their technical expertise:

I seek to act aiming at the integrity of care, always calling on other professionals when I identify demands that are beyond my knowledge (I.5).

One interviewee pointed out that the effectiveness of comprehensive care for the frail elderly requires coordination between the actions carried out by the team and the guarantee that one of the professionals is constituted as the reference for the elderly in that service. For her, disjointed actions, as sometimes observed, can lead to the duplication of actions or even the lack of responsibility of the team for the care of the user:

Sometimes in this type of work, the coordination of care is lost […] Responsibilities are not distributed, and the elderly may be left unattended in some of their needs (I.3).

Two interviewees indicated that it is essential that professionals are trained to act from the perspective of teamwork. This requires knowledge not only of their own specificities and competences, but also of the specificities and competences of the other members, so that the integration of knowledge and the qualification of care is viable:

It is important to pay attention to the skills of professionals to know in which part of the work they can bring greater contributions to the team (I.8).

In line with this, one interviewee stated that, in order to understand the contribution of the other professional in the team, it is necessary to adopt an available posture for listening and for dialogue. In this sense, open spaces for respectful communication and appreciation of different knowledge favor reflection on the actions developed with the subject, as well as the planning of actions and the alignment of interventions among members. They identify that, at times, they are faced with challenges in professional practice regarding the establishment and implementation of this dialogic posture among team members:

Teamwork is not something simple, but it is possible when there are professionals who are willing, trained and focused on the same objective. We often find it difficult to establish dialogue and plan actions [...]. It is a challenge, because we bump into the other’s profession, the other’s competence, and we always have to dialogue (I.5).

Another challenge identified by one interviewee, specifically in the hospital environment, refers to the organizational culture that results in the hierarchy between the values attributed to different professions. This fact hinders the sharing of knowledge and, therefore, the empowerment of the elderly regarding their health and disease process. In this sense, he also mentioned that care centered on the doctor and the lack of recognition of the knowledge of other professional categories impact teamwork and the quality of care:

In the hospital, care is organized based on the figure of the doctor. Because of this, the horizontality in the relationship with other professionals is often compromised - a fact that interferes with care, since certain knowledge is more valued (I.6).

As a way to deal with this challenge in his professional practice, the interviewee highlighted the importance of considering the horizontality of knowledge in teamwork, subject-centered care and the promotion of actions aimed at professional training for teamwork, as well as the focus of this content already in undergraduate health courses.

Another challenge mentioned by two interviewees for comprehensive care for frail elderly people was the limitation related to the structure for the development of professional practice, with regard to materials, equipment, physical space and trained human resources:

The limitation is often the service itself, because of the lack of material resources to carry out the activities and of trained professionals (I.3).

Articulation of networks and intersectoriality

Professionals recognize the relevance of intersectoriality in assisting the frail elderly. In this context, one interviewee pointed out that the articulation with professionals from the network services is essential for comprehensive care, as the complexity of needs goes beyond the specificities of the service:

As references for elderly care I adopt interdisciplinarity and intersectoriality […] I always try to involve the team and understand the needs that need articulation with the network (I.1).

The articulation between services was mentioned both in the sectorial and intersectorial scope. For its effectiveness, the interviewees mentioned that they develop actions, such as: implied referrals; shared services; case discussion; and matrix support with teams from other services.

Aiming to demonstrate the complexity of the sectorial and intersectorial articulation, the occupational therapists mentioned different services to which they seek to articulate to favor the integrality of the care offered to the frail elderly. These are shown in Table 4.

Tabel 4
Articulation of sectorial and intersectorial network carried out by the interviewees for assistance to frail elderly people (working contexts, services and equipments) in the city of São Paulo, 2017.

Working contexts	Services and equipments
Healthcare	Traditional Chinese Medicine Unit
	Elderly Health Reference Unit (URSI)
	Basic Health Unit (UBS)
	Psychosocial Care Center (CAPS)
	Coexistence and Cooperativeness Center (CECCO)
	Elderly Monitoring Program (PAI)
	Multiprofessional Homecare Team (EMAD)
	Specialized Rehabilitation Center (CER)
	Expanded Family Health Center (NASF)
Social Assistance	Food on Wheels (Alimentação sobre Rodas)
	Long Stay Institution for the Elderly (ILPI)
	Specialized Reference Center in Social Assistance (CREAS)
Education	Universities (cultural and extension projects aimed at seniors)
	Elementary schools (intergenerational projects)
Community	Social clubs
	Coexistence Nuclei
	Churches and resident’s association (groups for seniors)

The professionals pointed out barriers that they face to carry out network work. One interviewee, who worked in healthcare in the hospital environment, mentioned that the specificity of the service in caring for the elderly population leads to isolation, and fragments the care provided. She mentioned that the focus on very specific actions can limit the look at other demands and needs. Still, for her, the organizational issue of health equipment makes it difficult to implement the referral and counter-referral system:

The service makes our work a little difficult, because it is a specific outpatient clinic […] so we were focused on a demand (I.1).

In this sense, reinforces that the articulation of the sectorial and intersectorial network would be a way to reduce the isolation of the service and favor the integrality of care:

This situation impacts on care, so it is always necessary to be in contact with other equipment in the network (I.1).

The interviewees stated difficulties in carrying out implied referrals that guarantee users' access to services, a circumstance that commonly hinders adequate care for the needs of the elderly. In addition, one professional mentioned the restriction in the offer of places in other equipment in the care network, a fact that impacts the continuity of care:

Elderly people often need care that is not provided in this clinic. When we are going to make the referral, some do not get the vacancy, a situation that impacts the continuity of treatment. As is the case with neurology, many users have the need, but when we refer, places are limited (I.2).

Relevant aspects in comprehensive care for frail elderly people

Occupational therapists highlighted the importance of the centrality of care in the needs of the elderly. In this sense, it is necessary to understand their sociocultural context, their life history and the meanings attributed by them to their illness process and/or social vulnerability. The active participation of the elderly in the construction of therapeutic projects was also identified as a relevant aspect:

I try to include the subject as an active participant in their care (I.2).

The interviewees also emphasized the importance of establishing a relational space with the subject, in which mutual respect and trust favor joint actions. To promote comprehensiveness, they seek to understand the biopsychosocial complexity of the subject to be covered in care. This expanded view allowed for individualized care, a fact that was highlighted as an ethical and political commitment to the elderly:

I believe that our main contribution is to be able to see the elderly in their entirety, taking into account the cognitive, affective, physical social and spiritual aspects (I.8).

In the context of health, the interviewees highlighted the promotion of quality of life, through which they sought to understand the impact of senescence and senility processes in the daily lives of the elderly and the meanings they attributed to their health and disease processes, in addition to promoting the leading role in decision-making in relation to their therapeutic processes.

One of these interviewees pointed out that promoting the quality of life of the elderly implies investing in prevention and health promotion in order to reduce frailty or delay the progression of their chronic diseases:

Something I always consider is prevention; preventing the frailty process from intensifying. I always seek to promote health and quality of life (I.4).

The occupational therapists affirmed the stimulation of the frail elderly's remaining capacities, favoring the maintenance and/or increase of independence and autonomy in daily activities. Also, they sought to rescue significant activities and invested in identifying new activities desired by the user:

Our work allows the elderly to resume activities, and discover new potential (I.2).

I believe that the contributions of occupational therapy go towards everyday life, in emphasizing the elderly’s ability to carry out their activities even with limitations, as well as encouraging autonomy (I.1).

The interviewees who worked in the context of social assistance pointed out the importance of encouraging autonomy, citizenship and the exercise of social rights. For them, the interventions emphasized social protection and the reduction of social vulnerability:

In social assistance, we work with the concept of social protection, which concerns the guarantee of rights, so we are always attentive to situations of social vulnerability (I.7).

In this context, they highlighted the importance of identifying situations of violation of rights and evaluating the possible need for institutionalization of the elderly, through situations of violence that increase their fragility and threaten their survival:

We carry out assessments to understand whether the elderly person needs institutionalization, that is, we seek to identify the extent to which keeping the elderly person in daily life and in family life does not result in damage and situations of violence (I.7).

They also emphasized that the care of frail elderly who are already institutionalized requires special attention to the maintenance and increase of autonomy, independence and coexistence, as institutional routines and often rigid organizational structures in these institutions can contribute to functional dependence, isolation and decreased autonomy of the elderly:

Important references for my work are coexistente and participation, especially if the elderly person is in the ILPI (I.7).

At the ILPI, the great challenge is the institution’s routine, which, sometimes makes the elderly a little more dependent […]. The elderly who are institutionalized are already in a fragile process, and this process is often intensified due to the characteristics of institution (I.8).

Furthermore, the interviewees inserted in different care contexts recognized the inclusion of the family and caregivers in the work with frail elderly as being essential. They considered it essential to contextualize the monitoring process in the elderly's social support network. In this sense, some professionals mentioned actions such as the establishment of partnerships with family members and caregivers that favor their reception, guidelines for facilitating care and technical support for daily adaptations that consider the needs of everyone involved. These aspects help in the continuity of care, in the division of care among family members and in reducing the burden of care:

The occupational therapist has an important role in the dialogue with caregivers and family members of the elderly […]. The work with the support network is constant, in order to provide guidance and understand demands (I.8).

We often contribute with the team to adapt the routine of that family so that care for the frail elderly is possible […]. We think of alternatives to magane the burden, division of tasks, small changes that make daily life easier… always seeking quality of life and autonomy (I.7).

Other objectives in working with frail elderly people mentioned by the interviewees in their practice were: fostering the elderly's social participation in the community sphere, their insertion in living spaces and encouraging their participation in sociocultural activities. These aspects aimed to avoid the institutionalization of the elderly, expand their social support network and enhance their significant daily experiences:

I always consider the social participation of the elderly. For this, we seek to articulate the network. We seek the core of coexistence, libraries and cultural spaces (I.8).

Finally, the interviewee (I. 9), inserted in the context of culture, pointed out the investments in the production of experiences and in the construction of affective bonds that were allied with expressive and artistic practices, favoring the constitution of collectives that produce the experimentation of multiplicities, the promotion of subjectivities and the engendering of the individual in their social environment:

In culture, I consider that the most important premise is the constitution of collectives. Each subject with their uniqueness adds to the formation of a group that produces experiences and fosters subjectivities (I.9).

Discussion

This study aimed to understand the role of occupational therapists who work with frail elderly people in different care contexts: health, social assistance and culture. The results identified interventions shared with other professionals and with services from the sectorial and intersectorial network and aspects considered relevant in the construction and development of occupational therapists' actions in the care of frail elderly people.

The results indicated that the assessment and intervention of occupational therapy with frail older adults encompasses the family, the community and the environment. This scope is in line with the understanding that frailty is a complex condition, in addition to functional disability (Fritz et al., 2019).

Regarding the actions carried out by the interviewees in the context of health, the focus was on the preservation of independence, autonomy, promotion of social participation and technical and matrix support. It is identified that, in the care offered to this population in healthcare services, occupational therapy directs its performance to the subject and their needs, with one of the objectives being the improvement or maintenance of functional capacity (Almeida, 2003). In dialogue with these considerations, the PNSPI (Brasil, 2006) points out as the main purpose in the care of the elderly in recovery, the maintenance and promotion of autonomy, considering that, for this population, the concept of health is more related to the condition of autonomy and independence, than the presence of diseases.

Occupational therapists in the healthcare area reported that the actions were aimed at increasing social participation. These actions are considered to be in line with the World Health Organization regulations on healthy aging, which recognize the need for investment in actions in the different areas of the elderly's life, including the promotion of social participation and the performance of social roles (Organização Mundial da Saúde, 2015).

Regarding the matrix support placed by the interviewees as being offered to caregivers and teams involved in monitoring frail elderly people, it is believed that this action favors the establishment of organizational arrangements for work management, which are directly related to the expansion of possibilities of carrying out the expanded clinic and integration between different professions and specialties (Campos & Domitti, 2007).

Occupational therapists inserted in the field of social assistance affirmed the development of work that converges with the National Policy for Social Assistance (PNAS). It defines social protection as the form institutionalized by society to offer protection to a part or set of members, in the face of natural or social situations and/or conditions that predispose to vulnerability, such as the aging process with frailties. In this perspective, the importance of the distribution and redistribution of material and cultural goods for the survival and social integration of the elderly population is emphasized. In addition, social protection must ensure safety, survival, acceptance and family living, in addition to implying the development of actions aimed at ensuring opportunities for older people to live together, which presupposes facing situations of confinement and loss of relationships (Brasil, 2010a).

The literature states that the work of the occupational therapist in the field of social assistance should consider the construction of life projects, mediation of conflicts, collective interventions in the life contexts of the elderly, rescue of the oral history of life and cultural and intergenerational negotiation (Neves & Macedo, 2015). A consonance was found between the performance of the interviewees with frail elderly people and the performance foreseen for the occupational therapist in the Unified Social Assistance System (SUAS),

In addition to these considerations, interventions aimed at reducing the impacts of institutionalization processes, as well as situations of violence, were mentioned. Moreover, the interviewees mentioned the need to reflect and act on the disruptions in the daily lives of the elderly and their families through the possibility and/or need for institutionalization processes. It is understood that occupational therapists presented alignmen with the National Health Policy for the Elderly in their performance (Brasil, 2010a), which aims to guarantee the social rights of the elderly, autonomy, integration and social participation.

Some interviewees from the areas of social assistance and health stated that the implementation of institutionalization processes often predisposes to an increase in functional incapacities. In ILPIs, it is essential to have a multidisciplinary team - including occupational therapists - in order to establish actions to promote health and prevent disabilities, in addition to carrying out interventions aimed at promoting self-care, autonomy and independence of the elderly by as long as possible, always taking into account the uniqueness of the subject (Watanabe, 2009).

Finally, in the context of culture, the interviewee pointed out the dialogue with different institutions, aiming at the participation of the elderly. They also highlighted the need to guarantee access to culture through the organization of artistic practices and cultural activities. It is identified that their performance is in line with the International Plan of Action for Aging (Organização das Nações Unidas, 2002), which states that all subjects have the right to participate in cultural life and enjoy the cultural goods present in the community. Accordingly, among the government actions to implement the National Immunization Program (Brasil, 2010a) in the area of ​​culture, sport and leisure, there is a guarantee for the elderly to participate in the creation and enjoyment of community cultural goods.

This interviewee also stated that the role of occupational therapy is aimed at the possibility of apprehension of multiplicities, the production of subjectivities and the engendering of collectives. The literature understands that, taking into account the different conditions of vulnerability experienced by many elderly people, participation in culturally diverse spaces represents a means for exercising citizenship and for social intervention (Coutinho et al., 2009). It is recognized that the development of cultural practices with the elderly can provide the expansion of emotional support networks and sociocultural relationships, enabling the construction of new life projects and exchanges of personal and collective experiences (Coutinho et al., 2009). Therefore, projects aimed at inclusion must understand the cultural dimension as an important strategy, which, for this, can count on different professionals, including the occupational therapist (Coutinho et al., 2009).

The interviewees from different areas considered teamwork as a factor that enhances care, as it can favor meeting the multiple needs of the elderly, through the exchange and composition of the different specificities of the team members. According to Peduzzi (2001), teamwork is a modality of collective action that materializes through the establishment of reciprocal relationships between multiple technical interventions and interaction between agents from different professional areas.

Considering that the aging process is multifactorial, the needs of the elderly population will permeate several specialties. Therefore, for the realization of comprehensiveness, it is recommended that services be composed of multidisciplinary and/or interprofessional teams (Peduzzi, 2001). However, the results of this study showed that the existence of a team in the service does not necessarily translate into articulated attention among the members. In this sense, one of the interviewees points out that she experiences the hierarchy of knowledge in the hospital context, with care centered on the medical professional, which hinders the comprehensive care provided to the elderly. The National Humanization Policy (Brasil, 2009) understands that, for the realization of the expanded clinic and comprehensive care, it is essential to link different disciplines and horizontalize knowledge.

In addition to emphasizing the importance of teamwork, sectorial and intersectoral articulations were identified as ways to promote the agency of care, leisure and coexistence spaces, in order to provide comprehensive care and the quality of life of the elderly. It is worth mentioning that intersectoriality represents the articulation of knowledge and experiences, enabling the planning, implementation and evaluation of policies, programs and projects as a way to achieve effective results in complex situations (Oliveira et al., 2014).

In this context, the interviewees mentioned the establishment of partnerships with network services that allowed them to promote the participation of the elderly in the community and their appropriation of the resources present in the territory. The National Information Security Policy (Brasil, 2018) includes, among its guidelines, intersectorality with a view to comprehensive care, recognizing that care for the elderly will necessarily require the agency of various services and equipment, in a work articulated in network.

The network actions mentioned by the interviewees favored the insertion of frail elderly people in spaces of health, leisure, culture and sociability. The experience of participating in these spaces allows the redefinition of meanings attributed to everyday life, as well as the expansion of social and support networks (Neves & Macedo, 2015).

On the other hand, the interviewees mentioned difficulties in articulating the network, which impacts the comprehensiveness of the care provided to the frail elderly. According to Aoki et al. (2017), integrality is often threatened due to the disarticulation of services in the territory, a situation that can generate the isolation of actions. In addition, the obstacles in the execution of network work show physical, attitudinal and institutional barriers that influence the user's access to equipment (Aoki et al., 2017).

Other aspects considered relevant in the construction of care processes for frail elderly were mentioned by the interviewees; among them, the centralization of the elderly's needs, the shared construction of singularized actions, the promotion of the subject's active participation in the care process and the understanding of the biopsychosocial complexity required for the performance. These aspects are related to the guidelines of the concept of extended clinic, which recognizes the need to expand the object of work and the care proposals involved, with investment in the relationships and co-responsibility of users for this process (Brasil, 2009).

Another aspect mentioned by the interviewees was the inclusion of the family in the care processes for the frail elderly. In this sense, occupational therapists emphasized the importance of providing information and resources to families to deal with the changes required in the home environment, of assisting in the adaptation of daily activities, and carrying out interventions with an emphasis on the instrumentalization of formal and informal caregivers to facilitate the tasks required in caretaking. In addition, they highlighted the importance of providing support to family members, considering the burden that is often present in the care of frail elderly people. This last aspect concerns the relevance that the occupational role of caregiver starts to play in the subjects' lives - which accumulates with other occupational roles already performed -, which can represent suffering to family members and an important demand for occupational therapy performance (Dahdah & Carvalho, 2014).

As limitations of the study, the small sample size was identified. In addition, only occupational therapists working in health, social care and culture were interviewed, a fact that is related to the adoption of the “snowball sampling” methodological technique. However, it is recognized that occupational therapy is present in the monitoring of frail elderly people in other contexts, which could be investigated in future studies. In view of this fact, it is relevant to expand the research to other areas mentioned in the National Information Security Policy (Brasil, 2018), such as Education and Work, in order to identify the role of the professional category with this population.

Despite these limitations, the research proved to be essential to understand the role of occupational therapists who work with frail elderly people in health, social care and culture, besides the actions developed in teams and networks. In this sense, it is considered that the results obtained in this research are of great relevance for expanding the understanding of the work of occupational therapists with frail elderly people, allowing professionals to recognize the actions they can perform with this population, in addition to reflecting on the challenges faced in practice.

Conclusion

Occupational therapists in their work with frail elderly in different care contexts are faced with the challenge of incorporating the premise of comprehensiveness as a guide for assistance, as well as the articulation of networks, the promotion of teamwork and the horizontality and integration of knowledge.

These professionals have faced these challenges through complex work with this population. Different actions that aimed, among other things, the preservation of functional capacity, investment in meaningful activities, the promotion of social participation, monitoring and intervention in situations of violation of rights, the constitution of collectives, support for caregivers and the circulation and experimentation of cultural spaces and the territory were identified.

The actions are supported by public policies, including: those aimed at aging; those on the principle of singularized care centered on the subject's needs; those in understanding the biopsychosocial complexity and contextual aspects that influence the experience of aging and care processes; the emphasis on expanding and strengthening the social support network; the importance of teamwork to provide comprehensive care to frail elderly people; and in the development of shared actions resulting from sectoral and intersectoral articulation.

Based on the results, it is considered essential to expand the insertion of occupational therapists in multidisciplinary and interprofessional teams, as well as the investment and strengthening of the insertion of occupational therapists in different contexts of care for the frail elderly.

• 1
  Ethical procedures: this study was approved by the Ethics and Research Committee under opinion number 2178.750 on July 19^th, 2017.

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Edited by

Section editor

Profa. Dra. Marcia Maria Pires Camargo Novelli

Publication Dates

• Publication in this collection
  11 Oct 2021
• Date of issue
  2021

History

• Received
  09 Dec 2020
• Reviewed
  31 Mar 2021
• Accepted
  15 Apr 2021