Mental health promotion and protection actions aimed at the elderly in the context of primary health care: an integrative review

The increase in the elderly population requires rethinking the organization of society, especially health services. The aim was to analyze actions aimed at promoting and protecting the mental health of the elderly in the context of primary health care, through an integrative review. The databases used were: Lilacs, Scopus, IBECS, Medline, CINAHL, BDENF and Index Psicologia. The descriptors used were “elderly”, “health promotion”, “mental health” and “primary health care”. The final sample included 15 articles. The results indicate that group actions contribute to the reduction of depressive symptoms; health education in the perspective of active learning, aiming at health literacy and memory workshop strengthening spaces for socialization. Matrix support is highlighted as an indispensable tool for new mental health practices. We conclude that the moment is right for expanding the scope of actions offered to the elderly in psychological distress. Efforts have been detected in the production of care aiming at integrality, which is still incipient. PHC to be relevant, so that nurses can implement this program in the different Health Units, evaluating its long-term effectiveness. The interventions are led by PHC nurses in their approach of common mental disorders (CMD) and involve nine weekly 90-minute group sessions, daily training and reinforcement sessions 19 The results show moderate effectiveness of the intervention in reducing symptoms of anxiety and depression, suggesting that the mindfulness intervention guided by primary care nurses can be a care alternative for CMD at this level of care 19 .


Introduction
The growing increase in the elderly population that has been taking place all over the world leads to the need to rethink the current organization of society aiming to deal with this reality, which more specifically affects health services.
In Brazil, this population grew rapidly and significantly, reaching 13.5% of the total Brazilian population in 2018 1 .
The concern with these individuals derives from the multiple physical, emotional and social changes that make them more susceptible to the presence of multiple diseases and changes in their health status, which are characterized by their chronicity and complexity, interfering with their quality of life and, therefore, requiring attention.
Mental health problems must be highlighted among the elderly population, being attributed to stressful events, the presence of illnesses, disabilities and social isolation.A study carried out in a northeastern Brazilian state showed an overall prevalence of 55.8% of elderly people with Common Mental Disorders, and the most often reported symptoms were: being easily frightened, feeling nervous, tense or worried, which are related to a depressive mood 2 .
Moreover, social representations of health professionals and the community collaborate for the problems related to the mental health of the elderly to be mistaken by the natural aging process, impairing diagnosis and treatment 3 .
Social isolation, the death of people close to them, the presence of multiple diseases, aging contribute to mental health problems among the elderly, as well as factors such as low level of schooling, being female and advanced aging.Therefore, it is suggested that health professionals be trained to work with these people using an interdisciplinary approach, based on health promotion actions.In this perspective, primary health care (PHC) represents a favorable scenario 4 .
The International Plan of Action on Ageing (PIAE, Plano Internacional de Ação sobre o Envelhecimento) regarding the mental health of the elderly, provides for the development of strategies that favor the early identification and treatment of people in mental suffering.Its objective is to develop education and awareness actions aimed at the population, in order to achieve a healthy aging, strengthen the network of care and support for the elderly, involving the family and the community 5 .
The PHC is responsible for meeting a large part of the needs, and it is expected that the health needs of the elderly be met in their entirety.For this purpose, in addition to the basic team that integrate the Family Health Strategy (FHS) units, it counts on the Expanded Center for Family Health and Primary Care (NASF-AB, Núcleo Ampliado de Saúde da Família e Atenção Básica), which operates as a multidisciplinary and interdisciplinary intervention team integrated to the PHC teams, joining the professional teams in the field of mental health 6 .
The Psychosocial Care Center (CAPS, Centro de Atenção Psicossocial), being referral services in mental health, must also operate in the matrix support logic for PHC teams.However, the challenge of supporting them in the practice of services is acknowledged, essentially regarding the health promotion actions 7 .
When evaluating the performance of comprehensive care for the elderly in PHC, carried out in 68 municipalities in the interior of the state of São Paulo, it was observed that the promotion and prevention actions are incorporated in a few services and in an incomplete manner, and although there is a consensus on the relevance of these actions, the practices are restricted to care for Chronic Non-Communicable Diseases (CNCDs) 8 .
Similarly, the Mental Health care of the elderly in PHC comprises outpatient care practices and the presence of a conceptual transition regarding the view of the aging process and Mental Health 9 .
Despite the successful experiences with the implementation of the FHS, the view point centered on the disease persists, especially in relation to the elderly population, with the biomedical model of health care prevailing 10 .
Movements for the expansion of actions to promote mental health in PHC have been identified.However, it is still incipient to the tensioning of actions in the psychosocial perspective 11 .
Based on the above, it is understood that it is necessary to overcome the challenges of production of mental health care and enhance territorialized care, considering the importance of advancing in health promotion and prevention of damage to the mental health of the elderly.Thus, the objective of the study is to analyze the actions to promote and protect the mental health of the elderly in the context of primary health care available in the literature.

Method
This is an integrative review, and this study corresponds to a research method that enables the analysis of scientific research in a systematic and broad manner, favoring the characterization and dissemination of the produced knowledge 12 .It stands out for demanding the same standards of accuracy, clarity and reproduction used in primary studies, in addition to constituting the broadest methodological approach regarding literature reviews 13 .
The integrative review consists of six steps: 1) identification of the topic and selection of the research question; 2) establishing the eligibility criteria; 3) identification of studies in scientific databases; 4) evaluation of selected studies and their critical analysis; 5) categorization of the studies; 6) evaluation and interpretation of results and presentation of data in the integrative review structure 12 .
The study was guided by a protocol elaborated by the researchers, which allowed for a clear definition of the investigation purposes and the identification of the variables of interest, facilitating the sample selection, maintaining the focus and limits for the investigation.
The research question was created according to the PICo strategy (P-population; I-interest; Co-Context) 14 , considering the following structure: P -elderly people; I -mental health promotion actions; and Co-Primary Care.Therefore, this investigation was conducted based on the following question: "What are the mental health promotion and prevention actions aimed at the elderly in the context of primary health care available in the literature?" The data search was carried out in electronic databases: US National Library of Medicine (PUMED); Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); Cumulative Index to Nursing and Allied Health Literature (CINAHL-Ebsco); Web of Science and Scopus (Elsevier); BDENF -Nursing; IBECS and Index Psicologia -Technical-scientific journals.For the search in the databases, descriptors present in the Health Sciences Descriptors (DeCS) and their equivalents in the Portuguese language in the Medical Subject Headings (MeSH) and List of Headings of CINAHL were selected.
The following inclusion criteria were adopted: primary articles that presented health promotion actions in primary care, published from 2014 to 2021, in English, Portuguese or Spanish and with the full text available.The exclusion cri-teria were: editorials, theses, dissertations, review articles, those already selected during the search in another database and the ones that did not answer the research question.
An advanced search form was used to systematize data collection, respecting the peculiarities of each database.Thus, the Boolean combination was used: idoso OR aged OR elderly OR  Article selection was carried out blindly and independently by two reviewers, who achieved an agreement rate above 90% after reading the titles and abstracts.To ensure a broad search, the manuscripts were accessed through the journal portal of the Coordination for the Improvement of Higher Education Personnel (CAPES, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), in the virtual private network (VPN) provided by the São Paulo State University "Júlio de Mesquita Filho".
An instrument built by the researchers was used for the extraction and synthesis of the selected articles.The following data were extracted: author, year, country of publication, type of study, actions and contributions.As for the level of evidence, the articles were evaluated according to the concept proposed by the evidence-based Practice, classified into seven levels 15 .
According to the adopted literature, evidence level 1 is considered to be evidence from a systematic review or meta-analysis of randomized controlled clinical trials or clinical guidelines based on systematic reviews of randomized controlled clinical trials; level 2, evidence derived from a well-designed randomized controlled clinical trial; level 3, evidence of well-designed clinical trials without randomization; level 4, evidence from well-designed cohort and case-control studies; level 5, evidence from a systematic review of descriptive and qualitative studies; level 6, evidence from a single descriptive or qualitative study; level 7, evidence from opinions from authorities and/or expert report 15 .
Data collection was carried out in two stages.The first consisted of identifying 4,018 publications, of which, after applying the inclusion and exclusion criteria, 15 articles were selected for the review sample.For the selection of publications, the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed, as shown in Figure 1.
The data were tabulated in a chart and the critical analysis and reflective synthesis were carried out in a descriptive manner, according to the findings about the performance of psychosocial care in the context of primary care.
Since this is an integrative review, the investigation was not submitted to the Research Ethics Committee; however, the conceptions of the authors of the manuscripts used in this investigation were preserved.

Mental health promotion and protection actions aimed at the elderly in the context of primary care
It is evident that interventions aimed at prevention, implemented in groups, reduce depressive symptoms and enable mental health promotion for the elderly; thus, this care approach is considered a potent one (Chart 1).It is noteworthy that strategies in this direction, value the human essence and promote listening, understanding, the strengthening of bonds and affective ties between people and professionals [16][17][18][19][20] .According to some authors 16 , the elderly community group (ECG) is characterized by leisure activities such as games, dances, manual activities and tours, which produce satisfaction among the participants, as they allow the exchange of affections, socialization, building bonds, in addition to enable the autonomy in choosing what they want to experience, allowing the protagonism of the elderly.
In this sense, they point to the power of these spaces as a device for deinstitutionalization and health promotion, favoring active aging 16 .
Similarly, the Therapeutic Community Group (TCG) is evidenced as a collective psychosocial intervention that offers benefits to those involved and can contribute to the reduction of individual care, establishing a scenario in which the professional identifies specific needs, producing significant actions, for health promotion and disease prevention.This practice is a relevant one, considering that this approach is not always possible in individual care 21 .
The therapeutic group can contribute to the reduction of the stigma related to mental illness and the promotion of mental health oriented to relational care technologies as the main tools, which are accessible and low-cost 21 .
From the perspective of health education, the active learning program in health literacy is identified as a strategy, related to lifestyle habits, physical activity and nutrition among elderly community residents with superficial knowledge of health.It is evident that the active learning program can contribute to the healthy aging process, expanding the possibilities of socialization and favoring the management of depressive symptoms.Moreover, it can prevent functional decline among the elderly 18 .
Another identified strategy was the memory workshop (MW), which was established in three categories, namely: finding out that you were already experiencing memory failures, fear of losing one's memory and desire to participate in health promotion activities 22 .
This strategy enables self-esteem and the strengthening of socialization spaces, in which they explained their experiences, anxieties, favoring exchanges and strengthening bonds, which contributed to giving them a feeling of belonging to the group, the resignification of the aging process and importance in the family.Therefore, the elderly suggest that MW should be a continuous work offered by the BHU.Therefore, the power of PHC and its wide scope of action is recognized, considering the needs of the territory 22 .
Significant reductions in the aspects of emotional loneliness are highlighted for the elderly who participated in the Lifestyle Matters intervention, which is a preventive intervention aimed at promoting mental health, involving weekly group sessions, including interventions in the elderly lifestyle based on occupation, aiming to promote greater social interaction 23 .
This review reveals a pilot study carried out in Asturias, with the implementation of a self-care and mindfulness program (PAMAP) in a PHC health unit.Mindfulness is the term used in the scientific literature for meditation practices that encourage acceptance of the present and the development of self-care and effective coping skills.With the implementation of the pilot study, its effectiveness in reducing pharmacotherapy and symptoms of anxiety and depression was considered significant in the short term 19 .
Thus, the coordination of the Mental Health Service in the area considered its application in PHC to be relevant, so that nurses can implement this program in the different Health Units, evaluating its long-term effectiveness.The interventions are led by PHC nurses in their approach of common mental disorders (CMD) and involve nine weekly 90-minute group sessions, daily training and reinforcement sessions 19 .
The results show moderate effectiveness of the intervention in reducing symptoms of anxiety and depression, suggesting that the mindfulness intervention guided by primary care nurses can be a care alternative for CMD at this level of care 19 .
Also regarding depression, considering its high incidence among the elderly and the impacts on Quality of Life (QoL) and the aging process 17 , they reiterate that the assessment and treatment of elderly individuals with depressive symptoms should occur predominantly in PHC, aiming to building a bond between service users and the professionals who provide care, with the objective of preventing and treating the disease 17 .
Therefore, they consider that multidimensional interventions have an impact on QoL and on depressive symptoms in elderly Brazilian individuals living in the community in the context of PHC.The interventions are carried out by a multidisciplinary team and are based on the identified needs, using active methodologies to adapt to the needs of the elderly, oriented towards changes in lifestyle habits and promotion of social interaction, reducing depressive symptoms and improving physical function 17 .
Therefore, it is concluded that the work in PHC requires great creativity and innovation potential from the teams, whose interventions must be holistic and multifaceted 17 .
Home visits and educational actions aimed at mental health care practices are highlighted, based on the listening to health needs 24 .
Matrix support (MS) stands out as an indispensable tool in mental health care in PHC due to the need to integrate it into daily life for the implementation of comprehensive health care 25 .MS is considered essential to the management change of health services, considering its potential to transform the hierarchical logic of health management and for the integration of mental health actions in PHC 26 .Some authors 27 have highlighted that mental health specialist nurses, through the matrix support strategy, were essential in supporting PHC nurses in implementing a routine assessment of anxiety among the elderly people in Australia.These specialists were responsible for training the PHC professionals to recognize and respond to the mental health needs of elderly people aiming at disease prevention and psychosocial care promotion 27 .
The mental health actions of Matrix Support in the territory are intertwined with the motivations of matrix supporters and nurses, considering that intentions and expectations permeate the health care for people and their families 28 .Impacts of this matrix support are identified in four dimensions, namely: changes in the professionals' attitude; expanding access to services; development of new care practices and increased effectiveness.Emphasis is placed on the capacity for empathy and understanding of the person in psychological distress, contemplating relationships and creativity for the production of care, which should favor the use of light, light-hard and hard technologies 25 .
The same authors point out that the diversity in the possibilities of mental health care produced by CHAs, considering the heterogeneous character of these professionals and the integration of technical skills and knowledge from previous experiences, strengthens significant actions.It is also pointed out that the MS allowed the CHAs to learn about the CAPS proposal, in addition to enabling the construction of communication instruments to direct the cases, aiming to establishing a more effective integration between the services 25 .
Matrix support is seen as a facilitator of mental health care in the psychosocial perspective, as it favors teamwork and expands the professionals' view of the possibilities of intervention, promoting actions in the territory and the construction of care while respecting the different users' dimensions 29 .In this sense, some authors 30 point out that it is possible to find issues that favor the work of matrix support and are essential to understand the reality, such as: case sharing; collective and shared work; the availability and accessibility of professionals; building bonds; and the sharing of responsibilities 30 .
A study carried out in Indonesia called the 'Mental Health Gap Action Programme (mhGAP)' by the World Health Organization (WHO) implements an additional mental health training for pairs of General Practitioners and Nurses in their primary care network.General Practitioners, integrated and supported by primary care nurses, could effectively manage mild to moderate mental health problems commonly identified in users at this level of care 31 .
Researchers 20 mention an effective strategy to prevent severe depression episodes in the elder-ly promoted by lay counselors in the context of primary care in low-and middle-income countries.It involves actions such as problem-solving therapy, brief behavioral treatment for insomnia, self-care education and assistance in accessing medical and social programs 20 .
The telementoring program, such as the Extension for Community Healthcare Outcomes (ECHO) and the Geriatric Mental Health (GEMH) programs, provides the PHC clinician with knowledge to carry out the mental health practice of the elderly, contributing to cost reduction in urgency 32 .In this sense, it is highlighted that developing disease prevention and health promotion actions offers a low cost and also improves people's quality of life throughout life 27 .
The PHC physicians have advanced in identifying elderly people at high risk of cognitive impairment, and the use of the Mini-Mental State Examination (MMSE) has allowed the identification of people at risk of cognitive decline 33 .
Finally, the effectiveness of the reflection facilitated through feedback from the network services is explained, in which, among the issues that emerged, the conflicts regarding role of interests stand out.Thus, the discussions gave the local services the opportunity to identify themselves as part of the network, initiating communication movements between them to solve problems 33 .

Conclusions
The literature review provided the analysis of actions aiming to promote and protect the mental health of elderly individuals in the context of primary health care.Seeking to promote elderly health, group actions working with this population were identified, contributing to the reduction of depressive symptoms; health education from the perspective of active learning, aiming at health literacy and memory workshop strengthening socialization spaces.
Matrix support stands out as an indispensable tool in the construction of new practices in mental health; however, the challenge of strengthening it in the practice of services is acknowledged.The effectiveness of the reflection facilitated through the feedback from the network services enables the emergence of conflicts of interests and roles, allowing the local services to identify themselves as part of the network in solving problems 34 .
It is demonstrated that the telementoring program provides the PHC clinician with knowledge to carry out the mental health practice of the elderly, contributing to the reduction of costs in urgency.Thus, it is highlighted that disease prevention and health promotion actions offer a low cost, as well as improve people's quality of life throughout life.The time to expand the scope of actions offered to the elderly in psychological distress is identified, thus detecting efforts for the production of care aiming at comprehensive care.However, this process has shown to be an incipient one.
The chosen method of study, the integrative review, showed to be an effective one for the understanding of the topic, even with the small number of selected articles; however, the identified material allowed establishing a national and international panorama on disease prevention and health promotion actions aimed at the elderly population in the context of PHC.
geriatric OR geriatrics AND Promoção da Saúde OR Health Promotion OR Educação Paciente OR Patient Education OR Health Education OR Educação em Saúde AND saúde mental OR Mental Health AND Primary Health Care OR Atenção Primária Saúde OR Atenção Basica OR Estrategia Saúde da Família.
Synthesis of the analysis of selected articles, Marília, SP, Brazil, 2021.Synthesis of the analysis of selected articles, Marília, SP, Brazil, 2021.
it continues Synthesis of the analysis of selected articles, Marília, SP, Brazil, 2021.