Challenges faced by the Family Health Team in caring for older adults with Alzheimer’s disease and their caregivers

Abstract

Objective  This study aimed to describe the challenges faced by the Family Health Team in caring for older adults with Alzheimer’s disease and their caregivers.

Method  A qualitative case study was conducted, involving healthcare professionals from Family Health Teams in Rio Branco, AC, Brazil, as well as caregivers of older adults with Alzheimer’s disease residing in this municipality. Data were collected through semi-structured interviews, systematized using the Collective Subject Discourse technique, and analyzed according to the principles of Social Representation Theory.

Results  Findings indicate that staff and material shortages, along with an overloaded outpatient service, contributed to the emergence of fragmented and inconsistent care. Moreover, empirical actions prevailed, mainly due to a lack of technical training among Family Health Strategy professionals, who feel unsupported because multidisciplinary teams are not readily accessible when assistance is needed for managing more complex cases.".

Conclusion  The current care model reflects a fragmented approach, insufficient to ensure access to health services and highly dependent on multidisciplinary teams. This leads to empirical and uncoordinated practices that, while occasionally adequate for managing Alzheimer’s disease, may, in other instances, be ineffective—leaving older adults, their caregivers, and families unassisted in facing the disease and its complications.

Keywords
Unified Health System; Primary Health Care; Family Health Strategy; Older Adult Health; Alzheimer’s Disease; Qualitative Research.

Resumo

Objetivo  O estudo buscou descrever os desafios enfrentados pela equipe Saúde da Família no cuidado à pessoa idosa com doença de Alzheimer e ao cuidador.

Método  Realizou-se uma pesquisa qualitativa do tipo Estudo de Caso, da qual participaram profissionais de saúde vinculados a equipes de Saúde da Família de Rio Branco, AC, Brasil e cuidadores de pessoas idosas com doença de Alzheimer residentes nesse município. Os dados foram obtidos por meio de entrevistas semiestruturadas, sistematizados através da técnica do Discurso do Sujeito Coletivo e analisados segundo os preceitos da Teoria das Representações Sociais.

Resultados  Foi constatado que fatores como a escassez de pessoal e materiais somaram-se à sobrecarga do serviço ambulatorial na gênese de um cuidado generalista e descontinuado. Ademais, evidenciou-se o predomínio de ações empíricas, sobretudo devido ao deficit na formação técnica dos profissionais da Estratégia de Saúde da Família, os quais, veem-se frequentemente desamparados frente a baixa acessibilidade das equipes multiprofissionais ao demandarem auxílio na condução de casos mais complexos.

Conclusão  O atual perfil da atenção demonstra cuidado fragmentado, insuficiente em viabilizar o acesso aos serviços e dependente da atuação das equipes multiprofissionais, implicando atos empíricos e não coordenados que, se em alguns casos mostram-se adequados ao manejo da doença de Alzheimer, em outros, podem ser pouco efetivos, deixando a pessoa idosa, seu cuidador e o núcleo familiar desamparados frente à doença e seus agravos.

Palavras-chave
Sistema Único de Saúde; Atenção Primária à Saúde; Estratégia de Saúde da Família; Saúde do Idoso; Doença de Alzheimer; Pesquisa Qualitativa

INTRODUCTION

Non-communicable diseases (NCDs) exhibit long-term profiles with little or no prospect of cure, which, although they do not always lead to death, can result in a loss of functionality. Among these diseases, dementia syndromes represent one of the most significant forms of morbidity in old age, characterized by a decline in cognitive aspects such as language, judgment, orientation, and memory².

Alzheimer’s disease (AD), the most common form of dementia worldwide, has no definitive treatment, and its management is limited to slowing symptom progression and providing non-specialized care aimed at maintaining daily activities. These responsibilities are typically delegated to the affected individual's closest family members, who are often also older adults facing their own health challenges³.

Although the diagnosis of AD typically has a substantial impact on the life of the older adult, it can affect their family and caregiver even more severely, as the deterioration of cognitive functions significantly alters the affected individual's interpersonal relationships and leads to major changes in their living environment⁴.

The complexity of the health demands presented by the caregiver–older adult dyad requires actions and services that take into account the specific needs of these individuals and their families, aiming for effective practices aligned with current public policies³. In this context, Primary Health Care (PHC) plays a key role, as its operations are based on the biopsychosocial care model, which is capable of more comprehensively addressing the health needs of individuals and the communities to which they belong⁵.

The Family Health Strategy (FHS), the core of this new model, seeks to ensure comprehensive care through the work of Family Health Teams (FHT), providing broad and long-term care that improves individuals' health conditions, autonomy, and quality of life⁵. The FHS is responsible for caring for frail older adults through health promotion and disease prevention actions, while also supporting the family and caregiver throughout the progression of the disease—whether by guiding them on AD management or by intervening to maintain the health of family members⁶,⁷.

Considering this perspective, the present study was conducted in Rio Branco, the capital of the state of Acre, Brazil. In 2021, the municipality’s Primary Health Care Network was organized into 12 health segments that guided user referrals from a Family Health Unit (FHU) to a Primary Care Reference Unit (URAP) or a Polyclinic⁸.

In these segments, each of the 74 existing FHUs was allocated according to its territorial location, with their activities anchored in the work of 81 FHTs⁹,¹⁰. This structure covered 54.91% of the population and contributed, among other aspects, to healthcare for older adults⁸, an age group that represented 7.95% of the municipality's inhabitants at the time¹¹.

Considering the role of Rio Branco’s PHC in coordinating care and the potential of the FHS to implement it in accordance with the biopsychosocial model, guided by the principles and guidelines of the Unified Health System (SUS), the following research question was formulated: What are the challenges faced by the Family Health Team in caring for older adults with Alzheimer’s disease and their caregivers?

With the global trend of demographic transition, the local healthcare system has increasingly dealt with the specificities of aging and its respective impacts on public health. From this perspective, the limited availability of scientific studies addressing this topic in Amazonian cities — particularly those focusing on AD — represents a barrier to fully understanding this emerging demand, justifying an investigation of this scenario from a local perspective.

Thus, the present study aimed to describe the challenges faced by the Family Health Team in caring for older adults with Alzheimer’s disease and their caregivers.

METHOD

A qualitative, exploratory case study¹² was conducted, based on the interpretation of the particular realities of caregivers of older adults with Alzheimer’s disease and professionals from the Family Health Team, who comprised the study population.

Participants were selected using a non-probabilistic approach, employing purposive sampling to encompass the diversity of the social and cultural spectrum of the study setting.

To identify the study population, one FHU from each of Rio Branco’s 12 health segments was selected. In each of these units, the coordinators were responsible for selecting an FHT, which, in turn, indicated the participants. A total of 24 individuals were included in the study: 12 healthcare professionals from the Family Health Strategy and 12 caregivers of older adults with Alzheimer’s disease.

The study included healthcare professionals of both sexes working in FHUs in 2021. Exclusion criteria comprised professionals who had been in their respective units for less than six months, as well as those who were on leave or vacation during the fieldwork phase of the research.

Additionally, among the caregivers, those aged 18 years or older, of both sexes, residing within the catchment area of the selected FHUs were included. Caregivers lacking sufficient physical, mental, or cognitive capacity to participate in the study were excluded.

Data collection was conducted through semi-structured interviews using two different interview guides. To identify potential errors and weaknesses in the interview scripts and subsequently correct them, a pre-test of the data collection instruments was conducted with four individuals who had characteristics similar to those of the target population. These pre-test interviews were not included in the study analysis.

The fieldwork phase took place in October 2021. Initial contact with the participants was made by phone for caregivers or in person for healthcare professionals (or for caregivers who did not have an active phone number registered in the FHU records).

After the initial contact with the participants, clarifications were provided regarding the general characteristics of the study, its objectives, and the methods used in its development, as well as explanations concerning the researchers' interests and expectations in conducting the study. Among the contacted participants, only one healthcare professional declined to participate due to the requirement of having their interview recorded, and they were immediately replaced.

All interviews were conducted by the same individual, an undergraduate researcher and the primary author of this study, who had been previously trained in qualitative data collection. Participants were interviewed in private settings, without the presence or interference of third parties. No maximum or minimum duration was imposed on the interviews to ensure an environment conducive to free expression.

The interviews were recorded in "MP3" format and fully transcribed into "DOCX" files. The audio and text files were encoded and stored on a hard drive and in cloud storage, protected by a password known only to the researchers. The records were identified using sequential codes to ensure the confidentiality of participants' data.

For the synthesis of the collected data, the Collective Subject Discourse (CSD) technique by Lefèvre and Lefèvre13 was used. This data tabulation method employs Key Expressions (KE) to construct a Central Idea (CI) or Anchoring (AC), which then guide the formation of a "synthetic discourse," the Collective Subject Discourse itself. In this study, the KE were identified through manual reading, coding, and tabulation performed by the researchers.

A relevance criterion for analysis was the presence of three or more KE in the composition of a CI or AC. The analysis of results was based on the Theory of Social Representations (TSR)¹⁴, and the definition of analytical categories was conducted a posteriori, after emerging from the field data. A total of seven discourses were analyzed and discussed in the composition of this study.

It is important to emphasize that the research complied with the guidelines set forth by Resolution 466/12 of the National Health Council for scientific studies involving human subjects. Data collection was carried out only after obtaining approval from the Research Ethics Committee of the Universidade Federal do Acre (CEP-UFAC), as per the Consolidated Opinion Number 4.846.345, dated July 14, 2021.

DATA AVAILABILITY

The complete dataset supporting the findings of this study is available upon request via email to the corresponding author, Lucas S. A. Costa.

RESULTS AND DISCUSSION

The study sample consisted of 24 participants, categorized into two groups: caregivers and healthcare professionals. Among the caregivers, all were women (12; 100%), and one-third of them were older adults (4; 33.3%). Similarly, among the professionals in the FHT, females predominated (9; 75.0%). The sample included one physician, one nursing technician, four nurses, and six community health agents (CHA), with an average tenure of 9.62 years at the FHU where they worked.

The systematization technique of the CSD enabled the formation and analysis of 11 discourses containing three or more KE. Among them, seven (Chart 1) were selected for discussion in this study and categorized into three main themes: “Fragmentation of care,” “Insufficiency of the Family Health Strategy in enabling care,” and “Dependence on multiprofessional teams.”

Chart 1
List of Central Ideas by category and the corresponding number of Key Expressions. Rio Branco, AC, 2021.

Categories	Central Idea	Number of KE*
Fragmentation of care	Weakness of monitoring	8
	Occasional home support	4
Insufficiency of the Family Health Strategy in enabling care	Unavailability of resources	5
	Lack of support in accessing services	5
Dependence on multiprofessional teams	Technical incapacity of teams	3
	Difficulty in accessing multiprofessional support	3
	Need for specialized support	3

• *KE: Key Expressions. Source: Authors.

In the caregiver group, the question " How has the healthcare team assisted in caring for your family member with Alzheimer’s disease?" led to the identification of two CIs: Weakness of monitoring and Occasional home support; while the question "What are the main challenges you perceive in the collaboration between the caregiver and the healthcare team?" resulted in the CI called Lack of support in accessing services (Chart 2).

Chart 2
Correlation of central ideas and their respective Collective Subject Discourses obtained from caregivers of older adults with Alzheimer’s disease. Rio Branco, AC. 2021.

Question	CI* identified	Collective Subject Discourse
How has the healthcare team assisted in caring for your family member with Alzheimer’s disease?	CSD** 01 (Weakness of monitoring)	We have never had support, like someone from the health post coming here, health staff helping us... Not for me, not for my mother either. Doctors don't come here, nurses... It's the Health Agent who visits us, you know? And they just inform us about upcoming consultations, like for those with high blood pressure, for older adults... That's true, they just let us know the days for consultations, you see? But the help I get is only if I go there [...]. [...] There was the issue with the vaccine; they came here to apply it after I insisted a lot, right? They came, applied the coronavirus shot for prevention. That was about three to four months ago. Then I kept insisting to take the second dose, that they should come here to apply it because I have difficulty going out with my mother, right? Sometimes there’s no car for them to come, so they don't come...
	CSD 02 (Occasional home support)	They do make visits, but not very frequently, you know? They come to give vaccines, change dressings, because she often gets sores here and there. If she has any problems, because she can no longer walk, she depends on us for everything... Then they come here, do a check-up... In case of an emergency, like an accident, they come here to see how she’s doing, examine her, and determine if she needs to go to the Emergency Room or if it’s something else... You know? The visits are only when necessary, because the number of Health Agents is reduced. There are very few, very few who work in this area.
What are the main challenges you perceive in the collaboration between the caregiver and the healthcare team?	CSD 03 (Lack of support in accessing services)	I think there are several issues. One of them is having to move my mother from here... needing a medication and always having to request a new prescription, you know? Because leaving the house makes it difficult. Before, my mom was fine, but now she’s not anymore. And to schedule appointments, I have to go to the health center... I even stopped visiting the health center to make appointments because it’s just a headache, it’s so exhausting, and we’re already worn out. You get there and don’t find the support, that... You know? It’s complicated. So I don’t want to have any more problems than I already have, you know? Another thing: even getting medication like dipyrone is hard. I get my dad’s medication, which is for blood pressure—he takes two medications for blood pressure: one we buy, and the other we get at the health center. My mom needs to take two as well... And at the last consultation, I didn’t even get all the medication at the health center because they didn’t have it. I haven’t even been taking my own blood pressure medication for a while because it’s not available there... And with my salary, plus my mom’s, we can only cover her expenses.

• *CI: Central Idea; **CSD: Collective Subject Discourse. Source: Authors

Among healthcare professionals, the question " For you, what are the biggest challenges when dealing with this type of patient in the daily routine of the healthcare team?" resulted in three CIs: Unavailability of resources, Technical incapacity of the teams, and Difficulty in accessing multiprofessional support, while the question "How would you describe the support provided to older adult with Alzheimer’s disease by the Family Health Team in which you are inserted?" brought forth the CI Need for specialized support (Chart 3).

Chart 3
Correlation of Central Ideas and their corresponding Collective Subject Discourses obtained from Family Health Strategy professionals. Rio Branco, AC. 2021.

Question	CI* identified	Collective Subject Discourse
For you, what are the biggest challenges when dealing with this type of patient in the daily routine of the health team?	CSD** 04 (Unavailability of resources)	Here, we have a large number of people. And I think the biggest difficulty we have is giving more attention to these patients who need to be followed up. Not only to the Alzheimer’s patient, but to the patient who is disabled, to the bedridden patient, to the patient with a mental disorder... So, these patients should receive more attention, and we still get very caught up, either with the administrative part or the ambulatory-care part. We lack vehicles to be there constantly, because sometimes the patient lives in a very distant or dangerous area for us to go, even with our transportation, it’s complicated. Sometimes, there’s a lack of medication, because Alzheimer’s medication is purchased, it’s not available in the public network, and sometimes it’s hard to find. It’s a lack of support.
	CSD 05 (Technical incapacity of teams)	It’s really complicated, even for us to have an idea of how to help this patient, especially because we don’t know much about this disease, so we don’t even have the ability to predict something because it’s pointless... There are things I can improve, but I don’t know how, I don’t know where to start, I don’t know how to develop it. I know how to pass on what I know, which I can share with another older adult, but it’s not the same thing. It’s not the same work, right? Sometimes I think, “I have training in Family Health.” But it’s no use if the rest of the team doesn’t have the same perspective, you know? So, you’re either swimming against the tide or you’ll have to provide training, work a lot with this team so that they speak the same language. The teams need to be well-trained, and in this regard, the health department doesn't provide that support right now.
	CSD 06 (Difficulty in accessing multiprofessional support)	My challenge today regarding this is the care, not from the unit or the team, but from the multidisciplinary team, because we see the need for follow-up[...] There should also be support in this sense to look after this person, but sometimes we can’t provide that support because we don’t even know where to ask for help. Then, they will enter the system just like everyone else: “Oh, they need to go to the psychologist,” so a referral is made; they go to the doctor, another referral is made, and they will follow the flow like any other person. There’s no differentiated approach, you know? When we had the NASF***, we would call them, and we were always in contact, but now we no longer have that […]. Now, our contact is with the EMAD****. We call, but the person can’t always get into the EMAD because it’s already full, you know? So I don’t have a nutritionist, I don’t have a physiotherapist, I don’t have a multidisciplinary team to exchange experiences with... I don’t have a speech-language pathologist, which is greatly needed. I don’t have that.
How would you describe the support provided to older adult with Alzheimer’s disease by the Family Health Team in which you are inserted?	CSD 07 (Need for specialized support)	Here in the Family Health Strategy, support for bedridden patients is still limited, so we like to call the EMAD, which is a multidisciplinary team from the City Hall, and they have all the professionals: physiotherapists, psychologists, doctors, nurses... We usually call the service if someone has a wound, needs a catheter, or things like that, you know... Because they have a large team, and it’s much better there. When a person enters the EMAD program, they are better followed up because they receive all this assistance.

• *CI: Central Idea; **CSD: Collective Subject Discourse; ***NASF: Expanded Family Health and Primary Care Center; ****EMAD: Multiprofessional Home Care Team. Source: Authors

Fragmentation of care

Non-communicable diseases, such as Alzheimer's disease, pose a challenge to the organization of SUS and to the healthcare workforce, as they require changes in the care model and in the overall system structure. These conditions demand an innovative approach to the functioning of the health system and the execution of tasks by teams, as they require continuous, integrated, and coordinated attention¹⁶.

In this context, according to Ceccon et al.³, PHC should function as a care model whose responsibilities contribute to addressing the health needs of older adults (the group most affected by these conditions), using measures aimed at reducing unnecessary interventions, increasing access to services, and prioritizing actions that consider PHC users holistically.

However, in Rio Branco, PHC Continues to offer a fragile response in terms of Care comprehensiveness and continuity. The perspectives expressed in CSD 01 (Chart 2) Reveal a reality in which FHT, instead of acting as a mediator of care, merely provides occasional support to the needs of the patients with AD and their caregivers.

In this fragmented care profile, services focus on procedural attention, reducing the role of PHC to the execution of technical tasks such as vaccinations, prescription renewals, or scheduling consultations, marginalizing planned and guided home care as outlined by the FHT.

Considering that the population in question faces significant physical limitations, home care (HC) becomes a crucial element in the delivery of care, directly influencing service adherence. When their needs are met, users tend to establish a lasting relationship that enables the provision of long-term care¹⁷.

Although no accessible studies quantify HC coverage within the FHS in Rio Branco, PHC services only covered 54.91% of the population in 2021, nearly 15% less than the national coverage estimate provided by the Primary Health Care Department (69.⁵%)¹⁸.

In practice, beyond occurring at lower-than-expected proportions¹⁹, the execution of home visits focuses less on health promotion and disease prevention and more on intervening or minimizing the health-disease process, as evidenced by CSD 02 (Chart 2).

Through the analysis of this discourse, a contrast emerges between an idealized view of care and its reality. In this discourse, the home visit, instead of serving as a tool to achieve a more holistic approach to the individual's health, is presented more as an intradomestic reproduction of the biomedical model it seeks to transcend, serving the purpose of intervening in acute or highly severe health conditions.

It is important to consider that providing health care at home is not just about bringing the health team to patients with mobility issues or offering guidance on hygiene and nutrition. This approach fundamentally involves the need to investigate and understand the socioeconomic and cultural context surrounding the individual/family in their most intimate environment²⁰.

Although home care is essential for achieving the goals of the FHS, to serve this purpose and truly enhance the management of non-communicable chronic diseases (such as dementia syndromes), it must align with the delivery of expanded care, addressing the various dimensions of the individual affected and those to whom the disease extends²¹.

Insufficiency of the Family Health Strategy in enabling care

One of the obstacles to this is the scarcity of resources, widely associated with the low capacity of the FHT to maintain home care, as explored in CSD 03 (Chart 2) as a barrier to providing ideal care.

From a technical and organizational standpoint, for PHC to fulfill its role in care coordination, basic resources, such as medications and other supplies essential for patient comfort, are indispensable²². The insufficiency of resources leads FHT teams to adopt a posture of distance from individuals affected by chronic diseases⁵.

Given the difficulties in conducting home visits, outpatient care is prioritized over interventions more focused on the individual's uniqueness²³, especially because, in the general view of professionals, factors like welcoming, bonding, and humanized care are often considered secondary to approaches that require material and tangible resources⁵.

This preference for “intra-unit” services is evidenced in Teston’s study²⁴ as a driving factor in the process of “ambulatory shift” in Primary Health Care, which was indirectly addressed in CSD 04 (Chart 3) and ultimately hinders patient access to healthcare services.

In this context, the challenges reported by users of PHC services are numerous, ranging from geographical barriers to the organization of the healthcare team’s workflow. When dealing with dependent older adults, these issues become even more complex, as they often have reduced mobility, making them reliant on a caregiver for transportation³.

Added to this is the asymmetry in the approach among the different FHT: while some prioritize the access of older adults to services despite difficulties in obtaining care, others adopt stricter postures focused on programmatic actions and fixed schedules³, neglecting the specific needs of this population and compromising efforts to achieve health equity.

Dependence on multiprofessional teams

Furthermore, the lack of technical knowledge to manage complex cases remains one of the main obstacles in caring for individuals with Alzheimer’s disease and their caregivers. More than just managing health conditions, these individuals require compassionate and technically appropriate care that prioritizes their quality of life²¹.

Managing severe dementias is generally a challenge for most professionals. In the advanced stages of the disease, individuals require palliative care, and the lack of experience in this area may be one of the causes of this difficulty, compromising the management of the disease and leading to numerous complications that ultimately result in recurrent hospitalizations and increased mortality²⁵.

Supporting the idea, this study evidenced that one of the main barriers to providing care was linked to the technical incapacity of the FHT, which, in the absence of training to care for individuals with dementia, finds itself reliant on empirical practices and the generalization of care provided to older adults without this condition, as expressed in CSD 05 (Chart 3).

Such adversities may be caused by a gap in the training of healthcare professionals²², who, although they understand the importance of caring for people with incurable diseases, are frustrated by the lack of knowledge and skills to perform their functions outside the context in which they normally do so²¹.

Thus, as reflected in CSD 05, even though the Family Health Strategy (FHS) professional is aware of their technical deficiencies, they struggle to address them, due to the marginalization of the topic, even in continuing education activities within Primary Health Care. This aspect contributes to the FHT becoming more reliant on other components of the Primary Health Care system, particularly because of the need for multidisciplinary care, which FHT professionals believe is not accessible within PHC.

In this research, these needs were closely linked (but not limited to) the emotional fragility of the caregiver and the family unit. However, as the disease progresses, it is common for the person with dementia to begin exhibiting complex health demands, making it essential to consolidate a service coordinated with other stakeholders involved in home care²².

The difficulty in accessing the Multidisciplinary Teams in Primary Health Care (eMulti), formerly known as the Expanded Family Health and Primary Care Center (NASF-AB), and the teams from the Home Care Service (SAD) has, therefore, been a limiting factor in the care of individuals with Alzheimer’s disease, as extensively discussed by the healthcare professional in CSD 06 (Chart 3).

Supporting this perspective are the findings from a research conducted by Aranovich and Krieger²⁶, where NASF-AB was identified as a service that is accessible only in extreme situations, always relying on the specific knowledge of professional areas. For example, when issues related to tube feeding arise, nutrition is consulted, or in cases of greater vulnerability, social services are involved, without any discussion or formulation of a long-term therapeutic plan.

The role of the Multiprofessional Home Care Team (EMAD) and the Multidisciplinary Support Teams (EMAP), in turn, although essential in providing assistance to individuals with end-stage Alzheimer’s disease, is often perceived as a replacement for actions previously carried out by the FHT in the home setting, as reflected in CSD 07 (Chart 3). This misconception of their role limits the actions of FHT professionals, who are reduced to identifying the frail older adult and referring them to other services.

Contrary to the view propagated by the professional, the efforts of these teams should complement rather than replace the activities already developed by the FHT, which serves as the coordinator of care and the core component for the functioning of home care¹⁹.

Even if the user receiving care is not under the direct responsibility of the FHS, it is important that these teams follow and support the other teams in the SAD, as this coordination between care sectors ensures more effective, high-quality assistance, ultimately reducing unnecessary hospitalizations²⁷.

The limitations of this study are related to the selection of participants. Considering that the target population was identified through the FHT, two implications must be considered: the caregivers included in the sample were under the supervision of a team, inadvertently excluding those who had never received care from the FHS or who had lost follow-up over time; similarly, the professionals selected were inevitably those with prior experience in caring for patients with this condition, thus excluding those with limited or no knowledge of the disease and its implications for the health of the patients and their caregivers.

CONCLUSION

Chronic conditions, such as Alzheimer’s disease, pose significant challenges for the Unified Health System, requiring changes to the care model and the management of services.

Although professionals in Family Health Teams have a comprehensive vision, they usually encounter various limitations that undermine the quality of interventions. Factors such as staff and resource shortages, along with the overload of outpatient services and the lack of technical training among professionals, exacerbate the issue. Even when seeking assistance, they find themselves constrained by the limited accessibility of multiprofessional teams.

In summary, Rio Brancos’s Family Health Strategy revealed a fragmented care pattern, insufficient in enabling access to services offered within the scope of Primary Health Care, and dependent on the actions of multiprofessional teams. This leads to empirical or uncoordinated actions that, while appropriate in some cases for managing the condition, may be ineffective in others, leaving the older adult, their caregiver, and the family unit unsupported in the face of the disease and its complications.

Given the complexity of the issue addressed in this study, it is crucial that further investigations be conducted in different moments and settings, with the aim of identifying gaps in current care models, thereby expanding the understanding of the issue and how the Unified Health System can act to improve current interventions to meet the needs of this population, especially within the context of Primary Health Care.

• DATA AVAILABILITY
  The complete dataset supporting the findings of this study is available upon request via email to the corresponding author, Lucas S. A. Costa.
• Funding
  There was no funding for the execution of this work.

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Edited by

• Edited by
  Rayssa Horacio Lopes

Data availability

The complete dataset supporting the findings of this study is available upon request via email to the corresponding author, Lucas S. A. Costa.

Publication Dates

• Publication in this collection
  25 Apr 2025
• Date of issue
  2025

History

• Received
  17 July 2024
• Accepted
  14 Jan 2025