The speech therapy health based on the institutionalized elderly speech

This study aims to presenting a case study that reveals the health profile speech of individuals living in long-stay institution for the Elderly, located in a city in the south-central region of Paraná state in Brazil, based on the perception of its own residents . This is a case report from a qualitative study conducted by through semi-structured interviews involving 15 seniors. Upon analizing the feedbak from the elderly participants, the outcome presented that the institutional environment favors isolation . As for vocal health, most seniors reported non –perception of change in their voice upon aging . Regarding to the aspects related to listening perception it is possible to observe their awareness of the social and emotional consequeces of this problem to their lives. Thus, due to the importance of allowing voice / time to institutionalized elderly, this research devises opportunities for reflexion on the construction of speech focused on aiding this apopulation, based on the necessity for interaction / socialization of institutionalized elderly , so that long-term institutions do notbe meant as just « old deposits . »


INTRODUCTION
The sociosanitary scenario of demographic and epidemiological transition, characterized by the increase of the aging population and the increasing prevalence of chronic degenerative diseases, has brought to light needs related to the care at the end of life 1 .In our country, the aging process occurs rapidly and in a context of social inequalities, weak economy, rising levels of poverty, poor access to health services and limited financial resources, that is, without structural modifications that meet the demands of the new emerging age group 2 .
This significant growth of the aging population is a phenomenon that has raised several challenges in enabling a healthy old age, from which people are able to manage their own lives 3 .
A factor worth mentioning in this scenario is that the family has found increasing difficulties to perform certain activities related to the care of their elderly in

ABSTRACT
This study aims to presenting a case study that reveals the health profile speech of individuals living in long-stay institution for the Elderly, located in a city in the south-central region of Paraná state in Brazil, based on the perception of its own residents .This is a case report from a qualitative study conducted by through semi-structured interviews involving 15 seniors.Upon analizing the feedbak from the elderly participants, the outcome presented that the institutional environment favors isolation .As for vocal health, most seniors reported non -perception of change in their voice upon aging .Regarding to the aspects related to listening perception it is possible to observe their awareness of the social and emotional consequeces of this problem to their lives.Thus, due to the importance of allowing voice / time to institutionalized elderly, this research devises opportunities for reflexion on the construction of speech focused on aiding this apopulation, based on the necessity for interaction / socialization of institutionalized elderly , so that long-term institutions do notbe meant as just « old deposits .» KEYWORDS: Homes for the Aged; Health; Speech, Language and Hearing Sciences than 60 years of age were excluded from this research.
Semi-structured interviews were conducted according to a script prepared by the researchers, which included 35 items, with questions that identified the institutionalized elderly in their sociodemographic characteristics (gender, age, marital status, education, reasons for institutionalization) and the health conditions, specifically those related to speech therapy health.Thus, the script contained questions of four validated instruments, which were: 1) Conditions of literacy in the aging process: a review with elderly people older than 65 years of age The interviews were carried out individually in a physical space provided by the management of the institution, between January and March 2013, and were registered through audio recordings.The thematic analysis of the data followed the path proposed by Minayo 13 which recommends three steps to be followed: 1st stage) The pre-analysis: consists in a thorough contact with the material collected in order to know its content, organize it and systematize it according to the research's hypotheses and objectives; 2nd stage) The exploration of the material: the analysis of the statements according to the established categories; 3rd stage) Handling and interpretation of the results obtained: the researchers propose their inferences and conduct their interpretations according to the theoretical framework and proposed objective.
The established categories of analysis according to the topics evidenced during the individual semistructured interviews were: 1st -Written and oral language (interaction) in the life of the institutionalized elderly; 2nd -Vocal perception in institutionalized elderly; 3rd -Auditory perception in institutionalized elderly; 4th -Feeding of the institutionalized elderly and their specificities: orofacial motor skills.
The results are presented by means of literal transcription of the participants' speech, highlighting the main excerpts in italics.The elderly are identified by the letter S followed by a number from 1 to 15.
is understood that outlining the health profile of the individuals residing in these institutions from their own perception is the first step to be taken in order to understand the specific demands of this population.Despite the large number of ILPIs in Brazil, there are only few studies verifying the functional profile of these institutionalized elderly, especially when taking into consideration issues related to the speech health, including hearing, language, voice and speech motor skills.This fact hinders the implementation of care programs directed to this population and also the orientation of the professionals involved in their care 7 .
According to data from the Institute of Applied Economic Research (IPEA, for its acronym in Portuguese) 8 , among the various health services offered in Brazilian ILPIs, aspects related to the speech health have the worst rate for monitoring the resident population in all regions of the country, that is, it is the less frequent.
However, Speech Therapy as a science can and should contribute significantly to the health of the institutionalized subjects, since it addresses language, hearing, speech and orofacial motor skills, that is, essential aspects to the promotion and maintenance in the quality of life of these subjects.Thus, this study aims to present the health speech profile from the perception of the elderly living in a philanthropic Long Stay Institution for the Elderly (ILPI), in a town in the south central region of Paraná state.

CASE PRESENTATION
This study, of a qualitative nature, was approved by the Ethics Committee in Research of the Centro Universitário de Maringá, under the number 114.859/12.It was carried out in a private and nonprofit long stay institution for the elderly, in a town located in the south central region of Paraná.
Fifteen subjects participated in the study, between the ages of 60 and 93 years, of both genders, all of whom signed a free and clear consent form, which explained the steps of the research as well as its purpose and reasons.It should be stressed that 83 subjects live in this ILPI, and most of the residents have psychiatric disorders and do not meet the inclusion criteria of this study.
The inclusion criteria for the participants were: being a resident of the ILPI, being at least 60 years old and show no neurological difficulties related to language.
Subjects who presented impossibilities and/or linguistic limitations related to aphasias, Parkinson's disease, Alzheimer's and other demential or neurological diseases, as well as the subjects with less attended school, who are single and are coming from a rural areas.Also, in this table, it is evident that the most frequent reason for institutionalization, reported by the research subjects, refers to the lack of family support.

RESULTS
As for the sociodemographic characteristics of the institutionalized elderly, as evident in Table 1, there is a predominance of subjects who have never 1st category of analysis -written and oral language (interaction) in the life of the institutionalized elderly When asked whether they talk to each other, the statements collected from the elderly show that there is not always interaction between them and many do not want to be there, there are no plans for a future.
S 9: You know, I'm kind of antisocial, I exchange a word when it is really necessary, there are many here that I don't know even the name.I cannot see in this place someone who I can really have confidence in.
S 6: Our conversation here is only to complain, I cannot get used to here.It's all very different from what I have experienced.
Other subjects, in an heterogeneous and singular way, take the interaction as an opportunity to demonstrate their social participation within the institution and even give meaning to the life in the ILPI.These individuals' statements emphasize that in all cycles of life the subject depends on significant experiences, on experiences that give meaning to their life, starting from the language.
S 2: I see people who become isolated here.I do not!I talk to the staff, and there are some who stay quiet, who do not get together or mix themselves with the others, who remain isolated.By talking, we help others.S 6: For if there's one thing I always did was chat.When I came here a couple of months ago I didn't want to eat, could not sleep and only wanted to cry.But with time I began to have a word with one, with another, until I saw that it was hopeless.Now what I do is chat, the day goes by and we do not even see it.
In the statements of S 2 and S 6 it is made explicit that language is an essential activity for social inclusion.As the subjects talk and chat, they manage to overcome a situation of isolation and the lack of desire to eat and to live.With language, that is, from the relationship with others, inevitably mediated by language, these subjects indicate the feasibility of a better quality of life in old age that is being lived in an ILPI.
About the reading and writing activities, based on statements that the subjects who attended school produced, in the light of the questions addressed to them, it is clear that these elderly see reading as a signifying practice in the life in the ILPI.S 9: What I do here is read, it is my refuge.Too bad there are only few who bring books to us, it is what is missing here.
S 15: Today I do not like to read because my sight is no longer helping me.And magazines are difficult here.Every now and then appears a newspaper, so we read package inserts that I really like to read.
14 S: I read a bit during the day to exercise the mind.
As for the seniors who did not attend school, their relationships with the written language are manifest through a notion of faults, difficulties and fears.S 4: I know I do not listen well, people always have to repeat things.
S 5: I do not like to chat with the deaf, because, in chatting with who is deaf, if we scream it means we are aggravating it, so better not to talk.
S 12: Well, I have a buzzing in one of the ears that never stops.
These discourses emphasize the heterogeneous manner in which the subjects deal with their own auditory perception.For S 4, this perception is linked to the decrease of hearing acuity.Now S 12 links his hearing to a continuous noise.In contrast, S 5 relates hearing to the difficulty of interacting with the ones presenting deafness.
4th category of analysis -Feeding of the institutionalized elderly and their specificities: orofacial motor skills.
The elderly were unanimous in recognizing that structural changes with aging lead to changes of the oral functions.
S 9: Chewing and eating is different today, for example, in order to eat meat today it has to be a very well cooked meat!The teeth do not help more, the taste is different.
S 2: Nowadays even a soup is tough to eat.
The changes in orofacial motor skills due to the effect of aging can interfere with this pleasant time of humans, feeding.Such changes present in the statements of the subjects, bring repercussions in the everyday life of the elderly who are faced with the need to adapt themselves to new situations concerning old oral habits.

DISCUSSION
The results of this study confirm the trend of studies in this area, which shows that among the most common causes that lead to the institutionalization of the elderly are the absence of the family, the difficulty of the family in taking care, conflictual family relationships coupled with the lack of income and lack of housing 14 .It should also be clarified that subjects with mental disorders and under 60 years of age reside in the ILPI in which this research was conducted.These two characteristics of the subjects were also found in the research of Pollo and Assis (2008) 15 .It is noteworthy that the Long Stay Institution for the Elderly, in which the study was conducted, is a social welfare, private and non-profit organization.This ILPI is maintained by donations from the community and businesses that help the financial needs presented, and by the social security benefits of the institutionalized elderly (retirements, continuous cash benefits -BPC for its acronym in Portuguese).Several elderly people come to this S 7: I'm afraid even to pick up a book.I could not study in my time.And how I wish I had.

S 8: I have a hard time to read and write, because I see when I write my name, that sometimes it seems that it doesn't go.
Just as it was said about the oral language, it is evident the importance of the written language in the lives of institutionalized persons.The person identified as S 9 even states that reading is his refuge and that he misses people bringing books to be read in the ILPI in which he resides.Likewise, the subject S 14 takes reading as a possibility of exercising his mental processes and, therefore, his knowledge of the world.The texts produced by individuals who did not have the opportunity to attend school, announce an interesting possibility for speech therapy practice, which is to work with the written language.In a heterogeneous way, it is possible to think of the speech therapy work sometimes filling gaps left at other moments of life, sometimes helping to overcome fears about the language or also taking reading as a bond with the other, book authors, magazines, and other written materials.

2nd category of analysis -vocal perception in institutionalized elderly
With regard to the vocal changes reported by the elderly in the aging process, it is observed the non-perception of vocal alterations over the years.
S 1: My voice has always been good.Did you know I sang at church?Here I do not sing anymore, I think my voice is normal.
S 3: I see no difference in my voice over the years.
S 7: The breath ends up quickly sometimes, but I do not think my voice is weak.
These speeches corroborate the assertion that there is an absence of perceiving changes in vocal parameters as consequence of aging, and such absence may be related to a vocal adaptation.The organic change is universal, however, perception is subjective and is also related to what comes to be growing old for each subject, as well as the changes that are being experienced throughout life.

3rd category of analysis -auditory perception in institutionalized elderly
With regard to the perception of hearing impacts, it is possible to perceive a greater demand on the part of the institutionalized elderly, especially when compared to vocal aspects.In the content produced in the texts of these elderly, the perception that they have from the emotional and social/situational consequences is characterized by their hearing loss: well as the fact that it changes according to age, physical characteristics, social environment and life history 19,20 , it is seen that this lack of awareness by the research subjects regarding such changes may be related to a vocal adaptation.Studies reveal the non-perception of changes in vocal parameters as a consequence of healthy aging, because such changes do not interfere greatly in the communicative performance and on the voice-related quality of life 21,22 .These studies converge with the present research, in which most of the elderly showed a positive assessment regarding their own voices and showed no perception of changes in the voicerelated quality of life.
Regarding self-perceived hearing health reported by the elderly who participated in this research, a higher proportion revealed the perception of restrictions on social participation because of hearing difficulties.These data are therefore consistent with studies 23,24 claiming that hearing impairment affects not only the hearing, it also brings, in the social sphere, consequences on the quality of life of the elderly.As it related to cultural and emotional factors, the hearing disadvantage can be overvalued or denied by the elderly 24 .Thus, there are people with minor disabilities, but significant difficulties, as well as people with significant loss, without major impact on their daily life.It can happen that the elderly with hearing impairment, aware that the problem in interpersonal communication is created because of their own difficulty, often submit themselves and become more quiet and reclusive 24 .These feelings can cause certain withdrawal of the subject from social interactions.These notes reflect relevant questions about the institutionalized elderly, considering that by itself, the institutional environment already favors the isolation and mental inactivity.Researches 24,25 reveal HHIE as an important screening instrument to relate hearing loss and quality of life, in order to be able to analyze the subjective and qualitative dimensions of the hearing impairment.
In this study it was also noted the high frequency of tinnitus, reported by institutionalized elderly.Research 26 conducted with 320 subjects, of both sexes, with at least 60 years of age, which aimed to investigate the hearing and labyrinthine complaints in a sample of Brazilian elderly population in an outpatient ward, in a region where most of elderly population is very needy, also evidenced high proportion of tinnitus being the second most common otological complaint.Called tinnitus, this buzzing can be considered as the conscious perception of a sound that originates in the ears or in the head of the subject, without the presence of an external sound source 27 .The buzzing exerts negative influence on welfare, but the degree of interference is related to institution to get the assistance needed to live the last years of their lives.And many are received after a social study performed by Social Service professionals, belonging to the Social Welfare Policy of the municipality (Center of Specialized Reference for Social Assistance or Reference Center for Social Assistance -CREAS or CRAS for their acronyms in Portuguese).The profile of accepted subjects is well defined: elderly who have no financial means to stay with the family; elderly in situations of abandonment; elderly with fragile or broken family ties; elderly living with situations of self, family or institutional neglect, abuses, maltreatment and other forms of violence.
The institutionalization of the elderly is a complex issue, both socially and personally.And whatever the circumstances of institutionalization, the elderly experiences a new and sometimes frightening reality, making it difficult to organize in a peaceful and balanced way this new experience that they have to live away from home, family and social networks built throughout life.Added to this situation, in general, the institution is not prepared/structured to offer services that respect the uniqueness, privacy and lifestyle of each and every elderly.
Studies 14,16 emphasize that in the institutional environment there is little interaction between the residents, many silences and waiting.Some institutionalized elderly define themselves by what they lost.Their lives are no longer full of projects or activities and seem oddly resigned to this condition.
Before such reality, the importance of the speech therapist stands out in this environment in order to redirect the situation starting from the language/ interaction, as well as maximize the role of language as a discursive effect of meaning, as a symbolic activity that (re) gives meaning to the heterogeneous life stories of each subject and (re) organizes memories of the past, experiences of the present and future, promoting social integration 3,17 .
Regarding the mode of written language, based on the statements that the subjects of the study who attended school produced, it is clear that such elderly consider reading as an indispensable activity in the ILPI life.As for the elderly who did not attend school, their stories in relation to writing are manifest from fears and difficulties.Such reports are immersed in the existing social discourse of a society grounded in the precepts of productivity and efficiency, which states that anyone who does not study cannot participate in forms of social enjoyment 18 .
With regard to the perception of the elderly about their vocal health, the data from the present study indicate absence of perception of vocal changes of the subjects over the years.From this point of view, given the importance of the voice as production which carries with it feelings and emotions, as can and should be worked on by the Speech Therapy.The identification of the speech health profile of the subjects of this case study indicates the need of increasing the speech-language actions capable of improving the quality of life of the elderly residents in ILPIs.

FINAL CONSIDERATIONS
In ILPIs, where the elderly are often viewed as inactive and whose opportunity to have a say and speak for themselves is a rare situation, it is emphasized, in this case study, the importance which the discursive production of older people assumes about the perception they have about speech therapy health.
The results of this study open a chance of reflection for possible speech therapy interventions directed towards institutionalized elderly, in order to improve this population's quality of life.In this sense, these results enable the awakening to a necessary critical stance, rather than a passive one, in the face of questions posed by the reality of the institutionalized.
It is necessary that researches with similar methodology used in this study may be conducted with a larger number of participants and in ILPIs from different Brazilian realities, so that it may be possible to implement strategic fields in the area of Speech Therapy, related to the elderly residing in ILPI.
Thus, it is reiterated that these results indicate the need for Speech Therapy to profile institutionalized elderly in ILPIs, according to their perceptions, taking into account the varieties and peculiarities of aging, in order to implement self-care actions, empowerment of the elderly and enabling them to respond in health to the social needs.
the understanding and definition of well-being that the subject has 28 .
Aspects of the process of feeding deserve special attention, since they are directly related to the nutrition and quality of life of the elderly people, and the myofunctional modifications presented during feeding can lead to social isolation 29 .In this study, the elderly reported difficulties in chewing, relating them to their dental conditions, and symptoms such as coughing and gagging.In Fazito's study 30 , who compared feeding complaints of elderly people with and without dentures, the main difficulty found was to chew food which interferes in swallowing, in the presence of cough and/or gagging and in the presence of food scraps after swallowing.Another study 31 , aimed to characterize the speech therapy findings in oropharyngeal swallowing in healthy elderly subjects with or without complaints of swallowing, all seniors claimed more than one eating complaint.
Seniors residing in ILP are generally in situations of greater restriction in terms of social participation, and the impact that institutionalization can have on the communication of the elderly is not yet well known 32 .In this research, the elderly elucidate, each in their own way, a look at their speech health.It is evident that social losses already suffered with the institutionalization process by breaking the relational network, combined with changes in speech-language aspects, have negative impacts on relationships/interactions among the elderly, affecting their own well-being, with consequences that denote a tendency to social isolation.
Thus, in the pursuit of promoting a healthy and dignified aging, it is imperative the speech therapy care with the institutionalized elderly, since the ineffective relationship between the elderly themselves, the presence of tinnitus, the hearing loss and the changes in oral and swallowing functions