Evaluation of elderly persons ’ functionality and care needs 1

Objective: To evaluate the elderly persons’ functionality, based on the International Classification of Functionality. Methods: a cross-sectional, descriptive study; a stratified random sample of 903 elderly persons; a confidence level of 95%; and a margin of error of 2.5%. Questionnaire based on the International Classification of Functionality; data was collected based on structured interviews undertaken by health professionals in the health centers in the Alentejo region of Portugal. Results: 30.7% of the elderly persons stated that they were illiterate, and 22.9% lived alone. Feeding/dietary (18.7%), housing (19.2%) and health needs (26.0%) were not met. Orientation functions were maintained in 83.4%; 58% of the elderly persons referred to pain so intense that it required care; 73.3% of the elderly persons did not have functional dentition. Levels of performance were superior to 80% in the participation activities: washing oneself (82.6%), toileting (92.2%), dressing, eating, and drinking (89%). Conclusion: although a progressive decline in functionality is observed as age advances, the majority of dimensions are preserved until around 75 years of age.


Introduction
Demographic ageing is a global reality, although it is more evident in some countries than others (1) .The population aged over 65 is going to have an exponentially greater demographic representativeness (1)(2) .This population is associated with negative social perceptions and incapacity (3)(4) , as well as with an increase in costs and social resources to the health services (3,5) .This is because, according to some studies (6) , elderly people have a high prevalence of chronic illness, with multimorbidity predominating.
A set of reasons for this phenomenon are habitually presented, among which the authors highlight the association between the constant increase in life expectancy at birth* and the reduction in the synthetic fertility index**.Life expectancy at birth, at a global level, passed 47.7 years in 1950, rising to 69.3 in 2010.
In some, more 'elderly' countries (e.g.Portugal), the average life expectancy has already reached 79.8 years (76.7 for men, 82.8 for women), while the synthetic fertility index is 1.37 children per woman (7) .
In Portugal, in 2001, the proportion of people aged 65 or over was 19%, whereas a decade previously it had been 16% (8) .The results of the 2011 Census indicate that the country's rate of ageing is 129 (129 elderly people for 100 young people) (8) .In the last decade, the dependency ratio rose from 48 in 2001 to 52 in 2011.
The exacerbation of the total dependency ratio is the result of the rise in the rate of dependency of elderly people, which increased by approximately 21% over the last decade (8) .The Alentejo is the region of Portugal which has the highest ageing index (179), representing an elderly population which is 25.3% of the total.It was for these reasons that the authors chose this region to carry out their research.
For this reason one is confronted by a new context which has repercussions for all levels of society: the health system needs to be prepared conceptually, organizationally and logistically for a rising demand for care, from a population with differing characteristics.
It is, therefore, important to pose the following questions: How should elderly people's care needs be evaluated?Centered on the illnesses and resulting incapacities, or in the remaining capacities for meeting their needs in context?
Functional status, as well as being an indicator for health status, is an excellent indicator for predicting health care's costs and resources (5,9) .A person's functionality and incapacity are understood as a dynamics interaction between the states of health (e.g., illnesses, disorders, lesions, traumas) and the contextual factors.In order to classify functionality, the World Health Organization (W.H.O) created the International Classification of Functionality (ICF), which was adopted by Portugal (4) and whose use is recognized as bringing various advantages.
The incapacity indicators -namely, those to do with limitation of activity and limitation of functional capacity -allow the subsequent definition of health care needs (10) .
For this reason, it is important to develop an instrument for evaluating elderly people's functionality (11)(12) , based in a classification whose general objective is to permit a unified, standardized language, as well as a working structure for the description of health and states related to health.It was based in this classification that the authors undertook the development of the Elderly Core Set (13) .
In this context, the authors proposed to carry out a study based in the following question: What is the epidemiological profile of functionality of the population aged 65 or over, resident in Alentejo?
The study objectives were: Evaluate the functionality of the population aged 65 or over, resident in Alentejo, based in the International Classification of Functionality (ICF); Indicate the functional limitations of the population aged over 65 and resident in Alentejo.

Method
In terms of methodology, the present study is cross-sectional and descriptive.

Presentation of data
Taking into account the dimension of the present study, only parceled data are presented.The authors will systematically provide evidence on the dimension of functionality and the dimension of incapacity, and the consequent care needs.The data was selected bearing in mind the most important care needs perceived by the authors.

Socio-demographic characterization
The final dimension of the sample was of 903 individuals, of whom 43.2% were male and 56.8% female, distributed across various age groups as may be verified in Table 1.After statistical analysis, it was determined that the difference compared to the initial sample is not significant. Regarding

Discussion of data
It is not easy to discuss the data presented because there are few studies -whose objective is to investigate functioning in the elderly -based in populational samples and based in the ICF.In spite of this, the authors can highlight some of those which they consider more significant.
In relation to the socio-demographic data, what stands out is the predominance of the women in all of the age groups considered.If one considers the totality of the sample, there is a masculinity ratio of 76, compared to 72.4 which is the masculinity ratio for the population of Portugal in general, aged 65 and over (8) .
This difference is congruent with all the other indicators relative to ageing in the Alentejo region, which confirm it to be a region with a particularly elderly population.
On the other hand, the most recent data (8) show that the imbalance in the ratio of men to women, with the latter predominating, is accentuated as age advances, andfurther -that this process has become more pronounced over the last few years.
The data relating to level of schooling, like those relating to the activities of reading and writing, contrast with the data according to which 34.6% of the elderly persons have no schooling at all (7) .They also contrast with the data from the 2001 Employment Survey (7) , through which the educational levels of the elderly population were determined, based on the categories of the International Standard Classification of Education (ISCED).According to that survey, more than half of the population aged 65 or over (55.1%) had no education at all.This proportion was higher in the case of women (64.7%, as against 41.3% for men).Comparing the data from these entities with that from the present study, it was determined that since 2001 a considerable reduction had been ascertained in the number of elderly people who couldn't read or write.It was also verified that there is an important difference between the declared level of schooling and the observed ability to Rev. Latino-Am.Enfermagem 2013 Jan.-Feb.;21(Spec):52-60.
read and write.Lastly, the elderly population generally continues to have low levels of schooling, and within this category, women have lower levels than the men.
Regarding the close family network, the authors emphasize the high percentage of elderly people who live alone (23%).Concerning self-assessment of financial situation, the authors stress the similarity between this data and that provided by the Eurostat (14) on the risk of poverty among the elderly.The authors thus ascertained that this reduced systematically between 2004 and 2009, although in 2010 there was an inversion in the tendency, with it rising to 21.0%.
Among the data relating to functionality, the authors start by referring to the Body functions, specifically, to the functions of orientation and memory.
A study undertaken with the objective of investigating memory complaints in people aged 65 or over in Madrid concluded that 32.4% of the individuals reported subjective memory complaints (15) .for preserving health and quality of life (16) .Quality of sleep is associated with age, as sleep disorders occur more frequently after the age of 75.Almost half of older adults report difficulty in getting to sleep and remaining so (17) .In its turn, an epidemiological study undertaken in a district in Italy (18) concluded that insomnia was observed in 44.2% of the population, while drowsiness was found in 31.3%, snoring in 47.2% and sleep apnea in 9.0%.Considering this, it may be affirmed that the data presented here fit in among the complaints associated with this stage of life, which does not mean that they do not deserve every care and attention, even if only because of this function's interference in many others, such as in the carrying out of the activities of participation.
As mentioned above, concerning the hearing functions, 15.6% of the elderly present some level of difficulties requiring care, this being more evident in individuals aged between 75 and 84 years.According to one nationwide study carried out in the United States of America (19) , approximately 30% of people aged between 65-79, and 37% aged 80 or over, have loss of hearing capacity.In two studies carried out with Latin-American populations, and based on self-reported data, it was concluded that hearing loss affects 25 -58% of people aged 65 or over (20)(21) .
In the functions of pain, the problem is more serious, with approximately 58% of the sample to be included among those requiring care.Another study concluded that 39.9% of a sample of elderly people in the suburban zone of London had experienced pain in the previous four weeks (22) .In its turn, a study carried out by the University of Texas Medical School, undertaken with a sample population of Mexican-Americans aged 74 or over, concluded that 64.7% referred to having pain in the previous four weeks, and that 49.7% reported that this pain had interfered with carrying out their activities of living.For women, low levels of schooling, fragility, reduced mobility, incapacity, elevated comorbidity and BMI, and symptoms of depression are significantly associated with the intensity of the pain and the interference with the activities of living.
It therefore seems that pain is an altered function in a high percentage of the elderly population.This is a problem because of both the pain itself, and because of where it mainly occurs, which without doubt induce greater levels of immobility.For these reasons it requires an appropriate intervention.
In the activities included in the self-caring group it may be ascertained that a percentage of people (between 4 and 14%) have difficulties which require therapeutic care, and that there is a statistically significant association with age.
In a cross-sectional populational study of elderly (aged 60 or over) residents of the urban zone of the city of Ubá, in the state of Minas Gerais, Brazil, the result found after evaluation of the scores on a scale of self-perceived functional capacity in the ADL (Activities of Daily Living) (23) determined that 20.2% were in the first three levels of classification (very bad, bad, and average) and presented dependency in at least one ADL.

Conclusion
The development of this study allowed the taking of decisive steps in the creation of the Core Set for the Elderly.Through the work done, the conditions have been created for continuing the development of this instrument, which may be transformed into a transprofessional instrument for the evaluation of functionality and care needs for the elderly.
Additionally, this study allowed the investigation of the functionality and care needs of the elderly in the Alentejo region, based on an evaluation based on the ICF.This allows one to see the situation in perspective, that is, considering the elderly people's bio-psycho-social dimensions.Thus, based in the data presented, one can understand that the elderly people's functionality is maintained at high percentages until about the age of 75.From that age onward, a progressive decline may be ascertained, with increasing percentages developing difficulties which require therapeutic help.It can be seen that low literacy, as well as financial difficulties, can constitute obstacles to functioning -and consequently to the elderly people's health conditions.
Based in this study's data, it is possible to envision an intervention directed at this population group's needs, setting out integrated measures which would allow the development of factors promoting health and reducing this population group's medicalization.
Data collection ran from June to December 2011.The necessary ethical procedures were followed, namely the submitting of the study to the Research Ethics Commission of the Health Sciences faculty of the University of Évora and the obtaining of informed consent on the part of the participants in the study.
* Nomenclature of Territorial Units for Statistics of Portugal www.eerp.usp.br/rlae

Table 1 -
Distribution of the sample by sex and age Regarding Close family network, 14.4% did not have children, and approximately 23% of the elderly people -principally in the age range 75 -84 years - Level of schooling it was determined that 30.7% stated that they could neither read nor write, this percentage being predominantly female (21.5%) and in the age groups 75-84 and 85 years and over.Characterization of functionality and care needsAmong the various Body functions, the researchers evaluated the global mental functions, in which the functions of orientation and sleep were highlighted.It was determined that in relation to the former, 94.6% of the elderly did not mention any problems.However, a total of 5.4% of the elderly responded in the affirmative to the two classes of response, which indicates a need for therapeutic care.The need for care is more evident in the individuals aged 85 or over (p-value Chi-Square Tests < 0.001).It was determined that in regard to the sleep functions approximately ¾ (74.8%) of the elderly people did not mention any problems.The remaining quarter, however, (25.2%) present a level of problems which requires care.There is, however, no significant association (p-value Chi-Square Tests >0.05) between the functions of sleep and the age group.being more evident in individuals aged between 75 and 84 (p-value Chi-Square Tests <0.001).Concerning the pain functions, the authors noticed that the majority of the elderly persons (58.2%) * Financial support paid monthly to elderly people with few financial resources.It is complementary to the pension which the elderly receive.
Rev. Latino-Am.Enfermagem 2013 Jan.-Feb.;21(Spec):52-60.presented an intensity of pain which required therapeutic care, but that this was not related to age.The most intense pain was located in the lumbar region, in the right knee, the posterior region of the right leg and in the dorsal region.
Regarding the activity of Reading, it was determined that while 59.1% did not present any difficulty, or only a mild difficulty, 40.9% of the elderly persons presented a moderate-intense difficulty in reading (2.8%) or complete difficulty (38.1%).As for the activity of Writing, an identical phenomenon was observed, that is,

Table 2 -
Distribution of some activities of self-care in relation to age Lopes MJ, Escoval A, Pereira DG, Pereira CS, Carvalho C, Fonseca C. (continue...)

Table 2 -
(continuation) Lopes MJ, Escoval A, Pereira DG, Pereira CS, Carvalho C, Fonseca C. 79.8% of the individuals studied.Some type of functional limitation was observed in 44.6% of the elderly people, and total incapacity in 2.0%.When the association with the distinct age ranges was verified, it was observed that increase in age entails greater compromise in functional capacity.
Classification as 'good' or 'very good' was observed in