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SMAD. Revista eletrônica saúde mental álcool e drogas

versión On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.16 no.1 Ribeirão Preto enero/mar. 2020

http://dx.doi.org/10.11606/issn.1806-6976.smad.2020.153846 

ORIGINAL ARTICLE

 

Life and health conditions of the elderly with mental disorders according to sex*

 

 

Maria Cássia Corrêa Mazzi FreireI; Maria José Sanches MarinI; Carlos Alberto LazariniI; Daniela Garcia DamacenoII

IFaculdade de Medicina de Marília, Marília, SP, Brazil
IIUniversidade Estadual Paulista "Júlio de Mesquita Filho", Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil

Corresponding author

 

 


ABSTRACT

OBJECTIVE: to analyze the conditions of life and health of elderly users of an outpatient mental health facility in accordance with the gender.
METHOD: a cross-sectional study conducted in an outpatient mental health facilities in the countryside of São Paulo, with 138 elderly, through interviews. The inferential analyzes were performed by using the Pearson Chi-square test and the extension of the Fishers exact test.
RESULTS: women are more often the prevention of cancer, flu vaccination, use of auxiliary aids when necessary; present diagnoses in mental health carried out in adult life, marital status "lives", independence in activities of daily living and mood disorders and personality. The men had their diagnoses in mental health later, use habit of alcohol and mental and behavioral disorders due to use of psychoactive substance.
CONCLUSION: the living conditions and health of elderly people with mental disorder have different characteristics when comparing males with females. This evidences the need for the search for knowledge of the differences, for those who attend them professionally, considering the contexts that led to illness and current health conditions.

Descriptors: Social Conditions; Mental Health; Elderly; Health Status.


 

 

Introduction

In Brazil, for decades, the aging process has been put on the agenda by scholars of the subject, who point to consequences of the increase in the number of elderly, without increasing the quality of life. This population has numerous health problems, requiring greater care, especially in the case of elderly people with mental disorders.

A European study estimated that one in two seniors had experienced a mental disorder during their lifetime, one in three in the year preceding the survey, and one in four at the time of the interview. The most common disorders were anxiety disorders followed by affective and psychoactive substance use disorders. Therefore, it is necessary to refine the diagnosis of mental disorder among the elderly and to provide quality mental health services to them(1).

A national study conducted in the interior of the state of São Paulo, Brazil, with 219 elderly attended by the Family Health Strategy, identified that 19.6% had scores above seven, ie, indicating the presence of mental disorder(2).

Currently, assistance to people with mental disorders is predominantly community based. The Mental Health Care Policies that, since 1978, passed through the Psychiatric Reform movement, guide, among other actions, the de-hospitalization, resulting in the creation of scenarios, such as the Psychosocial Care Centers (CAPS), the Volta Program. Home and Matrix Support, with Mental Health Specialists for Primary Care Teams. In addition to these, in the 1980s, specialized mental health outpatient clinics were created as retirement devices, complementary services that act in the continuity of treatment(3).

With changes in psychiatric intervention practices, which began with the reorganization of the mental health care model in the 1980s, there was a 44.8% reduction in the number of beds in psychiatric hospitals. Psychiatric hospitalizations decreased by 35% in the period between 1996 and 2005, but in this period there was an increase of 89.3% in the mortality of patients diagnosed with mental disorders(4).

On the quality of outpatient services produced after the Psychiatric Reform movement, a study by the Regional Council of Medicine of the State of São Paulo pointed out flaws in the functioning of CAPS, such as the lack of back-up for psychiatric hospitalizations and emergencies, especially the lack of medical professionals, among others. others, which impairs mental health care(4). There are also no more enlightening studies on specialized mental health outpatient clinics.

40% of UN member countries are known to have no mental health policy. In addition, caring for the elderly is not considered a priority in most countries of the world(5). Elderly people with mental disorders, acquired in adulthood or old age, have very complex living and health conditions, which requires adequate recognition so that actions can be directed to this portion of the population.

In addition, it is necessary to consider that, among the elderly with mental disorders, there are issues related to sex, since men and women are forced to assume a socially and historically constructed position, which is a determining factor for living and health conditions(6).

Living and health conditions, therefore, refer to the broader concept of health proposed by the Federal Constitution of 1988. It involves social determinants that translate into more general conditions, such as socioeconomic, cultural and environmental conditions, including working conditions, housing, sanitation, health services, education, social and community networks, which determine people's way of life and configure themselves as producers of health and ways of getting sick and dying(7).

Considering that health equity, as a principle guaranteed in the Constitution, is recognized from the delimitation of the needs of specific groups, this study had as its guiding question: "What are the living and health conditions of elderly people with mental disorders, according to sex?".

In this context, the objective was to analyze the living and health conditions of elderly mental health outpatients according to gender.

 

Method

Cross-sectional, descriptive and analytical study, conducted at a Mental Health Outpatient Clinic of a Higher Education Institution in the Midwest of São Paulo State, Brazil, with elderly people with mental disorders.

The sample size was calculated using the following statistical parameters: elderly population attending the mental health outpatient clinic, on average = 208 (data provided by the Institution's Technology and Information Center); 5% sampling error; confidence level of 95% and maximum percentage of 50%, requiring 138 individuals. The sample included the elderly who had cognitive, visual and auditory ability to answer the questionnaire, who had at least one confirmed diagnosis of mental disorder, excluding dependents of caregivers.

For data collection, the questionnaire used was based on the Health, Welfare and Aging (SABE) project(8), which has sociodemographic data, including gender, age, education, marital status, religion; o Brazil Economic Classification Criterion, age of retirement, economic participation within household income, source of income, residence characteristics and basic sanitation data. Regarding health conditions, data were collected regarding communication conditions, self-perceived health, alcohol use, influenza vaccine in the last year, prevention of breast/cervical/prostate cancer, hearing conditions, vision, chewing, use of assistive devices and falls.

In addition, the elderly were asked about the presence of the main signs and symptoms and diseases present in aging; medical diagnosis of mental disorder (obtained from consultation of medical records), age at which diagnosis was made, number of hospitalizations in the last year and access to treatment in mental health. To assess the degree of dependence, the Lawton & Brody Scale was used(9). Gender was defined as an independent variable. The others were treated as dependent variables. Data was collected by the lead researcher from January to March 2016.

Statistical analyzes were performed using SPSS software, version 17.0. Inferential analyzes were performed using Pearson's chi-square test and Fisher's exact test extension. In all conclusions obtained by inferential analyzes, the significance level α equal to 5% (p < 0.05) was used.

The study was approved by the Human Research Ethics Committee of the Marilia Medical School, following Resolution 466 of 12/12/2012 of the National Health Council, according to number 1.050.605. Participants were informed by the interviewer about the nature of the study, objectives, methods and expected benefits, potential risks and possible discomfort by the interviewer and, to participate, signed the Free and Informed Consent Term (FICT).

 

Results

Of the 138 respondents, 47 were men and 91 women. Both sexes showed a predominance of age between 60 and 69 years and incomplete initial grades (1st to 4th grades) [The legislation does not use Elementary school I and II, just elementary, I suggest using initial grades] while schooling. For marital status, there was a tendency for a statistically significant difference between the sexes (p = 0.06), with women pointing to the option "live without a partner" in a greater proportion than men. The Catholic religion was the most present among the interviewees. Men declared themselves Catholics in greater proportion than women (p = 0.02) (Table 1).

Regarding economic classification, there was a predominance of class C in both sexes. Most of the interviewees were retired. Predominantly, after age 60, retirement represented the main source of income and respondents reported that they participated economically, sharing responsibility with another family member.

As shown in Table 2, most respondents had spontaneous speech and understanding of the questions. Most rated health as good or fair. Regarding alcohol use (previous consumption, frequency and quantity), there was a statistically significant difference in relation to gender, with men reporting higher use (p = 0.01). A positive association was found between sex and influenza vaccination (p = 0.05), and women performed such practices in a greater proportion. There was no positive association regarding number of falls and gender.

As for the sense organs, most men and women rated vision as good or fair, denied hearing problems, and never or rarely had problems with chewing. Positive association between appliance use and gender (p= 0.02). The most frequently used braces were glasses and dental prostheses. For instrumental activities of daily living, a positive association was found between the parameter and gender (p=0.02), with women showing greater independence in relation to men.

Regarding the reported health problems, which are shown in table 3, women reported the highest presence of rheumatism (p=0.03), obesity (p=0.01) and orthostatic hypotension (p=0.03). Insomnia was the most commonly reported health problem, followed by high blood pressure and diabetes in both sexes.

Regarding the diagnosis of mental disorder, among men, there was a predominance of organic mental disorders, including symptomatic ones; mental and behavioral disorders resulting from psychoactive substance use and neurotic disorders such as generalized anxiety disorders.

The percentage of elderly with diagnoses belonging to the schizophrenia groups (F20-F29) was similar in both sexes. Among women, diagnoses of mood and personality disorders were more frequent. Women treated at this mental health outpatient clinic had the majority of diagnoses in adulthood (59.3%) and men were diagnosed at age 60 or older (61.7), differing statistically (p= 0.01).

Regarding hospitalizations, 25.4% had one hospitalization and 13.8%, two hospitalizations in the last year. About the elderly interviewed, it was found that more than half attended only the mental health outpatient clinic. The vast majority, in both sexes, never had psychotherapy treatment (Table 4).

 

Discussion

In this study, 138 elderly people were interviewed, and the majority, both men and women, were between 60 and 69 years old. Another study found similar data, besides confirming that, in this age group, the elderly have a better self-perception of health compared to the elderly of other age groups(10).

Of the interviewed elderly, most were women, a finding similar to that found in another study also conducted at a mental health outpatient clinic(11). In this sense, data from the IBGE, from 2018, express the growing aging of the Brazilian population, and of the individuals over 60 years old, 8.6% are women and 6.8% men(12), which points to the feminization of old age(13).

Women are the main consumers of outpatient services, as they are more likely to express distress and seek medical services for emotional or physical complaints(14).

Women had a higher percentage for the marital status "live alone", and the abandonment by the husband in the case of mental illness is not uncommon, an issue also pointed as a disadvantage to the woman's care, because when the man becomes psychically ill, the wife tends to continue by their side(15).

In addition, to explain the fact that among women, the condition of living without a partner prevails, other variables can be considered, such as life expectancy, which in 2012 was 71 years for males and 74.6 years. for females. Since men die earlier, there are considerable numbers of widowed women(16) who can often choose life without a new partner because they still abide by social norms and rules or because the family does not declare support for new love relationships.

Regarding mental health and gender, when considering the female characteristic of informal health care providers, it is appropriate to question the conditions of women who need psychiatric assistance and demand care. Single or childless, in a situation of mental suffering, they have characteristics contrary to those socially expected, more linked to the exercise of the role of wife and mother(14). It is observed that society maintains the collection of maternal function, however, some conditions hinder this execution(17).

The Catholic religion was mentioned by the majority, meeting the 2010 census(16).

When considering the entire Brazilian elderly population, about half have less than four years of study. Low education, especially among women, can be attributed to the characteristics of society and education policies prevalent in the 1940s, when access to education was still very restricted. In 2000, the average number of years of schooling of the elderly responsible for the households was 3.5 years for men and even less for women, who were 3.1 years old. In this sense, the data obtained in this study do not differ from those of the Brazilian population(18). Importantly, low education and income mean less access to basic services(19).

The elderly surveyed belonged predominantly to economic class C, similar to a population-based study conducted in a city in the interior of Rio Grande do Sul, Brazil, with 1,448 elderly, which showed that 56.8% of respondents belonged to this economic class(20).

Most of the elderly interviewed were retired after the age of sixty. This data meets the social indicators for retirees or pensioners in the Southeast Region(18). A study conducted at the Federal University of Rio Grande do Norte, between 2002-2005, evaluated retired employees for mental disorders and found that 35% retired between the ages of 50 and 59 years. Anticipation of retirement may occur because these people have psychological distress prior to old age, carrying years of disability, which affects work(21).

Regarding the source of income, IBGE data corroborate those obtained in this study: elderly men have income that comes mainly from retirement (58.7%) and women have income from both retirements (42.2%), pension (14.4%) or other source of income (26.7%)(22).

Approximately half of the elderly studied reported participating economically, sharing responsibilities with other family members. Although the elderly in question are users of the Unified Health System (UHS), reported that most of the spending was on health (31.9% of men and 37.4% of women). This information, when associated with other sociodemographic characteristics of the elderly, such as source of income and social class, can infer that elderly with mental disorders who use the outpatient clinic have few financial resources to maintain a satisfactory living condition.

Among the elderly interviewed, few were those who could not communicate verbally clearly, even considering that some mental disorders bring difficulties in understanding and verbalizing words spontaneously, requiring help from others to support communication.

Previous use of alcohol was positively associated with gender (p = 0.001), and men reported this practice more. A descriptive study with data from the National Health Survey (NHS), referring to alcohol abuse in the 30 days prior to the interview, showed that the prevalence was 13.7%, being higher among men (21.6%) compared to women (6.6%), with a predominance of young people (23). According to a study conducted in two CAPS AD in the city of Florianópolis /SC, Brazil, in adulthood, the diagnosis of alcohol dependence differs in the proportion of 8.5: 1 and 5.5: 1 between men and women, respectively(24).

A study carried out in Portugal with elderly assisted at a Family Health Unit showed a significant presence of alcohol use, with prevalence also in men (56.2%). In addition, one third of the sample had a hazardous consumption, defined as that greater than or equal to 14 standard units of ethanol (168g) per week(25).

Regarding influenza vaccination, there was also a statistically significant association in relation to gender, with women adhering more than men to this practice. This confirms the pattern found in the female population regarding greater pursuit of health care and prevention. In Rio Grande do Sul, Brazil, it has also been shown that older women adopt healthy behaviors and health risk prevention measures more often than men, since they are given more frequent advice on healthy habits(26).

The degree of dependence on daily living activities, which is an important indicator of the elderly's living and health conditions, was higher among men. However, the diversity of instruments used for this evaluation and the fact that it is performed mainly in the institutional context makes any attempt to compare the data difficult.

Concerning health problems, the elderly with mental disorders follow the pattern of high prevalence of chronic non-communicable diseases, especially hypertension and diabetes, which contributes to the deterioration of their health status, since they are diseases that present a high risk of cardio-circulatory complications, and lead to the use of a large number of medications, which can interfere with autonomy and quality of life, especially considering that these problems add to the mental disorder(27).

In addition, most respondents pointed to the presence of insomnia, despite monitoring at the mental health outpatient clinic and use of psychotropic drugs. Literature data indicate that 44.9% of the elderly have some sleep disorder, being the highest frequency in women (51.5%) and bring, as associated factors, sex, pain, urinary incontinence and nocturia(28).

Obesity has been the most common problem among women when compared to men. Literature review on the subject showed that women have obesity rates close to double compared to men, being the most critical age group from 60 to 69 years(29). There are also positive associations between obesity and mood disorders and anxiety(30).

The results of this study coincide with the fact that in men, mental and behavioral disorders resulting from the use of psychoactive substances prevail, and in women, those related to mood and personality disorders(31). Different theories explain the differences in the prevalence of mental illnesses between men and women, and they relate these differences to both internal and external issues, especially the social functions related to sex, indicating that they are related to gender with a difficult to understand multifactorial network(32).

This article highlighted the differences between the sexes, highlighting issues that refer to the challenge of understanding the world in which the individual is inserted, knowing the past that influenced him and motivated the disease and the conditions of aging(33).

Finally, the study's limit is the fact that the data were collected only at the mental health outpatient clinic of an educational institution, which may not represent all elderly people with mental disorders, since in other important scenarios , such as CAPS and hospital care services, may have different conditions, sometimes with more severe problems.

Therefore, it is understood the need for further studies that, besides revealing the differences between the sexes, can more directly demonstrate the specific needs of elderly people with mental disorders.

 

Conclusion

In this study, it was possible to evidence significant differences between living and health conditions and gender of elderly attended at mental health outpatient clinic. Women showed greater acceptance of the influenza vaccine and used, to a greater extent, appliances such as glasses and dental prostheses when needed; tended to marital status "live alone" and greater independence in activities of daily living. Men had later mental health diagnoses after age sixty. Almost all of them had previously used alcohol and were more dependent on instrumental activities of daily living.

The findings indicate the importance of increasing knowledge about the needs of elderly people with mental disorders, with care measures and policies aimed at early treatment, in order to minimize the impact of mental illness on the aging process. It is necessary to recognize and attend to the inherent specificities of sex, which implies an enlarged and contextualized perspective that is not restricted to this variable alone. Access to specialized treatment in mental health, in the various life cycles, becomes, in this scenario, essential to maintain adequate health conditions in aging.

 

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Corresponding author:
Daniela Garcia Damaceno
E-mail: daniela.garcia22@yahoo.com.br

Received: Jan 22nd 2019
Accepted: Jul 29th 2019

 

 

Authors' contributions: Study design and planning: Maria Cássia Corrêa Mazzi Freire, Maria José Sanches Marin, Carlos Alberto Lazarini. Data collection, analysis and interpretation: Maria Cássia Corrêa Mazzi Freire, Maria José Sanches Marin, Carlos Alberto Lazarini. Statistical analysis: Maria Cássia Corrêa Mazzi Freire, Maria José Sanches Marin, Carlos Alberto Lazarini. Preparation and writing of the manuscript: Maria Cássia Corrêa Mazzi Freire, Maria José Sanches Marin, Carlos Alberto Lazarini, Daniela Garcia Damasceno. Critical revision of the manuscript: Maria José Sanches Marin, Carlos Alberto Lazarini, Daniela Garcia Damasceno.
All authors approved the final version of the text.
Conflict of interest: The authors declare no conflict of interest.
* Paper extracted from master's thesis "Condições de vida e saúde de idosos atendidos em ambulatório de saúde mental", presented to Faculdade de Medicina de Marília, Marília, SP, Brazil.

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