Abstract

This paper aimed to identify and analyze in national and international literature whether and how the theme of violence is addressed in the studies of public policies for older adults in Long-Term Care Institutions (LTCI). We conducted an integrative review of the published literature between 2010 and August 2016. The primary bibliographic databases were consulted using descriptors “idoso”, “políticas públicas”, “instituição de longa permanência para idosos”, “asilo”, “casa de repouso” and “ILPI” in Portuguese and their equivalent in English and Spanish. A total of 77 papers were analyzed, of which 12 were Brazilian and 65 were foreign (of these, 30 were from the U.S.). The analysis showed that many countries have long-term care policies governing the modalities of service providers. Only eight works addressed the issue of violence within LTCIs within older adults’ protection policies, and affirm that countries in Latin America and Asia must advance this agenda and place the issue of violence against seniors on the agenda of priorities. No Brazilian paper addressed the issue directly, although it has become clear that neglect and other forms of violence hang over Long-Term Care Institutions for the Elderly (LTCIEs).

Key words
Long-term care institutions for the elderly; Public policies; Elderly; Violence; Elderly long-term care

Introduction

This paper aims to analyze the national and international literature on the issue of violence in elderly care public policies, especially those geared to Long-Term Care Institutions for the Elderly (LTCIEs).

The establishment of social security systems accompanied by specific public policies for certain populations facilitated greater longevity of the world population, although there are contrasts between the different countries. Factors such as medical and scientific advances, increased urbanization, increased participation of women in the labor market, increased schooling, increasing dissemination of contraceptive methods, culminating in declining birth rate, reinforced these demographic changes. Demographers estimate that the number of people aged 60 years and older on the planet will increase from the current 630 million to about 2 billion by 2050, outweighing the number of children and adolescents¹1 Farfel JM, Jacob Filho W. Epidemiologia e fisiologia do envelhecimento. In: Nitrini R, Jacob Filho W, Organizadores. Demências-enfoque multidisciplinar: das bases fisiopatológicas ao diagnostico e tratamento. São Paulo: Atheneu; 2011. p. 1-6..

It is known that the elderly population has a high incidence of chronic morbidities such as diabetes, arterial hypertension, neurodegenerative diseases, among others, that frequently affect their basic (eating, dressing, walking, performing own hygiene) or instrumental (preparing meals, using public transport, managing finances, making purchases, among others) activities of daily living (ADL). Compromised activities of daily living generate a functional dependence that, in turn, affects relatives who take care of them, when there are no other feasible alternatives¹1 Farfel JM, Jacob Filho W. Epidemiologia e fisiologia do envelhecimento. In: Nitrini R, Jacob Filho W, Organizadores. Demências-enfoque multidisciplinar: das bases fisiopatológicas ao diagnostico e tratamento. São Paulo: Atheneu; 2011. p. 1-6..

For those situations where older adults are dependent, long-term care is an essential support for the seniors and their family and is characterized as a wide range of services and care for people who are in a situation of dependence²2 Matus-Lopez M. Tendências e reformas nas políticas de atenção aos idosos com dependência. Cad Saude Publica 2015; 31(12):2475-2481.. According to Pasinato and Kornis³3 Pasinato MTM, Kornis GEM. A inserção dos cuidados de longa duração para idosos no âmbito dos sistemas de seguridade social: experiência internacional. In: Camarano AA, organizadora. Cuidados de longa duração para população idosa: um novo risco social a ser assumido? Rio de Janeiro: IPEA; 2010. p. 39-66., the incorporation of long-term care for the elderly with some level of dependence on social security systems is a challenge for social policymakers and managers. Many countries have specific long-term care policies, while in others, informal care provided by relatives or nonprofit LTCIEs (in most situations) predominates, as is the case of Brazil, characterized by low participation of institutions.

Camarano and Kanso⁴4 Camarano A, Kanso S. As instituições de longa permanência para idosos no Brasil. R. Bras. Est. Pop. 2010; 27(1):233-235. affirm that there is no consensus about what an LTCIE is, and they believe its origin is related to asylums, initially aimed at the low-income population that needed shelter. These asylums resulted from Christian charity in the absence of public policies that included this care for the elderly. Ordinance Nº 73, of the Ministry of Social Security and Social Assistance and the State Social Assistance Secretariat, defines that LTCIEs are institutions that are intended for the care of older adults, regardless of their dependence concerning daily life activities, and should provide individualized care with a standard of dignity, preserve autonomy, independence and family and community life⁵5 Brasil. Portaria nº 73, de 10 de maio de 2001. Aprova as Normas de funcionamento de serviços de atenção ao idoso no Brasil. Diário Oficial da União 2001; 10 maio..

The care provided in the family environment seems to be the most common and even recommended for less social impact on the lives and daily living of seniors. However, some issues must be remembered, such as the workload of family caregivers, their physical and emotional exhaustion, and the more significant economic constraint of the family group, which may contribute to a context that facilitates situations of violence. On the other hand, LTCIE care may also be accompanied by other situations of violence, such as neglect of basic care (hygiene, drug administration, lack of interactive spaces) due to the shortage of vacancies, overcrowding of institutions, lack of training of its professionals, aspects that are provided for in the current legislation. Such actions that translate into fundamental rights violation can be understood as violence perpetrated in this institutional environment.

Methods

This is an integrative review of the national and international literature that aimed to answer the question: Is the issue of violence addressed in the studies on elderly care public policies, particularly those addressed to LTCIEs? To do this, we searched for literature in the following websites: Virtual Health Library (BVS), Medline (via PubMed); Scopus and Web of Science. For VHL the search expression used was idoso AND políticas públicas AND instituições de longa permanência para idosos OR asilo OR casa de repouso OR ILPI, and in the Spanish language anciano AND políticas públicas AND hogares para ancianos. All descriptors were previously consulted in the Health Sciences Descriptors (DeCS). Concerning other international databases, we searched in the Medical Subject Headings (MeSH) the more adequate terms, using the following search strategy: (public policy) AND (homes for the aged OR old age home OR nursing home OR long-term care OR care homes) AND (aged OR elderly). It is essential to highlight that descriptors violence and abuse in the BVS and Violence and correlated terms atrocities, aggress Negligence and malpractice in the other databases were previously associated with each of these strategies; however, few papers were found. Therefore, a broader search was adopted, so that in the analysis of the papers, a discussion could be made about violence in the context of LTCIEs policies later.

Papers’ inclusion criteria were: written in Portuguese, English and Spanish; published from 2010 to August 2016; addressing violence in the context of LTCIEs or to refer to elderly care public policies regarding LTCIE-similar equipment. This time selection was chosen to capture the scientific production after the finalization of the Action Plan for Coping Violence against the Elderly, of the Special Human Rights Secretariat, whose one of its priorities actions aimed at the institutional space and long-term care in force until 2010⁶6 Brasil. Direitos humanos e cidadania: Plano de ação para enfrentamento da violência contra pessoa idosa, 2007-2010. Rio de Janeiro: Fiocruz; 2007..

Consulting all sources, excluding duplicate papers, sections such as editorials and authors’ comments and abstracts without full-texts, resulted in a total of 102 papers, 90 international and 12 Brazilian. After reading the abstracts of these 102 papers, a total of 77 works were analyzed, as per Figure 1.

The collected material was classified considering the period of publication, the country of study and the methodological approach used by the authors, as well as issues related to violence within policies geared to the LTCIEs and gaps in this theme.

The analysis identified and grouped the collection into three categories: the first one refers to the characterization of the collection gathered (paper methodology, central theme of the study and brief description of long-term care in different international settings); the second characterizes violence in the light of public policies, and the third focuses on Brazilian LTCIEs and evidence of violence within those services.

Results and discussion

Characterization of the collection gathered and analyzed

Most papers are from the U.S. (n = 30), followed by Brazil (n = 12), Japan (n = 8), Australia (n = 6) and France (n = 5), China and Canada (n = 3 each), Taiwan (n = 2) and finally, Singapore, Portugal, North Korea, Hong Kong and England with one paper each. Two papers addressing long-term care in Latin America in a broad and perspective compared between several countries of the continent and one paper of a multicenter affiliation (U.S. and Singapore) were also found. Even including in the search strategy descriptors in the Spanish language, only two studies produced with a focus on Latin American countries other than Brazil were identified.

It was verified that, on average, 11 papers were published each year, with a higher concentration in 2015 (n = 15), followed by 2011 and 2012 (n = 13 each), 2013 (n = 12), 2010 (n = 11) and 2014 (n = 10), and finally, 2016 (n = 3). It is worth noting that the review was conducted in August 2016 and did not cover all the publications of 2016.

Twenty-one papers addressing LTCIEs or residential services mainly focused on the context of long-term care policies were found. Most of the studies (77%) address LTCIEs along with other modalities of services that provide such care. However, not all papers describe the policy in force in the country where the study was conducted, and similarly, only eight papers directly address the issue of violence.

Several productions explain these long-term care modalities under broader legislation with other services for such care. Another observation is that few studies explicitly address violence, although issues such as prejudice, caregiver overloading, and qualification of professionals working in these services, can provide elements to reflect on how violence may be veiled in these spaces without having the necessary visibility. Although gender issues were relevant in the study on violence and population aging, they were not identified in the discussions of the studies. (Table 1 shows the central themes in which the collected papers were classified.

The papers were also classified by methodology used into quantitative, qualitative, theoretical or reflective studies and literature review. Productions using quantitative methods included cross-sectional descriptive (most of which analyzed secondary data), retrospective, cohorts, economic analysis studies, among others. Qualitative manuscripts relied on reports of experience and ethnographic research through individual interview techniques or focus groups. We also identified theoretical papers or reflexive essays that focused on public policies aimed at long-term care or on ways to promote more qualified care for the elderly population. We also found review papers, as shown in (Table 2, and we did not identify mixed-approach (quantitative-qualitative) studies.

As mentioned, 77% of the papers discuss LTCIEs within the long-term care policy, showing that these establishments are thought alongside other types of services through which care is provided to the elderly.

Forty-eight of the 66 foreign papers evidenced that many countries have specific policies related to long-term care for older adults, which cover various care equipment such as Daycare; Homes; Home Care, Financial Relocation to Family Members or Informal Caregivers. It should be emphasized that this work focuses on homes. Homes are devices responsible for providing 24-hour care to the elderly in general, with a significant degree of dependency and are equivalent to LTCIEs in Brazil. In the U.S., these services are called “nursing home” and are intended for the elderly who require more care and consequently with a higher degree of dependence²2 Matus-Lopez M. Tendências e reformas nas políticas de atenção aos idosos com dependência. Cad Saude Publica 2015; 31(12):2475-2481.^,77 Miller EA, Tyler DA, Mor V. National newspaper portrayal of nursing homes: Tone of coverage and its correlates. Medical Care 2013; 51(1):78-83..

Unlike that observed in other countries, whose international papers were analyzed here, where residential services (similar to LTCIEs) underlie the health sector, in Brazil, they are allocated to the Unified Social Assistance System (SUAS). A 2009 study reported that this is the primary mode of long-term care in the country, and in this same year, accounted for a total of 3,548 LTCIEs⁸8 Camarano AA, Mello JL. Cuidados de longa duração no Brasil: o arcabouço legal e as ações governamentais. In: Camarano AA, organizadora. Cuidados de longa duração para população idosa: um novo risco social a ser assumido? Rio de Janeiro: IPEA; 2010. p. 67-91..

Public policies and long-term care institutions for the elderly: violence in its most hidden face

Public policies are guidelines, guiding principles of action, rules and procedures for relations between public power and society, mediations between actors of society and the State, aiming to guide actions that typically involve an investment of public resources⁹9 Teixeira EC. O papel das políticas públicas no desenvolvimento local e na transformação da realidade. Salvador: AATR; 2002.. Thus, one can think that public health policies aim to guarantee care to the population, through health promotion, protection and recovery actions, ensuring the integrality of care, converging to the different realities and health needs.

Taking into account the aging population and the possible growth of the elderly in situations of violence, many sectors were pressured to formulate policies, guidelines and studies to address this reality.

The World Health Organization (WHO) defines violence against the elderly as follows: “One or repeated acts, or lack of appropriate action, occurring in any relationship that causes harm or omissions concerning them.” Such violence can be expressed as self-inflicted violence; interpersonal violence and collective violence¹⁰10 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. Relatório mundial sobre violência e saúde. Genebra: Organização Mundial da Saúde; 2002.. Violence can also take the form of various forms of physical, psychological, sexual abuse and neglect. Souza and Souza¹¹11 Souza ER, Souza AC. Violência contra a pessoa idosa: o desrespeito à sabedoria e à experiência. In: Njaine K, Assis SGA, Constantino P, organizadores. Impactos da Violência na Saúde. Rio de Janeiro: Fiocruz; 2013. affirm that the most recurrent violence in this group is neglect, abandonment and self-neglect. It should be noted, however, that “invisible” violence can be perpetrated without being considered as such. According to Minayo and Souza¹²12 Minayo MCS, Souza ER. As múltiplas mensagens da Violência contra Idosos. In: Minayo MCS, Souza ER, organizadoras. Violência sob olhar da saúde: a infrapolítica da contemporaneidade brasileira. Rio de Janeiro: Ed Fiocruz; 2003. p. 223-242., violence can be conceptualized as:

(...) interpersonal social relationships of groups, classes, gender, or objectified in institutions, when different forms, methods and means of harming and annihilating others are employed, or of their direct or indirect coercion, causing them physical, mental and moral harm.

Such a definition helps to assimilate that although violence may have tangible expressions that leave marks, it can also be perpetrated by institutions without necessarily being personified in a single individual. Souza and Souza¹¹11 Souza ER, Souza AC. Violência contra a pessoa idosa: o desrespeito à sabedoria e à experiência. In: Njaine K, Assis SGA, Constantino P, organizadores. Impactos da Violência na Saúde. Rio de Janeiro: Fiocruz; 2013. warn that the rupture of fundamental rights, such as lack of civil identification, food, income, lack of health care, non-implementation of the social benefits of people over 60 years of age are also violence. This violation of fundamental rights is also mentioned by Boulding (apud Cruz Moreira and Neto¹³13 Cruz Neto O, Moreira MR. Concretização de políticas públicas em direção à prevenção da violência estrutural. Cien Saude Colet 1999; 4(1):33-52.) in defining structural violence as a concept that applies “both to the organized and institutionalized structures of the family and the economic, cultural and political systems that lead to the oppression of certain people who are denied advantages of society, making them more vulnerable to suffering and death.” The current economic-political system is shaped by the lack of State action to promote public policies to meet the needs of some population groups, and reduces this form of violence to the invisible sphere, making many in society not perceive this neglect of the State as violence¹⁴14 Almeida NKD, Coelho MTAD. A Violência Estrutural. In: Anais do XII Seminário Estudantil de Produção Acadêmica (SEPA Salvador); 2008; Salvador. p. 1-11..

From the collection of papers analyzed in the present study, seven papers published in the United States describe and question abuse against the elderly in long-term institutions.

Stark¹⁵15 Stark SW. Blind, Deaf, and Dumb: Why Elder Abuse Goes Unidentified. Nurs Clin North Am 2011; 46(4):431-436. puts elder abuse in the United States as a guideline that requires more attention as it is estimated that 84% of cases have never been reported to any protective bodies. She also points out that there is no federal law regarding elder abuse in the country, although each state has specific legislation to prevent elder abuse. The author emphasizes that this configuration leads to inconsistencies in the definition of abuse and different services for the same event.

Daly¹⁶16 Daly JM. Domestic and Institutional Elder Abuse Legislation. Nurs Clin North Am 2011; 46(4):477-484. corroborates and deepens this conception by reaffirming that there is heterogeneity in the definitions of elder abuse. The author cites that the most special mention of violence is in the federal code of practice applied to Nursing Homes when it states that the resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary isolation.

Contrary to this code, it is estimated that 36% of workers perpetrate physical abuse and 81% of them practice psychological abuse against elderly living in American LTCIEs¹⁵15 Stark SW. Blind, Deaf, and Dumb: Why Elder Abuse Goes Unidentified. Nurs Clin North Am 2011; 46(4):431-436..

Three more frequent types of neglect reported in nursing homes were identified: medical conduct-related neglect; neglect of professional caregivers and neglected hygiene and care for the physical environment. Of these, the greatest allegation of neglect was strongly associated with the attitude of professionals vis-à-vis the elderly, such as the difficulty of managing primary care, which sometimes caused health problems to the elderly. The other types of neglect were less reported¹⁷17 Phillips LR, Ziminski C. The Public Health Nursing Role in Elder Neglect in Assisted Living Facilities. Public Health Nursing 2012; 29(6):499-509..

One review¹⁸18 Castle N, Ferguson-Rome JC, Teresi JA. Elder abuse in residential long-term care: an update to the national research council report. J Appl Gerontol 2015; 34(4):407-443. pointed out that neglect in nursing homes reaches the rate of 9.8%, while abuse in daily care tops 17.4%. In assisted homes, neglect reaches 9.8%, and emotional violence 10%. These types of violence are usually attributed to the overload of the professionals who work in these institutions, and endure many working hours, have low salaries, with professional dissatisfaction and inadequate training for their work activities.

These different forms of violence evidenced by the literature, although not explicitly, can be considered as institutional violence. In an attempt to understand this concept, we resort to the work by Nogueira¹⁹19 Nogueira MI. Assistência pré-natal: prática de saúde a serviço da vida. São Paulo: Editora Hucitec; 1994. that defines it as the scarce or nonexistent benefits provided by the services. Institutional violence is also the result of the neglect of the public power concerning the policies that are often discontinuous and random, unplanned, or even improvised to meet the pressures of the press and organized groups.

Another type of neglect addressed in the American literature was described by Katz et al.²⁰20 Katz RV, Smith BJ, Berkey DB, Guset A, O'Connor MP. Defining oral neglect in institutionalized elderly: A consensus definition for the protection of vulnerable elderly people. J Am Dent Assoc 2010; 141(4):433-440. in defining and characterizing oral lesions such as infections or acute pain, such as neglect of oral health. The authors state that nursing homes receive from the federal government funds to ensure such care and therefore requires full coverage of oral health.

Jirik and Sanders²¹21 Jirik S, Sanders S. Analysis of Elder Abuse Statutes Across the United States, 2011-2012. J Gerontol Soc Work 2014; 57(5):478-497. argue that there are gaps on the issue of violence in policy, research and education/training components in the U.S., and stress the need to revise definitions, reporting requirements, education and training to address violence in American statutes of elder abuse.

A study in Taiwan²²22 Tsai ACH, Lai TM. Predicting the need of formal care In: Taiwan: Analysis of a national random sample. Arch Gerontol Geriatr 2011; 53(3):298-302. emphasizes the importance of considering cultural aspects in the formulation of public policies and asylum services since the elderly and the general population reject the idea of living in a care institution. The authors of this paper mention that children must fulfill this care when necessary.

Care provided by the family is an essential cultural value in Asian countries in general, although there are different realities. In the case of Japan, public policies consider strategies such as educational groups, collaborative networks, and specific health services for the elderly that are more dependent on attenuating the burden of caregivers, since this condition can lead to emotional exhaustion and trigger neglect situations²³23 Arai Y, Zarit SH. Exploring strategies to alleviate caregiver burden: Effects of the National Long-Term Care insurance scheme in Japan. Psychogeriatric 2011; 11(3):183-189..

In contrast to the reality of Asian countries, in Canada, generally, the children of the elderly are seen as caregivers, but the State has a significant share of responsibility in administering this care²⁴24 Guberman N, Laudie JP, Blein L, Olazabal I. Baby Boom caregivers: Care in the age of individualization. Gerontologist 2012; 52(2):210-218..

Muramatsu and Akiyama²⁵25 Muramatsu N, Akiyama H. Japan: Super-aging society preparing for the future. Gerontologist 2011; 51(4):425-432. find that Japanese elders are socially more isolated than in other Western countries. They believe that building communities that target older people can help build links and access services. In the same vein, Greenfield et al.²⁶26 Greenfield EA, Oberlink M, Scharlach AE, Neal MB, Stafford PB. Age-Friendly Community Initiatives: Conceptual Issues and Key Questions. Gerontologist 2015; 55(2):191-198. stress the importance of rethinking long-term care policies in age-friendly community initiatives and less focused on the individual. They argue that such collective actions have great potential for reducing isolation and ill-treatment against the elderly.

In Latin America, Matus-López²2 Matus-Lopez M. Tendências e reformas nas políticas de atenção aos idosos com dependência. Cad Saude Publica 2015; 31(12):2475-2481.^,2727 Matus-Lopez M. Thinking about long-term care policies for Latin America. Salud Colectiva 2015; 11(4):485-496. says that this region is still very marked by informal care, which is a strong characteristic of places that still lack public policies for long-term elderly care, with a strong predominance of asylum institutions (often philanthropic), although the author points out that this has been decreasing for some years. The exceptions are Chile and Uruguay, which have specific actions directed at dependent older adults. Even those countries that are at the forefront of the continent concerning public policies still have limitations and difficulties in financing health systems that ensure access to services²⁷27 Matus-Lopez M. Thinking about long-term care policies for Latin America. Salud Colectiva 2015; 11(4):485-496..

In the Asian continent and the Latin American region, although a significant portion of the population is aging, few policies and institutions of long-term care are noted. This observation points to the existence of structural violence that predominates in these areas, although it also occurs in other realities of the world, as per the Boulding apud Moreira and Neto¹³13 Cruz Neto O, Moreira MR. Concretização de políticas públicas em direção à prevenção da violência estrutural. Cien Saude Colet 1999; 4(1):33-52. concept used here. Informal care is still predominant in several countries of these continents, with great responsibility on the part of the family, which often becomes fragile.

Because of the socioeconomic shortcomings of many of these families, it is difficult to identify the thin line between the difficulties of meeting the needs of the elderly and the neglect of this care. What tends to predominate is the view of neglect and blame on the family, without a broader reflection being made.

Long-term care institutions for the elderly in the Brazilian reality: institutional violence in the implementation of elderly care policies

The national literature has diverse studies about the public policies of elderly care concerning the long-term care institutions for the elderly and the interface of this social assistance equipment with the health sector.

Of the twelve national papers selected, nine carried out field research in LTCIEs, and of these, four studies focused on nonprofit LTCIEs²⁸28 Oliveira MPF, Novaes MRCG. Perfil Socioeconômico, epidemiológico e farmacoterapêutico de idosos institucionalizados de Brasília. Cien Saude Colet 2013; 18(4):1069-1078.

29 Feliciani AM, Santos SSC, Valcarenghi RV. Funcionalidade e quedas em idosos institucionalizados: proposta de ações de enfermagem. Cogitare Enferm 2011; 16(4):615-621.

30 Gerlack LF, Bós AG, Karnikowski MGO, Lyra Júnior DP. Acesso e aquisição de medicamentos em instituições de longa permanência para idosos no Brasil. Sci. Med 2013; 23(2):90-95.^-3131 Nunes VMA, Menezes RMP, Alchieri JC. Avaliação da qualidade de vida em idosos institucionalizados no município de Natal, estado do Rio Grande do Norte. Acta Sci 2010; 32(2):119-126., which indicates that the Brazilian rationale of informal care still prevails, since the State rarely subsidizes public institutions, and the family is the primary responsibility for the care of the elderly. Minayo and Almeida³²32 Minayo MCA, Almeida LCC. Importância da política nacional do idoso no enfrentamento da violência. In: Alcântara AO, Camarano AA, Glacomin KC, organizadoras. Política Nacional do idoso: velhas e novas questões. Rio de Janeiro: IPEA; 2016. p. 435-456. argue that this institutional violence occurs due to the omission of the State that does not guarantee a more significant number of social support equipment to families.

Several papers pointed out a steady relationship of institutionalization with increased disabilities and dependence, and a smaller network of family and social support for the elderly. Also, these older adults, in general, have a low educational level, several chronic health problems and are socially vulnerable²⁷27 Matus-Lopez M. Thinking about long-term care policies for Latin America. Salud Colectiva 2015; 11(4):485-496.^,3030 Gerlack LF, Bós AG, Karnikowski MGO, Lyra Júnior DP. Acesso e aquisição de medicamentos em instituições de longa permanência para idosos no Brasil. Sci. Med 2013; 23(2):90-95.^,3333 Soares RFN. Reflexões sobre espaço de moradia para idosos e políticas públicas. Cad Tem Kairós Geront 2010; 13(8):91-107.

34 Silva J, Almeida M. Orientações Políticas e Prática Profissional em Instituições de Longa Permanência Para Idosos. Estudo Interdisciplinares sobre o Envelhecimento 2013 18(1):119-135.^-3535 Evangelista RA, Bueno AA, Castro PA, Nascimento JN, Araújo NT, Aires GP. Percepções e vivências dos idosos residentes de uma instituição asilar. Rev. Esc Enferm USP 2014; 48(2):81-86.. Fragile health conditions, coupled with poverty and deprivation of social rights, are violent situations³²32 Minayo MCA, Almeida LCC. Importância da política nacional do idoso no enfrentamento da violência. In: Alcântara AO, Camarano AA, Glacomin KC, organizadoras. Política Nacional do idoso: velhas e novas questões. Rio de Janeiro: IPEA; 2016. p. 435-456. as they are risk factors for conflicts, disagreements, violence and isolation of the elderly.

The lack of flexibility, the standardization of daily life and the rare stimulation of elderly autonomy was also a point raised by several authors³⁰30 Gerlack LF, Bós AG, Karnikowski MGO, Lyra Júnior DP. Acesso e aquisição de medicamentos em instituições de longa permanência para idosos no Brasil. Sci. Med 2013; 23(2):90-95.^,3333 Soares RFN. Reflexões sobre espaço de moradia para idosos e políticas públicas. Cad Tem Kairós Geront 2010; 13(8):91-107.^,3535 Evangelista RA, Bueno AA, Castro PA, Nascimento JN, Araújo NT, Aires GP. Percepções e vivências dos idosos residentes de uma instituição asilar. Rev. Esc Enferm USP 2014; 48(2):81-86.. Soares³³33 Soares RFN. Reflexões sobre espaço de moradia para idosos e políticas públicas. Cad Tem Kairós Geront 2010; 13(8):91-107. states that “institutionalization seems to inhibit the exercise of autonomy by the routine employed. The operating rules anticipate the verbalization of desires and needs; seniors are no longer able to make decisions about their own lives.” In a study that evaluated the quality of life of the elderly in six LTCIEs in the city of Natal, capital of Rio Grande do Norte, Nunes³¹31 Nunes VMA, Menezes RMP, Alchieri JC. Avaliação da qualidade de vida em idosos institucionalizados no município de Natal, estado do Rio Grande do Norte. Acta Sci 2010; 32(2):119-126. reported that the degree of autonomy was the lowest mean found among the different realms of the WHOQOL (quality of life evaluation tool) and emphasized that the maintenance of this autonomy in old age is closely related to the quality of life, since it is essential that it manages their life and daily activities.

This lack of exercise of autonomy, coupled with a rigidly structured daily life, which is not very stimulating and does not respect individual differences, contrasts with what the Statute of the Elderly³⁶36 Brasil. Lei 10.741, de 01 de outubro de 2003. Aprova Estatuto do Idoso. Diário Oficial da União 2003; 01 out. states in chapter 2: “The right to respect consists in the inviolability of physical, psychological and moral integrity, covering the preservation of image, identity, autonomy, values, ideas and beliefs, spaces and personal objects.”

A literature review³⁷37 Moreira PA, Roriz AKC, Mello AL, Ramos LB. Quality of Life of Institutionalized Elderly In: Brazil. Social Indicators Research 2016; 126(1):187-197. reinforces the idea that it is essential that the institutional community promote the autonomy of the elderly in order to improve the quality of life since the perception of autonomy and environmental aspects were the issues of lower satisfaction for institutionalized elderly living in these spaces.

The need for more educational, formative and training actions for professionals working at LTCIEs was also addressed in six publications²⁸28 Oliveira MPF, Novaes MRCG. Perfil Socioeconômico, epidemiológico e farmacoterapêutico de idosos institucionalizados de Brasília. Cien Saude Colet 2013; 18(4):1069-1078.^,3131 Nunes VMA, Menezes RMP, Alchieri JC. Avaliação da qualidade de vida em idosos institucionalizados no município de Natal, estado do Rio Grande do Norte. Acta Sci 2010; 32(2):119-126.^,3333 Soares RFN. Reflexões sobre espaço de moradia para idosos e políticas públicas. Cad Tem Kairós Geront 2010; 13(8):91-107.^,3434 Silva J, Almeida M. Orientações Políticas e Prática Profissional em Instituições de Longa Permanência Para Idosos. Estudo Interdisciplinares sobre o Envelhecimento 2013 18(1):119-135.^,3838 Feliciani AM, Santos SSC, Pelzer MT, Oliveira AMN, Pinho LB. Construção de ferramenta direcionada às instituições de longa permanência para idosos: relato de experiência. Rev. Eletrônica Enferm 2011; 13(2):474-482.^,3939 Lini EV, Portella MR, Doring M, Santos MIPO. Long-term care facilities for the elderly: from legislation to needs. Rev. RENE 2015; 16(2):284-293.. Lini et al.³⁹39 Lini EV, Portella MR, Doring M, Santos MIPO. Long-term care facilities for the elderly: from legislation to needs. Rev. RENE 2015; 16(2):284-293. point out that Brazil has different realities, but that, in general, LTCIEs have a very different standard than what is advocated in public policies: care activities are performed inappropriately, or professionals are not adequately qualified. Feliciani et al.²⁹29 Feliciani AM, Santos SSC, Valcarenghi RV. Funcionalidade e quedas em idosos institucionalizados: proposta de ações de enfermagem. Cogitare Enferm 2011; 16(4):615-621. point out that, besides the need for adequate human resources to meet the demand of residents, there is a lack of physical and material infrastructure, which are also crucial for the care of the elderly.

The need for professional training and qualification in health has also been raised in some international papers⁴⁰40 Porock D, Bakk L, Sullivan SS, Love K, Pinkowitz J. National priorities for dementia care: Perspectives of individuals living with dementia and their care partners. J Gerontol Nur 2015; 41(8):9-16.^,4141 Mcgee SJ, Kaylor BD, Emmott H, Christopher MJ. Defining Chronic Pain Ethics. Pain Medicine 2011; 12(9):1376-1384. that argue that such measures are essential for more effective interventions in the elderly with dementia or chronic pain, in order to avoid stigmatization and discrimination. On the other hand, through secondary data, Baldwin et al.⁴²42 Baldwin R, Chenoweth L, Dela Rama M, Liv Z. Quality failures In: residential aged care in Australia: The relationship between structural factors and regulation imposed sanctions. Australas J Ageing 2015 34(4):E7-E12. describe the sanctions to which some elderly homes were submitted in Australia, due to physical structure inadequacies concerning what is recommended by policies in that country.

The Brazilian scientific production²⁸28 Oliveira MPF, Novaes MRCG. Perfil Socioeconômico, epidemiológico e farmacoterapêutico de idosos institucionalizados de Brasília. Cien Saude Colet 2013; 18(4):1069-1078.^,3030 Gerlack LF, Bós AG, Karnikowski MGO, Lyra Júnior DP. Acesso e aquisição de medicamentos em instituições de longa permanência para idosos no Brasil. Sci. Med 2013; 23(2):90-95.^,3434 Silva J, Almeida M. Orientações Políticas e Prática Profissional em Instituições de Longa Permanência Para Idosos. Estudo Interdisciplinares sobre o Envelhecimento 2013 18(1):119-135.^,3939 Lini EV, Portella MR, Doring M, Santos MIPO. Long-term care facilities for the elderly: from legislation to needs. Rev. RENE 2015; 16(2):284-293. investigated the relationship between the services of the Unified Health System and the LTCIEs, pointing out the difficulties and inadequacies of elderly care. Gerlacket al.³⁰30 Gerlack LF, Bós AG, Karnikowski MGO, Lyra Júnior DP. Acesso e aquisição de medicamentos em instituições de longa permanência para idosos no Brasil. Sci. Med 2013; 23(2):90-95. found that access to medication at an LTCIE in Porto Alegre, Rio Grande do Sul, was a critical aspect between the nonprofit LTCIE and the SUS, since a quarter of the medicines used by the elderly could be acquired in the public network, but ended up being paid by the residents who already had a low income. In the same vein, a study²⁷27 Matus-Lopez M. Thinking about long-term care policies for Latin America. Salud Colectiva 2015; 11(4):485-496. found that 12.3% of the medicines prescribed for older adults of an LTCIE were not accessible in the public health network, which also indicates a need for broader dialogue between the SUS and these institutions. Lini et al.³⁹39 Lini EV, Portella MR, Doring M, Santos MIPO. Long-term care facilities for the elderly: from legislation to needs. Rev. RENE 2015; 16(2):284-293. point out that “one of the great complaints of managers of long-stay institutions for the elderly is the lack of service by the SUS, although it is in the area covered by Family Health strategies.” Although they do not mention the articulation between SUS and LTCIE, Evangelista et al.³⁵35 Evangelista RA, Bueno AA, Castro PA, Nascimento JN, Araújo NT, Aires GP. Percepções e vivências dos idosos residentes de uma instituição asilar. Rev. Esc Enferm USP 2014; 48(2):81-86. emphasize the importance of assuring to the elderly diverse care proposals that can transcend the supply of food and medicines. A national study⁴³43 Piuvezam G, Lima KC, Carvalho MS, Xavier VGP, Silva RA, Dantas ARF, Nunes VMA. Atenção primária à saúde e os idosos institucionalizados: a perspectiva da gestão municipal no Brasil. Revista Portuguesa de Saúde Pública 2015: 34(1):92-100. that covered two municipalities in each Brazilian region, and whose objective was to identify the actions developed in primary care with institutionalized elderly, found the lack of complex actions geared to neurodegenerative or rheumatic diseases, for example, in the way of exercising the integrality of elderly care, with scarcity and even absence, in many places, of actions with LTCIE elderly residents.

Several papers analyzed identified barriers in the interaction between LTCIE residents and the external community³¹31 Nunes VMA, Menezes RMP, Alchieri JC. Avaliação da qualidade de vida em idosos institucionalizados no município de Natal, estado do Rio Grande do Norte. Acta Sci 2010; 32(2):119-126.^,3434 Silva J, Almeida M. Orientações Políticas e Prática Profissional em Instituições de Longa Permanência Para Idosos. Estudo Interdisciplinares sobre o Envelhecimento 2013 18(1):119-135.^,3535 Evangelista RA, Bueno AA, Castro PA, Nascimento JN, Araújo NT, Aires GP. Percepções e vivências dos idosos residentes de uma instituição asilar. Rev. Esc Enferm USP 2014; 48(2):81-86.. Nunes et al.³¹31 Nunes VMA, Menezes RMP, Alchieri JC. Avaliação da qualidade de vida em idosos institucionalizados no município de Natal, estado do Rio Grande do Norte. Acta Sci 2010; 32(2):119-126. affirm that, despite the family bond, institutionalized elderly are excluded from the family context and thus lose contact with their immediate families. In a documentary and bibliographic analysis of LTCIE-related policies, Silva and Almeida³⁴34 Silva J, Almeida M. Orientações Políticas e Prática Profissional em Instituições de Longa Permanência Para Idosos. Estudo Interdisciplinares sobre o Envelhecimento 2013 18(1):119-135. observed that the integration between the residents and the community is recommended, but does not happen in practice, which suggests confinement of many seniors to the institutional environment. A qualitative study⁴³43 Piuvezam G, Lima KC, Carvalho MS, Xavier VGP, Silva RA, Dantas ARF, Nunes VMA. Atenção primária à saúde e os idosos institucionalizados: a perspectiva da gestão municipal no Brasil. Revista Portuguesa de Saúde Pública 2015: 34(1):92-100. conducted with 18 older adults in an institution of a Brazilian capital point to the abandonment of the elderly by the family as one of the most present themes in the interviews, which showed resentment and suffering.

Finally, the notes for improvement and development of public policies for institutionalized elderly were found in at least four publications²⁸28 Oliveira MPF, Novaes MRCG. Perfil Socioeconômico, epidemiológico e farmacoterapêutico de idosos institucionalizados de Brasília. Cien Saude Colet 2013; 18(4):1069-1078.^,3434 Silva J, Almeida M. Orientações Políticas e Prática Profissional em Instituições de Longa Permanência Para Idosos. Estudo Interdisciplinares sobre o Envelhecimento 2013 18(1):119-135.^,3535 Evangelista RA, Bueno AA, Castro PA, Nascimento JN, Araújo NT, Aires GP. Percepções e vivências dos idosos residentes de uma instituição asilar. Rev. Esc Enferm USP 2014; 48(2):81-86.^,3838 Feliciani AM, Santos SSC, Pelzer MT, Oliveira AMN, Pinho LB. Construção de ferramenta direcionada às instituições de longa permanência para idosos: relato de experiência. Rev. Eletrônica Enferm 2011; 13(2):474-482.. Silva and Almeida³⁴34 Silva J, Almeida M. Orientações Políticas e Prática Profissional em Instituições de Longa Permanência Para Idosos. Estudo Interdisciplinares sobre o Envelhecimento 2013 18(1):119-135. identified some gaps regarding the objectives, the target public, and the functioning of LTCIE in public policies, and the centrality of these care guidelines to the elderly in institutions is required. Lini et al.³⁹39 Lini EV, Portella MR, Doring M, Santos MIPO. Long-term care facilities for the elderly: from legislation to needs. Rev. RENE 2015; 16(2):284-293. affirm that it is essential to think about and elaborate other care alternatives, with institutionalization as the last possible alternative for the elderly.

In the collection analyzed, no Brazilian production addressed the issue of violence directly within the LTCIEs, although they identify the need for permanent training of professionals working in these institutions, which indirectly leads one to think that neglect can be a daily violence experience in these environments.

Although the literature analyzed here does not explain or evidence institutional violence, it appears in its most distinct expressions in institutional practices, whether in actions or omissions¹⁸18 Castle N, Ferguson-Rome JC, Teresi JA. Elder abuse in residential long-term care: an update to the national research council report. J Appl Gerontol 2015; 34(4):407-443.^,4444 Zanello V, Silva LCE, Henderson G. Saúde Mental, Gênero e Velhice na Instituição Geriátrica. Psicologia: Teoria e Pesquisa 2015; 31(4):543-550.. A study on the perceptions of LTCIE workers about violence⁴⁵45 Kullok AT, Santos ICB. As representações sociais de funcionários de uma Instituição de Longa Permanência sobre violência no interior de Minas Gerais. Interface (Botucatu) 2009; 13(28):201-212. identified the experiences of these workers as victims, but concerning the elderly, the violence reported by them happened outside and not within the institution.

Berzins⁴⁶46 Berzins MV. Violência institucional contra a pessoa idosa: a contradição de quem cuida [tese]. São Paulo: Universidade de São Paulo; 2009. contributes to the debate by revealing that the primary forms of institutional neglect can be perceived indirectly through complaints of lack of listening, coldness, harshness, inattentive care, among others. Thus, it is considered that the barriers to access to care with the SUS, the lack of training of the caregivers, the inadequate physical space and the lack of LTCIEs’ openness to the contact of the elderly with the community, can be considered institutional violence.

Final considerations

One limitation of this review is that authors have analyzed the issue of violence in the policies geared to LTCIE from the viewpoint of scholars and not the policies themselves.

In countries characterized by the insufficiency or absence of long-term care public policies and their difficult implementation, what prevails is the informality of families who take on a workload without proper preparation and support to perform this function. On the other hand, a portion of the elderly with limitations is directed to LTCIE, which is often of a philanthropic or non-profit nature, and also often does not comply with the guidelines and orientations recommended for care. This situation can lead to the most diverse forms of violence.

It is important to note that countries still lacking long-term care public policies can include this issue in their agendas, formalizing services to care recipients, and the State share with families the responsibility to provide for the needs of the elderly.

Such insufficiency of policies can be characterized as a structural violence that has affects at least two scopes: for the unassisted elderly, without the resources and support to maintain basic care and who, possibly, will have a compromised quality of life; on the other hand, it has repercussions on families who provide long-term care, since they are physically, emotionally and financially burdened, which culminates into ill-gotten relationships and the risk of intra-family violence.

In Brazil, the studies draw attention to the need for continuous training of LTCIE professionals; accessibility problems; the difficulties of health care in the SUS, as well as access to medicines; barriers of social interaction with the community and the need for improvements and implementation of Brazilian public policies.

The plan for coping with violence against the elderly, proposed as a strategic action the approval of the “National Policy of Long-Term Care Institutions for the Elderly” to establish a real diagnosis and gather proposals for the reformulation in favor of the elderly in order to avoid situations of abuse and ill-treatment that may be veiled in these institutions due to the absence of LTCIE-targeted policies. North American research in this review pointed to the need to revise legislation on the definition of elder abuse in institutionalization, in order to combat this phenomenon in nursing homes. Thus, one might ask: How is long-term care being thought in Brazil? Do Brazilian families support the amount of care the elderly need? How does Brazil address violence in LTCIEs?

Violence has not been directly or explicitly addressed in these studies, although the results indicate that there are forms of violations within these institutions that are institutional violence. Further studies focused on this theme are required to also think about ways to prevent violence.

References

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