Abstract

This study aims to investigate the implications of chronic noncommunicable diseases in dependent older adults. This is a multicenter, qualitative study in which semi-structured interviews were conducted with 59 dependent older adults diagnosed with chronic disease. The Thematic Analysis technique was used for analyzing the information. Most older adults were female, white, with low schooling level and lived with their daughters. All were undergoing drug treatment, and cardiocirculatory diseases were the most prevalent conditions. The implications of chronic diseases are manifested in the use of medications, which are also a risk factor; in the condition of dependence and in the experience with chronic diseases, which show more significant use of health services; the high economic impact of chronic diseases on families and the state; and the insufficient household income, which condition older adults to have few social and community support devices.

Key words:
Chronic noncommunicable diseases; Dependent older adults; Qualitative research

Introduction

Chronic noncommunicable diseases (NCDs) are characterized by pathologies of multiple causes and risk factors, long latency periods, and prolonged course. Furthermore, they have a non-infectious origin and can result in functional disabilities¹1 Brasil. Ministério da Saúde (MS). Diretrizes e Recomendações para o Cuidado Integral de Doenças crônicas Não-Transmissíveis: promoção da saúde, vigilância, prevenção e assistência. Brasília: MS; 2008..

In the early 20^th century, infectious diseases were the leading causes of death in the world population. Currently, NCDs are the leading causes of mortality, resulting from the best socioeconomic and health conditions in recent decades. In 2008, 36 million deaths were recorded globally, 63% of which due to NCDs, especially circulatory diseases, diabetes, cancer, and chronic respiratory disease. Older adults and people with low education and income were the most affected²2 Alwan A. Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries. Lancet 2010; 376(9755):1861-1868..

In Brazil, NCDs are the main burden of disease and death in the population and a significant public health problem. In 2009, the Disability Adjusted Life Years (DALY), which simultaneously measures the effect of disease mortality and morbidity on the population, accounted for 72% of the years of life lost²2 Alwan A. Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries. Lancet 2010; 376(9755):1861-1868.^,33 Schramm JMA, Oliveira AF, Leite IC, Valente JG, Gadelha AMJ, Portela MC, Campos MR. Transição epidemiológica e o estudo de carga de doenças no Brasil. Cien Saude Colet 2004; 9(4):897-908. In 2012, chronic diseases accounted for almost 70% of years of life lost due to disability in Brazil. This proportion increases with age, reaching almost 90% of all DALY among older adults aged 70 and over⁴4 Boccolini CS. Morbimortalidade por doenças crônicas no Brasil: situação atual e futura. Rio de Janeiro: Fundação Oswaldo Cruz; 2016.. Older adults over 80 years old have a higher mortality rate (74%) than those aged 60-79 (25%)⁵5 Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Chronic noncommunicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781):1949-1961..

NCDs in dependent older adults are associated with loss of functionality and are the leading cause of dysfunctionality in most South American countries, including Brazil. Dysfunctionality refers to deficiencies, activity limitations, or restricted community and social participation⁶6 Cabrera MAS, Andrade SM, Wajngarten M. Causes of mortality in elderly people: a 9-year follow-up study. Geriatria & Gerontologia. 2007; 1(1):14-20

7 Hansen EO, Tavares STO, Cândido SA, Pimenta FAlP, Moraes EN, Rezende NA. Classificação internacional de funcionalidade, de doenças e prognóstico médico em pacientes idosos. Rev Med Minas Gerais 2011; 21(1):55-60.^-88 World Health Organization (WHO). International Classification of functioning, disability and health: ICF. Genebra: WHO; 2001..

NCDs have a high economic cost for both the health system and society, negatively impacting countries’ development. Also, health professionals are poorly prepared to meet this group’s needs, as less than 15% of undergraduate health sciences programs in the Americas and less than 10% of primary medical specialties include Aging and Geriatric Health in their teaching plans⁹9 Pereira RA, Alves-Souza RA, Vale JS. Processo de transição epidemiológica no Brasil: uma revisão de literatura. Revista Científica da Faculdade de Educação e Meio Ambiente 2015; 6(1):99-108.^,1010 Organização Pan-Americana de Saúde (OPAS). Brasil. Envelhecimento e Saúde. Brasília: OPAS; 2018..

To produce subsidies for the elaboration of a Public Policy that considers specificities related to the effects of NCDs in the lives of dependent older adults¹¹11 Minayo MCS. O imperativo de cuidar da pessoa idosa dependente. Cien Saude Colet 2019; 24(1):247-252., this study aims to investigate the implications of NCDs in dependent older adults in municipalities in different Brazilian regions.

Methodological design

This is a qualitative study whose theoretical framework is included in the perspective of hermeneutics-dialectics, which valued the critical and comprehensive exercise of language, relationships, and social practices of people involved with dependent older adults in Brazil. It is nested in a multicenter research that aims to formulate subsidies to construct public policies on dependence.

Claves/ENSP/Fiocruz investigated in conjunction with eight educational institutions: University of Fortaleza (UNIFOR), Federal University of Pernambuco (UFPE), Federal University of Rio Grande do Sul (UFRGS), Federal University of Amazonas (UFAM), Federal University of Piauí (UFPI), Federal University of Santa Catarina (UFSC), and the Brazilian Ministry of Social Security.

The investigation covered eight Brazilian municipalities: Araranguá (SC), Brasília (DF), Fortaleza (CE), Manaus (AM), Porto Alegre (RS), Recife (PE), Rio de Janeiro (RJ) and Teresina (PI) in 2019.

Fifty-nine of the 64 older adults interviewed in the survey participated in this study (Table 1). The inclusion criteria were age ≥ 60 years; both genders; some physical, mental or cognitive dependence; diagnosed with NCD and able to respond to the interview. Older adults linked to Long Term Care Institutions or living alone were excluded. Older adults were identified by professionals from the Family Health Strategy, Hospitals, and other health services in the cities investigated.

The information was collected through semi-structured interviews, guided by a standardized instrument built by researchers from Brazilian universities, and carried out by adequately trained researchers. The topics covered in the interviews comprised information related to sociodemographic data; NCDs; family structure, functional, cognitive, mental/emotional, and social dependence.

Software Statistical Package quantified the sociodemographic aspects for the Social Sciences, version 20.0. The measure of the frequency of the characteristics of the participants was presented, which included aspects related to gender, race, marital status, age group, number of children and grandchildren, religion, and education; the number of diseases per older adult, medication, and a group of NCDs (neoplasms, diabetes, respiratory diseases, and cardiocirculatory diseases).

The interviews were audio-recorded and transcribed. It is noteworthy that the qualitative statements and data for quantifying the sociodemographic aspects selected for this study were collected from the textual corpus generated by the transcripts carried out by the researchers.

Qualitative statements were analyzed from the Thematic Analysis (TA) perspective. The thematic analysis described by Braun and Clarke¹²12 Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006; 3(2):77-101. is an analytical method used in qualitative research, which aims to analyze phenomena based on the data worked, thematizing meanings, and enabling thematic codification. The analysis was carried out in six phases: 1. Familiarization with the data; 2. Production of initial codes; 3. Search for themes; 4. Review of topics; 5. Definition and naming of themes; 6. Selection of examples experienced by the respondents that were converted into themes, subthemes, and final analysis. Figure 1 shows the themes and sub-themes that emerged from the respondents’ reports.

The Research Ethics Committee of the National School of Public Health (ENSP/Fiocruz) approved the research project.

Results and discussion

Sociodemographic characteristics

In this study, information from 59 dependent older adults who reported having NCDs was used. Most dependent older adults were female (62.7%), white (56.3%), with low schooling, and Catholic; 54.7% were long-lived, over the age of 80, lived without a partner, had children and grandchildren. Of the total, 37.5% lived with a daughter, and 31.3% with a partner, in their own home adapted to their needs (Table 2).

The data corroborate Brazil’s demographic projection, which indicates a higher proportion of white women among older adults due to the different mortality by gender and race, something that affects the black male population early¹³13 Instituto Brasileiro de Geografia e Estatística (IBGE). Tábua completa de mortalidade para o Brasil 2018: Breve análise da evolução da mortalidade no Brasil. Rio de Janeiro: IBGE; 2019.. Low schooling and worse socioeconomic conditions are associated with the loss of physical and functional capacity among older adults. They possibly accumulated a more significant disease burden throughout their lives, performed harmful work activities, have harmful lifestyle habits, and less access to health services. Also, the population aged 80 and over is increasing in Brazil and is the most vulnerable to several types of dependence¹⁴14 Camarano AA. Quanto custa cuidar da população idosa dependente e quem paga por isto? In: Camarano AA, organizador. Novo regime demográfico: uma nova relação entre população e desenvolvimento? Rio de Janeiro: Ipea; 2014. p. 605-623..

Older adults have a high number of children and grandchildren and count on the presence of their spouse or the person who cares for them, although many of them feel alone. This paradox may be the result of changes and family dynamics marked by the coexistence of great-grandchildren, grandchildren, and children in the same residence, while at the same time losing bond and solidarity¹⁴14 Camarano AA. Quanto custa cuidar da população idosa dependente e quem paga por isto? In: Camarano AA, organizador. Novo regime demográfico: uma nova relação entre população e desenvolvimento? Rio de Janeiro: Ipea; 2014. p. 605-623.. Most suffered from two diseases (50.3%), and all underwent drug treatment. Cardiocirculatory diseases had a higher prevalence (88.1%), followed by diabetes (23.1%), neoplasms (8.5%), and respiratory problems (3.4%) (Table 3).

Alves et al.¹⁵15 Alves LC, Leimann BCQ, Vasconcelos MEL, Carvalho MS, Vasconcelos AGG, Fonseca TCO, Lebrão ML, Laurenti R. A influência das doenças crônicas na capacidade funcional dos idosos do Município de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1924-1930. point out that chronic diseases have a strong influence on older adults’ functional capacity. Arterial hypertension increases by 39% the likelihood of becoming dependent in IADL (heart disease by 82% and lung disease by 50%). Cancer and diabetes have a moderate impact on the functionality of older adults¹⁵15 Alves LC, Leimann BCQ, Vasconcelos MEL, Carvalho MS, Vasconcelos AGG, Fonseca TCO, Lebrão ML, Laurenti R. A influência das doenças crônicas na capacidade funcional dos idosos do Município de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1924-1930.. For dependence in IADLs and BADLs, the likelihood more than doubled in the presence of each of these chronic diseases, increasing when older adults have more than one NCD¹⁴14 Camarano AA. Quanto custa cuidar da população idosa dependente e quem paga por isto? In: Camarano AA, organizador. Novo regime demográfico: uma nova relação entre população e desenvolvimento? Rio de Janeiro: Ipea; 2014. p. 605-623..

The maintenance of functional capacity can contribute to older adults’ quality of life as it is related to the conditions of individuals to remain active, enjoying their independence until the most advanced ages. Thus, the prevention and control of NCDs can improve activities and, consequently, promote the well-being of this population¹⁶16 World Health Organization (WHO). Relatório mundial de envelhecimento e saúde. Geneva: WHO; 2015..

Socioenvironmental characteristics

Family relationships, suffering, and resilience

The group of older adults interviewed had multiple NCDs, and they depended on third parties - at varying severity levels -for the performance of their BADLs and IADLs. Most reported living with daughter, husband, partner, sister, and grandson (only three lived alone: I live alone (Rio de Janeiro, Male, 80 years); I live very alone, what I really wanted was a person who spent the day here to talk to me (Piauí, Female, 86 years), which is compatible with Finucane’s¹⁷17 Finucane TE. How is geriatrics diferent from general internal medicine? Geriatr Gerontol Int 2004; 4:259-266. statements on this topic, by pointing out that dependent older adults are more fragile and vulnerable and more likely to die early if they do not receive care. The fact that older adults should be in the care of relatives was seen by 26 of them with a feeling of sadness, disgust, and feeling cornered:

The sadness perceived in the statements results from uselessness and the impossibility of carrying out pleasurable activities before NCDs. This sadness can lead older adults to social isolation and loneliness and become a vicious circle that must be broken because the more significant the sadness, the greater the isolation and loneliness, and the more the isolation and loneliness grows, the greater the feeling of sadness. Sadness is an understandable feeling in older adults with chronic disease because the uncertainties regarding their response to treatment, survival time, and cure cause anxiety and are stressful factors. Thirty-three older adults are already satisfied because they have developed strategies to continue living:

In the statement above, we observe a new meaning of pain and suffering in feelings of acceptance and pleasure by the older woman, valuing her ability to cope with adverse situations. This is compatible with the concept of resilience in old age since its “affective and cognitive reserves are manifested through the resources of coping and affective regulation, motivation, goals, and capacity self-beliefs”¹⁸18 Fontes AP, Liberalesso AN. Resiliência e velhice: revisão de literatura. Cien Saude Colet 2015; 20(5):1475-1495..

Living in the home environment and the protection provided by relatives who show understanding, empathy, and encouragement to positive experiences are factors that dignify the lives of older adults in the final stage of their existential cycle, especially those with NCDs. Notably, family support is referred to emotionally favorable interpersonal exchanges, together with the necessary and appropriate care that provides them with security¹⁹19 Figueiredo AEB, Silva RM, Vieira LJE, Mangas RMN, Sousa GS, Freitas JS, Conte M, Sougey EB. É possível superar ideações e tentativas de suicídio? Um estudo sobre idosos. Cien Saude Colet 2015; 20(6):1711-1719..

Some elderly respondents reported that they are cared for by only one relative.

Observing the statements of these older adults, it appears that relatives provide care due to a need driven by their physical or mental incapacity to take care of themselves, which raises the issue of the distress of relatives providing care to older adults alone, without shared responsibilities. As seen in this study, this overload can lead relatives to lose their previous social relationships and dissatisfaction for not carrying out personal and professional projects²⁰20 Osório AR, Pinto FC. As pessoas idosas: contexto social e intervenção educativa Lisboa: Instituto Piaget; 2007.. Besides the difficulties of children and other relatives sharing their time and responsibilities with caregivers, in Brazil, health and social policies provide insufficient resources to relieve the burden falling solely on the family.

Disease experience and gender issues

In the reports of dependent older adults, we aimed to observe how the disease experience²¹21 Alves PC, Rabelo M. Significação e metáforas: aspectos situacionais no discurso da enfermidade. In: Pitta A, organizador. Saúde e Comunicação: visibilidades e silêncios. São Paulo: Hucitec/Abrasco; 1995. [informar as páginas do capítulo] affects their lives and how they seek to level off this experience. We agree with Ricoeur²²22 Ricoeur P. Teoria da Interpretação. Lisboa: Edições 70; 1987. when he says that language is how private experience becomes public and is externalized. In this case, the experience of illness of dependent older adults studied here was expressed by the report of their experiences. We sought to understand their realities through their accounts. At least three attitudes are observed in these statements’ excerpts: distress and discontent, acceptance and positive attitude, and extreme thoughts about death.

When reflecting on the health status of older adults, marked by limitations and physical discomfort, the weight of the loss of physical autonomy, functional dependence, and the fact that they need a third person to support them is evident. This is how some older adults expressed their sadness and discontent:

This respondent’s vivid account points to the importance of work and production in men’s lives at any age since work is an identity pillar of masculinity and has a strong link with inclusion in the family that he establishes²³23 Zanello V. Saúde mental, gênero e dispositivos: cultura e processos de subjetivação. Curitiba: Appris; 2018.. The experience of a disease that creates dependence thoroughly challenges older adults, exposing their weaknesses and afflictions. The inability to perform daily tasks and the disillusionment caused by uncertainty about the future triggers a reaction of great suffering:

On the contrary, some older adults feel good and report their experience resiliently and positively. Giving positive meaning to the contingencies of dependence is emphasized by Dias²⁴24 Dias LF. Doença como experiência: seus episódios e suas narrativas Revista do Instituto de Políticas Públicas de Marília 2016; 2(1):78-89. when he states that: “When life does not smile exactly as one would like, for example, in the face of an episode of illness, some shortcuts are taken to solve practical problems and existential afflictions”.

The two cases cited are supported by the words of Laplantine²⁵25 Laplantine F. Antropologia da Doença. São Paulo: Martins Fontes; 2004., who argues that normal and pathological are no longer thought of in terms of being (something somewhere) but harmony and disharmony, and balance and imbalance. Therefore, the disease is no longer considered an enemy and strange entity, but a breakdown due to excess or lack. Thus, the existential consequences generated from a situation of dependence are mostly subject to how older adults are exposed to the world and their receptivity regarding the circumstances of their condition, but mainly, the support network they own and built throughout life. In this sense, the last stage of the existential cycle reflects human history and trajectory.

Some other older adults showed that it is unbearable for them to be living in a situation of suffering because of their comorbidities and dependence situation. Therefore, they present extreme thoughts such as the desire to end life, as a way to silence the experiences of distress, as in the following statement:

This last statement refers to what was highlighted by Shneidman²⁶26 Shneidman ES. Comprehending suicide. Washington: American Psychological Association; 2001. showing that suicidal behavior is the result of a feeling of intolerable pain related to frustrations due to basic unmet psychological needs; attitudes of self-depreciation; a self-image that cannot stand the intense psychological pain of the inability to perform daily tasks; the feeling of isolation and hopelessness to solve the causes of intolerable pain.

Gender inequalities are relevant in this study since the percentage of women (62.7%) living with NCDs is higher than among men (37.3%). While this issue has not been further explored in the interviews, they deserve some considerations.

Females’ predominance may be because women have a higher life expectancy in Brazilian society, although they are also the primary victims of domestic violence and discrimination in the access to education, income, food, work, and health care. This aspect contributes to the propensity to show more dysfunctionality than men at older ages, which was also observed in the studies by Botev²⁷27 Botev N. Older persons in countries with economies in transitions. Population Ageing: Challenges for Policies and Programmes in Developed and Developing Countries. Nova York: Fundo Populacional das Nações Unidas; 1999.

Gender is undeniably a fundamentally social category useful to the history of relationships between men and women and is a promising field for studies on inequalities and social hierarchies²⁸28 Filho AT. Uma questão de gênero. Cadernos Pagu 2005; (24):127-152..

Culturally, women are seen as more careful and more patient. They get faster care in health services and enjoy greater availability, which may be related to an alleged feminine fragility, and also because they are encouraged, from a young age, to seek the doctor, or to take care of the family, which requires more excellent care for oneself.

It is crucial to consider the words of Freud²⁹29 Freud S. Consequências psíquicas da diferença anatômica entre os sexos. Rio de Janeiro: Imago; 1996 when he states: all human individuals, as a result of their bisexual constitution and their crossed heritage, have both male and female traits, so that the content of the theoretical constructions of pure masculinity and pure femininity remains uncertain.

Male and female older adults experiencing chronic illness implies considering and intensifying gender-related studies and research as a fundamental strategy for implementing and implanting public policies to respond to this diversity positively.

Functionality and dysfunctionality

The most significant cause of dependence among older adults is the loss of functionality caused mainly by NCDs, which can be observed in the statements of older adults:

The importance of carrying out domestic activities for older adults is felt as the abortion of their possibilities to appear productive. This was the reality with which this 97-year-old woman lived. Her importance as a social being within her family is closely related to her gender destiny.

As we saw in the two respondents’ accounts, the importance of dysfunctionality in the study of NCDs transcends health/disease because its understanding offers the possibility of being worked on for health promotion, prevention, and improved community and social participation. Thus, it expands the perception of the disease of the health-disease binomial by introducing social difficulties in this perception and encouraging the adoption of support networks and facilitators⁷7 Hansen EO, Tavares STO, Cândido SA, Pimenta FAlP, Moraes EN, Rezende NA. Classificação internacional de funcionalidade, de doenças e prognóstico médico em pacientes idosos. Rev Med Minas Gerais 2011; 21(1):55-60.. More than dependence itself, the lack of this stimulus causes feelings of discouragement, isolation, and despair in older adults, as seen in the following statement:

In caring for the older adults with NCDs, it is essential to highlight the difference between performance, which assesses what is done daily, and functional capacity, which assesses the remaining potential in their condition. It is not acceptable to suppose that a limited capacity is due to one or more deficiencies or that the restricted performance occurs only because of one or more limitations. It is crucial to obtain as much information as possible about older adults’ disease experience and investigate the interrelationships between that experience and the socioenvironmental (exogenous) and personal (endogenous) aspects independently.

Today, many fields of knowledge in health, such as physiotherapy, physical education, nutrition, and dentistry, can contribute to older adults recovering their autonomy or reducing their suffering. For example, several authors²⁷27 Botev N. Older persons in countries with economies in transitions. Population Ageing: Challenges for Policies and Programmes in Developed and Developing Countries. Nova York: Fundo Populacional das Nações Unidas; 1999^,2828 Filho AT. Uma questão de gênero. Cadernos Pagu 2005; (24):127-152.^,3030 Damo CC, Doring M, Alves ALS, Portella MR. Risco de desnutrição e os fatores associados em idosos institucionalizados. Rev. Bras. Geriatr. Gerontol. 2018; 21(6):711-717. emphasize that many people in this social group become malnourished due to lack of knowledge or care, which worsens their physical and mental health, aggravating their dependence level. Alternatively, it is now known that older adults with a functional mobility disability can benefit from the help of technologies or worsen their performance in the family and social environment due to the lack of this opportunity³⁰30 Damo CC, Doring M, Alves ALS, Portella MR. Risco de desnutrição e os fatores associados em idosos institucionalizados. Rev. Bras. Geriatr. Gerontol. 2018; 21(6):711-717..

In summary, all aspects are essential in investigating the possibilities of improving dependent older adults’ performance. A dysfunctionality in one aspect of their life does not mean that they are dysfunctional in all others. However, discrimination on account of a chronic illness or social problems can limit their chances of performance.

Extra-family relationships

Thirty-three older adults reported social relationships with people in the community and others. This openness to remain present and participate, as far as possible, in the world they live in is a vital sign of resilience and healthy aging, which can be seen, for example, in the following report:

However, this openness to others is not an end-of-life construction. It is the result of an existence in which interaction was and continues to be a social value. Regardless of the family’s social integration, community support must be nurtured, since society is part (along with the family and the State) of the responsibility for the emotional, instrumental, and material support offered to older adults, particularly in the case of people in adverse social conditions¹⁹19 Figueiredo AEB, Silva RM, Vieira LJE, Mangas RMN, Sousa GS, Freitas JS, Conte M, Sougey EB. É possível superar ideações e tentativas de suicídio? Um estudo sobre idosos. Cien Saude Colet 2015; 20(6):1711-1719..

Community support devices must be accessible to all relatives and not just those who can afford to pay. In the case of the State’s role, public agencies responsible for providing care to dependent older adults should promote actions that improve their performance and rehabilitation. At the same time, they should support families through guidance and collaborate to have adequate conditions to perform the care function. In this sense, and as an example of a concrete support policy for dependent older adults and their families, the Ministry of Labor and Social Assistance recommendations to public and contracted services in Spain are mentioned³¹31 Silva JL, Marques APO, Leal MCC, Alencar DL, Melo EMA. Fatores associados à desnutrição em idosos institucionalizados. Rev Bras Geriatr Gerontol 2015; 18(2):443-451.. This quote considers the cultural proximity between the two countries: 1) prevention of situations of dependence and promotion of personal autonomy; 2) help at home (support for domestic activities and personal care); 3) day/night care centers; 4) institutionalized care, through geriatric homes and care centers for people with mental or physical disabilities; and 5) home tele-assistance, providing security and a better quality of life to people in their own homes.

Income and economic impact of NCDs

Most older adults studied here have a household income of between 1,000 and 2,000 reais per month. Only one receives 4,000 reais per month. This is one of the exogenous aspects that aggravate the consequences of the disease since the functionality and performance of older adults in a specific domain of their life result from the complex and dynamic interrelationship between their health condition and socio-environmental (exogenous) and personal (endogenous) aspects. A direct or indirect intervention in an element of this relational process can modify one or several aspects³²32 Pereira RJ, Cotta RMM, Franceschini SCC. Fatores Associados ao Estado Nutricional no Envelhecimento. Rev Med Minas Gerais 2006; 16(3):160-164.

The burden of chronic diseases can invariably interfere with the income and savings of individuals or households. Two possible approaches to explore the economic impact of chronic diseases are the cost perspective of not intervening and the prospect of benefiting from specific interventions. In general, the various means by which diseases can impact the economy are discussed in health and economic growth literature³³33 Nóbrega OT, Karnikowski MGO. A terapia medicamentosa no idoso. Cuidados na medicação. Cien Saude Colet 2005; 10(2):309-313..

The approaches to estimating the economic impact of chronic diseases in the literature fall into three main categories: (1) methods for estimating the cost of disease (COI - cost-of-illness); (2) economic growth models that assess the cost of chronic diseases with a focus on their impact on human capital or labor supply; and (3) full income method, which adds the value of health gains to national income³³33 Nóbrega OT, Karnikowski MGO. A terapia medicamentosa no idoso. Cuidados na medicação. Cien Saude Colet 2005; 10(2):309-313..

Indeed, prevention costs are lower than for hospitalizations. Therefore, investigations about morbidity and associated expenses become essential for the development of indicators that guide health promotion and the prevention of chronic diseases, aiming at improving the management of the health system³⁴34 Espanha. Ministerio de Trabajo y Asuntos Sociales Secretaría de Estado de Servicios Sociales, Familias y Discapacidad. Instituto de Mayores y Servicios Sociales (IMSERSO). Madrid: IMSERSO; 2004. Regardless of how sensitive the indicators are, it is known that the use of health and long-term care devices should not be considered expenditure but, instead, State investment, as they allow societies to enjoy their fundamental rights, and that includes dependent older adults¹⁵15 Alves LC, Leimann BCQ, Vasconcelos MEL, Carvalho MS, Vasconcelos AGG, Fonseca TCO, Lebrão ML, Laurenti R. A influência das doenças crônicas na capacidade funcional dos idosos do Município de São Paulo, Brasil. Cad Saude Publica 2007; 23(8):1924-1930..

An investigation and analysis of the expenditure of these older adults and the families who care for them, especially low-income people such as those interviewed, would provide an important parameter to measure their ability to have healthy longevity.

Medical, drugs, and health device support

Medication is the most widely used among the therapeutic resources available to care for dependent older adults and is an essential component since the presence of NCDs in older adults is frequent and sometimes requires different prescriptions.

Most older adults interviewed used several medications, which were necessary due to their condition. However, the use of many at the same time, without adequate and permanent control, is a risk factor as it causes adverse effects or drug interactions”³⁵35 World Health Organization (WHO). An estimation of the economic impact of chronic noncommunicable diseases in selected countries. Geneva: WHO; 2006.. Shrank et al.³⁶36 Shrank WH, Polinski JM, Avorn J. Quality indicators for medication use in vulnerable elders. J Am Geriatr Soc 2007; 55(Supl. 2):S373-S382. affirm that the side effects related to drug use, including tranquilizers for insomnia, induce avoidable older adults’ suffering and hospitalizations. Willcox et al.³⁷37 Willcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA 1994; 272(4):292-296. indicate that a relevant aspect found in studies on older adults is the high frequency of “drug interactions”, particularly in the group aged 80 and over. Therefore, and according to Rouchon and Gurwitz³⁸38 Rouchon PA, Gurwitz JH. Optimising drug treatment for elderly people. BMJ 2011; 315:1096-1099., the observation of medication use by older adults should be performed continuously and in frequent consultations. The appearance of new symptoms without an apparent cause must have as a hypothesis the adverse reaction of a drug and iatrogenesis, that is, complications from the overuse and concomitant use of various drugs that can end up in death³⁹39 Sharon M, David U, Himmelstein MD, Woolhandler S. Inappropriate Drug Prescribing for the Community-Dwelling Elderly. JAMA 1994; 272(4):292-296..

Most older adults voiced medical monitoring and the use of health devices on a larger scale:

This is explained by the functional limitations caused by chronic diseases and comorbidities and the risk of complications related to them, leading to greater use of medications.

Other authors also observed this aspect. Oliveira-Figueiredo et al.⁴¹41 Oliveira-Figueiredo DST, Felisbino-Mendes MS, Malta DC, Velasquez-Melendez G. Prevalência de incapacidade funcional em idosos: análise da Pesquisa Nacional de Saúde. Rev Rene 2017; 18(4):468-475 report that people over 60 with impaired functionality use health devices more often than older adults without dysfunction. This data applies to both public and private services.

Gadamer⁴²42 Gadamer HJ. O caráter oculto da saúde. Petrópolis: Vozes; 2006., concerning health, informs that “the increasing cost imposes, with extreme urgency, that health care be once again recognized and perceived as a general task of the population.”

Final considerations

This study showed vulnerabilities resulting from the aging process, illness, and dependence in elderly dependents living with NCDs, which indicates that this group of diseases is a significant public health problem. Aspects that contribute to the understanding of the dynamics of NCDs and the need for intervention by relatives, health services, and society were observed:

All the vulnerabilities explored in this paper are essential issues from a scientific viewpoint, for a more continent approach to older adults’ dependence, whose predominant factor is NCDs. Thus, we suggest carrying out further investigations, specifically aimed at the knowledge and prevention of NCDs and their weight in older adults’ dependence.

References

Publication Dates

History