ABSTRACT:

Introduction:

Diseases of old age have shown increasing prevalence in society. One of them is stroke, which can be conceptualized as the interruption of cerebral blood supply due to a leakage or blood vessel obstruction caused by clots.

Objective:

To verify the associations between sociodemographic factors and the functional capacity of elderly affected by stroke.

Methods:

This is an epidemiological, cross-sectional, and quantitative study, including 118 elderly people with paralyses due to stroke, who were registered in one of the Family Health Strategies units of Campina Grande, Paraíba, Brazil. Data were collected by means of home interviews. Two questionnaires were used, in which one was directed for assessment of sociodemographic variables and the second was called Barthel index for assessing the functional capacity of the subjects regarding the activities of daily life. The analysis was conducted using the statistical program SPSS.

Results:

There was a predominance of the female gender, widowed, without schooling, and with household income of up to one Brazilian minimum wage. The average age was 65 years (± 9.63). The Barthel index internal consistency was satisfactory, presenting values of Cronbach’s alpha coefficient in the range of 0.897-0.918. Total correlation of corrected items was greater than 0.4, and Cronbach’s alpha with a deleted item was also greater than 0.8. The activities with higher level of achievement difficulty were urination and evacuation. Association between functional capacity with race, age range, and schooling was found.

Conclusion:

It was seen that demographic factors might interfere with the functional capacity of elderly affected by stroke. Hence, it is believed that this investigation might have contributed to the reflection on this issue, thus supporting the promotion of these people’s access to health assistance programs.

Keywords:
Aged; Stroke; Geriatric assessment; Disabled persons; Activities of daily living; Socioeconomic factors

INTRODUCTION

According to the Brazilian Institute of Geography and Statistics (IBGE)¹1. Instituto Brasileiro de Geografia e Estatística (IBGE). Estudos e Pesquisas. Informação demográfica e socioeconômica. Síntese de indicadores sociais 2001-2010. Disponível em: http://www.ibge.gov.br (Acessado em 10 de maio de 2015).
http://www.ibge.gov.br... , the Brazilian population is in a process of demographic restructuring, showing a decrease in fertility rates, a reduction in mortality, and a consequent increase in life expectancy.

In Brazil, the elderly population, which showed a growth between 1990 (7.2%) and 2010 (10%), will grow in magnitude from 2020, going from 28.3 million (13.7%) to 52 million (23.8%) in 2040, which represents almost a quarter of all the inhabitants of the country²2. Mendes AC, Sá DA, Miranda MD, Lyra TM, Tavares RA. Assistência pública de saúde no contexto da transição demográfica brasileira: exigências atuais e futuras. Cad Saúde Pública 2012; 28(5): 955-64..

Consequently, diseases typical of old age have shown an increasing prevalence in society³3. Veras R. Population aging today: demands, challenges and innovations. Rev Saúde Pública 2009; 43(3): 548-54.. Among them is the cerebrovascular accident (CVA), or stroke, which can be considered as the interruption of the cerebral blood supply due to an extravasation or obstruction of the blood vessel, caused by clots⁴4. World Health Organization (WHO). The atlas of heart disease and stroke. Geneva: WHO; 2011. Disponível em: http://www.world-heart-federation.org/fileadmin/user_upload/images/CVD_Health/Global_CVD_Atlas.pdf (Acessado em 24 de julho de 2015).
http://www.world-heart-federation.org/fi... . There is a high incidence of CVA among the elderly individuals, with its peak between the sixth and the seventh decades of life⁵5. Oliveira AR, Araújo TL, Costa AG, Morais HC, Silva VM, Lopes MV. Avaliação de pacientes com acidente vascular cerebral acompanhados por programas de assistência domiciliária. Rev Esc Enferm USP 2013; 47(5): 1143-9.^,66. Lima ML, Santos JL, Sawada NO, Lima LA. Qualidade de vida de indivíduos com acidente vascular cerebral e seus cuidadores em uma cidade do triângulo mineiro. Rev Bras Epidemiol 2014; 17(2): 453-64.. Worldwide, it is the second cause of death in adults and the first cause of functional incapacity for activities of daily living⁴4. World Health Organization (WHO). The atlas of heart disease and stroke. Geneva: WHO; 2011. Disponível em: http://www.world-heart-federation.org/fileadmin/user_upload/images/CVD_Health/Global_CVD_Atlas.pdf (Acessado em 24 de julho de 2015).
http://www.world-heart-federation.org/fi... .

Data from a prospective Brazilian study indicate an annual incidence of 108 cases per 100,000 inhabitants, a fatality rate at 30 days of 18.5%, and at 12 months of 30.9%, the recurrence rate after a stroke episode being of 15.9%. Approximately one year after the first stroke, physical independence (for 66% of survivors) and occupation (for 75% of survivors) are the most affected domains⁷7. Brasil. Diretrizes de atenção à reabilitação da pessoa com acidente vascular cerebral. Brasília, DF: Secretária de Atenção à Saúde; 2013..

The most frequently observed complication after a stroke is motor impairment⁸8. Pinter MM, Brainin M. Rehabilitation after stroke in older people. Maturitas 2012; 71(2): 104-8.. Around 85.2% of survivors have some degree of motor impairment. As a result of the sequelae, subjects most often exhibit impaired ability to perform basic activities of daily living, such as eating, getting dressed, grooming, bathing, using the toilet, and walking⁵5. Oliveira AR, Araújo TL, Costa AG, Morais HC, Silva VM, Lopes MV. Avaliação de pacientes com acidente vascular cerebral acompanhados por programas de assistência domiciliária. Rev Esc Enferm USP 2013; 47(5): 1143-9..

Therefore, as a consequence of stroke, impairment of the survivors’ functional capacity can be observed⁹9. Costa FA, Silva DL, Rocha VM. Severidade clínica e funcionalidade de pacientes hemiplégicos pós-AVC agudo atendidos nos serviços públicos de fisioterapia de Natal (RN). Ciênc Saúde Coletiva 2011; 16 (1): 1341-8.^,1010. Ferri CP, Schoenborn C, Kalra L, Acosta D, Guerra M, Huang Y, et al. Prevalence of stroke and related burden among older people living in Latin America, India and China. J Neurol Neurosurgery Psych 2011; 82(10): 1074-82.^,1111. Raju RS, Sarma PS, Pandian JD. Psychosocial problems, quality of life, and functional independence among Indian stroke survivors. Stroke 2010; 41(12): 2932-7.. In this sense, functional capacity comprises the ability to maintain physical and mental abilities for autonomous and independent conduction of life¹²12. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: a multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78.. Thus, functional capacity is relevant in the planning and implementation of innovative policies aimed at the care of the elderly, focused on the quality of life.

In this sense, functional capacity can be assessed through the subject’s difficulty in performing their activities of daily living, which comprise the basic activities of daily living (BADLs), as well as the instrumental activities of daily living (IADLs). Activities of daily living are defined as self-care activities, such as eating or using the toilet. Therefore, they are indispensable for the maintenance of quality of life⁵5. Oliveira AR, Araújo TL, Costa AG, Morais HC, Silva VM, Lopes MV. Avaliação de pacientes com acidente vascular cerebral acompanhados por programas de assistência domiciliária. Rev Esc Enferm USP 2013; 47(5): 1143-9..

The present research will enable the exercise of healthcare for the elderly affected by a stroke, as well as the elaboration and adequacy of public health policies aimed at this population, with emphasis on self-care.

Believing the premise that sociodemographic factors may interfere with the patient’s level of ability to perform BADLs, the objective was to verify the associations between sociodemographic factors and the functional capacity of elderly people affected by stroke.

METHODS

This is a cross-sectional epidemiological study with a quantitative approach, conducted in 2015, in the city of Campina Grande, Paraíba, Brazil.

The population was composed of elderly people affected by stroke, registered to the units of the Family Health Strategy (ESF) in the city of Campinas. The sample consisted of 118 elderly people with muscular paralysis caused by CVA, registered in one of the 64 ESF units of the urban zone in the city. It should be noted that no sample calculation was performed, only a population census. In this sense, the 118 elderly patients with paralysis (monoplegia, paraplegia, tetraplegia, triplegia, or hemiplegia) due to stroke were included in the study, as they met the inclusion criteria: age greater than or equal to 60 years, and clinically diagnosed with stroke.

In 2010, the city of Campina Grande had a population estimated at 400,000 inhabitants, of whom 42,817 were elderly, or 10.7% of them. In the scope of primary health care (PHC), the municipality has 64 units of the ESF, comprising 85 Family Health teams, equivalent to a coverage of 77% of the population, as well as three teams from the Community Health Agents Program (PACS)¹1. Instituto Brasileiro de Geografia e Estatística (IBGE). Estudos e Pesquisas. Informação demográfica e socioeconômica. Síntese de indicadores sociais 2001-2010. Disponível em: http://www.ibge.gov.br (Acessado em 10 de maio de 2015).
http://www.ibge.gov.br... .

The data were obtained through home visits, with follow-up of a community health agent of the ESF, responsible for each micro-area. Two visits were made: one to establish contact, explain the research, and obtain the free and informed consent of the participants. On this meeting, a second visit was scheduled for the elderly who agreed to participate in the application of questionnaires I and II.

Questionnaire I was used to investigate the sociodemographic variables, while Questionnaire II (Barthel Index) was applied to evaluate the functional capacity of the participants for the BADLs: hygiene, getting out of bed, dressing, feeding, bladder and bowel control, walking, climbing stairs, using the restroom, sitting on a chair, and bathing. Each item included questions that received scores 5, 10, or 15, depending on the independence or need for help performing the activity. The overall result obeyed a growing scale ranging from 0 to 100 points. A score equal to 100 means total independence; 60 I − 100, slight dependence; 40 I − 60, moderate dependence; 20 I − 40, severe dependence and < 20, total dependence¹³13. Moura MJ, Fernanda A, Martins AM, Campos OM. Validation of the Barthel Index in elderly patients attended in outpatient clinics, in Brazil. Acta Paul Enferm 2010; 23(2): 218-23..

The data collected were analyzed using the Statistical Package for the Social Sciences (SPSS), version 20.0 for the Windows operating system, considering a statistical significance of 0.05. For the sociodemographic data and the Barthel index scores, frequencies, averages, and standard deviation were calculated. To verify the internal consistency of the Barthel index questionnaire, the Cronbach’s alpha coefficient was used. To analyze the associations between sociodemographic factors and functional capacity data for BADLs, the frequency ratios were compared using the χ² and Fisher’s tests.

In carrying out the tests, the variables were dichotomized. Thus, the Barthel index items were considered as follows: dependent = moderate, severe or total disability; independent = light or total functional capacity.

The project was approved by the Research Ethics Committee of Universidade Estadual da Paraíba. Only after the approval, data collection began, respecting the rights to secrecy, privacy, and refusal at any time of the investigation, without any type of burden.

RESULTS

SOCIODEMOGRAPHIC PROFILE

Table 1 shows the sociodemographic data related to the sample. Most of the participants are female, with a ratio of 1.07 women for each man. Among the 118 participants, the age ranged from 60 to 103 years, with a mean of 65 years (± 9.63). The majority self-declared as non-white (64.4%); having a religious creed (96.6%); with up to three years of schooling (80.5%); no partner (61.1%), and with per capita income of up to two minimum salaries (79.7%).

BARTHEL INDEX INTERNAL CONSISTENCY TEST

The internal consistency of the questionnaire called the Barthel index was analyzed using the Cronbach coefficient, according to Table 2. Satisfactory reliability was verified with a total Cronbach’s alpha of 0.917. The total correlation of corrected items was greater than 0.4 and of Cronbach’s alpha with deleted item was greater than 0.8.

FUNCTIONAL CAPACITY FOR BASIC ACTIVITIES OF DAILY LIVING

The functional capacity frequencies for basic activities of daily living are presented in Table 3. In percentage terms, the activities in which there was greater difficulty were micturition (73.8%) and evacuation (66.9%), while those with greater independence were climbing and descending stairs (44.1%) and washing (39%).

As shown in Figure 1, 37.3% (n = 44) of the participants ranged from moderate to total dependency.

RELATIONSHIP BETWEEN SOCIODEMOGRAPHIC FACTORS AND FUNCTIONAL CAPACITY

Table 4 shows that race (p = 0.027), age group (p = 0.001), and schooling (p = 0.041) are sociodemographic factors that are associated with the functional capacity of the elderly people with muscular paralysis due to CVA.

DISCUSSION

Among the participants of this study, there was a predominance of females. This finding differs from the study carried out in different health services in the city of Campinas, in the State of São Paulo, which used a convenience sample and evaluated the variable sex among the elderly individuals with stroke, concluding that they were predominantly male¹⁴14. Cruz KC, Diogo MJ. Evaluation of functional capacity in elders with encephalic vascular accident. Acta Paul Enferm 2009; 22(5): 666-72.. This fact can be explained by the difference between the selections of the study samples, since the relationships in the literature indicate that women are normally more dependent on daily activities than men, although they have a longer life expectancy with low quality⁵5. Oliveira AR, Araújo TL, Costa AG, Morais HC, Silva VM, Lopes MV. Avaliação de pacientes com acidente vascular cerebral acompanhados por programas de assistência domiciliária. Rev Esc Enferm USP 2013; 47(5): 1143-9.^,1212. Alves LC, Leite IC, Machado CJ. Factors associated with functional disability of elderly in Brazil: a multilevel analysis. Rev Saúde Pública 2010; 44(3): 468-78..

Regarding age, the majority of the participants self-reported an average age of 65 years (± 9.63). Another study, carried out in Natal, State of Rio Grande do Norte, Brazil⁹9. Costa FA, Silva DL, Rocha VM. Severidade clínica e funcionalidade de pacientes hemiplégicos pós-AVC agudo atendidos nos serviços públicos de fisioterapia de Natal (RN). Ciênc Saúde Coletiva 2011; 16 (1): 1341-8., aimed at evaluating the functional capacity of hemiplegic individuals after a stroke, emphasized that this disease has a higher incidence in people with advanced age, a period of life in which large death rates and sequelae can be observed.

With regard to to the other social variables, most of the subjects self-reported as being unmarried, and having low schooling and low family income. These results are worrying, as the consequences of stroke extend beyond mobility, interfering in the subjects’ physical and mental abilities¹⁰10. Ferri CP, Schoenborn C, Kalra L, Acosta D, Guerra M, Huang Y, et al. Prevalence of stroke and related burden among older people living in Latin America, India and China. J Neurol Neurosurgery Psych 2011; 82(10): 1074-82.. An elderly person affected by stroke is often a dependent person, who becomes partially or completely dependent on other people; in theses cases, the assistance is primarily exercised by the spouse, in order to satisfy their basic needs¹⁴14. Cruz KC, Diogo MJ. Evaluation of functional capacity in elders with encephalic vascular accident. Acta Paul Enferm 2009; 22(5): 666-72..

Regarding the frequencies of functional capacity for activities of daily living, the activities in which there was greater difficulty of accomplishment were urination and evacuation. This result differs from those found in a study conducted in Rio Grande do Sul, in which all participants had normal intestinal continence, and slightly more than half had normal urinary continence¹⁵15. Rizzetti DA, Trevisan CM. Avaliação da capacidade funcional em pacientes portadores de seqüelas de AVC participantes do projeto de hidrocinesioterapia aplicada às patologias neurológicas do idoso. Rev Cent Cienc Saúde 2008; 34(1-2): 32-6.. Difficulties in eliminations cause impairment of functional capacity, as well as may cause embarrassment for individuals, leading to, in several cases, social isolation¹⁶16. Moraes EN. Atenção à saúde do idoso: Aspectos conceituais. Brasília, DF: Organização Pan-Americana da Saúde; 2012..

Regarding functional capacity, a considerable frequency of the light dependence and independent levels was observed. Study on the functional capacity of the elderly after ischemic stroke, performed in the city of Fortaleza, Ceará, obtained a similar result. This, therefore, requires the caregivers to help with the activities of daily living in order to maintain the functional capacity of the elderly according to the individual characteristics of each situation, constituting one of the most important attributions of health professionals and lay caregivers¹⁷17. Vieira CP, Fialho AV, Almeida PC, Moreira TM. Idosos com Acidente Vascular Encefálico isquêmico: caracterização sociodemográfica e funcional. Rev Rene 2012; 13(3): 522-30..

Another study conducted using the Katz and Lawton scale to evaluate the functional ability of individuals with disabilities due to stroke has concluded that most of the elderly people affected by stroke carry out their activities of daily living independently and autonomously¹⁶16. Moraes EN. Atenção à saúde do idoso: Aspectos conceituais. Brasília, DF: Organização Pan-Americana da Saúde; 2012.. This fact suggests a more accurate analysis of each scale’s way of measuring, in order to compare the results obtained.

Regarding the association between sociodemographic factors and the functional capacity of elderly people with muscle paralysis due to stroke, a significant result was observed in the variables age, race, and schooling. This result was corroborated by the study on the evaluation of functional capacity in the elderly with stroke, which verified the age as inversely proportional to the functional independence measure, that is, the greater the age, the lower the functional capacity presented by the elderly¹⁴14. Cruz KC, Diogo MJ. Evaluation of functional capacity in elders with encephalic vascular accident. Acta Paul Enferm 2009; 22(5): 666-72..

With regard to skin color, brown was predominant. A study carried out in the city of Montes Claros, State of Minas Gerais, on the functional capacity among the elderly and the factors associated with disability found a higher incidence of disabilities in the self-reported brown elderly¹⁸18. Barbosa RB, Almeida JM, Barbosa MR, Barbosa LA. Avaliação da Capacidade funcional de idosos e fatores associados. Ciênc Saúde Coletiva 2014; 19(8): 3317-25.. These findings could be constituted by differences in socioeconomic conditions between ethnic groups, which, in theory, would favor the morbidity profile of this population, with consequent interference in the functional capacity of these individuals.

With regard to schooling, a survey applied with elderly in the urban area of São Paulo observed an association of schooling with functional decline in the elderly¹⁹19. Ferreira PC, Tavares DM, Rodrigues RA. Características sociodemográficas, capacidade funcional e morbidades entre idosos com e sem declínio cognitivo. Acta Paul Enferm 2011; 24(1): 29-35.. Low education has been related to the increase in the incidence of stroke, especially when associated with socioeconomic factors and limited information, primarily by impeding health knowledge and adherence to treatment, as well as maintaining healthy habits, while a higher level of schooling converges for greater longevity and better maintenance of lifestyles related to cardiovascular diseases²⁰20. Brito ES, Pantarotto RF, Costa LR. A hipertensão arterial sistêmica como fator de risco ao acidente vascular encefálico (AVE). J Health Sci Inst 2011; 29(4): 265-8..

CONCLUSIONS

The data analyzed show that most of the elderly people affected by stroke in Campina Grande are women, with low schooling and income, with a religious belief and without a partner. Although the participants presented disabilities in some variables, the sample was classified with a light degree of dependence. An association was found between race, age group, and schooling with the ability to perform BADLs. Thus, it is concluded that sociodemographic factors can interfere in the functional capacity of the elderly affected by stroke.

One limitation of the study that can be indicated is the impossibility of determining the directionality of the associations, since it is a cross-sectional study. It should be noted that the lack of similar studies, with respect to the approach and instruments used, made it impossible to compare the data obtained more accurately.

In this sense, it is believed that this work contributed to the reflection on this problem, thus helping in the promotion of the access of such people to the assistance programs developed by the ESF, in the improvement of the living and health conditions, as well as in the reproducibility of the method used by other studies.

References

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