Frequência de disfagia orofaríngea em idosos institucionalizados: uma revisão integrativa / Oropharyngeal dysphagia frequency in older adults living in nursing homes: an integrative review

RESUMO Objetivo Sintetizar o estado do conhecimento científico sobre a frequência de disfagia orofaríngea em idosos institucionalizados. Estratégia de pesquisa A pergunta de pesquisa foi formulada de acordo com a estratégia PECO e a busca foi realizada nas bases de dados Pubmed/Medline, Web of Science, Scopus, LILACS e SciELO, utilizando descritores e termos livres específicos. Critérios de seleção Artigos sem restrição de tempo ou idioma, que relatassem a frequência de disfagia orofaríngea em idosos institucionalizados e o critério utilizado para diagnóstico. Análise dos dados Foram analisadas as características da população, conceito de "disfagia orofaríngea", métodos para identificação do desfecho e a frequência de disfagia orofaríngea. A avaliação da qualidade metodológica dos artigos seguiu os critérios do Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Resultados Foram incluídos quinze artigos. Houve grande variabilidade quanto ao tamanho da amostra, com predomínio de idosos longevos do sexo feminino. O conceito de disfagia, quando mencionado, foi heterogêneo. Os critérios diagnósticos foram diversos e compostos, em sua maioria, por resultados de questionários ou testes clínicos. Nenhum estudo utilizou exames instrumentais. A frequência de disfagia orofaríngea na população estudada oscilou entre 5.4% e 83.7%, sendo mais elevada nos estudos que utilizaram testes clínicos, porém, com intervalos de confiança mais precisos naqueles que usaram questionários e amostras maiores. Conclusão A frequência de disfagia orofaríngea em idosos institucionalizados possui ampla variabilidade. As discrepâncias metodológicas entre os estudos comprometem a confiabilidade das estimativas de frequência e apontam a necessidade de pesquisas com critérios metodológicos mais bem definidos e padronizados.

ABSTRACT Purpose To synthesize the scientific knowledge on the frequency of oropharyngeal dysphagia in older adults living in nursing homes. Research strategies The study question followed the PECO strategy and the search was performed in the Pubmed/Medline, Web of Science, Scopus, LILACS and SciELO databases, using keywords and specific free terms. Selection criteria articles with no time or language restrictions that reported the frequency of oropharyngeal dysphagia in older adults living in nursing homes and the diagnostic criteria. Data analysis it was analyzed the population characteristics, the concept of "oropharyngeal dysphagia", the methods for identifying the outcome and the frequency of oropharyngeal dysphagia. The evaluation of the methodological quality of the articles followed the criteria of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Results Fifteen articles were included. There was great variability in relation to the sample size, with a predominance of longevous old women. The concept of dysphagia, when mentioned, was heterogeneous. Diagnostic criteria were diverse and mostly comprised of questionnaires or clinical trials results. No studies used instrumental tests. The frequency of oropharyngeal dysphagia in the studied population ranged from 5.4% to 83.7%, being higher in studies that used clinical tests, but with greater precision of confidence intervals in studies that used questionnaires and large sample size. Conclusion The frequency of oropharyngeal dysphagia in older adults living in nursing homes has wide variability. Methodological discrepancies among studies compromise the reliability of frequency estimates and highlight the need for research with better defined and standardized methodological criteria.

Use of medication reviews among older women with dementia, 2003-2015: A longitudinal cohort study.

OBJECTIVE: To identify factors associated with incidence of medication reviews (MRs), particularly in women with dementia and in residential aged care (RAC). METHODS: Data from 10 359 women in the 1921-1926 cohort of the Australian Longitudinal Study on Women's Health were linked to Medicare Benefits Schedule data to identify MRs for each year from 2003 to 2015. RESULTS: Incidence of MR increased from 2003 to 2013 (age 87-92 years) when 37.1% of women with dementia had a MR compared to 19.8% of women without dementia. Adjusting for time and other factors, the odds of having a MR were higher for women with dementia (AOR = 1.18, 95% CI: 1.06-1.32) and women in RAC (AOR = 3.61, 95% CI: 3.28-3.98). CONCLUSIONS: Although higher in women with dementia and those in RAC, utilisation of MR was modest. System-level interventions may be required to ensure the use and benefits of MRs.

Quality and Safety in Aged Care Virtual Issue: What Australian research published in the Australasian Journal on Ageing tells us.

OBJECTIVE: To review studies published in the Australasian Journal on Ageing (AJA) about the aged care workforce, and to identify influences on quality of care and potential policy directions. METHODS: Articles in the AJA on the aged care workforce published from 2009 to 2018 were identified, grouped into themes and rated for quality. RESULTS: Twenty-eight articles were identified. Articles fell into four themes: (i) staff knowledge, skills and attitudes; (ii) staff well-being and workforce stability; (iii) environmental factors that influence staff capacity; and (iv) interventions to improve staff capacity. Studies reinforced the importance of staff-consumer, staff-relatives and staff-staff relationships and a supportive workplace culture for staff work ability and capacity to provide high quality care. CONCLUSIONS: It is possible to improve practice in community and residential aged care, given: (i) enough staff; (ii) better training in person-centred practice; and (iii) a supportive staff culture that encourages staff to put their training into practice.

Bacteriuria and vitamin D deficiency: a cross sectional study of 385 nursing home residents.

BACKGROUND: Up to half of elderly people at nursing homes have asymptomatic bacteriuria, and concentrations of 25-hydroxyvitamin D (25OHD) are generally low. Vitamin D is a modulator of the immune system and involved in protection of the epithelium in the urinary tract as well. The objective was to determine a possible association between bacteriuria and vitamin D deficiency among elderly people at nursing homes. METHODS: Cross-sectional study: Voided urine specimens and blood samples for cultivation and analysis of 25OHD were collected from elderly people at nursing homes in Sweden. Exclusion criteria were: urinary catheter, ongoing antibiotic treatment, incontinence or dementia too severe to provide a voided urine specimen or leave a blood sample, unwillingness to participate or terminal illness. Urine cultures and serum 25OHD concentrations were outcome measures and the association of bacteriuria with vitamin D deficiency was determined by logistic regression. RESULTS: Twenty-two nursing homes participated and 385 of 901elderly people provided voided urine specimens and blood samples. The mean age was 87 (SD 6.7), 69% women, 19% received vitamin D supplement, 13% had diabetes mellitus, and 54% were diagnosed with dementia. There was significant growth of potentially pathogenic bacteria in 32% (123/385) of voided urine specimens. Escherichia coli were present in 83% of positive urine cultures. The mean concentration of 25OHD in serum was 35 nmol/L (SD 21). Thirty-seven per cent (143/385) had 25OHD < 25 nmol/L, and 3.1% (12/385) 25OHD < 12.5 nmol/L. No association between bacteriuria and 25OHD < 25 nmol/L, OR 1.4 (0.86-2.3; p = 0.18) adjusted for age, gender, diabetes mellitus and dementia was found. However, if using 25OHD < 12.5 nmol/L as a cut-off for vitamin D deficiency the adjusted odds-ratio was 4.4 (1.1-17; p = 0.031). CONCLUSIONS: Bacteriuria and vitamin D deficiency was common. No association between bacteriuria and 25OHD < 25 nmol/L was found. If using 25OHD < 12.5 nmol/L as cut-off for vitamin D deficiency there was an association. However, this has to be interpreted with caution as causality cannot be evaluated as well as only few residents had 25OHD < 12.5 nmol/L.

A música como terapia complementar no cuidado ao idoso em instituição de longa permanência (ILPI) / Music as complementary therapy in the care of the elderly in a long-stay institution (ILPI)

Este estudo tem como objetivo geral discutir os efeitos da música como terapia complementar no cuidado a idosos residentes em Instituição de Longa Permanência para Idosos (ILPI). Trata-se de um ensaio clínico com delineamento de séries temporais, usando abordagem mista, realizado no período de agosto a outubro de 2018 com 14 residentes de uma ILPI no município de Niterói tendo como critérios de inclusão os idosos com idade igual ou superior a 60 anos, residentes em ILPI e, como critérios de exclusão Idosos com perdas auditivas severas ou que entrem nos critérios de descontinuidade (falecimento, internação ou ter uma perda auditiva severa). A produção de dados ocorreu em três momentos, no primeiro foi realizada avaliação inicial de enfermagem utilizando formulário de identificação, escalas de avaliação geriátrica (Mini Exame do Estado Mental (MEEM) e Escala de Katz) e questões para identificar as preferências musicais de cada idoso, compondo um acervo digital individual, valorizando suas escolhas e opiniões. No segundo momento foram realizadas quatro sessões musicais, uma por semana, usando as músicas selecionadas no primeiro momento e reproduzindo-as em aparelho de headfone e, em seguida o idoso respondia uma entrevista semiestruturada, no início e final de cada consulta foram verificados os Sinais Vitais e aplicada a escala EMADOR e durante as sessões musicais era registrado em diário de campo todas as reações apresentadas pelos participantes. No terceiro momento foram aplicadas, novamente, as escalas de avaliação geriátrica, estas feitas no final da quarta sessão musical. Na análise, por meio da triangulação dos dados, foram associados os resultados quantitativos e os qualitativos de cada participante do estudo, com uma visão micro e, no total dos resultados, com uma visão macro, dos resultados obtidos. A pesquisa foi submetida ao CEP sob o CAAE 79953017600005243 e aprovado sob parecer n°2.548.033. Os resultados mostraram que o uso da música aliada ao cuidado de enfermagem de idosos possui efeitos significativos na cognição de idosos além de favorecer o acolhimento e a convivência social dos mesmos no ambiente de ILPI, além de apresentar diminuição nos relatos de dor e diminuição significativa no valor da pressão arterial sistólica e diastólica (p < 0,5), podendo ser usada como estratégia no cotidiano do cuidar da enfermagem, considerando-se que, como o cuidado, ela favorece a construção de subjetividades inerentes ao afeto e à criatividade e colabora tanto para criação de um ambiente terapêutico quanto favorece a expressividade do idoso e melhora sua socialização no grupo.

The experience of spirituality among institutionalized elderly people / Vivência da espiritualidade por idosos institucionalizados

Objective: To identify the meanings attributed to the experience of spirituality when faced with life situations among elderly persons living in a long-term care facility. Method: A qualitative, exploratory and descriptive survey was carried out, based on interviews with eight elderly people living in a long-term care facility for the elderly in the state of Rio Grande do Sul, Brazil. Results: The content that emerged from the interviews underwent qualitative analysis for the extraction of units of significance and the elaboration of two thematic categories: Spirituality/religiosity as a direction of life and spirituality/religiosity as a meaning for life and a source of renewal, fulfilment and happiness. Conclusion: When describing the experience of spirituality as an important strategy for finding meaning in life, the elderly persons in this study revealed it to be a psychic and emotional support for coping with existential challenges. This knowledge allows professionals working in these institutions to invest in practices that incorporate spirituality as an element of the comprehensive care of the elderly.

Objetivo: Conhecer o significado atribuído à vivência da espiritualidade diante das situações da vida pelos idosos residentes em uma instituição de longa permanência para idosos (ILPI). Método: Pesquisa qualitativa, exploratória e descritiva, realizada por meio de entrevista com oito idosos residentes em uma ILPI do interior do estado do Rio Grande do Sul, Brasil. Resultados: O que emergiu das entrevistas sofreu análise qualitativa para extração de unidades de significância e elaboração de duas categorias temáticas: Espiritualidade/religiosidade como direcionamento da vida e espiritualidade/religiosidade como sentido para vida, fonte de renovação, plenitude e felicidade. Conclusão: Os idosos deste estudo, ao expressarem a vivência da espiritualidade como estratégia importante de sentido para a vida, a desvelaram o como um suporte psíquico e emocional para o enfrentamento dos desafios existenciais. Essa compreensão permite aos profissionais que atuam nas ILPI investirem em práticas que incorporem a espiritualidade como elemento no cuidado integral da pessoa idosa.

Optimal healthcare delivery to care homes in the UK: a realist evaluation of what supports effective working to improve healthcare outcomes.

INTRODUCTION: care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use. METHODS: a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners. RESULTS: context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which 'wraps around' care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites. CONCLUSION: activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.

O sentido de ser-pessoa-idosa vivendo em instituição de longa permanência à luz da fenomenologia Heideggeriana / Meanings of religiosity and spirituality in the lived experience of the long-lived elderly person / El sentido de ser-persona-anciana viviendo en una institución de larga permanencia a la luz de la fenomenología heideggeriana

Nos últimos anos, projeções demográficas apontam para o crescimento acelerado do número de pessoas com 60 anos de idade ou mais no mundo e no Brasil. Paralelo a esse fenômeno, transformações socioculturais têm impactado as modalidades de cuidado ofertadas à pessoa idosa, sendo crescente o número destas encaminhadas para Instituições de Longa Permanência para Idosos (ILPIs). Este cenário impõe o desafio de compreender as pessoas idosas institucionalizadas em suas dimensões existenciais e de subjetividade. Trata-se de um estudo fenomenológico pautado na fenomenologia de Martin Heidegger e que objetivou desvelar o sentido de ser-pessoa-idosa vivendo em Instituição de Longa-Permanência para Idosos. Para a produção das informações foram realizadas 12 entrevistas fenomenológicas com pessoas idosas que vivem em uma ILPI no interior da Bahia, Brasil, de ambos os sexos, que moram na instituição há, pelo menos, quatro meses e que demonstraram condição cognitiva preservada para participar do estudo. As entrevistas foram realizadas no período de março de 2017 a agosto de 2018. A apreensão dos aspectos ônticos ­ a partir da compreensão vaga e mediana das vivências compartilhadas - possibilitou a construção de seis unidades de significado. A pessoa idosa que reside em ILPI mostrou-se como pessoa que: I. Vivencia a perda progressiva de autonomia e independência; II. Percebe a ida para a ILPI como trajetória circunstancial inevitável; III. O ser-com torna-se ser-só/ser-solitário; IV. Ex-siste imersa numa rotina vazia; V. Apega-se à religiosidade/espiritualidade como estratégia de resiliência e conforto; VI. Experiencia a ressignificação de percepções diversas. Após as etapas de apreensão dos aspectos ônticos, procedeu-se com a compreensão hermenêutica e a construção da unidade de significação: o sentido de ser-pessoa-idosa vivendo em instituição de longa permanência. Foi possível compreender que parte da facticidade do ser-aí lançado no mundo vivida pelo ser-pessoa-idosa é resultado de processos instituídos pela ILPI. Passíveis, portanto, de ajustes e redefinições. Conclui-se que, atualmente, a assistência em saúde à pessoa idosa que vive em ILPI centra-se no atendimento das necessidades fisiológicas do ente idoso, restringindo-se à instância ôntica. As necessidades ontológicas, as quais atentam para as particularidades do ser-pessoa-idosa que vive em ILPI seguem esquecidas. Uma vez que somos ôntico e ontológico, o cuidado limitado à instância ôntica sinaliza deficiências do processo de institucionalização. Assim, urge a necessidade de melhorias no cuidado que considerem o ente e incluam a busca continuada pela compreensão do ser-pessoa-idosa que vive em ILPI em suas diferentes e peculiares facetas do existir. Esse exercício é fundamental para garantir às pessoas idosas institucionalizadas o direito de envelhecer com dignidade e qualidade de vida.(AU)

A Structured Process Description of a Pragmatic Implementation Project: Improving Integrated Care for Older Persons in Residential Care Homes.

Evaluation of the implementation of integrated care can differ from trial-based research due to complexity. Therefore, we examined whether a theory-based method for process description of implementation can contribute to improvement of evidence-based care. MOVIT, a Dutch project aimed at implementing integrated care for older vulnerable persons in residential care homes, was used as a case study. The project activities were defined according to implementation taxonomy and mapped in a matrix of theoretical levels and domains. Project activities mainly targeted professionals (both individual and group). A few activities targeted the organizational level, whereas none targeted the policy level, or the patient, or the "social, political, and legal" domains. However, the resulting changes in care delivery arrangement had consequences for professionals, patients, organizations, and the social, political, and legal domains. A structured process description of a pragmatic implementation project can help assess the fidelity and quality of the implementation, and identify relevant contextual factors for immediate adaptation and future research. The description showed that, in the MOVIT project, there was a discrepancy between the levels and domains targeted by the implementation activities and those influenced by the resulting changes in delivery arrangement. This could have influenced, in particular, the adoption and sustainability of the project.

Vitamin D deficiency was common among nursing home residents and associated with dementia: a cross sectional study of 545 Swedish nursing home residents.

BACKGROUND: Residents of nursing homes may have low 25-hydroxyvitamin D (25OHD) concentrations. Associations between vitamin D and cognitive performance, dementia and susceptibility to infections are not clearly established. The aim of this study was to investigate the prevalence of vitamin D deficiency and to identify associated factors among residents of nursing homes for elderly. METHODS: In this cross-sectional study blood samples for analysis of 25OHD were collected from all participating residents of Swedish nursing homes for the elderly from January to March 2012. EXCLUSION CRITERIA: dementia too severe to collect a blood test, terminally ill or refusing participation. OUTCOME MEASURES: Serum 25OHD concentrations. Logistic regression to evaluate factors associated with vitamin D deficiency (25OHD < 25 nmol/L). RESULTS: Blood samples were obtained from 545 of 901 residents of 22 nursing homes. Mean age 86 years (SD 6.9), 68% were women. Prevalence of vitamin D supplementation 17%, dementia 55%, lack of appetite ≥3 months 45% and any antibiotic treatment during the last 6 months 30%. Serum 25OHD concentrations: mean 34 nmol/L (SD 21, median 27, range 4-125), 82% (448/545) had 25OHD < 50 nmol/L and 41% (224/545) had 25OHD < 25 nmol/L. Adjusted OR (95% CI; p-value) for possible predictors of vitamin D deficiency (25OHD < 25 nmol/L): vitamin D supplementation 0.075 (0.031-0.18; p < 0.001), lack of appetite ≥3 months 0.75 (0.50-1.1; p = 0.15), hours outdoors/week 0.99 (0.96-1.0; p = 0.62), Fitzpatrick skin phototype (4-6) 0.69 (0.44-1.1; p = 0.12); dementia 2.3 (1.5-3.4; p < 0.001) and antibiotics last 6 months 1.6 (1.1-2.6; p < 0.029), adjusted for age and gender. CONCLUSIONS: Vitamin D deficiency was common among nursing home residents and strongly associated with dementia. Regardless of causality or not, it is important to be alert for vitamin D deficiency in nursing homes residents with dementia. As expected vitamin D supplementation was associated with less vitamin D deficiency, however lack of appetite, staying outdoors and skin phototype were not significant predictors. Antibiotic treatments during the last 6 months were associated with vitamin D deficiency, potentially supporting the hypothesis that vitamin D deficiency is associated with infections.

Care and management demands of long-term care facilities for the elderly in Brazil: an integrative review (2004-2014) / Demandas assistenciais e gerenciais das instituições de longa permanência para idosos: uma revisão integrativa (2004-2014)

Abstract Objective: to analyze the care and management demands of Long-Term Care Facilities for the Elderly (LTCFs) in Brazil. Method: an integrative review of literature was carried out, organized into six stages: a) elaboration of a guiding question; b) online search of LILACS, SciELO, PubMed, the CAPES Portal and the Brazilian Society of Geriatrics and Gerontology databases; c) article selection, following the exclusion and inclusion criteria, with the sample composed of 17 articles; d) commented analysis of the selected articles; e) deliberation on the results obtained, formulated from the synthesis and interpretation of the selected studies; f) presentation of the results of the review. Results: the care demands identified are related to the process of caring and assume a working team with geriatric and gerontological knowledge, while the management demands include the means and resources needed so the care can be provided effectively. However, the LTCFs were found to rely on professionals who are unprepared to provide care or to assume an organizational management role, meaning care for the elderly is restricted to the essentials for their basic needs. Conclusion: the care demands were easily identified in the analyzed publications, however, there is a lack of research that evaluates management demands in a broader and more in-depth manner. It is suggested that studies aiming to broaden theoretical knowledge of the care and management demands of LTCFs are carried out, to stimulate effective and positive actions in the practices of these institutions, seeking to offer top quality care to elderly persons that live in these facilities, that responds to the real needs of their current stage of life.

Resumo Objetivo: analisar demandas assistenciais e gerenciais das Instituições de Longa Permanência para Idosos (ILPI) no Brasil. Método: revisão integrativa da literatura, organizada em seis etapas: a) formulação da pergunta norteadora; b) busca on-line nas bases de dados LILACS, SciELO, PubMed, Portal CAPES e Portal da Sociedade Brasileira de Geriatria e Gerontologia; c) seleção dos artigos obedecendo-se aos critérios de inclusão e exclusão, sendo a amostra composta por 17 artigos; d) análise crítica dos artigos selecionados; e) discussão dos resultados encontrados, elaborada a partir da síntese e interpretação dos estudos selecionados; f) apresentação dos resultados da revisão. Resultados: as demandas assistenciais desta revisão estão relacionadas ao processo do cuidar e pressupõem uma equipe de trabalho que detenha conhecimentos geriátricos e gerontológicos; por sua vez, as demandas gerenciais levantadas abrangem meios e recursos para que o cuidado seja eficientemente proporcionado. As ILPI mostraram, entretanto, contar com profissionais ainda despreparados para prestar a assistência e assumir a gerência organizacional, de forma que o atendimento aos idosos restringe-se ao essencial para a sua sobrevivência. Conclusão: as demandas assistenciais foram identificadas com mais facilidade nas publicações analisadas, constatando-se, entretanto, escassez de pesquisas sobre demandas gerenciais das ILPI de forma mais abrangente e aprofundada. Sugere-se a realização de estudos sobre demandas assistenciais e gerenciais nas ILPI, com vistas a ampliar o conhecimento teórico nesse campo e estimular ações positivas efetivas nas práticas dessas organizações, visando oferecer aos idosos que vivem nessas instituições uma assistência de qualidade que atenda às suas reais necessidades nessa fase da vida.

Long-stay institutions for the elderly: physical-structural and organizational aspects / Instituciones de larga estancia para personas de edad: aspectos físico-estructurales y organizativos / Instituições de longa permanência para idosos: aspectos físico-estruturais e organizacionais

Abstract Objective: To characterize long-stay institutions for the elderly in respect to physical-structural and organizational aspects. Method: This descriptive, cross-sectional, quantitative research was carried out in four long-stay institutions for the elderly in Salvador - Bahia, Brazil, between September and November 2013. Data were collected from the technical officers of the institutions using a questionnaire based on National Health Surveillance Agency standards. Results: This study highlights a partial compliance with current regulations both in respect to the physical-structural and organizational aspects. The elderly are exposed to an environment that is sometimes unhealthy with risk factors for health problems. Conclusion and implications for practice: There is need for adjustments in the institutions to comply with current legislation. This study shows the importance of a multidisciplinary team to provide comprehensive care of institutionalized elderly, with emphasis on the role of nurses in the qualification of institutions and valorization of the elderly.

Resumen Objetivo: Caracterizar instituciones de larga estadía para los ancianos como los aspectos físicos estructurales y organizativas. Método: Transversal, la investigación cuantitativa descriptiva, llevado a cabo en cuatro instituciones de larga estadía para las personas mayores de Salvador - Bahia, Brasil, entre septiembre y noviembre de 2013. Los datos fueron recogidos entre los responsables técnicos de las instituciones a través de un cuestionario basado en estándares Agencia Nacional de Vigilancia Sanitaria. Resultados: Este estudio pone de manifiesto un cumplimiento parcial de la normativa vigente, tanto en los aspectos físicos y estructurales como de organización. Los ancianos están expuestos a un ambiente a veces factores insalubres y de riesgo de problemas de salud. Conclusión e implicaciones para la práctica: Existe la necesidad de ajustes en las instituciones para el cumplimiento de la legislación vigente. Aboga por la importancia de un equipo multidisciplinario para la atención integral a las personas mayores institucionalizadas, con énfasis en el papel de la enfermería para la calificación de las instituciones y la apreciación de las personas mayores.

Resumo Objetivo: Caracterizar Instituições de Longa Permanência para Idosos quanto aos aspectos físico-estruturais e organizacionais. Método: Pesquisa descritiva, transversal, quantitativa, realizada em quatro Instituições de Longa Permanência para Idosos de Salvador - Bahia, Brasil, entre setembro e novembro de 2013. Os dados foram coletados entre os responsáveis técnicos das instituições através de um questionário baseado nas normas da Agência Nacional de Vigilância Sanitária. Resultados: Evidencia-se um atendimento parcial à regulamentação vigente tanto nos aspectos físico-estruturais quanto organizacionais. Os idosos são expostos a um ambiente, por vezes, insalubre e a fatores de riscos para agravos à saúde. Conclusão e implicações para a prática: Há necessidade de ajustes nas instituições para o atendimento à legislação vigente. Defende-se a importância de uma equipe multiprofissional para o cuidado integral às pessoas idosas institucionalizadas, com ênfase no papel da enfermagem para a qualificação das instituições e valorização dos idosos.

New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap.

In this paper, we outline the relationship between the need to put existing applied health research knowledge into practice (the 'know-do gap') and the need to improve the evidence base (the 'know gap') with respect to the healthcare process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in CGA; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base that requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed.

Cambios en la depresión y el sentimiento de soledad después de la terapia de la risa en adultos mayores internados / Changes in depression and loneliness after laughter therapy in institutionalized elders

Introducción. La vejez es una etapa que está enmarcada por una serie de fenómenos que inciden de forma negativa en la vida de las personas, entre otros, el sentimiento de soledad y la depresión. Objetivo. Evaluar el impacto de la terapia de la risa sobre el grado de depresión y el sentimiento de soledad, en un grupo de adultos mayores internados en centros gerontológicos. Materiales y métodos. Se hizo una investigación exploratoria con diseño cuasiexperimental, en la cual se aplicaron la escala de depresión de Yesavage y la escala ESTE de medición del sentimiento de soledad, ambas validadas para Colombia. La población objeto estuvo conformada por 49 adultos, entre hombres y mujeres de 59 años o más que viven en el hogar gerontológico Colonia de Belencito en el municipio de Medellín, Antioquia, en quienes se aplicó la terapia de la risa entre abril y julio de 2013. Se llevaron a cabo ocho sesiones semanales de terapia de la risa a cargo del grupo "Payasos Hospitalarios" de la Fundación Mediclaun de Medellín. Resultados. Se registró un descenso significativo en el grado de depresión, especialmente en aquellos con depresión inicial establecida (p<0,032). Las personas más receptivas fueron los adultos mayores internados sin pareja, con edades entre 65 y 75 años, pertenecientes al estrato dos y que recibían visitas. No se registraron cambios significativos en el sentimiento de soledad. Conclusión. Se resalta la importancia que tiene la terapia de la risa en la disminución del grado de depresión en adultos mayores. Los resultados concuerdan con la afirmación de que el constructo de soledad es independiente del de depresión.

Introduction: Old age is a stage characterized by a number of factors, such as loneliness and depression, that have a negative effect on people´s lives. Objective: To evaluate the impact of laughter therapy on the level of depression and loneliness in a group of institutionalized elders. Materials and methods: Exploratory research with quasi-experimental design applying Yesavage depression scale and the ESTE scale of loneliness, both validated for Colombia. The target population consisted of 49 men and women who were 59 years old or over, and lived in the Gerontological Home ´´Colonia de Belencito´´ in the city of Medellín (Antioquia); they were contacted between April and July 2013, and they received eight sessions of laughter therapy performed by the group "Hospital Clowns" of the Mediclaun Foundation from Medellín. Results: There was a significant decrease in the level of depression especially in those with initial depression established (p<0,032). The most receptive were institutionalized elders who did not have a couple, they were between 65 and 75 years of age, and they belonged to socioeconomic level 2 and did not receive visits. No significant changes in the level of loneliness were recorded. Conclusion: The importance of laughter therapy in reducing the level of depression in elders is highlighted. These results agree with the statement indicating that the construct of loneliness is independent from depression.

Histórias de cuidados entre idosos institucionalizados: as práticas integrativas como possibilidades terapêuticas / Historias de cuidado entre los ancianos institucionalizados: prácticas integradoras como posibilidades terapéuticas / Care stories of institutionalized elderlies: integrative practices as therapeutic possibilities

Objetivos: conhecer as histórias de cuidado e as implicações do uso da reflexologia podal em idosos. Método: pesquisa-ação, na qual foram realizadas sessões de reflexologia podal em idosos residentes em uma Instituição de Longa Permanência, situada no interior paraibano. A produção e análise das narrativas foram feitas de março a junho de 2012, através da história oral temática, que originou três eixos temáticos: As dores do corpo e da alma, Os chás e as massagens, O cuidado através dos pés. Resultados: dores difusas e dificuldades para dormir foram as principais queixas relatadas, para quais, os idosos utilizavam como recursos terapêuticos, os chás e as massagens. A realização da reflexologia além de permitir o alívio dos problemas mencionados, proporcionou bemestar, relaxamento, alívio da ansiedade e melhora na qualidade do sono. Considerações finais: as práticas integrativas possibilitam um cuidado integral ao idoso, pela facilidade de aplicação, promoção do relaxamento e bem-estar.

Aim: to understand the stories of care and the implications of using foot reflexology in the elderly. Method: action research, in which foot reflexology sessions were conducted in elderly residents of a long-stay institution located within Paraiba. The production and analysis of the narratives were made from March to June 2012, through thematic oral story, which originated three themes: The pains of body and soul, Teas and massages, Care through the feet. Results: diffuse pain and sleep difficulties were the main complaints reported, for which the elderly used teas and massage as therapeuticresources. Besides alleviating the previously mentioned problems, the realization of reflexology provided well-being, relaxation, anxiety relief and improved quality of sleep. Final considerations: the integrative practices enable a comprehensive care to the elderly, since they are easy to apply and promote relaxation and well-being.

Objetivos: conocer las historias de cuidados y las implicaciones del uso de lareflexología podal en el anciano. Método: investigación-acción, en el que se llevaron acabo sesiones de reflexología podal en ancianos residentes de una institución de largapermanencia ubicado en Paraiba (Brasil). La producción y el análisis de las narraciones serealizaron de marzo a junio de 2012, a través de la historia oral, originando tres ejestemáticos: El dolor de cuerpo y alma, infusiones y masajes, atención a través de los pies.Resultados: dolor difuso y dificultades para dormir fueron las principales quejasrelatadas, para las cuales, las personas de edad utilizan como recursos terapéuticos,infusiones y masajes. La realización de la reflexología además de permitir el alivio deestos problemas, proporciona bienestar, relajación, alivio de la ansiedad y mejora lacalidad del sueño. Consideraciones finales: las prácticas integradoras permiten unaatención integral de los ancianos, por la facilidad de aplicación y la promoción de larelajación y el bienestar.

Terapia de la risa en un grupo de mujeres adultas / Laughter therapy in a group of elderly women

Objetivo: explorar los beneficios de la terapia de la risa en un grupo de mujeres adultas pertenecientes a un centro gerontológico del Municipio de Envigado (Colombia). Metodología: estudio con enfoque cualitativo mediante entrevista semiestructurada a 10 adultas entre 59 y 97 años de edad, antes y después de la aplicación de 5 sesiones, una semanal, de terapia de la risa por parte del grupo Mediclaun ôpayasos hospitalariosõ. Resultados: muchos de los cambios percibidos en las adultas coinciden con la literatura en lo que respecta a una actitud más positiva, incremento de la confianza en el otro y la aceptación; expresan el pasado con menos dolor y un mayor agrado frente al acompañamiento familiar. Conclusiones: La terapia de la risa permite al adulto mayor encontrar fortalezas que puedan ayudarle a mejorar su presente, a su vez, lograr cambios en el individuo que se le revierten positivamente y a su relación con el entorno...

Objective: to explore the benefits of laughter therapy in a group of elderly women belonging to a gerontology center (Envigado, Colombia). Methodology: a qualitative study using a semi-structured interview with 10 adult women aged 59 to 97. The participants were interviewed before and after applying 5 weekly sessions of laughter therapy. Said therapy was administered by the Mediclaun "hospital clowns" group. Results: many of the changes observed in adult women are consistent with the results described in the literature in relation to a more positive attitude, increased confidence in people and acceptance; the participants expressed the past with less pain and had a greater liking towards family support. Conclusions: laughter therapy allows seniors to find the strength to improve their present situation, thus causing positive changes in their own self and in their relationship with their surroundings...

Influência da hidrocinesioterapia no equilíbrio postural de idosas institucionalizadas / Influence of hydrokinetic therapy in postural balance of institutionalized elderly people

O objetivo deste estudo foi avaliar a influência de um programa de hidrocinesioterapia em piscina rasa no equilíbrio postural de idosas institucionalizadas. Participaram do estudo 8 idosas institucionalizadas com média de idade de 62,95 ± 2,87 anos. O equilíbrio postural foi avaliado por meio de uma plataforma de força. Foram realizadas 3 tentativas em cada condição do teste de organização sensorial (TOS) previamente e posteriormente a intervenção de hidrocinesioterapia em piscina rasa. As variáveis analisadas foram: amplitude de deslocamento do centro de pressão (COP) na direção ântero-posterior, médio-lateral e velocidade de deslocamento do COP. Foi aplicado o teste Wilcoxon para a comparação entre as avaliações pré e pós a intervenção. Foi observada uma melhora no controle postural após a intervenção, visto que ocorreu diminuição do deslocamento do centro de pressão, principalmente na direção ântero-posterior. Para o grupo de idosas institucionalizadas participantes deste estudo, a hidrocinesioterapia realizada em piscina rasa foi capaz de melhorar o equilíbrio postural.

The purpose of the present study was to evaluate the influence that a hydrokinetic therapy program in shallow water has on postural balance of institutionalized elderly women. In this study 8 institutionalized elderly, with a mean age of 62.95 ± 2.87 years participated. The postural balance was evaluated through the force platform. 3 attempts in each sensory organization test (SOT) previously and subsequently the intervention of hydrokinetic therapy in shallow water were made. The variables analyzed were: displacement amplitude of the pressure center (COP) in the anteroposterior, mediolateral direction and displacement speed of the COP. An improvement in postural control after the intervention was observed, where a decrease on the displacement of the pressure center happened, especially in the anteroposterior direction. For the group of institutionalized elderly participants in this study, hydrokinetic therapy performed in shallow water was able to improve postural balance.

Falls prevention for the elderly.

BACKGROUND: An ageing population, a growing prevalence of chronic diseases and limited financial resources for health care underpin the importance of prevention of disabling health disorders and care dependency in the elderly. A wide variety of measures is generally available for the prevention of falls and fall-related injuries. The spectrum ranges from diagnostic procedures for identifying individuals at risk of falling to complex interventions for the removal or reduction of identified risk factors. However, the clinical and economic effectiveness of the majority of recommended strategies for fall prevention is unclear. Against this background, the literature analyses in this HTA report aim to support decision-making for effective and efficient fall prevention. RESEARCH QUESTIONS: The pivotal research question addresses the effectiveness of single interventions and complex programmes for the prevention of falls and fall-related injuries. The target population are the elderly (> 60 years), living in their own housing or in long term care facilities. Further research questions refer to the cost-effectiveness of fall prevention measures, and their ethical, social and legal implications. METHODS: Systematic literature searches were performed in 31 databases covering the publication period from January 2003 to January 2010. While the effectiveness of interventions is solely assessed on the basis of randomised controlled trials (RCT), the assessment of the effectiveness of diagnostic procedures also considers prospective accuracy studies. In order to clarify social, ethical and legal aspects all studies deemed relevant with regard to content were taken into consideration, irrespective of their study design. Study selection and critical appraisal were conducted by two independent assessors. Due to clinical heterogeneity of the studies no meta-analyses were performed. RESULTS: Out of 12,000 references retrieved by literature searches, 184 meet the inclusion criteria. However, to a variable degree the validity of their results must be rated as compromised due to different biasing factors. In summary, it appears that the performance of tests or the application of parameters to identify individuals at risk of falling yields little or no clinically relevant information. Positive effects of exercise interventions may be expected in relatively young and healthy seniors, while studies indicate opposite effects in the fragile elderly. For this specific vulnerable population the modification of the housing environment shows protective effects. A low number of studies, low quality of studies or inconsistent results lead to the conclusion that the effectiveness of the following interventions has to be rated unclear yet: correction of vision disorders, modification of psychotropic medication, vitamin D supplementation, nutritional supplements, psychological interventions, education of nursing personnel, multiple and multifactorial programs as well as the application of hip protectors. For the context of the German health care system the economic evaluations of fall prevention retrieved by the literature searches yield very few useful results. Cost-effectiveness calculations of fall prevention are mostly based on weak effectiveness data as well as on epidemiological and cost data from foreign health care systems. Ethical analysis demonstrates ambivalent views of the target population concerning fall risk and the necessity of fall prevention. The willingness to take up preventive measures depends on a variety of personal factors, the quality of information, guidance and decision-making, the prevention program itself and social support. THE ANALYSIS OF PAPERS REGARDING LEGAL ISSUES SHOWS THREE MAIN CHALLENGES: the uncertainty of which standard of care has to be expected with regard to fall prevention, the necessity to consider the specific conditions of every single case when measures for fall prevention are applied, and the difficulty to balance the rights to autonomous decision making and physical integrity. DISCUSSION AND CONCLUSIONS: The assessment of clinical effectiveness of interventions for fall prevention is complicated by inherent methodological problems (esp. absence of blinding) and meaningful clinical heterogeneity of available studies. Therefore meta-analyses are not appropriate, and single study results are difficult to interpret. Both problems also impair the informative value of economic analyses. With this background it has to be stated that current recommendations regarding fall prevention in the elderly are not fully supported by scientific evidence. In particular, for the generation of new recommendations the dependency of probable effects on specific characteristics of the target populations or care settings should be taken into consideration. This also applies to the variable factors influencing the willingness of the target population to take up and pursue preventive measures. In the planning of future studies equal weight should be placed on methodological rigour (freedom from biases) and transferability of results into routine care. Economic analyses require input of German data, either in form of a "piggy back study" or in form of a modelling study that reflects the structures of the German health care system and is based on German epidemiological and cost data.

Religious/spiritual coping in institutionalized elderly

OBJECTIVE: To evaluate the spiritual/religious coping (SRC) of elderly of two institutions of long-stay for elderly, from two towns Pouso Alegre and Santa Rita in south of Minas Gerais state Brazil and to correlate the SRC with personal characteristics. METHODS: The work is based on epidemiological and analytical cross-sectional design method with nonprobability sampling and sample of 77 elderly. The instruments used are characterization staff which consists of 15 multiple choice questions, scale of two dimensions SRC, SRC positive and SRC negative. RESULTS: both groups were balanced between the sexes, by the average age of 76 years old, 81.6 % did not complete primary education and 96.1 % practiced a religion. There was a high use of the SRC total average use and showed higher scores with age and time of residence and SRC Total. CONCLUSION: final analyses of the data demonstrated that the elderly uneducated and with religion presented SRC strategies so high and positive.

OBJETIVOS: Avaliar o coping religioso/espiritual (CRE) de idosos residentes em duas instituições de longa permanência; e correlacionar o CRE com características sociodemográficas e de saúde. MÉTODOS: Estudo epidemiológico, analítico com desenho transversal, amostragem não probabilística e amostra de 77 idosos. Na coleta de dados, realizada entre junho e agosto de 2010, foram utilizados dois instrumentos: caracterização pessoal constituída por questões fechadas; e a Escala CRE com duas dimensões, CRE Positivo e CRE Negativo. RESULTADOS: Os idosos apresentaram distribuição equilibrada entre os gêneros, média de idade 76,6 anos; 81,6% não possuíam Ensino Fundamental completo; 96,1% praticavam uma religião. Foi alta a utilização do CRE total e evidenciou maiores pontuações com as variáveis, idade e tempo de moradia e CRE Total. CONCLUSÃO: O mais velhos, sem escolaridade e com religião apresentaram estratégias do CRE de forma elevada e positiva para as adversidades vivenciadas no processo de institucionalização.

OBJETIVOS: Evaliar el coping religioso/espiritual (CRE) de los instituciones de ancianos em Pouso Alegre y Santa Rita do Sapucaí, Minas Gerais y correlacionar La CRE con características personales. METODOS: estudio epidemiológico, transversal analítico com El deseñ de muestreo no probabilístico y La muestra de 77 ancianos. Instrumentos: 1- caracterizacion 1) Caracterización del personal se compone de 15 preguntas de opción múltiple, 2) a gran escala con dos dimensiones CRE, CRE positivo y negativo. RESULTADOS: Ambos grupos fueron equilibrados entre los sexos, con edad promedio 76,6 años, 81,6% no completó la educación primaria, el 96,1% practica una religión. Hubo un alto uso de la CRE Total y mostraron mayores puntuaciones con las variables edad y tiempo de residencia y cree total. Las variables correlacionadas con la escala y factores. CONCLUSIÓN: Los mayores, sin educación y la religión se presentan las estrategias de CRE tan alto y positivo para las dificultades experimentadas en el proceso de institucionalización.

Aquatic physical therapy as a treatment modality in healthcare for non-institutionalized elderly persons: a systematic review / Fisioterapia aquática como modalidade de tratamento em idosos não institucionalizados: uma revisão sistemática

Objective: To review scientific literature pertaining to aquatic physical therapy in the elderly and institutionalized population. Methods: A qualitative systematic review of electronic databases MEDLINE and LILACS, with the topic index terms: "hydrotherapy", "homes for the aged or residential facilities", and "aged". In light of the lack of studies carried out on the institutionalized population, we opted for reviewing literature on the effectiveness of this modality of physical therapy treatment on the non-institutionalized elderly population in order to produce knowledge that can be critically analyzed according to its potential applicability for the institutionalized population. The methodological quality of the studies was assessed using the Delphi listing. Results: Of the 27 studies analyzed by their abstracts, 10 studies were excluded since they did not correspond to the eligibility criteria. We analyzed the subject characteristics of each study, as well as the quality of the methods (good methodological quality in 47% of the studies), the result measurements considered, the intervention strategies, the sites where they took place, and the professionals involved (76% by physical therapists). Conclusion: Although a large part of the studies demonstrated good results with aquatic physical therapy practice, none of them had been applied on long-stay institution for the elderly. Therefore, more studies are needed in this area for a model of assistance to long-stay institution for the elderly to be proposed.

Objetivo: Revisar a literatura científica acerca da efetividade da fisioterapia aquática na população idosa e institucionalizada. Métodos: Revisão sistemática qualitativa nas bases de dados eletrônicas MEDLINE e LILACS, com os descritores de assunto: "hidroterapia" ("hidrotherapy"), "instituição de longa permanência para idoso" ("homes for the aged, residential facilities") e "idoso" ("aged"). Diante da inexistência de estudos realizados na população institucionalizada, optou-se por revisar a literatura acerca da efetividade dessa modalidade de tratamento fisioterapêutico na população idosa não institucionalizada, a fim de se produzirem conhecimentos que pudessem ser analisados criticamente conforme sua aplicabilidade potencial na população institucionalizada. A qualidade metodológica dos estudos foi avaliada por meio da lista Delphi. Resultados: Foram excluídos 10 estudos dos 27 analisados a partir do resumo, por não corresponderem aos critérios de elegibilidade. Foram analisadas as características dos sujeitos de cada estudo, bem como a qualidade metodológica (boa qualidade metodológica em 47% dos estudos), as medidas de resultado consideradas, as estratégias de intervenção, os locais onde ocorreram e os profissionais envolvidos (76% por fisioterapeutas). Conclusão: Embora, grande parte dos estudos tenha demonstrado bons resultados com a prática da fisioterapia aquática, nenhum deles foi aplicado em instituição de longa permanência para idoso. Sendo assim, são necessários mais estudos nessa área para que seja proposto um modelo assistencial em instituição de longa permanência para idoso.