Renata
P .Veras
F o s te rin g h e a lth c a re fo r th e e ld e rly p riv a te
D e s p ite r e m a r k a b le g r o w th o f th e e ld e r ly p o p u la tio n , B r a z il w ill s till h a v e f o r s o m e tim e a la r g e s h a r e o f y o u n g p e o p le in its p o p u la tio n . T h is s itu a tio n d if f e r s s ig n if ic a n tly f r o m c o u n tr ie s in th e N o r th e r n H e m is p h e r e . I n th o s e c o u n -tr ie s , th e n u m b e r o f y o u n g p e o p le is s m a lle r , m o r e s ta b le o r th is n u m b e r h a s b e e n s h o w in g a te n d e n c y to d e c r e a s e f o r d e -c a d e s , w h e r e a s th e o ld e r s h a r e o f th e p o p u la tio n c o n tin u e s to g r o w .
T h e g r o w th p a tte r n o f th e B r a z ilia n p o p u la tio n h a s d if -f e r e n t c h a r a c te r is tic s f r o m c e n tr a l c o u n tr ie s . B r a z il f a c e s a g r e a t c h a lle n g e : th e a llo tm e n t o f r e s o u r c e s to a s s is t b o th a g e g r o u p s , e ld e r ly a n d y o u n g . B o th g r o u p s a r e in n e e d o f r e -s o u r c e -s a n d d e m a n d a g r e a t d e a l o f s e r v ic e s . T h u s , f u n d in g f o r s o c ia l p r o g r a m s s h o u ld b e d e s ig n a te d n o t o n ly to r e v e r s e , f o r in s ta n c e , th e h ig h in f a n t m o r ta lity r a te a n d m a ln u tr itio n . F u n d in g f o r s o c ia l p r o g r a m s s h o u ld a ls o b e d e s ig n a te d f o r e d u c a tio n a l p r o g r a m s , to c o m b a t c h r o n ic d is e a s e s s u c h a s a r th r itis , h e a r t, d e g e n e r a tiv e d is e a s e s , c o g n itiv e c h a n g e s a n d o th e r illn e s s e s ty p ic a l o f th e e ld e r ly . I n a d d itio n to h e a lth p r o b -le m s , th e r e a r e b e n e f its a n d p e n s io n e x p e n s e s f r o m th e s o c ia l s e c u r ity s y s te m to w h ic h a ll e ld e r ly p e o p le a r e le g a lly e n -title d . I n te r m s o f e c o n o m ic im p a c t, th e r e is a n e n o r m o u s d if -f ic u lty : tw o e c o n o m ic a lly in a c tiv e g r o u p s d e m a n d m e a g e r r e s o u r c e s f r o m a p o o r c o u n tr y w ith a b ig tr a d itio n o f lo w in -v e s tm e n ts in h e a lth c a r e a n d s o c ia l s e c u r ity .
P e r h a p s th e g r e a te s t s im ila r ity b e tw e e n B r a z il's e ld e r ly p o p u la tio n a n d th e e ld e r ly p o p u la tio n f r o m c e n tr a l c o u n tr ie s r e s id e s in th e p r o b le m s f a c e d b y e ld e r ly w o m e n . T h e m a r ita l s itu a tio n o f e ld e r ly p e o p le in B r a z il s h o w s th a t 6 8 % o f th e p e o p le w ith o u t a c o m p a n io n ( u n m a r r ie d , w id o w e d o r d iv o r c e d ) a r e f e -m a le s . D u e to c u ltu r a l f a c to r s , th e w o m a n m a r r ie s a t a n e a r lie r a g e th a n m a n . W o m e n £ s lif e e x p e c ta n c y is lo n g e r , th e r e f o r e , w o m e n a r e m o r e lik e ly to b e a lo n e in th e la te r y e a r s . W o m e n m a lT Y e a r lie r a n d liv e lo n g e r . T h e s c e n a r io g r o w s e v e n g lo o m ie r w h e n liv in g a lo n e is a ls o a c c o m p a n ie d b y p o v e r ty a n d c h r o n ic d is e a s e s . T h e c o m b in e d e f f e c ts o f lo n e lin e s s , p o v e r ty a n d ill-n e s s a f f e c ts a la r g e s h a r e o f th e e ld e r ly f e m a le p o p u la tio n . L ik e in th e c e n tr a l c o u n tr ie s , th is s itu a tio n is a ls o s e e n in th e m a jo r -ity o f th e a g e d B r a z ilia n w o m e n .
R e s e a r c h in e p id e m io lo g y in B r a z il is , w ith s o m e e x -c e p tio n s , v e r y m o d e s t. T h e r e f o r e , a n in c r e a s e in e p id e m io l-o g y r e s e a r c h is n e c e s s a r y . T h e p a p e r h e r e in p o r tr a y s a d r a f t p r o p o s a l f o r a s tu d y in e p id e m io lo g y . T h is p r o p o s e d s tu d y is b a s e d o n a n o th e r r e c e n tly c o n c lu d e d in v e s tig a tio n th a t y ie ld e d in f o r m a tio n to s h a p e m e d ic o - s o c ia l p o lic ie s f o r e ld -e r ly w o m e n . A d d itio n a p y , th is o r ig in a l r e s e a r c h p r o d u c e d s o m e h y p o th e s e s to b e c o n f ir m e d in s u b s e q u e n t s tu d ie s .
T h e a f o r e m e n tio n e d d r a f t s tu d y p r o p o s a l - " P r e v a le n c e S tu d y o - d e s p ite its lim ita tio n s , h a s a s its o b je c tiv e to s h a p e a p r o f ile o f e ld e r ly s u b je c ts r e s id in g in a la r g e u r b a n a r e a in B r a z il, n a m e ly , R io d e J a n e ir o . D u e to s o c io - e c o n o m ic d is -c r e p a n -c ie s w ith in R io d e J a n e ir o , th e a u th o r s d id n o t c o n -s id e r th e c ity a -s a w h o le , w h ic h w o u ld h a v e b e e n a d e s ir a b le te c h n iq u e in o r d e r to o b ta in r e c o r d s r e f le c tin g th e lif e c o n -d itio n s in th e p o o r e r a n d w e a lth ie r s o c ia l c la s s e s . I n s te a d , th e a u th o r s s u r v e y e d s o m e c ity a r e a s s e p a r a te ly . T h is w a s d o n e to a llo w a m o r e a c c u r a te r e c o r d o f r e g io n - s p s c if ic r e -a litie s ( R -a m o s e t a I ., lik e w is e p e r f o r m e d a s tu d y in S 5 0 P a u lo c ity ) .
T h e r e f o r e , R io d e J a n e ir o w a s a s s e s s e d in " h o m o g -e n o u s a r e a s " , th a t is , n e ig h b o r h o o d s a n d s o c ia l c la s s e s d is -p la y in g s im ila r f a c ilitie s .
E p id e m io lo g y , a s a s c ie n c e , h a s b e e n d e m o n s tr a te d to c a r r y p o w e r f u l in s tr u m e n ts to p r o d u c e c r itic a l d a ta f o r p la n -n i-n g , im p le m e -n ta tio -n , a n d a s s e s s m e n t o f s o c ia l s e r v ic e s . P r i-o r itie s c a n a ls o b e d e te r m in e d w ith th e h e lp o f e p id e m io l-o g y . R e g a r d in g th e e ld e r ly p o p u la tio n , s e v e r a l s tu d ie s e m -p lo y in g d a ta c o lle c tio n b y m e a n s o f q u e s tio n n a ir e s , h a v e b e e n s h o w n to h a v e s ig n if ic a n t v a lu e in d e te r m in in g e v e n ts a n d in th e c o n tr o l o f s o c ia l a n d h e a lth p r o b le m s .
T h e d e f in itio n o f th e d r a f t in s tr u m e n t is im p o r ta n t w h e n p la n n in g a n in q u ir y . D e s p ite o p e r a tio n a l b u r d e n s , h o m e in -te r v ie w s a r e b y f a r th e b e s t m e th o d in th e s tu d y o f a n e ld e r ly p o p u la tio n .
I n th e p r e s e n t s tu d y , a n in s tr u m e n t c a lle d B O A S w a s d e v e lo p e d . B O A S is a m u lti- d im e n s io n a l q u e s tio n n a ir e d e -v is e d f o r e ld e r ly p e o p le , a n d it w a s g r o u n d e d in s e v e r a l o th e r in s tr u m e n ts w ith a c c e p ta b le v a lid ity a n d r e lia b ility . B O A S
is com posed of nine sections. B eing a m ulti-dim ensional
ques-tionnaire for the third age, it is long because it is m eant to
cover a w ide range of features in the lives of elderly people.
T hus, the questionnaire draft proposal is to approach w ider
range of diagnosis. It does not explore specific features, but
constructs a profile of the elderly person. T he m ulti-dim
en-sional questionnaire is not m eant to obtain detailed
infonna-tion. It respects tim e lim itations as w ell as taking into
consid-eration the fact that it is an interview w ith an elderly
popula-tion. A t any rate, no research instrum ent should exceed 60
m inutes of application.
T hree areas w ithin R io de Janeiro w ere selected for the
study: C opacabam a, M U ier and S anta C ruz. T hese areas w ere
selected in keeping w ith socio-econom ic and dem ographic
data. Initially, a four-m onth-Iong enum eration w as perform ed.
T he B O A S application began in July 1988 and it w as
con-cluded in A ugust 1989. T he response rate w as excellent,
93.3% in C opacabana, 93.8% in M lJier and 93.1 % in S anta
C ruz.
T he use of m orbidity indexes to assess the health status
in the study of an elderly population, despite its clear im
por-tance, does not have the sam e predictive m eaning as in other
age groups. F rom 60 or 70 years of age, the m ajority of the
people have one or m ore chronic illnesses. T his (the presence
of chronic illnesses) gives the identification of a health
prob-lem a distinct degree of im portance as opposed to the other
age groups.
In this age range (60 to 70 years), it is m ore im portant
to record if an illness is lim iting the perform ance of a daily
routine in an independent and autonom ous m anner than to
identify the presence of an illness. F or instance, it is m ore
im portant to docum ent how a diagnosis of an arthritic
condi-tion is lim iting w alking (loss of independence) or if the
personiE s activities are only m ade possible w ith the help of a
w heelchair pushed by a third party (not autonom ous) than
recording the specific features of an arthritic condition.
T herefore, in the m ulti-dim ensional questionnaires
cre-ated for the elderly individual, the section nam ed activity daily
living (A D L ) as a tangible indicator in the definition of life
quality for the elderly person. It is also a valuable index to be
taken into account in the planning of health policies.
A nother im portant item analyzed in this study is the
m ental health of elderly subjects. In this present study, that
authors w ill present and discuss the results of the study of the
prevalence of O rganic C erebral S yndrom e (O C S -dem entia)
and depression. T he authors w ill also discuss the m
ethod-ological features involved in the reliability study as w ell as
validation of the B O A S m ental health segm ent. A description
of the procedures used in the pilot study is also approached.
T he B O A S instrum ent carries a m ental health segm ent
that is a P ortuguese translation of the short-C A R E . T he
short-C A R E P ortuguese translation em ployed w as the G uys H
os-pital and A ge C oncern P sychogeriatric R esearch P roject's
version. T his version w as steered by D r. A laine M urphy and
it is an adaptation, w ith few changes, of the original
instru-m ent developed by G araland. T he questionnaire possesses
scales for assessm ent of O rganic C erebral S yndrom e (O C S )
and depression (D ep). S C O carries 12 item s w ith scores
rang-ing from 0 to 9 points. T here are 3 I item s for depression, and
scores range from 0 to 28 points. T he pilot study belongs to a
body of quality assurance m easures aim ing at the next step in
the research. In this next step, the instrum ent w as assessed for
reliability and validity, w ith the subsequent prevalence study.
O nce this initial draft w as selected, a sm all num ber of
inter-view s w ere done for the pilot study w ith no statistical
analy-sis perform ed. T hese interview s focused on the case-to-case
basis (quality), aim ed at prim ing the instrum ents as w ell as
the procedures to be em ployed in the next step of the study. In
sum m ary, this pilot study can be considered as a fine-tuning
stage, previous to the study itself.
T here are five features regarding the B O A S m ental
health segm ent study that deserve com m ent. F irst, it is
neces-sary to observe that the m ajority of the studies to validate the
estim ated sensibility and reliability values display a w ide
con-fidence interval. T his is because of the sm all sub-sam ple em
-ployed in these validation studies.
T his feature (w ide confidence interval), although
receiv-ing little attention in the m ajority of the papers on validation
of diagnostic instrum ents, is of param ount im portance. T his
w ide confidence interval is im portant for the decision about
the cut points to be adopted. It is also im portant in appraising
the prevalence rates corrected from these studies. T hese
fea-tures m anifest them selves by m eans of abrupt changes in the
sensibility and specificity w hen the cut point is shifted to the
next point. T hus, the selection of these cut points should be
m ade rather carefully because one cannot state w ith a high
reliability degree that the rate of false-negatives and
false-positives are distinct for adjacent cut points.
