As necessidades das pessoas mais velhas com problemas de saúde mental.

Introduction: Aging population is a global phenomenon today, in both developed and developing countries, gradually leading to a change in the global demographic structure. It is estimated that within a few years Portugal will be one of the EU countries with the highest proportion of older people. Mental illness is a major focus of morbidity in this population sector, where there is a significant prevalence of depressive disorders and dementia. In association with these conditions cognitive, psychological and behavioral disorders occur together that cause problems and needs that require a contextualized response according to the characteristics of the population, existing resources and health priorities. Many of these expressions are relevant focus for nursing practice. In this framework, the main line of research of the present work was the needs of older people with mental health problems, from two analytical perspectives: one focusing on nursing foci ( component A ) and another based on the biopsychosocial model considering the needs covered and not covered in the environmental, physical, psychological and social model( component B ). Objectives: 1. To identify the focus of nursing care, more common in the mental health of elderly people, associating it with sociodemographic, clinical and functional factors. We also sought to make a contribution to the creation of a CIPE catalog and the development of a questionnaire for clinical nursing assessment in psychiatry and mental health. 2. Identify needs covered and not covered for the elderly with mental health problems and also analyze the relationship between these and the sociodemographic, clinical factors and functionality. Method: This study was divided into two components. Component A Focus of Nursing: initially carried out desk research based on the records of 71 users admitted to a psychiatric inpatient unit, aged 65 years, of both sexes, with mental illness diagnosed by ICD -9. System Support for Nursing Practice (SAPE) was used to access the data on Nursing and Medical Support (SAM) System for collection of other clinical data. To complete the sociodemographic and clinical characteristics, each user was questioned. Subsequently a similar pilot study was carried out with a sample of 75 users, recruited from the inpatient and outpatient settings from the Departamento de Psiquiatria e Saúde Mental (DPSM) of Unidade Local de Saúde do Alto Minho (ULSAM, EPE). The following were assessed: Mini Mental State Examination/MMSE and Clock Test/CDT (cognition), Geriatric Depression Scale/GDS (depression) and Zung Anxiety Scale/ZAS (anxiety), Barthel Index/BI and Index Lawton/LI (functionality) and Social Rate Graffar/GSC (sociodemographics ). Based on these two studies, a Delphi study to select and prioritize the most common foci and the content validity of a questionnaire for clinical nursing assessment of mental health and psychiatry was conducted. A panel of 50 qualified nurses was consulted for the Delphi study in 3 rounds. For each round a questionnaire was constructed and sent by email to the Delphi panel. In the first round the foci of nursing were identified and categorized, which served as the basis for the creation of the first phase of the catalog CIPE, having also selected 12 foci for the development of the instrument for clinical nursing assessment. In the second round a clinical list was validated for each focus and in the third round these utterances were classified according to their clinical nursing diagnoses for identifying the area of each focusing properties. Component B Identification of needs covered and not covered in elderly patients with mental illness, initially a pilot study was carried out on the same sample of 75 clients referred to in Component A. Later the main study was carried out with a sample of 306 users, recruited from impatient and outpatient settings of referred Departamento de Psiquiatria e Saúde Mental, of ULSAM, EPE. The evaluation protocol included the same instruments referred to above (MMSE, CDT, GDS, ZAZ, BI, LI, GSC), and the Camberwell Assessment of Need for the Elderly/CANE, needs assessment. Results: Component A Focus of nursing with the greatest consensus were: cognition (100%), memory and orientation (98%); loneliness and concentration (96%), depression, anxiety, attention and thinking (94 %), insomnia, sadness and self control (90 %). In different studies, there was a higher prevalence of outbreaks of the cognitive domain, appearing mostly in people with dementia. These foci appeared also negatively correlated with scores on cognitive tests (MMSE/CDT) and functionality (BI/LI), proving that people with low scores on these scales presented more changes at the level of these focus and major difficulties in achieving ADLs in general, with higher prevalence in instrumental activities. Several focus related to emotions were also identified, appearing mostly in people diagnosed with depression, and also positively correlated with higher scores on scales of anxiety and depression (GDS/ZAS). However, changes at the level of both these foci did not compromise the functionality and performance of the activities of daily living / ADL ` s. Moreover it was observed that focus of cognitive impairment were more frequent in older people unlike emotion related focus that appeared to be more associated with younger people. There were no significant associations between the foci of nursing and gender. The results of this component also allowed the creation of a CIPE catalog of nursing focus, which will serve to develop a procedure intended for the provision of care for older people in mental health and psychiatry. An interim version of a tool for clinical evaluation in this context was validated for the future with the aim of optimizing the collection of data, in a more rigorous and effective manner. Component B The most common psychiatric diagnoses were depressive disorder (33.7 %) and dementia (24.5 %). Most of the identified needs were covered in the area of physical health (87.6 %), home care (66.3 %), information (66.0 %), psychological distress (62.7 %) and food (61.8 %). The needs not covered were daily activities (46.7 %), psychological distress (25.8 %), memory (13.4 %), social benefits (11.4 %) and company (8.2 %). Most caregivers experienced psychological distress (65.1 %), while 24.1 % were not covered as this need. The majority of patients had cognitive impairment (MMSE, 47.4%; CDT, 68.4%) higher levels of depression (GDS, 64.7 %) and anxiety (ZAS, 57.6 %) as well as dependence on ABVDs (IB, 51.3 %) and in IADL's (LI, 83.3 %). There were negative correlations between global needs identified by the CANE and the results of the MMSE, CDT, BI and LI (rs = 0.69, rs = -0.52, rs = 0.76, rs = -0.86, respectively) and positive correlations with GDS (rs = 0.39). Discussion and Conclusion: With regard to Part A of this study, the results obtained in different studies were similar, indicating a large predominance of the focus of the cognitive domain and emotions. These areas appeared associated with specific problems and needs, difficulties in functionality, requiring particular attention, like areas relevant to nursing practice and the provision of health care in general. In this context, it is important to create and use assessment procedures in order to make an accurate and consistent identification of the problems of older people with mental illness. Given the limitations experienced with the use of CIPE in this study, it proved to be essential to improve this classification in order to make it more objective and appropriate to plan the activities of assessment and intervention in nursing. Taking into account the felt needs, and the difficulties previously reported, this study attempted to lay the foundation for the development of assessment and intervention in nursing, to address many of the identified needs and improve care in this context. With regard to work done in Component B, there was a predominance of needs not covered in terms of daily activities, psychological distress and memory, which has also been described by other authors. Most caregivers experienced psychological distress. Patients with dementia were those with a greater number of general needs, corroborated by cognitive deficits, lower functionality and higher levels of depression associated with a greater number of needs, similar to the findings of other international studies. The psychological distress whether of the elderly or of informal carers, was one of the most common needs not covered in the study population, suggesting little preparation of informal carers ( high degree of illiteracy ) and lack of stimulation and involvement of older people in activities which promote physical and mental health and. Overall, the large number of needs not covered, and the consequent lack of adequate responses cause more suffering and worry for older people and their carers. This reflects the currently worsening socioeconomic situation in Portugal, which makes these people the most unprotected and vulnerable to physical and mental illness. This condition requires a coordinated intervention based on a biopsychosocial perspective, to ensure better coverage of needs, promoting inclusion and quality of life of these people and their families / caregivers. Hopefully, this study, will have contributed to a greater identification of the needs of older people, demonstrating that planning and implementation of health care and social responses, with a more efficient approach is urgently needed.