Health profile of older adults assisted by the Elderly Caregiver Program of Health Care Network of the City of São Paulo

ABSTRACT Objective To assess the health profile of community-dwelling older adults, according to sex, assisted by the Elderly Caregiver Program of the City of São Paulo. Methods Secondary data of 535 older adults, assisted by ten Elderly Caregiver Program teams from the southern region of São Paulo, were collected from medical records and the Multidimensional Evaluation of Older People in Primary Care, after verifying the inclusion and exclusion criteria for the study and obtaining subjects’ consent. Results Older adults assisted by this program were predominantly female (77.6%), mean age of 76.2±8.0 years. They had negative self-rated health (67.8%), difficulties in instrumental activities of daily living (68.4%) and signs of mood changes (60.3%). A high prevalence of older adults with vision problems (58.8%), polypharmacy (58.1%), memory-related complaints (55.8%) and multiple morbidities (50.6%) were observed. The prevalence of multiple morbidities, polypharmacy, cognitive impairment and signs of mood changes were higher in women. On the other hand, men reported more hearing problems than women. Conclusion The poorer health conditions of the older adults in this study, evidenced by a high prevalence of subjects with negative self-rated health, difficulties in instrumental activities of daily living, multiple morbidities, polypharmacy and other complaints (sensorial changes, depressive and cognitive symptoms), reinforce the importance of this program as a long-term care policy and as a way to ensure these older adults can continue living in their communities.


❚ INTRODUCTION
The Brazilian population ages faster compared with that of developed countries, and does so within a context of economic inequality. In 2014, older adults accounted for 13.7% of the Brazilian population, whereas projections of the Brazilian Institute of Geography and Statistics (IBGE -Instituto Brasileiro de Geografia e Estatística) estimate that this rate will go up to 33.7% by 2060. (1) The higher number of older adults poses numerous challenges when it comes to public health, since the prevalence of non-communicable diseases (NCD), frailty and disability is higher in long-lived adults. (2)(3)(4) According to the Brazilian Longitudinal Study of Aging (ELSI-Brazil -Estudo Longitudinal de Saúde dos Idosos Brasileiros) investigating 9,412 subjects aged over 49 and over from 70 Brazilian cities, the prevalence of multimorbidity (three or more chronic diseases) at age ranges 60-69, 70-79 and ≥80 years was 52%, 61% and 67%, respectively. (2) Likewise, the presence of difficulties in at least one basic activity of daily living (BADL) was higher in the oldest-old (≥80 reported 42.7%) compared with younger age groups (60-69 years reported 21.8% and 70-79 years, 26.7%), and the demand for care was higher among the oldest-old, females, and subjects with fewer years of schooling. (4) Taking care of an increasingly older population is a challenge for developing countries like Brazil, which need to handle the issue of rapid population aging combined with great economic and social inequalities. (1) In respect to public health policies, (4) support for families with aged members has not been implemented yet throughout the territory, and policies aiming at longterm care are scarce. Currently, there are some aging in place care programs too allow aged patients to stay at home, such as the Greater Care Program in the city of Belo Horizonte, (5) and the Elderly Caregiver Program (PAI -Programa Acompanhante de Idosos) of the city of São Paulo. (6) The PAI is a modality of biopsychosocial home care for older people in a situation of clinical frailty and social vulnerability, offering the services of health care professionals and professional caregivers aiming at rehabilitation, maintenance/improvement of selfcare, and socialization. It was created with the purpose of providing integrated health care to dependent and socially vulnerable seniors, with difficult access to the health system and living in social isolation or exclusion, primarily due to insufficient family or social support. (6) Older adults assisted by the PAI are seen by a multidisciplinary team assigned to a Primary Care Unit (UBS -Unidade Básica de Saúde), composed of a coordinator, a physician, a nurse, two nursing attendants/technicians, a clerk and ten professional caregivers of older adults . The common skills of PAI professionals include disease prevention and health promotion, evaluations, plans of care and home visits, as well as matrix-based actions, shared management and continued education. (6) Considering the relevance of the PAI in ensuring frail and vulnerable older people can live as long as possible in their communities, we need to understand the profile of current patients to provide data for continuous improvement of the program.

❚ OBJECTIVE
To assess the health profile of community-dwelling older adults, according to sex, enrolled in the Elderly Care Program of the City of São Paulo.  The older adults assisted by the aforementioned PAI units were invited to take part in this research study, authorizing access to their medical records and their information in the Multidimensional Evaluation of Older People in Primary Care (AMPI/AB -Avaliação Multidimensional da Pessoa Idosa na Atenção Básica), after signing an Informed Consent Form (ICF). To be assisted by the PAI, users must be aged ≥60 years, live within the area covered by the corresponding UBS, and meet at least one of the following criteria, verified in the AMPI/AB applied by the UBS team: dependence in activities of daily living (ADL); impaired mobility; difficulty accessing health care services; insufficient family and social support; social isolation or exclusion; and being at risk for institutionalization. (6) Data collection took place in November 2018, when 1,297 seniors were being assisted. This number was used for sample size calculation, and led to a minimum sample size of about 297 seniors, considering a 95% confidence interval, 5% error margin and 50% estimated rate of chronic conditions and/or health problems (i.e., a rate as conservative as possible, ensuring, therefore, a larger sample).
In addition to the aforementioned inclusion criteria of the PAI program per se, this study included only older adults/people who had completed the AMPI/AB. Also, the AMPI/AB had to have been applied by a trained professional at least one year before, and answered by seniors themselves, with no interferences or help from third-parties. We excluded seniors who did not authorize access to their medical records and were not able to sign the ICF due to low schooling (illiterate), cognitive impairment and/or sensory impairment. After applying the inclusion and exclusion criteria, we collected data from 535 seniors.

Questionnaire
The AMPI/AB is a multidimensional evaluation tool used in Primary Care units in the city of São Paulo to rate the functional risk of older people. In addition to help build a registry of aged users, the AMPI/AB allows for better organization of the network's services and preparation of plans of care; assesses seniors' demand in the public health network, and improves the planning and management the care of the older people. (7) The questionnaire covers 17 parameters (age, self-rated health, family arrangement, chronic conditions, medications, hospitalizations, falls, vision, hearing, physical limitation, cognition, mood, BADL, instrumental activities of daily living -IADL, incontinence, unintentional weight loss and oral health), based on self-reported answers to 31 questions. In addition to providing information on the needs of the older people, the AMPI/AB has also been used to rate the level of frailty and refer older adults ou older people to specialized services, if there is a verified need for therapies and/or specific care. (6,7) According to AMPI/AB score, the older adults are classified as healthy (zero to 5 points), pre-frail (6 to 10 points) and frail (over 10 points). It is worth noting that this questionnaire is undergoing validation, and a preliminary study has shown good accuracy (area under the ROC -Receiver Operating Characteristic -curve -0.851, p<0.001) in detecting frailty, (8) based on the frailty phenotype proposed by Fried et al. (9)

Statistical analysis
The data are presented in percentages, according to the AMPI/AB parameters and the subjects' sex. We used the χ 2 test to check the distribution of answers in relation to sex. For all analyses, we considered a 5% alpha.

❚ RESULTS
We reviewed data from 535 older adults assisted by the PAI (mean age 76.2±8.0 years). The characteristics of the older adults are shown in table 1.
A little over half of the population assisted by the PAI at CRS-South was in the 75-89-year age group (53.6%), followed by 60-74-years (42.5%). The rate of oldest-old subjects (aged ≥90) was only 3.9%.
As for sex, there were more females (77.6%). Among the issues assessed by the AMPI/AB, the following stand out negative self-rated health (67.8% reported having fair, poor or very poor health), presence of multiple morbidities (50.6% reported having three or more chronic diseases), polypharmacy (58.1% used five or more medications), presence of sensory problems (58.8% had problems seeing and 41.1% hearing), complaints of cognitive impairment (55.8% had signs of cognitive deficit), mood changes (60.3% had depressive symptoms), difficulty performing IADL (68.4% required help in at least one activity), and presence of urinary incontinence and/or fecal incontinence (41.3%). Oral health or food intake problems were also reported by half of the older adults (51.3%), whereas only 25.7% reported having lost weight for no apparent reason in the last 12 months. As for family arrangement, 25.8% of respondents (total sample) declared to live by themselves. The prevalence of recurrent falls and hospitalizations (two or more in the past year) was 18.2 and 3.0%, respectively. Most of the older adults reported no functional limitations preventing them from performing self-care activities (82.6%), although 46.7% reported having some physical limitation.
With respect to the final classification in the AMPI/AB, the majority of the population assisted by the PAI was classified as pre-frail (45.1%) and frail (36.1%), and no statistical differences were observed in the prevalence of frailty between the sexes (Figure 1). network, (10) which interviewed 5,532 seniors from different regions of Brazil, with a prevalence of females of 65.6%. Similarly, a study with data from older people (60 and older) enrolled in the ELSI-Brazil, (11) the prevalence of females was 53.6%. (3) The feminization of old age, i.e., the greater proportion of women than man in the older population, particularly among the oldest-old, has relevant repercussions on the need for public policies. Compared with men, women tend to live longer with NCD and are at higher risk for dependence, in addition to commonly undertaking the role of caregivers for their spouses and then being alone at the end of life. (4,12) Since women also have lower schooling and wages when compared to men, they are more susceptible to frailty and lack of financial resources in old age. (12,13) Therefore, women have a greater chance of needing long-term care, due to greater disability as well as low social support, which could explain the greater proportion of older women assisted by the PAI.
This change in the health profile of the population of developing countries is taking place fast, and NCD now feature among the major causes of death and disability, in positions that were formerly occupied by infectious-contagious diseases. (1) Although aging is not synonymous with disease, the literature supports that NCD are more prevalent as we get older. (14) This is a relevant fact which impacts public policies, considering that NCD aggravate health conditions and may lead to functional decline, low quality of life, increased use of health care services, and higher health care costs. (14) In Brazilian community-dwelling older adults, the prevalence of multiple morbidities (two or more chronic diseases) varies from 36% to 42%. (2,13) In PAI subjects, however, the prevalence of three or more chronic diseases was 50.6%, and even higher among females (54.1%). Data from the Health, Well-Being and Aging study (SABE -Saúde, Bem-Estar e Envelhecimento) also confirm this greater prevalence of NCD in older women. Alvarado et al., (13) showed that 45.4% of older women enrolled in the SABE-Brazil study reported having two or more chronic diseases, whereas for men, the rate was 36.4%.
Another very common problem in aged patients with multiple morbidities is the excessive and/or improper use of medications. Population-based studies show that the prevalence of polypharmacy (regular use of five or more medications) among older adults may vary between 10.3% and 36%, (15)(16)(17)(18) which is lower than what was found in this study (58.1%). The main factors

❚ DISCUSSION
The prevalence of females assisted by the PAI was slightly higher (77.6%) than in other national studies, such as that conducted by the Brazilian Frailty in Older People (FIBRA -Fragilidade em Idosos Brasileiros) einstein (São Paulo). 2020;18:1-8 related with polypharmacy include negative self-rated health, the presence of NCD (especially cardiovascular and metabolic), and the use of health care services. (16)(17)(18) Additionally, data from the SABE-Brazil study (15) showed a greater risk of polypharmacy among women, and the oldest-old (aged >75 years). Among the older adults in this study, the majority were female (77.6%) and a large part was aged ≥75 years (57.5%), which may have contributed to the high rate of polypharmacy. We also found a greater prevalence of polypharmacy among females (62.6%) compared to males (42.5%). Polypharmacy increases the risk of negative outcomes in the old age, such as adverse reactions, functional decline, cognitive decline, urinary incontinence, falls, among others, (19) and this practice is considered a challenge for elderly care. (16,17) Self-rated health has been associated with the risk of death, particularly in the older adults. (20)(21)(22) According with Reile et al., (20) subjects with negative self-rated health have a twice-as-high risk of mortality in 5 years, compared with those who self-rate their health as excellent, even after adjusting for relevant covariates (comorbidities, functional capacity and depression). Bamia et al., (21) also found an increased risk of mortality in aged patients with negative self-rated health in different regions of Europe and the United States, and therefore concluded this is a quick and simple tool to identify groups of older people at risk for early mortality.
According to Kusumastuti et al., (22) the possibility to determine someone's risk of death using this health self-assessment is the same as with other more objective scores (comorbidity and frailty scores), which highlights the importance of considering the older adults selfperception of their own health status.
In this study, 67.8% of PAI participants reported having fair, poor or very poor health, which was higher than found in population-based data of communitydwelling older adults. Data from the last wave of the SABE-Brazil study, for example, showed that 48.9% of respondents self-rated their health as fair, poor or very poor, (23,24) and this was associated with the female sex, age ≥75 years, low income and fewer years of schooling.
According to the World Health Organization (WHO), the health of older people must be considered from a functional perspective, not based on the absence of disease. (25) Functionality, in turn, is determined by the level of help required by subjects for ADL, which is influenced by personal (physical and mental skills) and environmental factors, and the interaction between them. (26) The establishment of disability follows a hierarchical process that typically starts with the onset of a morbidity, leading to dysfunction, followed by functional limitations and, ultimately, full-blown disability. (27,28) According to Bleijenber et al., (29) older people with three or more chronic diseases have a threeto-five-fold higher risk of disability, as compared to individuals not suffering from such diseases. Therefore, it is essential to intervene early in the process of disability, with the view to preserve as much as possible the functional capacity of older people at risk.
In respect to ADL difficulties, we found that 17.4% of older adults enrolled in the PAI require help for at least one BADL. This finding supports other studies with Brazilian older adults, with the prevalence of BADL difficulties in community-dwelling older adults varying between 14.8% and 25.4%. (4) However, the rate of PAI participants who require help for IADL is twice as high (68.4%) compared with the SABE-Brazil study (approximately 30%). (4) This points to a greater level of dependence among PAI subjects, particularly in more complex tasks that are critical for maintaining their independence in the community. This raises concern, since the ability to perform complex activities seems to decline faster than for basic activities, and this can rapidly increase the level of dependence of these older adults. (30) By considering functionality as the main determinant of health in old age, it is imperative that older people's care be based on managing functional capacity and not existing chronic conditions. (31) Thus, in the line of care proposed for the older adults, the risk of developing frailty must be monitored based on the functional capacity and, as a consequence, and according to the needs, at different levels of care. (32) In the home care setting, the PAI contributes with integrated care for older adults in a situation of frailty and vulnerability, by providing support with health and social needs. (33) In this sense, the different health-related demands found among older adults enrolled in this study reinforce the major role of the PAI in maintaining the independence and autonomy of its users.
Finally, this study has some limitations that should be considered. By excluding illiterate older adults and those with cognitive and sensory impairment, due to their difficulty answering the questions in the AMPI/AB and/or signing the informed consent form, we have potentially excluded the most frail and vulnerable older people from the final sample. In addition, since the AMPI/AB is under validation, the authors chose not to discuss any data relative to the frailty classification, einstein (São Paulo). 2020;18:1-8 which still needs to be tested and confirmed in future psychometric studies.

❚ CONCLUSION
The poorer health conditions of vulnerable older adults assisted by the Elderly Caregiver Program, proven by the high prevalence of negative self-rated health, difficulties in instrumental activities of daily living, multiple morbidities, polypharmacy, and other complaints (sensory impairment, depressive and cognitive symptoms) underline the importance of this program as a long-term care policy, helping, therefore, ensure these seniors can continue living for as long as possible in their communities.

❚ ACKNOWLEDGMENTS
To the Municipal de Saúde de São Paulo, à Coordenadoria Regional de Saúde Sul, the Technical Health Supervisions and the Programa Acompanhante de Idosos teams for participating in the project. The present work was conducted with the support of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) -Financing code 001.