María Isabel Arteaga-Hernández,1 Martha Graciela Segovia-Díaz de León,2 Ma. del Carmen Pérez-Rodríguez,2 Maribel Cruz-Ortiz2
1Servicio de Terapia Cardiovascular, Hospital Central “Dr. Ignacio Morones Prieto”, Servicios de Salud del Estado de San Luis Potosí.
2Facultad de Enfermería, Universidad Autónoma de San Luís Potosí. San Luis Potosí, México.
Correspondence: Maribel Cruz-Ortiz
Received: April 19th 2014
Judged: August 29th 2014
Accepted: November 17th 2014
Introduction: The increase in the elderly population and sociocultural changes that it presents have increased the incidence of chronic and degenerative diseases. These changes have led to reassess the hospital care to ensure that these patients adapt to their social environment and disease stage does not impair its functional and intellectual capacity, and their basic human needs are covered, both when admission and at hospital discharge.
Objective: To identify the relationship between the functional capability in activities of daily living and human needs of seniors who leave from the internal medicine and surgery services in a public hospital.
Methodology: A study of cross-section with quantitative approach was conducted. Barthel Scale, the instrument for the evaluation of Virginia Henderson and the Short Portable Mental Status Questionnaire of Pfeiffer were used to collect the data.
Results: 185 questionnaires were applied to seniors with a mean age 72 years. Found significant differences between age and dependence, as older existed more depended. Women were those who had the highest proportion of dependence.
Conclusions: According with Virginia Henderson´s classification, most of the identified needs were not satisfied. These results indicate the need to improve and increase care during hospitalization, as well as training to family caregivers.
Keywords: Aged; Hospitalization; Mobility limitation; Nursing services
This study focuses on demonstrating the relationship between functional capacity in activities of daily life and the human needs of older adults discharged from internal medicine and surgery. The purpose was to visualize the needs and supports required by adults in the home after passing through the hospital, and to identify areas for improvement in preparation for discharge.
The aging of the population in Mexico became evident starting in the last decade of the twentieth century, and it will inevitably be the most marked demographic change of the century. Since old age is associated with varying degrees of dependency, the social and economic consequences of this change are of such importance that it is imperative to analyze and anticipate them to prevent their effects.1
Therefore, the current challenge is prevention and care for patients with diseases such as diabetes mellitus; obesity; mental, cardiovascular, pulmonary, and cerebral diseases; hip fractures secondary to osteoporosis; and falls. These diseases often accompany disability, dependency, and loss of basic and instrumental activities of daily life,2 and a high cost of care.3,4
Thus, the aging population and changes in morbidity are one of the biggest challenges that the health system faces, not only due to the increase of the population served and the frequent comorbidity that this presents, but also from the need to contain rising costs.
This has driven strategies like early discharge, home care, and the transfer of some activities previously carried out in the hospital, to homes to be taken on by primary caregivers.
In older adults, the strategies outlined are even more commendable because lengthening hospitalization can cause deterioration and disuse syndrome. However, for timely discharge to represent a benefit for the elderly, it is necessary to ensure that they receive direct care and adequate training during hospitalization, to preserve their functional capacity and their ability to successfully incorporate into their daily lives, preventing reentry.
Although statistical data place the physical health of older adults as an important issue because of the number of consultations and hospitalizations and their duration, as well as mortality rates, few data address the involvement of daily life.5
Knowing the level of functionality and future ability of older adults to perform the activities of daily living independently makes it possible to support them to adapt their environment in a way that fosters their independence and that of the primary caretaker, who takes on and complements care for the older adult.
Moreover, the normal changes due to aging and health problems of older adults are often manifested as declines in functional status, which may be aggravated during hospitalization. Therefore, the role of nursing is critical as it involves providing assistance, support, and education in the hospitalization process, for the older adult to cope with the new changes in their life and health status at hospital discharge.
The aim of the study presented was to identify if there is a correlation between the functional capacity of older adults and the satisfaction of their human needs.
A quantitative, descriptive, correlational, cross-sectional study was conducted. The collection period was from April 25th to May 26th, 2012, although a pilot test of the instrument was previously conducted.
The sample was non-probabilistic by quota, calculated in proportion to all patients discharged over a month. The size was defined as 185 older adults, regardless of gender, who met the following inclusion criteria:
Patients with severe hemodynamic deterioration or who died during the analysis period were eliminated from the study.
Functional capacity was defined as the degree of dependence or independence that the older adult has to perform activities of daily living. Human needs were considered the 14 basic needs, and as the role of nurse, the guidance that this person provides to help the patient regain or achieve their independence.6
The instruments used for this study were:
Before the data collection pilot test, approval was obtained from the Ethics Committee of the Facultad de Enfermería of the Universidad Autónoma de San Luis Potosi and the Committee on Education and Research of the health unit where the study was held. A fundamental aspect of this study was informed consent, which was obtained as stated in Articles 20 and 21 of the Ley General de Salud, sections I to IX; and Article 22, sections I and II, concerning the respect for fundamental principles and rights applicable to human beings.11
This research, in which only questionnaires were applied, was considered a minimal risk study, in accordance with Article 17 of the Reglamento de la Ley General de Salud en Materia de Investigación para la Salud.12
Once the protocol was approved, the pilot test was conducted to get an overview of the context of older adults and to test the applicability of the instruments. Therefore the time required for interviews was measured, especially for the human needs evaluation tool according to Virginia Henderson's model. The estimated interview implementation time was 30 minutes to an hour and a half.
The procedures for the selection of the subjects in the final stage were the same used in the pilot. Once the older adults were provided with basic information describing their participation and they consented to collaborate in the study (by signature for those who could write, and fingerprint for those who did not know how to write), the general information questionnaire was applied, which included demographic data, primary reason for admission, previous hospitalizations and illnesses, medication, and health status. Then the Barthel Scale was used to assess functional capacity at discharge and, finally, the human needs evaluation tool according to Virginia Henderson’s model.
For Pfeiffer’s Short Portable Mental Status Questionnaire, the sum of the raw data was made, then a point of error was subtracted if schooling was incomplete primary or less. The total sum, minus the indicated error point, was coded with the stipulated weightings of number of errors: up to two errors, normal intellectual functioning; three to seven errors, deficient intellectual functioning; eight to 10 errors, serious intellectual deficit.
Functional capacity was assessed by applying the Barthel Scale, which assesses basic and instrumental activities of daily living with totals and averages by age group and sex. With scores of absolute and relative frequencies, categories were identified according to levels of functional capacity and were contrasted with the human needs identified at discharge, an analysis carried out at the end as nominal variable for correlations with chi-squared.
Functional capacity according to basic and instrumental activities of daily living was processed with total and mean score in the age and sex groups; by category, with absolute and relative frequencies. The comparison with human needs identified at discharge was analyzed at the end as a nominal variable with chi-squared.
Processing was done with concentration data with the development of a database in SPSS version 18 and previous analysis of the quality of capture. The breakdown of interviewees was done with descriptive statistics of sociodemographic variables as absolute and relative frequencies, measures of central tendency, and dispersion.
The group of older adults had ages between 60 and 100 years, with a mean of 72 ± 7.97 years. Of the total (n = 119), 64.3% were between 60 and 74 years old and the rest (39.5%) were aged 75 to 100 years. As for sex, the majority were male (54.1%).
Table I shows the characteristics of vulnerability of the study group. Regarding health characteristics, differences in pathologies presented by patients were identified in each service. In the surgery department diseases of the digestive system predominated (33.9%), while in internal medicine, it was those related to the circulatory system (30.1%). After applying chi-squared, a significant difference was found in the prevalence of diseases in the two services (chi-squared = 74,861, df = 12, ns = 0.000).
|Table I. General characteristics and personal factors of older adults|
|Socio-demographic characteristics||64.3% are between 60 and 74 years|
|95% do not have paid employment|
|76.8% have incomplete primary education|
|39.1% live alone or with a child|
|Problems of safety risk||84.9% have problems seeing up close|
|81.1% have problems seeing far and have pain|
|68.6% have problems hearing|
|61.6% have had falls in the past year|
|The fall occurred at home in 52.4% of cases|
|45.9% have presented dizziness or instability when walking|
|Direct assistance needs||39.5% require wheelchair for movement|
|34.1% are supported with cane|
|30.8% are supported with walker|
|Needs for learning about self-care||71.6% take 1 or 2 medications||28.4% take 3 or 4 medications|
|62.7% have been hospitalized in the last 6 months|
|Source: General information form, San Luis Potosi, Mexico|
In both services, the older adults had prior physical problems that hindered the execution of basic and instrumental activities of daily living: 84.9% reported difficulty seeing up close, 81.1% pain and 74.6% lack of appetite, 68.6% had trouble hearing, 61.6% had fallen in the last year, and 45.9% reported dizziness or unsteady walking. Regarding previous history of hospitalizations, 62.7% reported having been hospitalized in the past six months. The majority, 169 (91.4%), took medications: 71.6% one or two, and 28.4%, three or four (Table I).
The 185 older adult respondents were asked if they used to perform some physical activity before hospital admission; only 54.1% answered affirmatively. Moreover, 95.1% reported pain that prevented doing exercise.
Figure 1 shows an average of 54.7 points in the basic activities of daily living of older adults discharged from the two services (maximum is 100). This means that more than half of the older adults evaluated in this study had functional capacity with moderate to severe impairment, requiring constant support for the execution of the activities of daily living and specific care.
Figure 1. Functional capacity of older adults in basic and instrumental activities of daily living, upon hospital discharge.
Regarding the functional capacities evaluated by Barthel Scale, the results are presented in Figure 2; one can see that 57% of seniors in this sample had severe dependence, indicating that this group needed substitute care for activities related to eating, moving, hygiene, and mobility. By linking these data to age groups and level of dependence, it was observed that dependence was directly proportional to age; when the older adults were stratified into two age groups, those from 75 to 100 years old had the highest proportion of severe dependence (72.3%); the most frequent level of dependence, both in this group and in those 60 to 74, was severe dependence (Table II).
Figure 2. Level of dependency of older adults in basic and instrumental activities of daily living, upon hospital discharge.
|Table II. Level of functional capacity of older adults by age group, upon hospital discharge|
|Level of functional capacity||60-74||75-100|
|Source: Barthel Scale / General information form, San Luis Potosi, Mexico|
As seen in the descriptive statistics, there was a directly proportional association between age and functional capacity. Table III shows that dependence was greater as age increased, a statistically significant association (0.001).
|Table III. Level of dependency of older adults upon hospital discharge by age and sex groups in medicine and surgery departments|
|Total/severe dependence||Independence /
|Age groups||60-74 years||68||56.6||52||43.3||11.527||1||0.001|
|DF = degree of freedom, ns = not significant.
Source: Barthel Scale.San Luis Potosi, Mexico.
There were also differences in relation to sex, since women had a higher proportion of total to severe dependence, and men of independence to moderate dependence.
As indicated in the methodology, Virginia Henderson’s Instrument for Human Needs was used to identify the patient's needs. Figure 3 shows the proportion of people with functional capacity to fulfill these. When needs were ungrouped by level of dependence, it was identified that most of these needs were not met.
Figure 3. Human needs and functional capacity of older adults upon hospital discharge.
The distribution of these needs differed according to the service in which the patient was evaluated. The proportion of needs was higher in patients discharged from the surgery department, reporting a percentage of non-fulfillment at 60% for all needs and slightly lower in the medicine department, with the lowest percentage for the need to work, at 52%. As such, the differences were not statistically significant, since upon executing the chi-squared analysis, significant differences were only found between the need for oxygenation of patients in surgery and medicine, with a significance level of 0.025.
In Figure 4 it is possible to see that all the unmet human needs were presented above 50% in older adults discharged from the surgery department. This percentage relates to the need for care during and after hospitalization.
Figure 4. Unmet human needs in older adults.
The demographic characteristics of the study population largely reflect the demographic transition phenomenon that many world regions are going through, including Mexico.1 The issue, as documented by theories of the demographic13 and epidemiological transition,14 is of changes that have lengthened life expectancy and changed the pattern of disease, which has resulted in predominance of chronic diseases at the expense of infectious diseases in an increasingly aged population.15
This phenomenon of lengthening life expectancy has appeared and evolved in Latin America as well. The SABE Survey (Salud, Bienestar y Envejecimiento in Latin America and the Caribbean) —developed by the Pan American Health Organization in the year 2000— identified that the average age in the group of Mexican adults older than 60 was 63 years.16 The present study identifies an older average age: 72 ± 7.97 years. While our study presents the results of a smaller sample than the SABE, whose characteristics are not generalizable to the entire Mexican population, it displays the rise of the phenomenon of population aging and the challenges it creates for the health system.
In our research, added to the lengthening of life expectancy were other characteristics that make for a highly vulnerable population (Table I) and that reflect the high demand for care that Mexico will face in the coming years, as noted by the Economic Commission for Latin America and the Caribbean.17
It is not just the increase in immediate care, but rather conditions that gradually increase or accelerate dependence if the acquisition of skills for health care is not promoted.
It is not only a transformation in the causes of disease, but also in the forms of care, which has led to the extension of time of disease, accompanied by the appearance of complications that can generate different disabilities. While these disabilities were presented in varying degrees, they were identified in most of the patients evaluated, which hinders the development of activities of daily living and increases the need for care and direct assistance and training addressed to the patient and the primary caregiver.
Furthermore, the data presented are consistent with what is stated in the SABE, showing that the difficulty in performing activities of daily living increases with age in all countries and is associated with an increased number of diseases.16
In this sense, Cruz et al.18 indicate that these phenomena of population change have multiplied and increased the complexity of the possibilities that current care has to respond to, when combined with what Lesthaeghe has called the second demographic transition, characterized by changes in family size, structure, and function that lead to decrease in the proportion of primary caregivers and increased care needs. In short, it is a phenomenon of increasing population in need of care and decreasing availability of caregivers in the home.19
The implications go beyond direct care, and impact the training of human resources, the adaptation of facilities and supplies, and promoting participation of older adults in all areas of social life. Such approaches strengthen the conceptualization of functionality that displaces the traditional vision centered on the disease and highlight the importance of understanding the interrelationship between body function and structure, activity, and participation, and demand an integrated response in nursing care, including personal and environmental factors.
Emphasizing this wider perspective on functionality it is not to downplay the disorders in bodily structure and function, and since they exist and are associated with chronic and continued health deterioration. Just in the present study, 62.7% of respondents reported having been hospitalized in the past six months due to hypertension and heart problems.
In addition to identifying the primary medical diagnoses presented by the people analyzed in this sample, we also looked for how they affect the level of functional capacity at hospital discharge and the execution of activities of daily living: on average, a moderate to severe level of dependence was identified (88.1%), and increased support was needed for activities such as going up and down stairs and walking or moving.
This trend is most evident at discharge: in both services the number of people who are independent to execute the activities of daily living decreased. Not only did the number of dependent people increase, but also their level of dependence. This phenomenon can be observed in studies like that of García García, executed in Spain: hospital discharge decreased mobility independence for up to 94% of seniors analyzed.20 Since the evaluated patients had been discharged, they needed adequate functional recovery to fulfill self-care and the demands involved in life at home. Although assessment was not done on patient admission, it is possible that if it had been done the results would have been close to those shown by Cruz Lendínez (in Spain)21 or Segovia and Torres (in Mexico),22 who affirm that the hospital has a negative effect and favors the reduction of functional capacity in a significant group of older adults.
This is even more worrying when one considers that 62.7% of seniors had at least one previous hospitalization in recent months and that repeated hospitalizations exponentially increased the loss of function for activities of daily living.
Authors like Loren Guerrero et al.23 suggest that there are gender differences in the levels of functional dependency when assessing the ability to perform the activities of daily living; in this regard, we found a prevalence of moderate to severe dependence in women. Despite this, we recognize the need to explore further these potential differences, given the traditional social role of women that naturalizes the execution of activities of daily living and that would predict male dependency.
Statistical analysis of the results identified a significant association between older age and greater dependence upon discharge, which coincides with the data provided in other studies.21 The results are alarming if one considers the data for Mexico provided by the Economic Commission for Latin America and the Caribbean: in 2050, the size of the adult population over 65 years will quadruple, reaching 25.9 million, with consequent implications for nursing professionals.
The data obtained allow one to project the likely needs of similar groups and to design specific plans and methodologies of standardized care for the resources required for care, such as health professionals, materials, methodologies, spaces, and so on.
However, the differences between services are oriented towards individualization: the unmet needs were higher in the surgery department, which could be related to both the patients’ pathologies and the procedures performed, as well as the operation of the service itself. In any case, we did not have the information to identify this relationship.
Considering that more than two-thirds of the study population had total to severe dependence in the 14 needs analyzed, it is overwhelming to think about the quantity and multiplicity of tasks that the nurse is responsible for, not only in direct care to the patient but also in teaching self-care and training the family caregiver.
In sum, the results point to the increased vulnerability of older adults during hospitalization, which is worrying considering that once they are discharged, they will return home with decreased functional capacity and increased health demands.
In memory of Dr. Martha Graciela Segovia Diaz de Leon, for her dedication and devotion to the profession, for her contribution to this work, and for her dedication in training nurses at the Universidad Autónoma de San Luis Potosi. May she rest in peace.
The authors declare that there is no personal or institutional conflict of interest of a professional, financial, or commercial nature, during the planning, execution, writing of this article.