Homes for the Aged: a study of a Health Region in Rio Grande do Sul, Brazil

Introduction: With the aging of the population, the demand for Homes for the Aged (HFAs) grows. Objective: To analyze resources and population of HFAs and to check the fulfillment of the criteria from the national regulations. Methods: Descriptive quantitative study including 11 philanthropic HFAs in the state of Rio Grande do Sul, Brazil. Data was collected through a questionnaire applied to the responsible for the facility. Results: The study comprised 318 workers and 522 elders. HFAs presented: some accommodations without private bathrooms (100%); external area and administrative office (72.7%); cafeteria and support room (54.5%); ecumenical room (36.4%); rooms with more than four beds (45.5%). The prevailing reasons for admission were brought by family member (69.2%); social vulnerability (36.4%). Death was the main reason for leaving the facility. The average age of elders was 76.8 years, 58.4% were women. The dependence grade was I for 31.1%; II for 33.9%; and III for 35%. Leisure and cultural activities occurred in 72.7% of HFAs. In 27.3% there were records of visits. Only 9.1% had cooperation from families. Available human resources were nurses (72.7%); physicians and nursing assistants (63.3%); physical therapists (45.5%); psychologists (36.4%); caregivers (27.3%); occupational therapists (9.1%). In 63.3% of facilities, workers carried out mixed activities. The costs were covered by retirement pensions, partnerships, and donations. The main obstacles were financial resources or dependence on donations and rigorous health surveillance or compliance with standards. Conclusion: The HFAs partially fulfill the national criteria, impairing the quality of care provided to elders.


INTRODUCTION
Population aging is a process of changes, presenting itself as a challenge, especially for developing countries like Brazil 1-3 . The high rates of population aging are explained by demographic changes in Brazil and in the world, mainly the fall in birth rates, mortality, fertility, and the reduction of infectious and parasitic diseases 4 . From these transformations, there is a new epidemiological profile of the population, which started to live longer, with a considerable number of people aged 60 years or more 3 .
In Rio Grande do Sul (RS), Brazil, the elderly population has increased significantly in recent years, advancing from 1,105,807 (10.7% of the state's population in 2001) to Pascotini FS, Nazario CG, Rosa RR, Silva RS, Fedosse E ABCS Health Sci. 2020;45:e020017 1,762,169 elderly people (15.7% in 2015). It is estimated that, in 2030, the elderly should reach 24% of the total population living in RS 5 .
In response to the increase in life expectancy and the reduction in the availability of family resources for the care of the elderly, the demand for Homes for the Aged (HFAs) 1 increased. Lately, HFAs operate practically with maximum capacity and, according to the forecast, in the next ten years, an increase of between 100% and 500% in the number of elderly people who will need to live in HFA can be expected 6 . Faced with this scenario of aging and family difficulties regarding the care of their elderly, there is an increasing concern with the necessary conditions for dignified care for this population 8 .

RESULTS
General Other studies show the same reality: the Brazilian resolution is not being followed in full 10,11 . The concern with the environment of the HFAs is based on the risk for the health of elderly 11  In assuring the professionalism required by Brazilian law, the HFAs must have human resources with a formal employment relationship to carry out the care activities. Therefore, the HFA is expected to have employees for leisure, cleaning, food and laundry activities, according to their size and the number of residents 7 .
In this study, there were eight (72.7%) HFAs which failed in this aspect. In most of them, the same employee performs several functions compromising the quality of care and, also, the quality life/health of the worker.
Such data confirm those of another investigation 18 , which found duplicate assignments in philanthropic HFAs, such as, the same worker cleaning the institution and washing clothes.  11,21 .
One of the difficulties reported by those responsible for the HFAs was the lack of therapeutic assistance (18.2%). It is known the importance of a team to achieve a qualified job, an extended assistance to the elderly, encompassing their needs and providing comprehensive health care, with a multidimensional view 22 .
Although the percentage of HFAs who recognized the lack of therapists is low, there is an advance in the conception of manag- As for the elderly residents in the HFAs, there was a predominance of women (58.4%), in agreement with the literature [27][28][29][30][31][32] .
Feminization in aging, that is, the fact that women are living longer than men, can be explained by several factors: lower consumption of alcoholic beverages and tobacco, higher frequency in health services and less exposure to risk factors of an occupational nature 27,30 . With regard to age, it was found that most of the elderly were between 70 and 79 years old, a situation also found in the study by Lenardt et al. 33 38 . In addition to the lack of human resources, lack of support from the municipality and lack of provision of therapeutic processes appropriate to the health needs of the elderly, discussed previously, the rigor of health surveillance to comply with laws and regulations (63.6%) also appeared great difficulty faced.
In the region, HFAs, because they are old, usually occupy houses that were not originally built to be an HFA, revealing inadequate structure by legislation and the need for reforms. Without the relevant professional assistance it becomes difficult to adapt them.
It was often found that there was a lack of space and the number of elderly people above the permitted limits. It should be noted that the lack of financial resources directly and negatively implies questions about care, structure and institutional functioning.
In this way, how to comply with the laws and norms foreseen?
This study made it possible to get to know the reality of the HFAs, spaces where care and administration are generally developed by lay people and with "good will", so that they do it with little or no financial retribution to match the daily complexity of work in and HFAs. Society support is irregular and government support is scarce. Strong disclosure of HFA conditions is required and strong appeal for legal solutions involving society in general, beyond government spheres.
The above considerations are echoed, in part according to Carvalho 39 , who states that, despite the fact that regulations have been in place for the functioning of HFAs since 2005, it is necessary to raise awareness and demand from those responsible for ensuring the successful aging of elderly residents 39 .
It is concluded that the HFAs in the 4th health region of elderly are in social and health vulnerability and that, as health conditions worsen, the HFAs tend to take care of organic decline through medication, neglecting the aspects of subjectivity. It is believed that professional attitudes may be different, such as those provided for in palliative care. In this sense, the final stage of life of institutionalized elderly people could happen to improve the quality of life of elderly people with chronic-degenerative pathologies, through the prevention and relief of suffering, with the early detection and comprehensive assessment and treatment of pain and physical problems, psychosocial and spiritual 40 . Thus, it is suggested that more research be carried out exploring this topic, with other methods and scenarios (including the private system), covering other regions of the state and the country.