RESEARCH ARTICLES

Characteristics of disorders among older adults and the care provided by a mobile pre-hospital service

Márcia Abath Aires de Barros^I; Danielle Samara Tavares de Oliveira^II; Mariana Albernaz Pinheiro de Carvalho^III; Maria das Graças de Melo Fernandes^IV; Kátia Neyla de Freitas Macedo Costa^V; Kamyla Félix Oliveira dos Santos^VI
INurse of the University Hospital Lauro Wanderley. Graduate student in Nursing at the Federal University of Paraíba. Researcher of the nursing and health care to the adult and elderly group. João Pessoa, Paraíba, Brazil. Email: marciabath@gmail.com. 
^IINurse. Graduate student in Nursing at the Federal University of Paraíba. Researcher of the nursing and health care to the adult and elderly group. João Pessoa, Paraíba, Brazil. Email: daniellesamara@hotmail.com
^IIINurse. Graduate student in Nursing at the Federal University of Paraíba. Researcher of the nursing and health care to the adult and elderly group. João Pessoa, Paraíba, Brazil. Email: mary_albernaz@hotmail.com.  
^IVNurse. Doctorate in Sociology. Professor at the Federal University of Paraíba, Clinical Nursing Department of the Science Health Center. João Pessoa, Paraíba, Brazil. Email: graacafernandes@hotmail.com.   
^VNurse. Doctorate in Nursing from the Federal University of Ceará. Professor of the Federal University of Paraíba of the Clinical Nursing Department of the Science Health Center. João Pessoa, Paraíba, Brazil. Email: katianeyla@yahoo.com.br.    
^VINurse at the University Hospital Alcides Carneiro. Graduate student at the Federal University of Paraíba. João Pessoa, Paraíba, Brazil. Email: kamylaoliveira@hotmail.com. 

ABSTRACT: Health professionals are concerned by the increasing numbers of elderly people suffering disorders from external causes. In that light, this retrospective, quantitative, documentary study aimed to characterize the main disorders among older adults in a mobile pre-hospital service in the city of Joao Pessoa, Paraiba, Brazil, and to examine the corresponding care provided by health professionals. Data were collected from 546 medical records of the city’s Emergency Medical Care Service, from January to July 2011. The study found that mobile pre-hospital care provided to elderly patients must be approached on clear criteria. The findings revealed a lack of specific planning for this public and an absence of specific care procedures given the increasing need for preventive approaches to elderly casualties.

Keywords: Elderly people; emergency; morbidity; external causes.  

INTRODUCTION

The growth of the elderly population is a worldwide phenomenon and, in Brazil, modifications occur radically and quite fast. The speed of the process of demographic and epidemiological transition experienced by the country in the last decades brings a series of crucial issues for managers and researchers of health systems, with repercussions for society as a whole1.
Despite the increase in the survival of the population be a world conquest, this phenomenon has been accompanied of the prevalence of chronic and multiple diseases, leading to increased demand for urgent and emergency care in this population, especially in cases of intensification of these problems2. The greater vulnerability of the elderly and the occurrence of grievance by external causes, such as violence, falls and car accidents, typical of urban development in the country, also increase their health care needs.
Given this context, among other conditions, it emerges the National Policy of Attention to the Urgencies (PNAU), established by Ordinance GM/MS No. 1.863, September 29, 2003, and, the Pre-Hospital Care (APH), which is operated by coordination between state, regional and local systems of health, with a view to guarantee the universality, fairness and completeness in attendance to emergency clinics and those related to external causes3. The APH is defined as the assistance provided in a first level of care to patients with acute cases, clinical in nature, traumatic or psychiatric that occurs outside the hospital environment, which can lead to sequels or even death4.
Among the measures to be imposed to cope with this new health care scenario the organization of networks of integral care to the urgency room has been determined, while maintenance chain to life, with the components: hospital, post-hospital, fixed pre-hospital and mobile pre-hospital, being the last one represented by the Mobile Urgency Attendance Service (SAMU)3 .
In relation to the type of pre-hospital emergency care in the elderly, studies conducted in five capitals in Brazil (Manaus-AM, Rio de Janeiro-RJ, Recife, Brasília-DF and Curitiba-PR) show that the most part of this assistance mode is performed as a result of clinical aggravations, which, in general, result in a high rate of mortality5. Similarly, the increase in the number of elderly who are victims of injuries from external causes serviced by SAMU is also object of concern of health professionals, by favoring the higher incidence of mortality from these individuals, compared to the general population6.
Thus, the objective of this study was to characterize the main grievance affecting the elderly population of a pre-hospital mobile service in the city of João Pessoa-PB, as, to verify the service provided to these elderly by the health professionals.

LITERATURE REVIEW
The pre-hospital attendance aims to reach the victim in the first minutes after the problem to their health and, thus, promoting the proper attendance and offering transport to a properly regulated hospital and integrated into the Unified Health System (SUS)7 . In Brazil, the structuring of this type of service was driven from the decade of 1990, with the reorganization of health services. It is worth mentioning that the first attendance pre-hospital mobile services have emerged in the southeast region, more precisely in the states of Rio de Janeiro and São Paulo, with the Fire Department, following the French model of care performed by this healthcare modality8. As an example of São Paulo, the SAMU was gradually implemented in several Brazilian cities, like Porto Alegre-RS (1995), Ribeirão Preto-SP (1996), to be standardized by Ordinance GM No. 1.863/2003, which established the pre-hospital mobile component of Pnau throughout the Brazilian territory3,8.
Currently, the SAMU is configured throughout the national territory and it is constituted by a central regulator attached to a fleet of vehicles designed to the attendance of basic life support (SBV), held by the basic support units (USB) and the “motorbike” ambulances, and the advanced life attendance support (SAV), held by the advanced support units (USA) and the rapid intervention vehicles (VIRs). The SBV is the preservation of life, without invasive maneuvers, with which professionals work under medical supervision. The SAV has features like invasive maneuvers of greater complexity, and, for this reason, this service is carried out exclusively by doctors and nurses4.
The service request is performed by the population through connection to the free system, on the phone, 192, willing throughout the national territory. The call is transmitted to the regulator doctor by the technical of medical regulation attendance (TARM), which quickly carries out the risk classification and designates to the fleet operator to put into action the basic support team, composed of nursing technician and paramedic driver or advanced support team, composed of a doctor, a nurse and  paramedic driver. These professionals should have a selective profile, with different skills than those of the attendance of traumatic and psychiatric clinical aggravations that affect different age groups in urgent and emergency situations. Among the important skills for practical exercise in pre-hospital attendance are the ability to perform the procedures, quickly clinical reasoning and psychological preparation8.
Anyway, it should be noted that, in recent years, managers of public health policy of the states are broadening the pre-hospital mobile attendance, by virtue of the growing need to reduce mortality, as well as the sequels produced by acute events in the pre-hospital setting, safeguarding the fundamental principles of fast, accurate and efficient attendance service.
Thus, it should be noted that the pre-hospital care should be distinguished when it comes to elderly person, because sudden manifestations of diseases and traumas are more frequent in this population compared to younger individuals; in addition to suffer influence of type of lesion, the elderly have specific features, such as: decreased physiological reserves, associated chronic diseases and medicines of continuous use9,10.
Considering this and also the scarcity of studies on the subject, especially in the city of João Pessoa-PB, it is emphasized the importance of knowing the characteristics of the diseases that require urgency attendance in the elderly population in this scenario, as well as the assistance provided to this population by health professionals in these circumstances. These findings may provide the identification of gaps and/or grievance in the quality of such assistance, which, once corrected enable improvements in the elderly attendance in the context of urgent and emergency.

METHODOLOGY
This is a retrospective and documentary study, with quantitative approach, held in the city of João Pessoa-PB, at the headquarters of the SAMU of this municipality. The empirical material that subsidized the research understood the attending forms in which the health professionals make the records relating to the clinical evaluation of the individual in a situation of urgency/emergency, as well as assistive and therapeutic procedures adopted by the teams of SAMU, both the SBV and SAV.
The determination of the sample was of probabilistic type, simple casual or random. To this end, the following procedures were adopted: initially it was identified the number of calls performed by the SAMU between the months of January to July 2011, obtaining the total of 15,279 attendances. Next, between them it was identified the amount of elderly people (60 years or more) assisted in the same period, which corresponded to 3,754. Later, considering the sampling fraction n/N, where N is the number of elements of the population and n is the number of elements, it was delimited the sample under investigation, which included 546 staff forms, randomly selected. The index of significance of the sample was 95% and the sampling error was 5%.
For the data collection was it was used a structured form contemplating demographic data (age/sex); place of occurrence; shift availability; type of vehicle released; comorbidities; type of occurrence and problem; clinical evaluation conducted in the elderly; registration procedures and outcome of care.
For the data analysis procedure it was used the titles of EpiInfo program and for the generation of results using the statistical program SPSS version 15.0. The data were arranged in tables and discussed in the relevant literature.
This survey obeyed to the rules and guidelines contained in Resolution No. 466/201211, of the National Health Council, which regulates research involving human beings, being respected the right to anonymity and secrecy, and was approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Paraiba (UFPB), under Protocol 0132/11.

RESULTS AND DISCUSSION
In relation to the type of attendance, it was focused on the nature of the occurrences in the elderly served by SAMU. 546 attendances forms have been evaluated carried out in the period January-July 2011.
Of the total of attendances, 355 (65%) were performed in clinical occurrences, followed by 144 (26.4%) in traumatic grievance (external causes), 39 (7.1%) in hospital transfers and only 8 (1.5%) in occurrences for psychiatric disorder. There were female predominance both in attendance to clinical grievance - 189 (53.2%) in the service and to grievance by external causes - 75 (52.1%). That ratio is reversed in attendance to hospital transfers - 24 (61.5%) men and psychiatric diseases - 5 (62.5%), according to the Table 1.

INSERIR TABELA 1 AQUI

Of the 546 (100%) analyzed forms, 302 (55.31%) did not have information about the presence of comorbidities, which may be considered sub-enrollment and not the absence of disease. With regard to the clinical evaluation of elderly, arterial hypertension was reported in 157 (28.75%), Diabetes Mellitus in 101 (18.5%) and the heart diseases in 58 (10.62%) of attendances for the elderly of the studied period.
It was found that 397 (72.71%) of attendance were made by basic support team on USB, plus eight attendances conducted jointly by “motorbike” ambulance and USB. An enhanced support was held in 85 (15.57%) of attendances by team USA, in 46 (8.42%) in support of the attendance of the team of USB, and in 10 (1.83%) in support of the “motorbike” ambulance team. Most of these attendances, 374 (68.5%), was held during the day and 172 (31.5%) during the night.
Then, the main clinical and traumatic causes were evaluated that led to put in action the SAMU, relating them to the team that provided the first accounts.

INSERIR TABELA 2 AQUI

Among the causes of 355 (100%) clinical occurrences, the relegation of the consciousness level was present in 82 (23.10%) attendances. 43 elderly (12.11%) were attended with hypertensive crisis and 37 (10.42%) with precordial pain. The basic support team met more occurrences by lowering the level of consciousness, totaling 60 (73.2%) attendances, and advanced support team was present in 30 (100%) incidents related to cardiopulmonary arrest. In the attendance to elderly affected by external causes, the fall of their own height was present in 94 (65.2%) of 144 (100%) traumatic grievance, followed by 22 (15.27%) for running over and 13 (9%) for car accidents. There are 11 (7.4%) attendances due to violence, being 6 (4%) for aggression and 5 (3.4%) per injury for cold weapon. Of the 144 attendances related to the external causes, the USBs were put into action in 136 and the USAs in only eight.

As regards the elderly evaluated by teams of basic and advanced support, health teams who attended, in the studied period, recorded that neurological evaluation was performed on 426 (78%) of these patients, and used the Glasgow Coma Scale in 420 (76.9%) of cases. The respiratory assessment was conducted in 464 (85%) of elderly, being the respiratory rate recorded in 369 (67.6%) of the forms and the pulse oximetry was recorded in 336 (61.5%) of cases. Hemodynamic assessment occurred in 507 (92.9%) of the patients, being used as parameter blood pressure in 446 (81.7%) of attendance forms and heart rate was used in 426 (78%) of records.
The main procedures performed by the teams of SAMU in serving the elderly affected by clinical grievance by external causes, for transfers and for psychiatric disorders are described in Table 2.

INSERIR TABELA 3 AQUI

It is highlighted that the pulse oximetry - 336 (61.5%), peripheral venous access - 306 (56.04%), capillary glycaemia - 244 (44.7%), the use of supplemental oxygen - 207 (37.9%) and medicines administration -148 (27.1%) were the most frequently recorded procedures, according to the Table 2.
Of the total number of attendances, 473 (86.63%) of elderly were removed to the emergency service of governed hospitals, 43 (7.88%) were seen at the site of occurrence, 28 (5.13%) were to death at the place of attendance and only two elderly refused attendance. Public state hospitals received most of these elderly (35.10%), municipal public hospitals received 19.03% and charitable hospitals received 12.05%. Only 32 (6.77%) of elderly were removed to private hospitals and 16 (3.38%) for military hospitals.
The analysis of urgent and emergency attendance of grievances to people with more than 60 years allows following the behavior of chronic non-communicable diseases (DCNTs), the impact of population growth and violence in this age group and the preparation of professionals working in pre-hospital care. Accordingly, studies about these conditions that affect the elderly are of fundamental importance for the planning of public health policies that may attend this growing portion of the Brazilian population. The main diseases associated with the elderly population are the neurological, coronary and those linked to traumas12.
With regard to the occurrences nature, this study accompanies other results evidenced in literature, corroborating that the largest portion of occurrences served by a pre-hospital service results of clinical emergency, with 65% of the cases13,14. However, is important to point out that 26.4% of the analyzed elderly were affected by damages due to external causes, evidencing the behavior of Brazilian demographic transition, in which the elderly maintain their functional capacity, remain active and perform their activities of daily life, in spite of frequent exposure to the trauma risks that this population is subjected15. The elderly trauma victims are, generally, independent people who can initiate a deterioration of their mental and physical health after accidents6.
The accidents and violence represent an important impact on functional capacity of the Brazilians elderly. The records provided by the Informatics Department of the Unique Health System (DATASUS) show that in 2008 the Brazil registered 122,065 hospitalizations of the elderly by external causes; among these, 49.5% refer to fall, 7.2%, transport accidents and 11.5% external causes not classified. The admissions for aggression represent 1.6% of the hospitalizations in same year16.
It is important to point out that many violent events do not require hospitalization and, therefore, are considered less serious, but they involve physical aggression, psychological and negligence to which the elderly are exposed in the family context, in the community and in institutions, and they are not notified. For this reason, we do not have the exact notion of violence experiences of Brazilians elderly17.
Elderly attendance who is a victim of events by external causes (accidents and violence) must be the subject of concern of professionals working in pre-hospital attendance, because the elderly are more physiological susceptibility in traumatic events, by arising comorbidity from chronic-degenerative diseases, contributing to the morbidity and mortality, along with the decline of the musculoskeletal and sensory system18.
The elderly population is the most exposed to death and to all kinds of external causes, except homicide and drowning, and falls are the events that most contribute to the production of fatal injuries in this population19.
Confirming data from the literature, one of the attendances made in traumatic events, the fall had the largest number of occurrences, with 65.28% of cases. The fall in the elderly nearly always comes with organism clinical changes or resulting from the natural process of human aging, however, like the other variants of the so-called external causes, it is preventable, through the reorientation of confluent public policies to elderly person15,20,21.
The falls are common events for all ages, however, in the elderly population are responsible for high rates of morbidity and mortality, so that changes of balance and gait expose the elderly to greater risks, contributing to the occurrence of traumas and reflecting on sequel of psychosocial  order, as grievance of autonomy, low self-esteem, anxiety and fear of falling22.
Among clinical occurrences, the neurological change was the main cause of putting into action the SAMU in relation to elderly, being assigned to the demotion of the level of awareness in 82 (23.1%) of cases, added to the registry of suspected cerebral vascular accident (AVC) in 27 (5.92%) of incidents and 18 (5.07%) for convulsive crisis.
In a study conducted in Porto Alegre-RS, it was identified that 20.04% of clinical cases performed by urgency attendance were the neurological aggravations, being the most common AVC diagnosis ranging in age from 61 to 79 years7. However, due to the greater portion of these attendances have been made by team consisting of nursing technician and paramedic driver, the association of neurological cause lifting or diagnostic elucidation was not performed.
The Resolution of the Federal Council of Nursing (Cofen) No 375/2011, which provides for the pre-hospital attendance of the nursing professionals, describes in its article 1º that: "In the pre-hospital attendance of basic support and advanced support of life, nursing procedures are developed according to the complexity and after evaluation of the Nurse"23. In this context, there is a need for the presence of the nurse in all modalities of attendance so that they can be established all the steps of the nursing process.
As the results revealed, the basic support teams were the most attended the elderly in this service, totaling more than 72% of occurrences. These data corroborate the study conducted in Porto Alegre-RS, where it was found that the USBs were responsible by performing 91.8% of care clinical occurrences, revealing that the basic support teams are one that most develop care patients served by pre-hospital care mobile attendances13.
It was found that basic support teams and advanced support used parameters of the Revised Trauma Score (RTS) for clinical evaluation of elderly. This tool is used for quick assessment of trauma victims, in which they are used the Glasgow Coma Scale, the respiratory rate and systolic blood pressure, noting that the greater the change in these parameters, the lower the probability of survival of patients24.

CONCLUSION
The technological progress of health sciences has contributed to improve the quality of life of elderly, stimulating and encouraging behavioral changes and causing them to adopt independent and active lifestyles. However, such behaviors have resulted in greater exposure to risk conditions, which is determined by the alarming growth of the elderly population victim of accidents and traumas.
Based on this research, it was found that the elderly population is representing an important focus of attention, especially for health services, in the face of significant population growth in this age group. Thus, it is beneficial that the various social sectors to develop and move forward in order to suit the contemporary reality.
The study identified that pre-hospital mobile assistance offered to elderly patients demands selective approaches. From the findings, the lack of specific planning for the public concerned and the absence of specific streams of attendance on the growing need for preventive approaches for elderly victimized was verified, being met as any other person of minor age.
This study reveals that the majority of attendances for the elderly conducted by SAMU in the municipality of João Pessoa were clinical in nature, in that the downgrading of the level of awareness was the main reason to activate the service for the population, and basic support teams were responsible for the primary review in this population, in most instances.
The attendance aimed at traumatized elderly or victim of acute emergency state is based on the same criteria applied to the adult and however, they should respect the specificities related to the contributing factors and constraints of this population. Thus, it is evidenced the need for a greater commitment concerning the implementation of Resolution Cofen nº 375/2011, by managers organs and continued training of the nursing staff, since these professionals participate actively in all the relative attendance to exacerbation of diseases in the elderly, aiming at the improvement of the assistance, the quality of the records and reporting information.

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