WHAT TAKEN THE ELDERLY PEOPLE TO INSTITUTIONALIZATION?

Objective: to describe the main reasons that led the elderly people to institutionalization. Method: this is a quantitative, cross-sectional study carried out in a long-term institution for the elderly by 219 medical records, using a questionnaire. For the association of continuous and categorical variables, the Kruskal-Wallis tests and Pearson's Chi-Square test were used considering p <0.05, presented in a table. Results: in total, 55.6% were female elderly, with a mean age of 77 years old (± 0.55). The main reasons were self-will, family issues, abandonment, and violence. The variables most related to the reasons for institutionalization were gender (p=0.013), marital status (p=0.041), company at home (p=0.001), receiving visits (p=0.011) and degree of dependency (p=<0.001). The determining causes that have led the elderly person to join a long-term institution were highlighted to the search for prior social actions and strategies, prior to institutionalization, in order to avoid their occurrence, overcrowding and the high costs in these establishments. Conclusion: it was observed that all the elderly person, regardless of the reason, were exposed to negative clinical and social outcomes. Descriptors: Homes For The Age; Health of Institutionalized Elderly; Aging; Public Health; Aged; Housing For The Elderly. RESUMO Objetivo: descrever os principais motivos que levaram os idosos à institucionalização. Método: estudo quantitativo, transversal, realizado em uma instituição de longa permanência para idosos, por consulta a 219 prontuários, utilizando-se um questionário. Para a associação das variáveis contínuas e categóricas, foram utilizados os testes Kruskal-wallis e o Teste Qui-Quadrado de Pearson considerando p<0,05, apresentados em tabela. Resultados: no total, 55,6% eram idosos do sexo feminino, com idade média de 77 (±0,55). Os principais motivos foram vontade própria, questões familiares, abandono e violência. As variáveis mais relacionadas aos motivos de institucionalização foram sexo (p=0,013), estado civil (p=0,041), com quem residia (p=<0,001), recebe visitas (p=0,011) e grau de dependência (p=<0,001). As causas determinantes encontradas que levaram os idosos à inserção em uma instituição de longa permanência chamam a atenção para a busca de ações e estratégias sociais e políticas prévias, antes da institucionalização, a fim de evitar a sua ocorrência, a superlotação e os custos onerosos nesses estabelecimentos. Conclusão: observou-se que todos os idosos, independentemente do motivo, estiveram expostos a desfechos clínicos e sociais negativos. Descritores: Instituição de Longa Permanência Para Idosos; Saúde do Idoso Institucionalizado; Envelhecimento; Saúde Pública, Idoso; Habitação para Idosos. RESUMEN Objetivo: describir los principales motivos que llevaron a los ancianos a la institucionalización. Método: estudio cuantitativo, transversal, realizado en una institución de larga permanencia para ancianos, por consulta a 219 prontuarios, utilizándose un cuestionario. Para la asociación de las variables continuas y categóricas, fueron utilizados los testes Kruskal-wallis y el Test Chi-Cuadrado de Pearson considerando p<0,05, presentados en una tabla. Resultados: en total, 55,6% eran ancianos del sexo femenino, con edad media de 77 (±0,55). Los principales motivos fueron ganas propia, cuestiones familiares, abandono y violencia. Las variables más relacionadas a los motivos de institucionalización fueron sexo (p=0,013), estado civil (p=0,041), con quien residía (p=<0,001), recibe visitas (p=0,011) y grado de dependencia (p=<0,001). Las causas determinantes encontradas que llevaron a los ancianos a la inserción en una institución de larga permanencia llaman la atención para la búsqueda de acciones y estrategias sociales y políticas previas, antes de la institucionalización, para evitar su ocurrencia, la superlotación y los costos altos en esos establecimientos. Conclusión: se observó que todos los ancianos, independientemente del motivo, estuvieron expuestos a resultados clínicos y sociales negativos. Descriptores: Hogares para Ancianos; Salud del Anciano Institucionalizado; Envejecimiento; Salud Pública, Anciano; Viviendas para Ancianos. Professor, Nursing Technician course at JK institution. Fortaleza (CE), Brazil. E-mail: valderina@gmail.com. ORCID iD: https://orcid.org/0000-0001-9286-4292; Nurse, Maurício de Nassau University. Fortaleza (CE), Brazil. E-mail: allynymobley@hotmail.com ORCID iD: https://orcid.org/0000-0003-3457-5788; Specialist, Ateneu University. Fortaleza (CE), Brazil. E-mail: renata.kelly29@gmail.com ORCID iD: https://orcid.org/0000-0002-1818-2071; Master degre (Ph.D. student), University of Ceará State/UECE. Fortaleza (CE), Brazil. E-mail: brunnakaren@hotmail.com ORCID iD: https://orcid.org/0000-0003-2808-7526; Specialist, City Hall of Fortaleza. Fortaleza (CE), Brazil. E-mail: saulfpl@yahoo.com.br ORCID iD: https://orcid.org/0000-0001-68769025; Master degree (Ph.D. student), Univesity of Ceará State/UECE. Fortaleza (CE), Brazil. E-mail: cintialiraborges@yahoo.com.br ORCID iD: https://orcid.org/0000-0002-5204-0173 ORIGINAL ARTICLE Lopes VM, Scofield AMTS, Alcântara RKL et al. What taken the elderly people to institutionalization? English/Portuguese J Nurs UFPE online., Recife, 12(9):2428-35, Sept., 2018 2429 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i9a234624p2428-2435-2018 It is known that institutionalization for the elderly people is characterized by the provision of care-oriented activities as well as long-term housing for those in need of care, philanthropy, private and governmental. With changes in the demographic and epidemiological profile in national and international levels, the search for this environment and service has been increased. Also, there are still few studies that indicate the number of institutionalized elderly and long-term institutions in Brazil. Up to 2010 in Brazil, there were around 65.2% of philanthropic institutions, 6.6% of public, and 84 institutionalized elderly people. In the international reality, mainly in developed countries, such as in the United States, in New York City in 2011, there were 16,100 homes for the elderly people. The concern in this country was not about the quantification and characterization of the institutions but about the increased implementation of health registration fees and adoption of electronic systems for the dissemination and exchange of information. It is emphasized that the demand for these places is mainly due to an increase in life expectancy; changes in family arrangements; the entry of women into the labor market; the breaking of family ties; self-care deficit and lack of financial resources. Whatever the reason for institutionalization (self-will, family issues and/or social vulnerability), the feeling that sometimes accompanies the elderly population is the burden and the contempt in their family or in society. The attention of the authorities, society, and experts on the subject is sought to draw up strategies for dealing with the situation so in the very near future, benefits and conditions will be provided for the permanence of the elderly person, for longer or definitively, within the family or subsidies for self-management, avoiding early institutionalization. It should be noted that once institutionalized, the elderly have a team of professionals responsible for welcoming, preserving and encouraging autonomy and independence-seeking to meet all needs and ensuring comprehensive care. The role of the health team in recognizing and understanding the changes in physical and/or mental status that may compromise the quality of life of the elderly residents is highlighted. ● To describe the main reasons that led the elderly people to institutionalization This is a cross-sectional, quantitative and descriptive study carried out in an institution for the elderly located in the Northeast region of Brazil. The data were collected in September 2015 by consulting the medical records in response to questions from a sociodemographic health assessment questionnaire. All 219 medical records of the institution were investigated. An instrument was used to collect data with objective questions about gender, age, marital status, old occupation, time and reason for institutionalization, family visit, company living home before institutionalization, comorbidities, degree of dependency and


RESUMEN
Objetivo: describir los principales motivos que llevaron a los ancianos a la institucionalización. Método: estudio cuantitativo, transversal, realizado en una institución de larga permanencia para ancianos, por consulta a 219 prontuarios, utilizándose un cuestionario. Para la asociación de las variables continuas y categóricas, fueron utilizados los testes Kruskal-wallis y el Test Chi-Cuadrado de Pearson considerando p<0,05, presentados en una tabla. Resultados: en total, 55,6% eran ancianos del sexo femenino, con edad media de 77 (±0,55). Los principales motivos fueron ganas propia, cuestiones familiares, abandono y violencia. Las variables más relacionadas a los motivos de institucionalización fueron sexo (p=0,013), estado civil (p=0,041), con quien residía (p=<0,001), recibe visitas (p=0,011) y grado de dependencia (p=<0,001). Las causas determinantes encontradas que llevaron a los ancianos a la inserción en una institución de larga permanencia llaman la atención para la búsqueda de acciones y estrategias sociales y políticas previas, antes de la institucionalización, para evitar su ocurrencia, la superlotación y los costos altos en esos establecimientos. Conclusión: se observó que todos los ancianos, independientemente del motivo, estuvieron expuestos a resultados clínicos y sociales negativos. Descriptores: Hogares para Ancianos; Salud del Anciano Institucionalizado; Envejecimiento; Salud Pública, Anciano; Viviendas para Ancianos. 1 Professor, Nursing Technician course at JK institution. Fortaleza (CE), Brazil. E-mail: valderina@gmail.com. ORCID iD: https://orcid.org/0000-0001-9286-4292; 2  It is known that institutionalization for the elderly people is characterized by the provision of care-oriented activities as well as long-term housing for those in need of care, philanthropy, private and governmental. 1 With changes in the demographic and epidemiological profile in national and international levels, the search for this environment and service has been increased. 2 Also, there are still few studies that indicate the number of institutionalized elderly and long-term institutions in Brazil. Up to 2010 in Brazil, there were around 65.2% of philanthropic institutions, 6.6% of public, and 84 institutionalized elderly people. 3 In the international reality, mainly in developed countries, such as in the United States, in New York City in 2011, there were 16,100 homes for the elderly people. 4 The concern in this country was not about the quantification and characterization of the institutions but about the increased implementation of health registration fees and adoption of electronic systems for the dissemination and exchange of information. 4 It is emphasized that the demand for these places is mainly due to an increase in life expectancy; changes in family arrangements; the entry of women into the labor market; the breaking of family ties; self-care deficit and lack of financial resources. [3][4][5][6] Whatever the reason for institutionalization (self-will, family issues and/or social vulnerability), the feeling that sometimes accompanies the elderly population is the burden and the contempt in their family or in society.
The attention of the authorities, society, and experts on the subject is sought to draw up strategies for dealing with the situation so in the very near future, benefits and conditions will be provided for the permanence of the elderly person, for longer or definitively, within the family or subsidies for self-management, avoiding early institutionalization.

It
should be noted that once institutionalized, the elderly have a team of professionals responsible for welcoming, preserving and encouraging autonomy and independence-seeking to meet all needs and ensuring comprehensive care. The role of the health team in recognizing and understanding the changes in physical and/or mental status that may compromise the quality of life of the elderly residents is highlighted. 7 • To describe the main reasons that led the elderly people to institutionalization This is a cross-sectional, quantitative and descriptive study carried out in an institution for the elderly located in the Northeast region of Brazil. The data were collected in September 2015 by consulting the medical records in response to questions from a sociodemographic health assessment questionnaire. All 219 medical records of the institution were investigated.
An instrument was used to collect data with objective questions about gender, age, marital status, old occupation, time and reason for institutionalization, family visit, company living home before institutionalization, comorbidities, degree of dependency and education level.
It should be noted that the "other" reasons include the elderly people from other shelters that were interdicted or elderly people that caused conflicts with residents of other shelters and those sent through the Public Prosecutor's Office. According to records analyzed in medical records, in relation to self-motive reason, the elderly person chose to reside in the institution due to weak ties in the family, whether formed by some degree of kinship or not; feeling of burden in the family; live alone and/or with another elderly person; selfperception of capacity and functional performance compromised; financial difficulties; suffer various types of violence in the family and in society and the death of the spouse.
As for family issues, the impossibility of assistance, conflicts, insufficient income, the insertion of women in the labor market, the lack of a care entity and the lack of physical and psychological structure by the caregivers and family members were highlighted.
The results are shown in table 1.

RESULTS
Lopes VM, Scofield AMTS, Alcântara RKL et al. In the results found, four determinant causes that led the elderly people to the insertion in a long-term institution were highlighted. This fact was highlighted to the search for previous social and political actions and strategies, before the institutionalization to avoid their occurrence, overcrowding and high costs in these establishments.
In this study, the reason of own will (29.6%) was highlighted, in contrast to another international study in which elderly people from the home (43.3%) and from hospitals and long-term care institutions prevailed (45.8%). 9 The sign of spontaneity for institutionalization may presuppose a new category of older people who are casting aside their prejudices and discriminations to experience another life and adapt with the reconstruction of new bonds and feelings, despite the challenges faced in a strange environment. In fact, increasing the age goes through the process of cognitive and emotional readjustment, resulting in the establishment of new goals, individual beliefs, norms and internal values, 9 especially in the change of environment.
On the other hand, such a finding may result from the interrupted family processes that bring to the aged feelings of being a burden to their loved ones, feelings of abandonment, revolt, hurt, anguish, despair, and helplessness. Such sensations can culminate in the development of diseases, the reduction of quality of life and institutionalization.
It was observed that the elderly person who were admitted to the institution by free will were male (58.5%), unmarried (40%) and widowed (27.7%) and living alone (47.7%). Not having or being distant from the family also contributes to social, financial and health vulnerability. The support of the family and society to the elderly person is fundamental to make them feel more protected, secure and able to resort to various support options to minimize feelings of sadness, loneliness and social isolation.
It was identified that many elderly people come to the institution victims of abandonment, violence or because they are homeless. The common characteristic is the situation of social vulnerability they have experienced throughout their lives. They are elderly people of low socioeconomic class, without education level and without relatives. There are still those who, when they became older and lacking the strength to face life alone, needed assistance and no one provided it since, in adult life, they were violent and negligent with spouses and children, having no affectionate support in old age. Also, there are others who dedicated their lives to the family, however, suffered or had violence inside or outside their own home.
It should be noted that, among the elderly people who suffered abandonment and violence, those living with spouses or children predominated (48.8%). Another Brazilian study, in the Northeast region, found that the main forms of elder abuse were psychological (40.2%) and abandonment (10.7%), and the profile of the perpetrator was, in most cases were children (54.5%) or spouses (11.6%). 10 Understanding the manifestation of violence against the elderly person, social vulnerability, and social support networks subsidizes actions to confront them 11 and to reduce institutionalization.
Some elderly people were admitted as victims of maltreatment and presented an initial revolt related to the distance/loss of the child or spouse, the loved one and loved one who, even in the face of aggression, was the only "support" and "reason of their life". At the entrance of the institutional context, often the victimized elderly person denies having suffered violence, mainly the psychological one, perhaps due to the development of naturalization in their situation, considering absolutely normal the way in which they lived. In this condition, there are many old women born in a macho and prejudiced society in which they are submissive and it is often the authority of man.
In relation to the institution´s search for other causes, the elderly come from other shelters. Once institutionalized, the Statute of the Elderly refers as a principle, to the maintenance of the elderly in the same institution, except in case of force majeure. 12 The institution of the study has more than a century of existence and works with people in situations of social exclusion, in recent years, on the elderly person. In several periods, it received elderly people who came from other shelters that closed because they did not comply with operating norms or lack of resources to provide adequate care. This indicates the lack of structure and noncompliance with the legal precepts of regulation of the institutions, as well as the difficulty of maintaining human resources trained and prepared to integrate a multiprofessional team. 13 Also, in the "others" reasons, elderly people who had internal conflicts in other long-term institutions with employees or residents were added. The coexistence with unknown people, the dependence of other people and the repudiation for being in that condition bring revolt and open up a range of situations, feelings lived and diverse moments associated to each of them. These particularities can make difficult the relationship and the good coexistence.
The dialogue, consensus of ideas, clarification, and support of friends and family for the mediation of conflicts 13 and the adaptation of the elderly to the institutional environment is needed in the dynamics of teamwork in a long-term institution. The change of service can be a traumatic event for the elderly person and lead to devaluation and discouragement of their autonomy and independence.
On the receiving of visits, significant association with the institutionalization motive was obtained (p=0.011). From the results, a high proportion of elderly people who are not visited, either by relatives or non-relatives (40.6%) were observed, in agreement with another study, in the Northeast region of Brazil, in which 72.2% of the elderly people did not receive visits. 14 A survey conducted in Brasília concluded that only 51% of the elderly people received visits from their relatives. 15 The Elderly Status establishes that the family is the main basis of care. 12 However, the dynamics of many families have changed over the years, which directly reflects the care of aging entities, since they are no longer a priority.
It is understood that some families suffer from financial issues associated with the difficult and costly treatment of the numerous comorbidities and the various medications used by the elderly population. This situation occurs due to the precariousness of living conditions and worse levels of health. Without social protection or government grants, families feel obliged to institutionalize their elderly family member, as the only alternative, to provide a better life and adequate care.
It is noted that dependence is a risk factor for institutionalization, 16 because the higher the degree of dependency, the greater the financial care and expenses that make family, friends, and neighbors seek long-term institutions. In this study, it can be seen that the elderly person who entered for the "other" reason are the most dependent. This is justified because many have been referred from other shelters and have already appeared with weaknesses, disabilities, and dependence.
It is expected that the elderly person who has entered voluntarily will have less dependency than the one who entered for any other reason. In general, the sample shows 65.7% of dependent elderly people. This data converges with national and international surveys, with a prevalence of 66.9% 17 and 92.5%, 9 respectively. The longer and more dependent, the greater the need for specialized and costly care.
It is pointed out that, in the context of institutionalization, the decline in physical and mental health, loss of functional capacity and weakening of family and social ties represent a barrier to active aging. 18 In any case, Brazilian and worldwide aging has contributed to accelerate the process of institutionalization and the need to offer housing services to the elderly person, resulting in greater public health expenditures, problems related to social security, poor reception, poor treatment of the elderly and disqualification of care.

Regardless
the reason for institutionalization, the staff of professionals from long-term institutions should respect the life history, feelings, values and cultural habits of the elderly person, contributing to the improvement of care and the diffusion of the idea that the institution is not only a place for the elderly people but a place to live with dignity and quality. 19 Regardless of the reasons for institutionalization, all the elderly people were exposed to negative social and health outcomes.
It is understood that, although the elderly people are supported by the Federal Constitution, by the Statute of the Elderly and by other public policies, it is still necessary to recognize them. Actions should not be carried out in a timely manner but should be expanded by raising awareness among children and stimulating intergenerational solidarity and re-establishing respect for the elderly in the family.
It is concluded that, in this context, it is important to investigate the reasons for the entrance of the elderly in these environments, such as physical, social, emotional, economic and/or cultural ones. Knowledge is fundamental for the elaboration of interventions directed to the families in order to postpone the entrance in the institutions since there are few and a great part of the existing ones has innumerable deficits of structure and professionals disqualified. Support should also be given to existing establishments in improving their services and