Family Functionality , cognitive status and social participation are related to survival in nonagenarians and centenarians : data from a Brazilian cohort study

Recebido em: 3 out. 2019. Aprovado em: 17 dez. 2019. Publicado em: 03 agos.. 2020. Abstract Aim: To evaluate whether family functionality, using the instrument “Adaptation, Partnership, Growth, Affection, and Resolve” (APGAR) and its components, as well as other health indicators, influences the survival of nonagenarians and centenarians. Methods: Participants were randomly identified and evaluated in their homes of Porto Alegre — Brazil. Death or survival information were verified by telephone or death registry system. Follow-up time measured the number of months between the first evaluation and the date of death or the last contact. Participants with APGAR ≥ 7 were classified with good functionality. The APGAR components were analyzed as yes or no. Results: Two-hundred-fourteen participants (73% women, age 92.4±3.59 years) were followed during 23±10.0 months. Sixty-on (28.5%) died. Survivors were younger (p<0.001), had better cognitive performance (p<0.001), and reported more frequently leaving home (p=0.010) and participating in social activities (p<0.001). Survivors had a similar frequency for good family functioning (90% p=0.994), but more often they were satisfied with their family time (p=0.032) and with the way the family showed affection and reacted to their feelings (p=0.083). Conclusions: Family affection and time were significantly associated with lower hazard-ratio, even adjusted for age, as well as cognitive performance, social activities and the habit of leaving home. In addition to the preservation of cognitive performance, to remain physically and socially active, family support is related to the higher survival rate in nonagenarians and centenarians in Brazil.


Introduction
Demographic aging is a fast-growing problem in developing countries, like Brazil. It results from the reduction of birth and fertility rates and the increase in life expectancy, due to the decrease in mortality. This decrease is due, among other causes, to greater access to health services. Among the older-adults, the population range of those aged 80 years or older, also called oldest-old, is the one that grows the most 1 .It is estimated that in 2050, the oldest-old will be 13.3 million people, representing 6.5% of the Brazilian population and 19.6% of the elderly 2 . Paschoal (2016) recalls that aging is accompanied by a greater chance of illness and decline of autonomy and independence 3 .
The family is the natural space of care for the individuals 4 . The weight of the aging process for families, especially from developing countries, is heavy. In developing countries, like Brazil, family and other informal social institutions assume the care role with little or no state support. As early as 1996, Rogers 5

Methods
Longitudinal, observational and analytical study. The data collected by the AMPAL project were used in the initial evaluation performed in 2016.
Surveillance for survival data was performed by telephone contact.

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The present research has as population nonagenarians and centenarians resident in private households living in Porto Alegre -Brazil who participated in the Multiprofessional Care to Oldest-old (AMPAL) project will be used as sample.
All the AMPAL project's oldest-old respondents were included in the present study, who answered the Family APGAR questionnaire in the initial evaluation of 2016. Excluded are those whose only available information or contact was in the initial evaluation of 2016. These participants were considered losses and without follow-up time.
Data from the initial AMPAL assessment were collected at the household of the oldest-old, with their own or their relatives.
The deaths of the participants were identified through the reports of the Funeral Service Center of Porto Alegre (CAF) and through telephone contact. From August 2018 to January 2019 all participants whose survival situation could not be observed in the CAF report were contacted by telephone for a follow-up interview.
The family functionality was evaluated through the family APGAR, developed by Smilkstein (1978) 7 and validated in Brazil by Duarte (2001) 8 . In the present study, two levels of family functionality will be considered: good functionality (APGAR 7 to 10) and family dysfunction (0 to 6). In cases in which the participant was not able to respond, the APGAR of the family was not filled out, and excluded from this study. In order to avoid embarrassment, while the participant answered the APGAR questions, family members were asked separately about other issues, such as medication in use and chronic diseases.
Regarding sociodemographic data, this study evaluated schooling and marital state. Social inte-          Figure 1A compares the survival curves of men and women.
It is possible to observe that the male survival, in general, is greater than the female survival, although not significant (p= 0.827).  according to the test score and schooling. It can be seen in Figure 1D that the participants with normal MMSE had greater survival than those Ilva Inês Rigo • Ângelo José Gonçalves Bós Family Functionality, cognitive status and social participation are related to survival in nonagenarians and centenarians 7/10 with a score below the limit (p<0.001). Figure 1E shows the participants' Kaplan-Meier curve in relation to leaving or not at home. Longer survival was observed among participants leaving home (p= 0.008). Participating in social activities ( Figure   1F) was a factor related to higher survival among AMPAL nonagenarians (p= 0.001).  A "Are you satisfied with the help you receive from the family?"; B. "Are you satisfied with the way your family and you talk and share the problems?"; W. "Are you satisfied with the way your family accepts and supports your desire to start, change or maintain activities or lifestyle?"; D. "Are you satisfied with the way your family shows affection and responds to your feelings such as irritation, hurt or love?"; 2E. "Are you satisfied with the time you spend with your family?"; F. with and without Family Dysfunction. Table 3 shows the results of the Cox Damage regression for the variables that had a significant difference in the survival analysis. Initially, a simple analysis was performed, which was adjusted by the age group, smaller or larger and equal to 92 years. Sex was included in the analysis because it was a factor associated with survival. Family dysfunction was included as the variable of in-terest in this study. Sex and family dysfunction remained without significant difference, even after adjusting for age group (p= 0.724 and 0.568, respectively). The age group greater than or equal to 92 years represented a 118% higher risk of death among nonagenarians and centenarians of AMPAL (p= 0.004). In the present study, the good family functionali- We believe that a larger sample can confirm that nonagenarians and centenarians with worse fa-mily functionality have lower survival rates.
The main factors related to survival in the present study were cognition, social interaction and physical functionality. The mean MMSE performance differed significantly between the surviving and the deceased group, the better MMSE performance represented a longer survival and a 84% lower risk of death compared to nonagenarians with abnormal MMSE. This finding was similar to that reported by a study with elderly individuals aged 80 years or older in China, among whom there was a higher mortality in the group that presented faster cognitive decline 17 .
Social interaction, evaluated in the form of leaving or not at home and participating in social activities such as groups, meetings with friends, had a significant association with greater survival and was a protective factor for mortality. This association remained significant after adjustment for age group. A meta-analysis with several age groups, but with a predominance of the elderly, identified social isolation and solitude as risk factors for mortality 18 . Among the nonagenarians, social interaction becomes more difficult, due to the physical dependence that some present, and by the network of friendships and family that is waning with the death of many loved ones.

Conclusion
This study concludes that active aging plays a fundamental role in the maintenance of the quality of life for the elderly. Reaching this age is already a great achievement, but mastery of your own body and intellect goes beyond the simple absence of disease. The predominance of satisfaction with family relationships demonstrates the role of the family as a support structure for nonagenarians and centenarians, without which, possibly, these individuals would not have reached longevity.
It is necessary to cultivate and devote time to these relationships in order to keep them active.
Having someone to share life with can be one of the reasons to stay alive.