INTRODUCTION

Aging is a physiological, psychological and sociological process that involves all of the functional and structural changes that occur over time at the level of cells, tissues, and systems of the organism.¹ The psychological dimension of old age, perception, learning, psycho-motor, problem-solving and personality characteristics of the human adaptability capacity in terms of changes as the chronological age progresses. Sociologically, old age is related to the behaviors expected from a particular age group and the values that society gives to that group.²

Looking at population statistics in the world and Turkey, there has been a significant increase in the older population in recent years. There are 901 million older people,³ who account for 12% of the world’s population. It is expected that this figure will be doubled in 2025 and reach about two billion in 2050.⁴

The older population is the fastest growing group, which has the most health problems and needs of health care.⁵ The need for long-term care and support with the growing population is also increasing.⁶ Physical problems in older people (falls, bone fractures, etc.) and chronic diseases increase dependency level.⁷ The difficulties that start with the loss of physical power, functional losses and difficulty in adapting the body to changing situations negatively affect the mental state of older people. This situation leads to negative feelings such as introversion, unwillingness and decreasing life satisfaction together with the sense of loneliness in older people.⁸ Dementia, delirium, Alzheimer’s disease, cognitive disorders, incontinence, physical limitations and problems with relatives cause social isolation among older people.^7,9 The social isolation and mental problems of older people lead to a deterioration in health status and a significant decrease in the quality of life.¹⁰ In addition, with the increase of age, loss of peers and close friends, social support and decrease in income levels may lead to significant changes in bio-psychosocial health. This situation affects the daily living activities of older people and causes significant changes in quality of psychosocial functioning.¹¹ Functional capacity is usually assessed through questionnaires of the elderly’s  report on the performance of daily living activities,  and the physical performance related to functional limitations  is  investigated  through physical tests where individuals perform specific tasks, which confers  greater responsiveness to relevant clinical changes.^12,13 Changes in the physiological, psychological, economic and social dimensions of the life not only affect older people, but also everyone who lives with older people.¹⁴

Limitations in functioning and dependence on other people in performing daily activities lead to a worse quality of life for older people and an increase in the social costs of care and health.¹³

Psychosocial functioning is a multidimensional concept that encompasses different aspects of functioning such as intellectual, social and cognitive functioning, psychosocial aptitude and measurement of physical needs.¹⁵ A national approach that providing care for older people should be developed to meet the needs of a growing population and improve the quality of care. Adaptation of the environment to meet the needs of older people, capacity, functionality and daily living activities need to be evaluated continuously.⁶ The belief that dependence is inherent to the aging process produces negative attitudes and intimidates the elderly population within a sociocultural context that values the preservation of autonomy and independence.¹² The World Health Organization has set five main goals to guide countries on how to improve the functional abilities of older people: to have a pleasant time with their peers, to organize health systems according to the needs of the older population, to develop sustainable and equitable long-term care systems, and to involve older people in decision-making process.⁴

For this reason, health and social services for older individuals should be addressed not only in traditional values but also in a holistic approach. Physiological, psychological, social and economic deficiencies must be identified and supported earlier stage to provide a better healthy aging of individuals. Self-care skills of older people, disorientation, depressive and anxious moods; the evaluation of psychosocial characteristics such as disquiet behavior and secession withdrawal from the society are very important in terms of planning health and social services for older population. There are a limited number of studies in the literature evaluating the psychosocial functionality of the elderly.^11,15-17 In line with this information, this study was conducted to evaluate the cognitive, psychological and social functioning of the older people who apply to primary health care services in a multi-faceted way.

Research Questions

Research question 1: Is there a difference between older people MOSES total, sub- dimension scores and their socio-demographic characteristics?

Research question 2: Is there a correlation between older people Katz ADL and MOSES score averages?

MATERIAL and METHODS

Study Design

This descriptive and cross-sectional study was carried out between February and November 2018.

Sample of the Study

The population of the study was composed of older people who applied two different Family Health Centers in the city of Mardin. In the study, no sample calculations were made and 200 elderly people who meet the inclusion criteria between the dates of the study were included.

Inclusion Criteria

Individuals who are over 60 years old, who do not have mental health problems and communication problems and who volunteer to participate in the study were included in the study.

Exclusion Criteria

Individuals who are tired of answering questions and do not volunteer to participate in the research are excluded.

Data Collection Tool

The Patients Information Form was used which included questions regarding socio-demographic information of the older people. Katz Index of Independence in Activities of Daily Living (Katz ADL) was used to determine the activity level. As for functional status, Multidimensional Observation Scale for Elderly Persons (MOSES) was used.

Patients Information Form: 17 open-ended and multiple-choice questions developed by the researchers in the literature^11,18-20 constitute independent variables.

Katz Index of Independence in Activities of Daily Living (Katz ADL): The Katz ADL index developed by Katz and collegues. In 1963 consists of six questions which include the information about the bath, dressing, toilet, movement, excretion, nutrition activities that evaluate the dependency status of the individual in performing daily life activities.

In the Katz ADL index, 0–6 points are dependent, 7–12 points are semi-dependent,13–18 points are evaluated as independent of 19, 20.¹⁸ While the Cronbach Alpha of the scale was 0.83, in our study, the Cronbach Alpha was found 0.85.

MOSES: The validity and reliability of the Multi-Dimensional Observation Scale for Elderly Persons (MOSES) developed by Helmes, Csapo and Short (1987) was conducted by Soygür and collegues. The Multidimensional Observation Scale for Elderly Persons has been developed in order to evaluate the psychosocial aspects and the functionality of the elderly. This scale consists of 40 items and evaluates five functional areas, each consisting of eight items. The lowest score and the highest score that can be obtained from the sub-dimensions of the scale; 0–25 for self-care, 0–30 for disorientation, 0–29 for depressive/anxious mood, 0–29 for disquiet behaviors, 0–25 for the community. Each item in the scale is scored between 0–4. Eighteen items of the scale are five and 22 items have four options. The lowest total score that can be taken from the scale is 0, and the highest score is 138 and the low scale score shows that the functionality of the elderly persons is high and the scale score is high, whereas the functionality of the elderly persons is low.¹¹ While the Cronbach Alpha of the scale was 0.87, in our study, the Cronbach Alpha was found 0.96.

Data Collection and Analysis

The data were collected from both the face-to-face interviews of the older people and the observations of nurses and family members who care for the older people. The application of data collection tools to the older people who agreed to participate in the study took approximately 15–20 minutes for each older people. SPSS 21.0 package program was used in the evaluation of data. The mean standard deviations, number and percent values were used in descriptive tables. For the evaluation of data that do not conform to a normal distribution, Kruskal-Wallis, Mann-Whitney U test and Spearman’s correlation analysis were used. The significance level of the study was accepted as p<0.05.

Ethics

For the application of the research, written permission was obtained from the scientific publication Ethics Committee of Mardin Artuklu University (approval number: 2018/01-6) and the institution to which the study will be conducted. After informing the older people who participated in the study voluntarily, they were informed about the research and their written and oral informed consent was obtained. This was conducted in consideration of the declaration of Helsinki.

RESULTS

Image Indices

The mean age of older people was 70.03±8.48 years. 54.2% of older people were female, 82.5% were married, 68% have chronic disease, 60% were illiterate, 87.5% were not working, and 71.5% used drugs, and 53.5% stated that their care was done by their spouses (Table 1).

The mean age of women participating in our study was 70.25± 9.32, and men 69.76

±7.39 years. It was found that 35.8% of women and 74.7% of men received care by their spouses. It was found that 70.6% of women and 96.7% of men were married.

The mean scores of Multidimensional Observation Scale for Elderly Persons (MOSES) were 24.36±22.38, the corresponding scores of Katz Index of Independence in Activities of Daily Living (Katz ADL) were 16.32±3.14. The mean scores of MOSES sub-dimension were followed as given. The mean scores of self-care sub-dimension were 3.73±6.10, 3.31±5.28 was for the disorientation sub-dimension, 8.45±6.24 was for the depressive-anxious mood sub-dimension, 3.42±3.61 was for the disquiet behavior sub-dimension, and 5.44±5.58 for secession from society sub-dimension (Table 2). The mean of Katz ADL in women was found 15.74±3.73, and 17.01±2.05 among men.

A significant difference was found between gender and MOSES total and self-care, depressive/anxious mood sub-dimensions (p<0.05). A significant difference was found between marital status and MOSES total and self-care, depressive/anxious mood, and disquiet behavior sub-dimensions (p<0.05). A significant difference was found between MOSES total and all sub-dimensions of education, study and assistive device use (p<0.05).

A significant difference was found between the presence of chronic disease and drug use and MOSES total and self-care, disorientation, depressive/anxious mood, and secession from society sub-dimensions (p<0.05). While there was no significant difference between the caregiver and depressive/anxious mood and disquiet behavior sub-dimensions (p<0.05), a significant difference was found between MOSES total and other sub-dimensions (p<0.05) (Table 3).

A moderate correlation was found between age and MOSES (p<0.001, r=0.503), and a moderate negative correlation between Katz ADL and MOSES (p<0.001, r=-0.581) (Table 4).

DISCUSSION

As it is the case in many countries all over the world, the demographic structure of Turkey has been rapidly changing. As fertility rates are falling and average life span is increasing, the share of the elderly within the population is constantly increasing.¹⁵ As the number of older people increase, the need for rehabilitative services will be increased and more psychological and social support will be needed in order to effectively manage the problems of the older individuals and their families in order to plan and develop older people’ care and health services and to support independence.¹¹ In addition, it is stated that care needs and activity levels of older people have an effect on life satisfaction and quality.^5,21,22 In this study, multidimensional evaluation of cognitive and psycho-social functionality of older people based on their daily life activities was performed.

In our study, the mean score of MOSES was 24.36±22.38. Since the scale has no predictive value, the highest score that can be obtained from the scale is 138, and the cognitive and psycho-social functionality of the elderly people who participated in our study was found to be low. This situation can be related to the fact that the majority of older people (68%) have chronic diseases, 53.5% of them are cared for by their spouses and the average age is high. Similarly, in the study of Nakamae et al.¹⁹ and Van Haitsma et al.¹⁷ the mean score of MOSES was found to be low. In some studies, conducted with different sample groups, the mean score of MOSES was found to be higher.^6,7,15,20 Nakamae et al.¹⁹ average age of the participants who participated in the study is advanced. It can be concluded that age is a factor affecting cognitive and psycho-social functionalities.

When the MOSES sub-dimensions were examined; while the mean scores of depressive/anxious mood and distance from society were high, the mean scores of self-care, disquiet behavior, and disorientation sub-scale were low. This situation can be deduced from the fact that the older people who participated in our research were depressed and moved away from the society. It may be due to the fact that the majority (53.5%) of the elderly individuals who participated in our research were dependent on their daily care. Van Haitsma et al.¹⁷, Nakamae et al.¹⁹ and Yamagami et al.²⁰ studied people with dementia, disorientation, secession from society and self-care sub-scale mean scores were high, while disquiet behavior and depressive/anxious mood sub-dimension mean scores were found to be low. In contrast to our study, it is thought that the high incidence of disorientation and self-care scores is due to the formation of dementia patients.

In our study, MOSES total, self-care and depressive/anxious mood sub-dimension scores were higher in women than in men. In addition, MOSES total and self-care, depressive/anxious mood, disquiet behavior sub-dimensions scores were higher in single or widowed than married. In the literature, it is stated that being a woman is a risk factor for depressive mood.^23,24 Similar to our study, Kaur et al.²⁵ reported that the lack of self-care was higher in older people who were widowed or divorced, whereas Ishak et al.²⁶ did not find a significant difference between marital status and self-care. It is thought that depressive/anxious mood is high among single or widowed people, lack of social support, lack of motivation, difficulties in communicating with the environment and may be caused by feeling alone. Similarly, in some studies, the prevalence of depression is more common in single and widowed ones; in some cases, it was determined that the marital status did not affect the level of depression.^23,27,28 This result is thought to be due to the fact that the mean age of women participating in our study was higher than that of men, the majority of women received care from people other than their spouses (children and caregivers, etc.) and the proportion of married people was lower than that of men. Because with aging, individuals’ dependence on others increases in meeting self-care needs such as nutrition, bathing, and discharge. In case of receiving care from people other than their spouses, they may think that there is a burden on others and cause anxiety and communication difficulties. Losing spouse or living alone can lead to problems such as depression, leading to a lack of social support and loneliness.^11,25

In our study, MOSES total and sub-dimension scores were higher in the elderly who were illiterate, not working, and who used assistive device. Similar to our study, Ikegami et al.¹² stated that low education level and non-working status are related to low functional capacity. In addition to keeping the elderly active, it is stated that being employed positively affects the psychosocial functionality by living with other people, maintaining cooperation and interaction and social support mechanisms.^9,12 Education level is important in providing and channeling financial resources related to care while contributing to the development of the skills and confidence necessary to maintain and maintain healthy aging.^12,13,16,29 The use assistive device (wheelchairs, canes, etc.) of the elderly reduces their functional capacity and increases dependency on others.

This situation can cause anxiety and social isolation in the elderly. Therefore, in our study, it is thought that the majority of the elderly do not work, are illiterate and use auxiliary equipment reduces psychosocial functionality. A significant difference was found between the presence of chronic disease and drug use, and MOSES total and self-care, disorientation, depressive/anxious mood, and secession from society sub-dimensions. With age, the number of chronic diseases seen in older people increase.³⁰ Chronic diseases may cause frequent hospitalizations, multiple drug use, economic and psychosocial problems in older people.^25,26,30 It is thought that this situation will affect psychosocial functioning in older people and decrease the quality of life.

In our study, the mean total score of the Katz ADL was 16.32±3.14. Those with an ADL score of 13 or above applied to the participants it has been evaluated as “independent”. Therefore, it is seen that older people who participate in the study have a high level of independence in performing daily activities. The results of some studies are similar to our research.^{9,12,13,18,31} Differently, in the study of Knapik et al.¹⁶, with patients with Parkinson, stroke and multiple sclerosis, daily life activity scores were lower. In this case, it is thought that the individuals participating in our study are physically less dependent.

Impaired cognitive and psycho-social functions are associated with the daily lives of the elderly. In our study, cognitive and psycho-social functions of older people decreased as age progressed. With aging, not only physical functions but also psychosocial functions decrease and slow down.^7,8 In our study, the MOSES score decreased as the independence of older people increased in the activities of daily living. The high level of independence of the older people in daily living activities shows the ability to perform independently in the self-care activities such as nutrition, dressing, bathroom, toilet, movement, and excretion without getting help from anyone. The problems in the physical field and the high level of dependence in the activities of daily living in older people cause a loss in the psychological and social areas.^23,30 This situation may affect the physical, social and psychological aspects of older people, and affect the well-being of the older population, which may lead to decreased life satisfaction and psychosocial functioning.^21,23 Therefore, it is thought that the high level of independence of older people in our study positively affects psychosocial functioning.

Limitations of the Study

This study, due to be made in two different Family Health Center providing primary health care services in the southeast of Turkey results cannot be generalized. For this reason, it is recommended to conduct the study in secondary and tertiary healthcare places and in different sample groups.

Conclusion

It is thought that the functionality and independence levels of older people are high and this is due to the fact that older people living with their family and coming to the Family Health Centers constitute the sample group. As the age increases, the MOSES score increases and therefore the functionality of older people decrease as the age progresses.

In addition, as the Katz ADL score increases, The MOSES decreases. This shows that as the independence levels of older people increase, the functionality increases. The evaluation of cognitive, psychological and social functions of the elderly who live alone or live with family members at home will support the psychosocial functionality of the elderly. Support by healthcare professionals can encourage older people to autonomy. For this reason, the psychosocial functionality of the elderly should be monitored periodically by the healthcare professionals and the deficiencies should be supported.

ACKNOWLEDGEMENTS

The authors are grateful to older people for participating in the study.

MAIN POINTS

• Physiological, psychological, social and economic deficiencies must be identified and supported earlier stage to provide a better healthy aging of individuals.

• Self-care skills of older people, disorientation, depressive and anxious moods; the evaluation of psychosocial characteristics such as disquiet behavior and secession withdrawal from the society are very important in terms of planning health and social services for older population.

• This study revealed that older people who come to family health care centers had high functional and independence levels.

ETHICS

Ethics Committee Approval: For the application of the research, written permission was obtained from the scientific publication Ethics Committee of Mardin Artuklu University (Approval number: 2018/01-6) and the institution to which the study will be conducted.

Informed Consent: Written and oral informed consent was obtained.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: H.U., Design: H.U., Data Collection and/or Processing: H.U., Analysis and/or Interpretation: B.V.D., Literature Search: B.V.D., Writing: B.V.D., Critical Review: B.V.D.

DISCLOSURES

Conflict of Interest: The authors declare no conflict of interest.

Financial Disclosure: The authors declare that this study received no financial support.