Nursing intervention with old people at home involves their recognition as multidimensional human beings, multifaceted, unique and unrepeatable, given its biographical and socio-cultural stories. Implies the recognition of the "Being" complex and multifaceted, who by inalienable right and with free will, must give its opinion and decide on all everyday actions with its development implications, until the end of life. Among other things, the purpose of the intervention is to preserve the autonomy and enjoy better quality of life, even when they suffer disease processes. The approach concerning the consultation of mental health nursing at older people’s home that is presented here, is based on theoretical and experiential knowledge acquired in different care as psychiatric and mental health nurse in the community context. Is also based on the experience as teacher involved in the training of nurses and nurse specialists in Mental Health and Psychiatric Nursing in the Autonomous Region of Madeira (RAM). It aims to enhance the relevance and feasibility of this consultation as proximity strategy and communication with older people at risk and/or affected by mental health problems. With regard to the planning and structuring of a mental health and psychiatric nursing consultation at home is presented a case, whose content is of our responsibility, to through its schematic presentation provide an example capable of achieving the results arising from the direct intervention of the nurse.

Keywords: nursing, mental health, psychiatric care, consultation; older people, domicile, community

CINTESIS, the center for research in health technologies and services; DGS, directorate general for health; OE, portuguese nurse`s order; WHO, world health organization; RAM, madeira autonomous region

Scope of intervention of mental health nurses

In the older people, the functional needs and problems that show are wide and affect not only the body but also has a psychosocial impact. The multiplicity of factors and dimensions involved vary not only with the players but also with the contexts. From the physiological to psychological including cognitive and affective, social, spiritual, to the idiosyncratic cultural expression, when they come together, are often complex, requiring more differentiated interventions within mental health and psychiatric care. Require that the professionals are holders of knowledge, technical and relational skills, and cultural sensitivity necessary to act holistically and therapeutically.

The nurses are involved in health promotion and prevention of harmful changes at the individual level, but also have a relevant role in society by providing care to groups experiencing disease processes, avoiding the complications and arising damage.¹ A considerable share of the older people, suffer from multi morbidity² that cause limitations whether at functional and instrumental levels and interfere with the autonomy. Such contingencies are relevant to mental health, and connect with negative experiences, feelings of loss, sadness, the reduction of the real and perceived personal control. The adaptive mechanisms that the older people holds to deal with those situations may not be sufficient and the persistent suffering can be complicated with increased dependency. It should be noted that "there is no health without Mental Health"³ and that the problems and mental disorders has progressively increased, including in developed countries.⁴ In Portugal, affect a large proportion of the older population.⁴ The program of action for the Mental health of Portugal,⁴ contemplates the older population as risk group, to which must dispense outreach care. The nurses are qualified to do so.

At present, the nursing intervention in the households and communities have greater accuracy, because it is there that the majority of older people and very older people remain for longer periods of time. It should be noted the relevance of that strategy for the care of mental health and psychiatric nursing, customized and culturally sensitive. At RAM is in the community that the older people do need more support, when they experience a transactional processes⁵ associated with prolonged evolution and disabling diseases such as dementia or other mental disorders. The change in rhythms of life requires the mobilization of a wide range of knowledge and resources to ensure quality of life, to the sick person to family and caregivers.⁶ The concomitance of multi morbidity and its manifestations requires continuous adaptation of responses to be available. The specific training of nurses in psychiatric and mental health is essential to ensure client-centered care, safe and of good quality.

Many older people have basic necessities affected by problems arising from depressive disorders, dementia, anxiety disorders, in particular addiction to alcohol or psychoactive drugs, along with other chronic morbidities. The risk of decline increases when the elderly live alone and are not mobilized the resources and supports in order to counteract the discomfort, suffering and anguish. When in solitude, are usually nurses who make themselves available to provide them both emotional and instrumental support being often the sole source of support in the households.

Consultation of mental health nursing at home

In view of the foregoing, assume relevance the following issues:

What can be made the psychiatric and mental health nurses in the community in order to support the older people and their families in the area of mental health? What are the goals and expected results of the nursing intervention? What strategies can be used in the intervention? When it becomes fundamental the nursing intervention at home to old person? The consultations occur in diverse situations, often when the beneficiaries have limitations for travelling to health center. It has a variety of reasons, namely the purpose of providing care for the restoration of health, maintenance, and to avoid complications including hospitalization and institutionalization in nursing homes. Parallel, consultations are used for guidance and education to the families/caregivers and convivial. It should be noted that in Portugal, many of the caregivers of older people dependents are adults, usually wives and daughters, middle-aged or elderly too.^7,8 However, many of those with advanced age live alone, the health and social services become their only sources of support.⁹

It should be noted the relevance of preventive mental health nursing consultations at home, including as a strategy/Interventional methodology of proximity in the communities and socio cultural realities approach,¹⁰ as well as socioecological contexts, which are fundamental determinants of health/mental health, either on an individual and collective perspective. In psychopathological situations that affect the elderly, specialist care request occurs often belatedly, at the stage where the dependency is installed and the cognitive deterioration, behavioral changes and suffering are very significant.

At RAM, the teams of health of primary health care (CSP) include the nurse psychiatric and mental health specialist. They are responsible for regular and periodic monitoring of the situation of health of populations, in different age groups and are "at the forefront" to detect in time those at risk and with signs and symptoms of illness or suffering. Without discontinuity in contact with populations, they intervene proactively. The planning of mental health and psychiatric care implies the knowledge of the realities of communities in general and health of citizens in particular, and identification/inventory of needs in nursing.^11,12 Nursing intervention to older people must fit within the scope of planning in health.¹³ The demographic and epidemiological indicators should be considered in the design of plans, projects and mental health programs directed to this population group. The answers should fit the needs identified by the nurses, especially those of seniors, families, caregivers and communities. The contact with the populations must be proactive and motivating its participation.

Family contact with the nurse
D the client's sister, addressed the mental health and psychiatric Nurse at the Health Center, requesting help for the older sister. She mentioned that MB since a few months ago changed her normal behavior, surprising D increasingly with its new attitudes and mood swings. Since about three weeks, she dint ‘got out of her house. So D became very worried and resolved to go herself to visit MB. She found her tearful and was surprised the way she was dressed at noon (in pajamas), as well as the carelessness that appeared both in the arrangement with itself or on the housing. By questioning her about why she had not visited her in the last two weekends, as usual, MB answered that she did not want to be "a burden" for the family. Referred also to have no desire to leave the house for any location where she could find or need to talk to other people. D notice that her sister was thinner since the last time she had been with her for about three weeks and questioned her about how she fed, being the response of MB that "in recent times had no desire to eat" and much less to go to the supermarket to do shopping. Missed the answers of her sister she asked her if she felt well and MB replied shrug and referring to "little matter ... I'm not doing anything here. Do not miss, I'm just a nuisance! "

When D insisted for both to go at the supermarket or to go to D house, because she had noticed that there were almost no food in the home of his sister, MB refused referring that she was tired, that she is sick of life and want to disappear. Then she added "don't bother me ... it's not worth it! You have so much more important to worry about ". D leave her sister alone at home but she was be very worried, and this made her to go to the health center in the area of residence of MB to request help.

The nurse pondered the situation presented and questioned D about the possibility of bringing sister to the nursing consultation at the health center. D answered that had already suggested this possibility, however her sister refused. (D) asked if the nurse could not visit her sister at home, because she was convinced her sister would to be receptive receive the nurse and do some talking.

The nurse confirmed that it was possible, however, suggested B to question MB and then to confirm on MB willingness to receive the visit.

Two days after:

Visit planning and structuring for mental health nursing at home

1. Individual process query of client and confirms that MB has 67 years of age, single and resident in an urban area of easy accessibility. Check also that she exercised the profession as administrative employee in a public Department.

In the nursing historic notes, the nurse noted that there are three years that MB does not seek the health center or nursing consultations there. Previously recurred to health center episodically being only two nursing records, one of about 6 years ago and another held three years ago, when searching the nurse to update vaccination. There were no other significant records.

There no carried out previous home visits.

2. Provides the resources required and the time available to perform the consultation (about 60 minutes including of the movements that take 20 minutes).
3. Determines the objectives in view of the fact that it is the first visit to the home and the first nursing consultation that takes place on the client.
4. Elaborates the query plan of nursing.

Second step: Home-visit plan implementation of the nursing consultation

Initial phase-beginning of the relationship between the client and the nurse13,14

1. presentation and reception
2. start of the relationship between the client and the nurse
3. clarification of the goals for the consultation at home by the Nurse
4. clarification of expectations and objectives of the client
5. validation of joint objectives for the nursing consultation

Development phase–sedimentation of the relationship with the client

1. global and specific assessment based on a theoretical model of nursing
2. evaluation of the physical and mental state of the client
3. environmental assessment
4. Identification of needs, risks and outbreaks to nursing intervention
5. definition of actual and potential problems
6. validation of the risks and problems defined with the client
7. negotiation of agreement on therapeutic work plan
8. reconfirmation of work objectives and expected results
9. setting relating to strategies and therapeutic interventions to achieve

Finalization phase-strengthening the relationship with therapeutic purpose

1. clarification of questions, expression of positive and negative affections
2. renegotiation of joint working strategies
3. timing of individual actions and to undertake short-term joint
4. provision of timely contacts including specialist mental health nurse and mental health center
5. Farewell

Third step: Evaluation of the visit-the continuation of the re-engineering process of nursing 

1. preparation of nursing records in the nursing process of the client
2. final evaluation of the results of the visit at home
3. adjustments in terms of therapeutic nursing intervention
4. self-assessment of nurse
5. the case, sharing information with the health team

In summary, hereby were presented the steps considered essential to the achievement of the mental health and psychiatric nursing consultation at home to an elderly person.

According to the estimates and projections of certified bodies, it will increase, in the coming decades, the number of older people and the problems related to the mental health field, including limitations and dependencies associated with depressive disorders, anxiety disorders and dementias, which will involve an increase and diversification of answers provided by the health services to local communities, including in households^9,15 in which the psychiatric and mental health nurses, are essential. The training required to psychiatric and mental health nurses should configure itself wide, multifaceted, multidimensional and cross-cultural sensitivity. Nurses need to develop relational and therapeutic skills to understand the expectations on health and about the disease, as well as the personal fulfilment of who care, including advanced age, contributing to the achievement in the best way for personal and for the community’s gains relating to mental health.^16,17

Just sustaining the involvement of experts nurses in mental health and psychiatric at a solid human and multicultural training, based on innovation and scientific evidence as well as taking advantage of technological advances and knowledge for the benefit of humankind and societies is that health systems will promote mental health and prevent diseases causing great suffering. The experts nurses in psychiatric and mental health, through a quality performance in aging communities, have an important role to play in the satisfaction of essential needs and the promotion of well-being in the restoration and compensation of imbalances and problems associated with neuropsychiatric diseases, which result in damages and costs to the populations and communities. It is intended to stress the importance of mental health gains, sensitive to nursing care mainly resulting from interventions, in particular with the older people including domiciles.

I acknowledge my colleague Professor of the Madeira University, Ana Filomena Matos Natividade Carvalho who read and reviewed this article before being proposed for publication.

I declare there is no conflict of interest. The article is original and of my exclusive authorship.

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