REVISÃO

Elderly people living alone

Pessoas idosas que vivem em domicílios unipessoais

Raul de Paiva Santos, M.Sc.*, Aline Mara Gonçalves, M.Sc.**, Bárbara Caroliny Pereira, M.Sc.***, Tamires Marta Caliari, M.Sc.****, Wanessa Cristina Tavares Araujo, M.Sc.*****, Daniele Sirineu Pereira, Ft., D.Sc.******, Lori E. Weeks, PhD*******

*Doutorando do Programa Interunidades de Doutoramento em Enfermagem, da Escola de Enfermagem de Ribeirão Preto e da Escola de Enfermagem da Universidade de São Paulo (USP), **Doutoranda do Programa de Pós-Graduação em Biociências Aplicadas à Saúde, da UNIFAL/MG, Alfenas/MG, ***Doutoranda do Programa de Enfermagem Fundamental da USP, Ribeirão Preto/SP, ****UNIFAL/MG, *****Docente de Pós-Graduação na Escola de Negócios e Desenvolvimento de Excelência – ENDEX, Pouso Alegre/MG, ******Profa. Adjunta na UNIFAL/MG, ********PhD in Adult Development and Aging, Associate Professor, School of Nursing, Faculty of Health, Dalhousie University, Canada

Received: Jan16, 2019; Approved: April 10, 2019.

Correspondence: Raul de Paiva Santos, Rua Pio XII, 601, 37137-136 Alfenas MG, E-mail: raulpaivasantos@hotmail.com; Aline Mara Gonçalves: lingoncalves@hotmail.com; Bárbara Caroliny Pereira: barbaracarolinypereira@gmail.com; Tamires Marta Caliari: tami.caliari@hotmail.com; Wanessa Cristina Tavares Araujo: wanessaaraujo2009@hotmail.com; Daniele Pereira Sirineu: daniele.sirineu@unifal-mg.edu.br; Lori E Weeks: lori.weeks@dal.ca

Abstract

Introduction: In the last decades, a social phenomenon has emerged: the number of elderly people residing in single-person households, that is, living alone. Among these individuals are those who accumulate losses in health, social and personal life during their lifespan. Objective: To integrate scientific knowledge about elderly people living alone. Methods: It is an integrative review performed on four international databases. The theoretical reference of the Quality of Life was chosen to categorize the results. Results: After critical reading and analysis of 16 selected articles, two main themes and four subthemes emerged. The first main theme was named by “Contextualization of the Elderly that Lives Alone”; the second main theme was called “The role of family in the life of the elderly living alone”. Conclusion: This age group needs a support network to maintain their quality of life; this network must encompass family members, friends, neighbors and health professionals and these must aid the elderly living alone in daily activities, travels and healthcare, among others; since the elderly living alone usually present chronic conditions, cognitive/motor deficit and higher risk of social isolation.

Key-words: gerontology, geriatrics, nursing, Physical therapy.

Resumo

Introdução: Nas últimas décadas um fenômeno social vem emergindo: o número de pessoas que residem em domicílios unipessoais, isto é, que moram sós. Dentre esses indivíduos destacam-se aqueles idosos que acumulam perdas na saúde, na vida social e pessoal durante o seu ciclo vital. Objetivo: Integrar o conhecimento científico sobre as pessoas idosas que moram sós. Métodos: Revisão Integrativa de literatura realizada em quatro bases de dados internacionais. O referencial teórico da Qualidade de Vida foi escolhido à categorização dos resultados. Resultados: Após a análise e leitura crítica das 16 referências selecionadas, emergiram dois temas principais “Contextualização da pessoa idosa que vive só”, que foi subdividida em quatro subtemas. O segundo tema foi nomeado como “O papel da família na vida da pessoa idosa que vive só”. Conclusão: Esse grupo etário necessita de uma rede de apoio para manutenção de sua qualidade de vida; tal rede pode ser formada por familiares, amigos, vizinhos e profissionais de saúde e esses devem auxiliar a pessoa idosa que reside só em suas atividades diárias, viagens, cuidados de saúde e outros; pois o idoso que mora sozinho geralmente apresenta condições crônicas de saúde, déficit cognitivo e/ou motor, com risco ao isolamento social.

Palavras-chave: gerontologia, geriatria, enfermagem, Fisioterapia.

Introduction

This research focuses on elderly people living alone seeing that, with increasing longevity, many individuals in advanced ages will find themselves fragile and living at home, often alone. Nevertheless, some elderly people continues to experience good health in the last stage of life, however, many will experience a decrease in functional capacity and an increase in dependence [1], whether it is dependency to perform daily life activities or as a health and social support resources. In this context, the elderly person living in a single-person household, that is, living alone becomes common. Such a population can be found in this experience, either by family abandonment, children evasion and death of the spouse.

Initially, aging is a stage of the life cycle, irreversible, natural and that occur differently from individual to individual. It is accompanied by progressive losses in bodily functions and social life. It depends on the basic skills and abilities acquired throughout life, the environment [2] and behavioral (eating habits and water intake, harmful habits such as smoking, alcoholism, among others). Population aging, on the other hand, occurs when there is an increase in the participation of the elderly in the total population; the increase in population’s average age occurs at the same time.

From the demographic point of view, it is the result of the maintenance for a generally long period of growth of the stratum of older people larger than that of the younger population. Thus, it is an age group that is in the last phase of life; emphasizing that aging is more extensive and intricate of peculiarities, since it has a direct or indirect influence on the life of individuals, their families and structure, the demand for social and/or health public policies and the distribution of resources in a Society [2].

In view of the recent trend towards a reduction in the number of children, an increase in divorces, the changes in lifestyle, an improvement in the health of older people and an increase in longevity, the number of elderly people living alone is expected to grow [3]. By alone, it is considered that elderly person who does not reside with their family members, including those who live with employees [2]. Nevertheless, even though they do not represent a large contingent of family arrangements in Brazil, the number of elderly people residing in single-person households has increased considerably [3]. The situation, on the other hand, can only be temporary [2]. However, little is known about the elderly living in single-person households, regarding the way they face daily difficulties, how they seek help and who forms their support network [4] and their health situation.

In the context of population aging, some factors, such as child evasion and the death of the spouse, have pointed to the occurrence of a new phenomenon, the increase in the number of elderly people living alone. In this scenario, enhancements in life of the elderly may occur, such as improvement in autonomy and independence. However, this situation may be adverse for the elderly population, considering the potential for social isolation, the risk of falls, comorbidities and their burden on the independence, self-care and quality of life of the elderly person residing in a single person's household; some domains of quality of life may be affected by the situation of living alone.

From this perspective, the objective of the review was to contextualize the knowledge produced in the literature about the elderly person living in a single-person household; aiming to answer the research question: what is the general context of the elderly person who resides alone?

Methods

Integrative review, using the method proposed by Whittemore & Knafl [5], which recommends the following steps: 1) Identification of the research problem and selection of the hypothesis, 2) Establishment of eligibility criteria, 3) Definition of the information to be extracted from the selected studies, 4) Data analysis, 5) Interpretation of results and 6) Presentation of the revision/synthesis of knowledge.

In the first stage to guide this review, the following questions were asked: what is the general context of the elderly person who resides alone? What are the triggering factors to live alone? What are the positive and negative factors of an elderly person living alone? The research process was carried by the authors (RPS, DPS). In the second stage, the following eligibility criteria were delimited: free and full availability online, papers published in the last two decades; and in the Portuguese, English or Spanish. Books, editorials, dissertations, theses and studies that did not refer to the subject were excluded.

The search in the literature was carried out in the National Library of Medicine (Medline) via Pubmed, with the "elderly" AND "living alone" key-words; in the Latin American Literature in Health Sciences (Lilacs) database was used "elderly" [Subject Descriptor] AND "alone" [Words]; in Cumulative Index to Nursing and Allied Health (Cinahl) the search strategy "elderly" [Major word in subject heading] AND "living alone" [Abstract] was applied; Finally, in the Web of Science database, were used "elderly" [Topic] AND "living alone" [Topic] strategy; in addition, to better support, complementary literature or other sources were used, such as a specific geriatrics and gerontology treaty and studies of secondary sources found in the references of the surveys included in the review. The descriptors in health sciences, as well as the MeSH Terms and the Databases researched, are shown in table I.

Table I - Researched databases, descriptors and key-words applied.

Source: authors.

It was defined by the authors that the following information would be extracted from the papers: data about housing conditions, risk of falls, health status and presence of diseases, positive, negative and triggering factors to elderly people to live alone. Besides, the categorization of the results was based on the Quality of Life Theoretical Frame. It was also adopted the Evidence Level [6], which classifies the scientific papers into seven levels: I Systematic reviews or meta-analysis of Clinical Study with randomization; II Clinical trial with randomization; III Clinical study without randomization; IV Cohort or case-control study; V Systematic review of descriptive/qualitative studies; VI Descriptive or qualitative studies and VII Expert Opinion.

Theoretical framework of quality of life

It is known that to live alone to the elderly person can be considered a singular and complex situation; some factors of psychosocial life may improve, such as autonomy and independence; on the other hand, there are chances of family relationships and with friends getting weaker. In this sense, may occur changes in the quality of life of this elderly person who lives alone; therefore, the Quality of Life referential was adopted to guide this review.

From this perspective, the concept of Quality of Life - QoL is complex and encompasses many aspects of human life. This concept considers the individual's perception of his position in life in the context of culture and society in which he lives and in relation to his goals, expectations, standards and concerns [7].

The categorization of this Integrative Review of literature was based on the Theoretical Framework of QoL, since alterations in the four domains of QoL can occur in elderly individuals living alone. Physical domain, which includes sleep and rest, pain and discomfort, among others; Psychology domain that involves positive feelings, self-esteem, spirituality/religion /personal beliefs, and others; the domain of Social Relations, which includes social support, personal relationships and sexual activity and, finally, the environmental domain, which covers physical security and protection, financial resources, health and social care, leisure, transport and the physical environment (pollution, noise, traffic, climate) [8].

Results

The researched databases, as well the sample selection process is available in details in an adapted version of the PRISMA Flow Diagram (Figure 1).

The characterization of the studies analyzed regarding authorship and year of publication, focus, main results and level of evidence is available in Table II. The papers included in this integrative review investigated several themes, such as habitation conditions, the general quality of life of the elderly, chronic diseases and psychological distress, family dynamics of the elderly living alone. It was also founded information regarding differences in care between sexes, cognitive impairment and socioeconomic data of the elderly.

Initially, a total of 16 researches papers were included in the review, six cohort research articles, five qualitative studies, three descriptive research articles, a narrative review and an observational study. Moreover, five research articles were from Brazil, two from China and one from Canada, French, Iran, Japan, Norway, Singapore, Spain, United Kingdom and United States.

In relation to the year of publication we have most scientific articles published in the last five years, denoting an update in the researches and in the specific knowledge of the subject, previously established. In relation to the evidence level [6], eight articles had VI and eight IV level, that is, the specific literature on the elderly living alone is not incipient, with scientific evidence varying from weak to moderate; including qualitative research, descriptive and cohort and population studies, with large sample. It is worth mentioning that even with knowledge produced in a reasonable amount, the subject of the elderly who lives alone must still stimulate researchers from the different areas of science in their researches; with a view to consolidating knowledge in this field.

Due to the complexity of the theme of the elderly person that lives in a single-person household, two main themes and four subthemes were elaborated. The first one was named by "Contextualization of the elderly that lives alone" and the second main theme, was called "The role of the family in the life of the elderly person living alone", both themes and subthemes are discussed below.

Table II - Characterization of the sample regarding authorship, year and Country of publication, study focus, method and population, main findings and evidence level of studies. (n= 16). (see PDF annexed).

Discussion

After critical reading, the authors were recognizing patterns and similarities in articles, which led to the identification of two main themes and five subthemes, they are described below.

Theme I: Contextualization of the elderly that lives alone

The first category deals with the general context of life of the elderly person who lives alone, on the prevalence of the elderly in this new condition of living, the cumulated losses on aging, among others. Thus, the elderly person has become part of a vulnerable social group, as they may experience gradual losses of physical health and intellectual resources, as well as coexist with chronic conditions that accumulate during the aging process [9].

Therefore, the prevalence of "living alone" at the end of life varies widely in the world, but in all countries the growth of this part of society has been formidable in recent decades, even in societies in which, traditionally, there are strong family ties [10], such as Brazil. Although the number of elderly people living alone is little significant, in relation to other home-based arrangements, the number of elderly people living alone increases over the years [3]. Yet, living alone is a choice of the elderly along with their family and directly depends on maintaining the autonomy and independence of this elderly individual [11].

In this context, it is known that living alone increases the risk of social isolation of the elderly and can causes adverse consequences to health [12]. In this sense, "being old", living alone and the experiences of health losses, can change the daily rhythm of the individual and it is imperative that daily life be restored to another rhythm. Thus, the coping experience depends on how the elderly person acquires a natural rhythm, adapting to a new life and a new condition, to live alone [13]. In the same way, aging should not be considered as synonymous of incapacity, and this calls for the attention of health professionals to the need of planning interventions, aimed at maintaining the functional capacity of the elderly person who lives alone. In addition, to promote intervention programs that improve living conditions, social and family interaction [15].

It should be emphasized that health professionals also need to include in their care planning, the promotion and encouragement of the autonomy and independence of this elderly person, be it to the activities of daily living, the use of pills, hygiene care, among others, so it feels active and perceives itself as an integral and important part of the Society.

Therefore, keeping in mind that living alone may be a choice of the elderly, it is perceived that compromised physical health and low socioeconomic levels reduce the chances of this individual choosing to live alone. In this context, for an elderly person to choose to live alone, it should have better health, financial and educational conditions [3]. Although the choice to live alone can mean an alternative to the elderly, who wish to maintain their autonomy and independence; on the other hand, may be the last alternative to those elderly people who, although they feel alone, do not have other people who can co-reside. Thus, the reality of the elderly living alone should be considered by the Academy and those responsible for the elaboration of Public Health Policies [4].

Summarizing, the elderly person who lives alone, can be in such an experience by its own choice, aiming at independence and autonomy; on the other hand, there are individuals who live alone for lack of choice, or for loss of spouse, child evasion or for long physical distances between elderly and family members/ friends; as well as family difficulties in organizing their support to the elderly person who lives alone.

Subtheme I: Triggering factors to elderly to live alone

Factors that may contribute to the elderly's choosing or going to live alone are variable, including socioeconomic conditions, death of the spouse, evasion of children, large geographic distance between children, grandchildren and the elderly and others. Among the elderly with high levels of income and education, the chances of living alone are greater. There is a tendency of valuing privacy and choice, by elderly people with higher socioeconomic levels; with greater ease of choice, in the purchase of everyday consumer goods and access to health care [3].

Leaving aside the question of the elderly's choosing to live alone, we should think that some of these are found in this situation by obligation or even family abandonment; under this perspective, the formulation of Social and Health Public Policies is required to help this specific population, especially those of lower economic classes [3]. Such policies may involve partnerships between the government, social, health and education sectors; with a view to promoting, maintaining and rehabilitating health, as well as stimulating independence for self-care, control of chronic conditions and prevention of functional decline in old age.

In relation to the activities of the elderly person who live alone, they focus on preparing the meals of the day, performing self-care, listening to the radio or watching television, napping during the day, making telephone calls at some time to friends and family. In this sense, with a routine, this agenda becomes predictable and provides the elderly with a reason to consider the future [13].

We can say that there are two main types of elderly people living in single-households, those with a more favorable socioeconomic condition and choosing to live alone; and those with low socioeconomic level, often with comorbidities, functional decline and other fragilities and found themselves living alone. In this context, health professionals need to be attentive, especially in relation to the elderly person who had no choice and had to live alone, requiring greater support from the multi-professional team; for the maintenance of their lives. The needs of this specific population must be heard and guide the multi-professional clinical practice, as they are more likely to effectively assist by considering the whole context, hearing and understanding the complaints of the elderly.

Subtheme II: Positive factors of living alone

This subtheme is about the positive factors of living alone, among them stand out the increase of independence, the maintenance of privacy, the non-dependency of family members or others for their health care and daily activities, the lack of feeling a 'burden' to their families, among others.

In a study in São Paulo, which investigated the relationship between income and the chance of the elderly living alone, it was found that, in relation to health, a higher proportion of elderly people living alone perceived their health as "good", distinctly of elderly people who were not under such condition. In addition, in relation to functional incapacity and chronic health conditions, the elderly living with other people presented worse health situations [3].

A common discourse made by elderly people living alone is "not being a burden" and / or disrupting their family and their routine; however, can be understood as a strategy for maintaining freedom of making decisions, keeping its autonomy, away from the possible influence of children [11], other relatives and friends. Nevertheless, the elderly who lives alone and maintain positive acceptance of the new condition of living alone tend to better contact community nurses, family and friends [13], which may imply a greater demand for health services and self-care, as well as maintaining ties/ relationships with family and friends.

Some elderly people living alone may not feel alone, since at least in part they have chosen this condition of life. In this sense, although they have the effects of living alone, such as poor daily social relations, they do not experience emotional disturbances because they chose to live alone [16]. In this context, in a study of 619 elderly women in the community, an "advantage" is suggested when living alone, and an elderly woman who lives alone can be physically more active and psychologically healthier [12]; besides, the fact of working and living alone can be considered as a predictor of high scores of functional capacities [14].

The possibility to choose to live alone provides the elderly with a sense of freedom and maintenance of independence [17], by ensuring the preservation of their own physical space, their memories and ties with friends and community, as well as social space. It is also important to mention that this elderly person should perceives himself as an integral and important individual to the Society [11]. From this perspective, the elderly living alone that have appropriate family and multi-professional health team support; may have decreased chances of cognitive and functional decline, loss in independence and autonomy.

Subtheme III: To live alone versus feeling of loneliness in elderly people

In the critical analysis of the selected articles, a recurring theme was the feeling of loneliness; so, in this category we intend to contextualize this feeling of loneliness in the elderly population that lives alone.

In a study of Amirkola, Babol with 1544 elderly, living alone had significant statistical correlation with unexplained headaches, falls and presence of depressive symptoms in the elderly [15]. Hence, feelings of loneliness in the elderly who live alone do not depend on the frequency of their relationships with children and friends, but on the quality of relationships, expectations and satisfaction of communication. From this point of view, older people, when they do not have their expectations met in relation to visits from family and friends, are not satisfied with communicating with them, develop feelings of loneliness, and the complications of this loneliness can manifest themselves in several aspects in the mental and physical health of the elderly [15]. Given the risk of negative feelings, the Academy, Society, Families and health professionals are urged to plan policies and implement strategies that minimize the risk of development of negative health conditions. These strategies should also act to strengthen the bond between the elderly, their family, the community and the multi-professional health team.

On the other hand, in a French prospective cohort study with 3,777 elderly people, not all individuals living alone had feelings of loneliness, though, 24.9% reported feeling lonely, compared to 5.6% in elderly people living with others [16]. However, not all the elderly people who lived alone felt alone. This fact can be explained because the elderly person can choose to live alone because it is robust and independent, besides compensating in other ways the solitude, with a rich network of social support and the engagement in the community [16].

In this perspective, elderly people who live alone and have feelings of loneliness are probably those who did not choose this situation, they were forced to live alone, for reasons such as: family members living in distant cities, divorce, death of the spouse or single people [16]. In a study with Asian elderly immigrants residing in Canada, it was found that elderly individuals living alone had lower family relationship scores, differently from those living with their family members. Nevertheless, living with others does not mean reducing loneliness, since elderly women who stay at home for long periods of time can experience the lack of attention, affection and respect of family members [18].

Lastly, many elderly people may be living alone since they do not have relatives or friends who care about this condition, so this context of solitude needs to be effectively worked out by the health team; and requires adequate care and management at all levels of care, especially in Primary Care. It is also indispensable to stimulate contact with other people, elderly or not, the insertion into groups of activities for the elderly, encouragement to carry out activities that were performed before living alone (such as handiworks, religious activities, shopping, etc.) and, if necessary, the psychological care and support.

Subtheme IV: Singularities and differences between sexes of elderly people living alone

Another recurrent theme that emerged from the article sample was the differences and singularities between elderly. Thus, when we approach the relationship of the elderly with the situation of living alone, there is a distinction between the sexes, concerning adaptation to the new situation, leisure activities, programs to promote healthy aging, among others.

In relation to living alone, there is an impact of such condition on chronic health conditions, however, with differences between the sexes: living alone had a significant impact on cognitive impairment and depression in elderly men; while in women, the experience only had an impact on the occurrence of falls [15]. Moreover, part of the explanation of fertility and living alone is strictly demographic: not having or having fewer children decreases the possibilities of relatives (grandchildren and great-grandchildren) available to co-residing; thereby reducing the chances of residing with others regardless of any residential preferences. There is also the fact that having no child or low fertility is more common in unmarried women, so living alone at the end of life may be a result of not having a partner [10].

Inherent in the life activities of older people, there are clear differences between the sexes: elder women tend to have a greater choice of activities, such as making handicrafts in general, seeking health services, listening to radio and watching television and religious Tv shows, besides, they perform household activities. However, for elderly women with health commitments and those older ones, living alone can be considered as a disadvantage [12]. As for men, it may be extra costly to find meaningful activities at home when they are not interested in watching TV or reading [13] or solving puzzles. An alternative would be the participation in groups of elderly people, and we can observe the existence of a group of elderly men who gather to interact, talk and play cards, for instance, forming an important social interaction in this stage of life. It is worth mentioning that elderly women living alone may depend on relationships for emotional support; since individual (or family) relationships may have a protective effect against negative psychological changes in such women [19], such as depressive symptoms, anxiety, isolation, feelings of loneliness, among others.

In short, women's marital and reproductive trajectories can alter the opportunity to build a family structure to co-reside, which can lead to living alone at the end of life. However, improvements in the health and economic status of the elderly to live alone are making it more possible among those with more advanced ages [10]. It is worth emphasizing that the contingent of elderly people living alone tends to increase, considering the changes in the age pyramid and the resulting population aging. This implies directly in public health policies and calls attention to the need to design and implement health promotion programs of this specific population, to minimize potential losses in physical and psychological health.

Theme II: The role of family in the life of the elderly person living alone

A recurring subject during the critical reading of most of the references was the relationship of the family to the elderly who lives alone, their support and assistance in some activities of the elderly person who lives alone and others; which are described in this topic. It is also known that the family plays an important role in the life of the members during their lives when an old person decides or is obligated to live alone.

When the elderly person chooses to live alone, the family recognizes their ability to make decisions and perform daily life activities [11], such as caring for their own hygiene, buying and preparing their food, and so on. However, even in need of help in many activities, the family must respect the elderly’s decision to continue to live alone [11]. It is emphasized that, geographical proximity does not directly imply in a greater contact of the elderly individuals with their children, grandchildren [2] and other relatives. Thus, the elderly’s change to the living alone situation, may result in an approximation of the children, but some may move away or wait for their help to be requested. In this respect, there is no family consensus on who will be responsible for helping elderly people who now resides alone [11].

The family can help the elderly who lives alone in various activities, such as: traveling to distant places (trips and consultations with health professionals), bureaucratic and financial issues, which provides the elderly person with a sense of security [11]. Yet, even if the elderly person who lives alone receives visits during the day, one’s may still feel lonely most of the time; since it can be difficult to keep in touch with children and friends as they have difficulty moving from one place to another. Yet, children often live far away; one of the strategies to overcome this distance between the children and the elderly person who lives alone is the telephone, which allows more contact, even at a distance; becoming an important social activity of the elderly [13]. It should be noted that, in a globalized world, part of the elderly population has access to the internet, which may facilitate communication with family members.

When the elderly person is already living alone, family members may choose to hire a caregiver to assist in daily activities. However, family members can take direct care, maintaining communication with other family members, thus sharing responsibility for decisions [11]; regarding the health or financial status of the elderly, for instance. It is worth stressing that, depending on family behavior, for example, be more imperative or authoritarian, the elderly individuals may have their autonomy principle distraught, because their voice of choosing what they see as best for themselves can be silenced if family members take most decisions by them.

Concerning family relationships, there is communication between the one elected as the main caregiver and the others, to once again share responsibility for decision making; even those more distant relatives are informed about the general, financial and health conditions of the elderly who lives alone [11]. Moreover, the quality of life of the elderly who reside only with their spouses tends to be lower due to the absence of other members of the family [20]. Such a population, fragile or not, demands the support of others (family, friends and others) so that they can live the remaining years, independently or with assistance, with dignity, well-being [4] and improved quality of life. It is noticed the urgency to expand strategies aimed at raising the family's awareness of the dependent elderly, regarding the importance of family care [21], expanding the elderly population living alone, dependent or not, since they have risk of social isolation and the development of adverse health-related situations, such as depression, anxiety and social isolation.

Likewise, having an elderly person living alone can generate feelings of family concern about violence and the risk of falls [11], the general deterioration of health status, not eating or taking the medication properly, among others. In the context of population aging, bearing in mind the decline in fertility and the increase of single-person households in developed societies, such an association should be considered as an essential aspect of aging [10]; expanding to emerging and developing societies, where aging becomes more representative each year. Thus, the Government's role consists in encouraging family members to provide greater support to the elderly who live alone and to act to improve health services and support; is recommended to health managers that prioritize health promotion programs for the elderly and allocate financial resources for their maintenance [22]; building partnerships with educational and health areas and with the community.

The responsibility to provide financial, emotional, spiritual, and health care support should be emphasized in children [9] and other family members. Since "living alone" can be facilitated if the relatives of the elderly are prepared during the family life cycle; the process begins after the death of the spouse and the detachment of the children that moves from the parent house to study in other cities and/or marriage; the families then choose a primary caregiver, this process occurs without some formal agreement between the Family members; they may worry about the risk of violence, accidents, falls and isolation and perceive a need to return the elderly person to the home of a relative, but respect the elderly’s decision to live alone.

The importance of the family in accompanying elderly people is evidenced, since the presence of family members can make the elderly feel important, welcomed and safe, when the family is interested in their health and well-being. At a time when the health team can act as a link between the family and the elderly who live alone, this family begins to participate actively in life and care for the elderly, which can contribute to their autonomy, to the development of self-care skills; in addition to providing improvements in living alone, which for many may be permeated by insecurity, fear, sadness, social isolation, physical and functional decline.

Lastly, to achieve adequate health care for the elderly, health professionals should consider their whole life history and the entire current context of living alone, so that we can plan and implement individualized and effective health care, aiming at quality of life, independence and personal autonomy of the elderly.

Conclusion

The reality of the elderly person who lives alone is intricate of specificities. Firstly, the causes involve the death of the spouse, evasion of the children and even individual’s choice, with a view to maintaining their privacy or to "not be a burden" to family members. Their everyday life may involve physical exercise and leisure time, performance of basic and instrumental activities of daily life, such as self-care in relation to health, housework, shopping, cooking for themselves, among others; which may be related to the maintenance of autonomy and independence. On the other hand, to live alone may boost the risk of social isolation, due to geographical distances of family and friends, or their negligence; the development or increase in the symptoms of anxiety, sadness and loneliness.

While elderly people living alone are nearing the end of life, health professionals should be able to assist these individuals in physical and psychosocial health. Therefore, the professional who is part of the health team, especially in Primary Care, should pay attention to the elderly person who resides alone, since this specific population may be experiencing problems since the acceptance of the situation of life, which may be new and frightening, even in performing daily activities. To have a better chance of effectively and fully assist this unique population, it is necessary to create and maintain ties between the elderly who lives alone, its family and the multi-professional health team.

In turn, this tie establishment is necessary for the elderly person to rely on the health team and this allows the development of a unique health care plan and the proper implementation of it, which should focus on the individual; that encompasses physical exercises, participation in elderly groups (to play cards, to learn handicrafts, do stretching and other physical activities guided by a professional), maintenance of interpersonal relationships, especially with family and close friends, prevention of functional and cognitive decline of the elderly person residing alone; aiming to avoid social isolation and negative feelings of anxiety, fear and depression and the maintenance of autonomy and quality of life.

It is important to mention the limitations of the review, which include: reduced number of databases investigated and consequently the number of articles included in the analysis; should also be emphasized the importance of future researches, with variable methods that might approach in different ways the subject of elderly people living alone, as well as their housing and health condition, quality of life, positive and negative factors, the role of the family and of the multi-professional health team, among others.

Acknowledgements

The present research was accomplished with support of Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brazil (CAPES) – Code: 001.

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