= Figure 1 - Flowchart of selected articles to compose the integrative review.
![](3D"1104HTMLEN_arquivos/image006.png")
= Source: Survey data, 2020.
NURSING INTERVENTIONS FOR=
THE
PREVENTION OF FALLS IN THE ELDERLY IN PRIMARY CARE: INTEGRATIVE REVIEW
INTERVENÇÕES DE ENFERMAGEM PARA PREVENÇÃO DE QU=
EDAS
EM IDOSOS NA ATENÇÃO PRIMÁRIA: REVISÃO INTEGRATIVA
Paulo Henrique Fernandes dos Santos[1] * Denise Galvão Sampaio[2] * Marina Morato Stival[3] Luciano Ramos de Lima[4] *Walterlânia Silva Santos[5] * Silvana Schwerz Funghetto[6]
ABSTRACT
Aim: identify how nursing interventions proposed to prevent falls in the elderly in the context of primary care. Methods: integrative literature review; studies were identified= in the PubMed, CINAHL and LILACS databases in April 2020. Results: fifteen articles were selected, from which two main th= emes emerged: nursing interventions related to the assessment and management of = the risk of falls in elderly people in primary care; nursing interventions in multidisciplinary programs for the prevention of falls in the elderly in primary care. Final considerations= : nursing interventions for the prevention of falls in the studied population= consist of assessing the risk of falls; guide the elderly/caregivers regarding the promotion of safety at home and behavioral changes; promote permanent educa= tion for the health team on the subject; lead and/or participate in multiprofessional programs with a fall prevention panel. These findings can contribute to the planning of actions of professionals who are daily faced = with the challenge of preventing falls in elderly people in primary care.
Keywords: Accidental Falls; Aged; Nursing; Nursing Care; Prim= ary Health Care.
RESUMO
Objetivo: identificar as intervenções de enfermagem
Palavras-chave: Acidentes por Quedas; Idoso; Enfermagem; Cuidados de
Enfermagem; Atenção Primá=
ria à
Saúde.
INTRODUCTION=
Falls consist of events in which the individual falls to the ground or lower leve= ls inadvertently, except for intentional changes in position to lean on furnit= ure, walls or other objects. They are considered an important public health prob= lem, a priority issue in the health field worldwide and are mainly related to the elderly population, in view of the morphological and physiological changes inherent in the aging process that increase the vulnerability to these even= ts(1).
Accor= ding to the World Health Organization (WHO), falls are the second leading cause = of accidental or unintentional death worldwide, and the elderly aged 65 years = and over are the ones who suffer the most from fatal falls(2). Data referring to episodes of falls in this population are alarming and indicate that between 28 and 35% of people aged ≥ 65 years experience at least= one episode of fall per year, and for those aged ≥ 70 years, the estimate increases to 32 to 42%. It is estimated that about 5% of falls in the elder= ly in the community cause fractures, and 5 to 10% cause soft tissue and head injuries(1).
Sever= al factors contribute to the occurrence of falls. These factors can be classif= ied as intrinsic, related to characteristics inherent to the individual, such a= s advanced age, diseases and fear of falling; and in extrinsic ones, which concern the interaction with the environment, such as slippery floors, insufficient lighting, among others. It is noteworthy that extrinsic factors are conside= red modifiable, therefore, they are the target of preventive actions(3-4)<= /sup>.
Consi= dering that falls are preventable events, it is essential to adopt preventive acti= ons, for example, the identification of risk factors(5). In this cont= ext, the work of nurses in preventing falls in the elderly is highlighted, given their notorious role in primary care. The nurse is competent to perform clinical judgment and establish accurate Nursing Diagnoses (ND) - for examp= le, the ND of the ICNP Risk for Fall and Risk For Fall-Related Injury(6), or the ND of NANDA-I Risk for Falls(7), which favors the establishment of interventions aimed at preventing falls and their conseque= nces(8).
It is noteworthy that the WHO considers the prevention of falls as one of the international goals of pati= ent safety. In addition, the National Patient Safety Program, created in 2013 by the Ministry of Health, Anvisa and Fiocruz, established the Fall Prevention Protocol in order to reduce the occurrence of these events and their damage= (9), however, The preventive measures proposed are aimed at the hospital context, with a gap with regard to actions that suit the specificities of the elderly assisted in primary care.
This same gap is observed in t= he nursing literature, in which studies aimed at addressing falls (including n= ursing diagnoses, results and interventions) in institutionalized(10) a= nd hospitalized(8-11) elderly are found, however, there are still f= ew works carried out with elderly people in the community and that synthesize knowledge about nursing interventions for the prevention of falls.
Given= the above, the objective of this research was to identify the nursing intervent= ions proposed for the prevention of falls in the elderly in the context of prima= ry health care available in the literature.
METHODS
This is an integrative literature review, a type of investigation used in Evidence-Based Practice, which incl= udes the search, critical analysis and synthesis of available scientific evidenc= e on a particular topic or issue, aiming at the incorporation of new knowledge in clinical practice(12).
This review was carried out in six stages: identification of the theme and definition of the research question; choice of inclusion and exclusion criteria for studies; definition of the information that will be extracted from the studies; evaluation of the stud= ies included in the sample; interpretation of results and presentation of the review(12).
The research question was delimited with the help of the PCC strategy, thus, it was considered P (patient): elderly; C (concept): nursing interventions to prevent falls; C (context): primary health care. Therefore, the research question was "What nursing interventions are proposed to prevent falls in the elderly in the context of primary health care?"(13).
Then, the eligibility criteria of t= he studies were defined. The inclusion criteria consisted of: studies developed with an elderly population (age ≥ 60 years); that addressed nursing interventions to prevent falls; performed in the context of primary care; published in Portuguese, Spanish or English; made available in full. Studies with other populations (adults) in the context of institutionalization and/= or hospitalization were excluded, as well as reviews, experience reports, edit= ors' opinions, publications in conference proceedings and editorials.
The searches were carried out in Ap= ril 2020 in the PubMed, CINAHL and LILACS databases with the DeCS and MeSH descriptors: aged, accidental falls, primary health care, nursing, nursing care. These descriptors were combined using the Boolean operators AND and O= R to compose the search strategies, according to the specificities of each datab= ase. For LILACS, descriptors in Portuguese and Spanish were included (Chart 1).<= /span>
=
= Chart 1<= span style=3D'font-size:12.0pt;line-height:150%;font-family:"Times New Roman",se= rif; mso-fareast-font-family:Times;mso-fareast-language:PT-BR'> - Search strateg= ies, according to selected databases.
|
Databases |
Search strategies |
|
PubMed |
("aged"[MeSH Terms] OR “aged”[All fields]) AND ("accidental falls"[MeSH Terms] OR “accidental falls”[All fields]) AND ("primary health care"[MeSH Terms] OR “primary health care”[All fields]) AND ("nursing"[MeSH Terms] OR “nursing”[All fields]) |
|
CINAHL |
“aged” AND “accidental falls” AND “primary he= alth care” AND “nursing” |
|
LILACS |
(“Aged” OR “Anciano” OR “ |
= Source: Survey data, 2020.
The studies that resulted from the search were exported to the EndNote Web reference manager, in which the duplicates were excluded. Then, they were exported to the Rayyan tool, where titles and abstracts were read and selected individually and independently = by reviewer 1 (DGS) and reviewer 2 (PHFS). Soon after, the two reviewers began reading and analyzing the articles in full, to select the studies that would compose the final review sample. At the end of these procedures, disagreeme= nts were resolved between the two reviewers.
After selecting the studies, data w= ere collected in a spreadsheet consisting of the following variables: authors, = year of publication, country where the study was conducted, nature and type of study, research participants and, finally, the results that allowed to answ= er the research question of this review.
Subsequently, the studies were evaluated according to the level of evidence: (1) results of meta-analysis = of controlled and randomized clinical studies; (2) evidence obtained from individual studies with an experimental design; (3) evidence from quasi-experimental studies; (4) evidence from descriptive (non-experimental) studies or with a qualitative approach; (5) evidence from case or experience reports; (6) evidence based on expert opinions(14).
Finally, the stage of interpretatio= n of the results was conducted, with thematic categorization by similarity of th= emes to facilitate the synthesis and presentation of the review results.<= /span>
RESULTS
=
A total of 346 references were
identified, distributed in the three databases, and 53 duplicates were
excluded. Then, the titles and abstracts of 293 articles were read, and of
these, 37 were eligible to read the full text. After a thorough reading and
application of the established exclusion criteria, 15 articles were selected
for the synthesis of evidence, according to the PRISMA model (Figure 1).
= Figure 1 - Flowchart of selected articles to compose the integrative review.
= Source: Survey data, 2020.
The 15 studies included were carried out from 1999 to 2017, in the United States (n=3D3), Brazil (n=3D2), New Zealand (n=3D2), Australia (n=3D1), Belgium (n= =3D1) , China (n=3D1), Spain (n=3D1), Portugal (n=3D1), United Kingdom (n=3D1), Sweden (n= =3D1) and Thailand (n=3D1). Two studies were published in Portuguese (n=3D2), one stu= dy in Spanish (n=3D1) and the others were published in English (n=3D12). The characterization of the articles was presented in Chart 2.
Chart 2 - Characterization of articles contemplating nursing interventions for the prevention of falls in the elde= rly in primary care, according to: authors, year of publication, country, nature/type of study, level of evidence and research participants. Brasilia, DF, Brazil, 2020.
|
Authors |
Year of publication |
Country |
Nature and type of study |
Level of evidence |
Survey participants |
|
Allen A; Simpson JM(15) |
1999 |
United Kingdon |
Quantitative, experimental |
2 |
Elderly |
|
For= tinsky RH et al(16) |
2004 |
United States |
Quantitative, observational |
4 |
Professionals, including nurses |
|
Ell= ey CR et al(17) |
2007 |
New Zeland |
Quantitative, experimental |
2 |
Elderly |
|
Pra= t-González I; Fernández-Escofet E; Martínez-Bustos S(18) |
2007 |
Spain |
Quantitative, observational |
4 |
Elderly |
|
Ell= ey CR et al(19) |
2008 |
New Zeland |
Quantitative, experimental |
2 |
Elderly |
|
Mil= isen K; Geeraerts A; Dejaeger E(20) |
200= 9 |
Bel= gium |
Quantitative, observational |
4 |
Elderly and professionals, including nurses |
|
Woo= J et al(21) |
2009 |
China |
Quantitative, observational |
4 |
Elderly |
|
Mac= êdo ARC et al(22) |
2012 |
Brazil |
Quantitative, observational |
4 |
Elderly |
|
Res= nick B et al(23) |
2012 |
United States |
Quantitative, experimental |
2 |
Elderly |
|
Cab= rita MFG; José HMG(24) |
2013 |
Portugal |
Quantitative, observational |
4 |
Elderly |
|
Rom= i H; Wen= dy M; Terry PH(25) |
2014 |
Australia |
Quantitative, observational |
4 |
Elderly and professionals, including nurses |
|
Fer= nandes BKC et al(26) |
2016 |
Brazil |
Quantitative, observational |
4 |
Elderly |
|
Boo= rgird C et al(27) |
2017 |
Thailand |
Quantitative, experimental |
2 |
Elderly |
|
Fah= lström G= et al(28) |
2017 |
Sweden |
Quantitative, experimental |
2 |
Elderly |
|
Rei= noso H; McCaffrey RG; Taylor DWM(29) |
2017 |
United States |
Quantitative, experimental |
2 |
Elderly |
Source: Survey data, 2020.
As for
the methodological characteristics, the sample consisted of studies of a
quantitative (n=3D14), qualitative (n=3D1), experimental (n=3D7) and observ=
ational
(n=3D8) nature, with level of evidence 2 (n =3D7) and 4 (n=3D8), whose part=
icipants
are elderly, nurses and other health professionals who work in the context =
of
primary health care.
The analysis of the articles identified two recurrent themes: i) nursing interventions related to the assessment and management of the risk of falls= in elderly people in primary care; ii) nursing interventions in multidisciplin= ary programs for the prevention of falls in the elderly in primary care (Chart = 3).
Chart 3<= span style=3D'font-size:12.0pt;line-height:115%;font-family:"Times New Roman",se= rif; mso-fareast-font-family:"Times New Roman";color:black;mso-fareast-language: PT-BR'> – Nursing interventions for the prevention of falls in the elderly = in primary care. Brasilia, DF, Brazil, 2020.
|
Nursing interventions related to = the assessment and risk management of falls in the elderly in primary care |
|
|
Authors |
Main results |
|
Allen A; Simpson JM(15) |
Nur= ses conducted a fall prevention program for seniors who had recently fallen. = The program included: comprehensive assessment, home visits, surveillance of environmental risk factors, medication review, referrals, and resistance exercise. Other professionals contributed to the construction of physical assessment, exercise and medication review components. |
|
Woo= J et al(21) |
Nurses develope= d a tool to predict falls in elderly people in the community. They performed = risk identification through rapid screening and referrals for detailed assessments. |
|
Mac= êdo ARC et al(22) |
Nurses developed actions related to the identification of aspects of autonomy and independ= ence of the elderly, identification of intrinsic and extrinsic factors related= to the occurrence of falls. |
|
Res= nick B et al(23) |
Nurses performe= d a multicomponent intervention that involved the implementation of a care philosophy in which they helped the elderly with functional tasks and physical activity, environmental assessments, set individual goals, mento= ring and motivation. |
|
Cab= rita MFG; José HMG(24) |
Nur= ses carried out home visits, observed the high incidence of falls in the elde= rly, identified the factors that affect health, autonomy, such as multiple chr= onic pathology, polymedication, domestic accidents, hospitalizations, changes = in the family structure, evaluated their physical and psychological environm= ent, social and environmental. They provided guidance on safety and autonomy a= nd, if necessary, made referrals to other professionals on the team. |
|
Fer= nandes BKC et al(26) |
The identification of nursing diagnoses contributed to the beginning of the establishment of care actions aimed at the elderly in order to minimize t= he prevalence of incidents of falls. Nurses intervene through prevention, encouraging or monitoring the practice of physical exercise, evaluating possible domestic risks (slippery carpets and floors) and monitoring the medications that make the elderly more vulnerable to falls.= |
|
Nursing interventions in multidisciplinary programs for the prevention of falls in the elderly in primary care |
|
|
Authors |
Main results |
|
For= tinsky RH et al(16) |
Nur= sing identified the barriers when addressing the seven risk factors for falls: gait and transfer difficulties, balance disorders, use of various medications, postural hypotension, sensory and perceptual deficits, probl= ems with shoes and feet, and environmental risks. Nurses proposed fall risk management strategies, provided education to health care providers, direct intervention and referrals. |
|
Ell= ey CR et al(17) |
Nur= ses conducted risk assessment and management in the home environment to reduce the risk of further falls, provided counseling and referrals (eg, to the exercise program conducted by a physical educator or physical therapist).= The intervention included: i) health assessment; ii) domestic risk assessment; iii) bone health assessment; iv) referral to The Otago Exercise Programme= . |
|
Pra= t-González I; Fernández-Escofet E; Martínez-Bustos S(18) |
Nursing worked, together with physicians, in the implementation of a protocol for screeni= ng risk factors for falls. The intervention included: exercises and training= to increase muscle strength and balance, medication review, correction of vi= sion and hearing loss, changes in the environment and recommendation of an adequate diet. |
|
Ell= ey CR et al(19)<= /p> |
Nur= ses with experience in gerontology visited the elderly in their homes and performed a standardized health assessment, using an algorithm to assess = the risk of falls. It also referred the elderly to The Otago Exercise Program= me, under the responsibility of a physical educator or physiotherapist. Nurses observed the need for environmental changes. |
|
Mil= isen K; Geeraerts A; Dejaeger E(20) |
The nurse identified the risk factors, provided education on the importance of exercise/individualized exercise program, performed pertinent referral according to risk factors, implemented education on the effects of medications on falls, advised to prevent postural hypotension and wearing appropriate shoes, performed the checklist for home safety and environmen= tal assessment. |
|
Rom= i H; Wen= dy M; Terry PH(25) |
The introduction of a program of multiple interventions, with the role of nursing, with a focus on providing culturally specific education on the r= isk of falls, effective behavioral changes for the prevention of falls and th= eir consequences. |
|
Boo= ngird C et al(27) |
The nurses were part of a multidisciplinary home exercise program that includ= ed multiple interventions. They carried out home visits, obtained information about environmental risk factors, encouraged the practice of physical exercise and the adoption of safe behavior in these activities. |
|
Fahlstr |
Nur= sing assistants worked together with physiotherapists in home exercise program= s. Nursing assistants supervised the performance of activities during eight = home visits, helped and encouraged the performance of activities. |
|
Rei= noso H; McCaffrey RG; Taylor DWM(29) |
Nurses particip= ated in the development and implementation of a fall risk prevention program. Their actions consisted of identifying risk factors during screening, managing and monitoring hypotension, optimizing environmental safety and = shoe modifications. Together with other professionals, they carried out a thor= ough review and adjustment of diseases and pharmacological treatments.<= /span> |
= Source: Survey data, 2020.
DISCUSSION
The
professional nurse has an important contribution to the health care of the
elderly in primary care. Among its attributions, we highlight providing
comprehensive care to the elderly, providing assistance in the home environ=
ment
and carrying out a multidimensional assessment of the elderly. Their perfor=
mance
must address the main problems that can compromise the health of this
population, for example, falls(30).
In
this sense, this integrative review sought to identify nursing interventions
for the prevention of falls in the elderly in primary care. The articles
included were published between 1999 and 2017, carried out in several
countries. The heterogeneous characteristics in relation to publication date
and country allow us to infer that nurses working in primary care have focu=
sed
their attention on falls in the elderly and improved their performance over=
the
years to prevent these events in the public in question.
The
analysis of the studies that integrated the sample of this review allowed u=
s to
identify two recurring themes in the articles, the first on nursing
interventions related to the assessment and management of the risk of falls,
and the second covers nursing interventions in the context of multidiscipli=
nary
prevention programs of falls in the elderly in primary care.<=
span
style=3D'mso-bookmark:_Hlk55980003'>
A
study carried out in the United States pointed to the role of nursing in
identifying risk factors for falls, including gait and transfer difficultie=
s,
balance disorders, use of various medications, postural hypotension, sensory
and perceptual deficits, problems with shoes and feet and environmental ris=
ks.
After identifying the risk factors, the nurses established fall risk manage=
ment
strategies, with direct interventions, pertinent referrals and offering
training for the health team(16).
Another
research article carried out in Belgium showed that nurses worked to identi=
fy
risk factors, offer guidance on the importance of physical exercise, effect=
s of
medications that can trigger falls, prevention of postural hypotension and =
use
of appropriate shoes. In addition, they also carried out an environmental
assessment and applied a checklist for home safety(20).
In
fact, nurses play a relevant role in identifying the risk of falls in the
elderly. An integrative review study reiterated the importance of nurses, w=
ho
maintain a greater bond with the elderly in their home environment, in the
identification of environmental risk factors and those predisposing to falls
and guidelines that address the real needs of the elderly, encouraging the
practice of physical exercises to maintain balance and promote a safe home
environment that maintains the autonomy and independence of the elderly
The
role of nurses in implementing and conducting fall prevention programs for =
the
elderly was also identified. In the United Kingdom, the program included ho=
me
visits, comprehensive assessment of the elderly, identification of risk fac=
tors
with an emphasis on environmental factors and medication review(15).
In the United States, nurses worked on optimizing environmental safety,
modifying shoes and reviewing medications(29).
One
aspect that drew attention in the studies mentioned was the possibility of
nurses working even in the home environment of the elderly. The home visit =
is
considered an activity outside the basic health unit, it is a means of care
that has light and light-hard technology, involving a more humanized, welco=
ming
care that requires sensitivity from the professional to identify needs=
(32).
According
to the Ministry of Health(33), the need for nurses to have
comprehensive and humanized care for the elderly in the context of their ho=
me
is evident, in order to provide individualized care for each elderly person,
promote actions to identify risk factors, the occurrence of falls during
screening, optimizing the safety of the environment, guiding the elderly and
their families about the risks of falling, with clear language for better
understanding; modify shoes and provide education about the importance of
exercise.
The
articles revealed that during home visits, in addition to the assessment of
intrinsic and extrinsic factors for falls, and identification of environmen=
tal
risks, nurses offered guidance on environmental safety, promotion of the
autonomy of the elderly and assessed the need to refer them for assessment =
of
other health professionals(22-24). To help assess the risk of fa=
lls,
nurses also apply standardized health assessments and evidence-based algori=
thms
to assess the risk of falls(19).
It
is important to emphasize the need for nurses to use tools that favor the
identification of the risk of falls in the elderly in their clinical practi=
ce,
such as the determination of nursing diagnoses(26). In this sens=
e, a
survey carried out in the Federal District - Brazil, with the objective of
evaluating the nursing diagnosis of Risk for Falls in the elderly in primary
care, highlighted the importance of nurses using this resource together with
other instruments to assess the risk of falls. Determining the diagnosis Ri=
sk
for Falls enables the initial risk assessment and favors the nurse's
decision-making when choosing the necessary interventions(34).
Another
aspect that drew attention in the articles was the nurse's decision-making =
on
referring the elderly for evaluation by other health professionals. Although
nursing interventions are essential for the prevention of falls, it must be
assumed that these events are very complex, of multifactorial origin, and t=
hat
it is only possible to achieve good results with the elderly if there is a
multidisciplinary assessment and intervention.
In
this sense, the second theme that emerged from the analysis of the results =
was
about nursing interventions in the context of multidisciplinary programs for
the prevention of falls. Even though the identified nursing interventions a=
re
similar to those presented in other articles, it is interesting to see how
these interventions can contribute to achieving goals in the context of
multidisciplinary work.
In
a study carried out in Spain, nurses worked together with physicians in the
implementation of a protocol for screening the risk of falls, medication
review, correction of vision and hearing impairment, and changes in the
environment(18). In Australia, nurses contributed to education a=
bout
the risk of falls, behavioral changes and setting goals to increase the
motivation and self-efficacy of the elderly(25).
In
another study, developed in Thailand, nurses were part of a home exercise
program, in which they performed home visits to identify environmental risk
factors, encouraged the practice of physical exercise and the adoption of s=
afe
behaviors(27).
The
review also included The Otago Exercise Programme, in which nurses with
experience in gerontology conducted the assessment and management of
environmental risks at home, provided counseling and referred the elderly to
the physical exercise program conducted by physical therapists and physical
educators, with the purpose of to improve balance, muscle strength and the
ability to walk(19). Also in the context of the program, nursing
assistants contributed to the supervision of the elderly during the executi=
on
of the exercises(17).
The
participation of nurses in programs whose central component is physical
exercise deserves attention, since it has been shown that the regular pract=
ice
of physical activity as an isolated intervention is associated with a better
health condition of the elderly and a lower incidence of falls(35 ).
Even though it is not the nurses' competence to act in the prescription and
guidance for the practice of these exercises, it was found that they can
contribute to other aspects of these programs, such as in the comprehensive
assessment of the elderly, in the identification and management of the risk=
of
falls (especially the environmental risk), in addition to offering guidance=
for
the elderly and caregivers.
A
possible limitation of this study is the unavailability of some articles for
full reading, however, it did not prevent the achievement of the proposed
objective. Furthermore, this review has contributed to filling a gap that
exists so far in terms of the synthesis of studies that address relevant
nursing interventions for the prevention of falls in elderly patients assis=
ted
in primary care.
FINAL CONSIDERATIONS
The integrative r=
eview
made it possible to carry out a synthesis of studies on nursing interventio=
ns
for the prevention of falls in the elderly in primary care. These intervent=
ions
consist of: evaluating/identifying intrinsic and extrinsic risk factors for
falls, with an emphasis on modifiable factors; identify and manage
environmental risks, in the opportunity of home visits; provide guidance for
the elderly/caregivers regarding the promotion of safety in the home
environment and the need for behavioral changes; promote continuing educati=
on
for the health team about preventing falls; conduct and/or participate in
multidisciplinary programs with the purpose of preventing falls.
It is believed th=
at
these findings can contribute to the planning of actions of nursing
professionals who are daily faced with the challenge of preventing falls in=
the
elderly population in the home context and in health units.
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DOI:
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Autor
Correspondente: Paulo Henrique Fernandes dos Santos=
Endereço:<=
/b> Universidade de Brasília, Faculdade Ciências da Saúde
Asa Norte, CEP
70910900 - Brasília, DF, Brasil
E-mail: paulofs@unb.br
Submission:<=
/span> 2021-05-05
Approval: 2021-05-30
[1] Universidade de Brasília, Brasília, Brasil. ORCID:
https://orcid.org/0000-0003-4533-0129
[2] Universidade de Brasília, Brasília, Brasil. ORCID:
https://orcid.org/0000-0002-2005-3834
[3] Universidade de Brasília, Brasília, Brasil. ORCID:
https://orcid.org/0000-0001-6830-4914
[4] Universidade de Brasília, Brasília, Brasil. ORCID: ht=
tps://orcid.org/0000-0002-2709-6335
[5] Universidade de Brasília, Brasília, Brasil. ORCID:
https://orcid.org/0000-0001-6266-8901
[6] Universidade de Brasília, Brasília, Brasil. ORCID:
https://orcid.org/0000-0002-9332-9029
= =