| 1. |
- Eriksson, Staffan, 1969-
(författare)
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Falls in people with dementia
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Falls and concomitant injuries are common problems among large groups of the elderly population, leading to immobility and mortality. These problems are even more pronounced among people suffering from dementia. This thesis targets fall risk factors for people with dementia in institutions. The overall aim of this thesis was to investigate risk factors for falls, predisposing as well as related to circumstances surrounding falls, and to do this as efficiently as possible. In a prospective cohort study including residents of residential care facilities with and without dementia, the fall rate was higher for those with dementia, the crude incidence rate ratio (IRR) was 2.55 (95% CI 1.60–4.08) and the adjusted IRR was 3.79 (95% CI 1.95–7.36). In the group of people suffering from dementia, including 103 residents, a total of 197 falls resulted in 11 fractures during the 6-months follow-up period. From the same baseline measurements 26% and 55%, respectively, of the variation in falls could be explained in the group of residents with and without dementia. Fall predictors significantly and independently associated with an increased risk of falls in the group of people suffering from dementia were the category “man walking with an aid” and the use of more than four drugs. In a prospective cohort study, including 204 patients in a psychogeriatric ward, a total of 244 falls resulted in 14 fractures. Fall predictors significantly and independently associated with an increased risk of falls were male sex, failure to copy a design, use of clomethiazole, and walking difficulties. Treatment with statins was associated with a reduced risk of falls. With these fall predictors in the negative binomial regression (Nbreg) model, 48% of the variation in falls was explained. The data from the psychogeriatric ward were also analysed with the use of partial least squares regression (PLS) and regression tree to be compared with the results of the Nbreg analysis. PLS and regression tree are techniques based on combinations of variables. They both showed similar patterns, that a combination of a more severe level of dementia, behavioral complications and medication related to these complications is associated with an increased fall rate. Thirty-two percent and 38%, respectively, of the variation in fall rate were explained in the PLS and regression tree analysis. The circumstances surrounding the falls in the psychogeriatric ward were analysed. It was found that the fall rate was equally high during the night and the day. A large proportion of the falls was sustained in the patients’ own room and a small proportion of the falls was witnessed by the staff. This pattern was even more pronounced during the night. The proportion of diurnal rhythm disturbances and activity disturbances was higher for falls at night than for falls during the day. Circumstances associated with an increased risk of falls, as shown by a short time to first fall, were anxiety, darkness, not wearing any shoes and, for women, urinary tract infection. The proportion of urinary tract infection was also higher in connection to falls sustained by women than to falls sustained by men. This thesis confirms that people suffering from dementia are prone to fall. Walking difficulties, male sex and impaired visual perception are factors that should be considered in the work of reducing falls among people suffering from dementia. Furthermore, falls at night, behavioral complications and medication related to these complications should also be considered in this work, especially as the dementia disease progresses. A larger portion of the variation of the outcome variable was explained by the Nbreg model than the regression tree and PLS. However, these statistical methods, based on combinations of variables, gave a complementary perspective on how the fall predictors were related to falls.
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| 2. |
- Bergman, Jonny, 1973-
(författare)
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Seeking empowerment : asylum-seeking refugees from Afghanistan in Sweden
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The purpose of this study is to contribute to the understanding of how asylum-seeking refugees manage their lives in the situation they are in, a situation in which they are dependent and have to wait for decisions on whether or not they will get to stay in the country in which they have made their application for asylum. The elaboration upon these questions and the purpose of the study is approached through a field study of asylum-seeking refugees from Afghanistan in Sweden. The thesis presents a background of international migration, refugee migration, refugee migration from Afghanistan and the reception of asylum seekers and refugees in the EU and Sweden, which tells us both that asylum seekers and refugees are not welcome in the countries of the ‘North’, where policies of containment and repatriation are the most common features of treating the refugee ‘problem’ and that the long period of waiting and uncertainty creates a situation of passivity and ill-health among the asylum seekers. Employing grounded theory methodology in different forms based in data from fieldwork, including participant observations and informal conversations, the study applies a constructionist grounded theory approach in the analyses of the situation and the management thereof. Steered by this constructionist grounded theory approach, strengthened by a situational analysis, the thesis presents a situational frame pointing to the situation for the asylum-seeking refugees as temporal and dependent on Swedish national discourse, racism and paternalism. With this background and frame and generated by data from the field study, the thesis goes on to present the situation as disempowering. The disempowering processes are illustrated through looking at dependence and inhospitality, and are characterised by the asylum-seeking refugees’ oscillation between feelings of hope and despair. It becomes, however, also evident that the asylum-seeking refugees take action and that they are supported by latent empowering processes. The actions taken are categorised as actions of empowering in opposition to the processes presented as disempowering. The actions of empowering are connected to keeping oneself occupied, searching for and maintaining social contacts and in the asylum-seeking refugees’ representations of themselves. From the presentation of the situation as disempowering and the actions taken by the asylum-seeking refugees in response to this situation as actions of empowering, a process characterised as seeking empowerment is presented. In this process empowerment is discussed as the establishment of power to resist. During the discussion of the concept of seeking empowerment it is shown how the asylum-seeking refugees in this study, through their actions of empowering, try to resist the disempowering situation. By seeking to establish power to resist, they are seeking empowerment.
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| 3. |
- Gustafson, Niklas, 1966-
(författare)
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Lärare i en ny tid : Om grundskollärares förhandlingar av professionella identiteter
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In the past two decades the Swedish compulsory school for students aged 7 to 16 has undergone major processes of reform and change. On a structural level these have ushered in a new era with a fundamentally changed assignment for the schools and its teachers. In this thesis, however, it is assumed that the teachers as individual actors and as groups have agency to accomplish change and alter structures. The thesis has been written within a several years’ interactive research project with teachers from three compulsory schools. Based on data created in the project on how new and changing groups and working groups within teachers’ work lead to an extended assignment, the study focuses teachers’ negotiation of professional identities regarding the entire work situation. Etienne Wenger’s (1998) social theory on identity, entitled “Communities of Practice”, is used to deepen the understanding of the data. In the framework of an interactive research project the overall aim of the thesis is to describe and analyze how teachers negotiate professional identities in compulsory school. The aim is also to describe and analyze teachers’ learning and development of knowledge in the project. The central research question is: How and about what do teachers negotiate professional identities in different communities of practice? By using the interactive research approach the goal has been to develop a democratic dialogue and learning processes together with the participating teachers. One ambition is to enhance the knowledge of teachers as co-researchers within research projects and as teacher-researchers at work in school. The fora of the interactive project were informal talks, dialogues for learning, individual interviews and focus groups. The results of the study show that teachers negotiate professional identities in a flexible expanding multimembership of communities of practice. As brokers of information and knowledge between and within communities of practice at school, and from various identity positions, the teachers negotiate overlapping identities. Memberships in communities for adults only are growing in relation to teachers’ work regarding the entire work situation. The study’s main conclusion is that teachers in the new era negotiate identities within a web of tensions between fragmentation and coherence of the complexity of the work in its entirety through the multimembership in communities of practice. The thesis proposes that an awareness of complexity is fundamental, and that such an understanding can be enhanced by the teachers by developing themselves as brokers and by their reification of boundary objects within a complex multimembership. Analysis of data shows that teachers in the interactive project have had the opportunity to further develop competences to negotiate identities as teacher-researchers at work in school. Data from the project are moreover analyzed within the context of globalized and diversified structural changes such as decentralization, economic transformations, cultural standardization, the individualized knowledge society and the reflective society. A conclusion is that teachers seem to operate within an increasing globalization of the teaching profession and towards identities as globalized teachers.
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| 4. |
- Gustafson, Åsa, 1968-
(författare)
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Sköra livsmönster : Om integrations- och normaliseringsprocesser bland bosniska flyktingar
- 2004
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this study is to illustrate and unfold the dynamic interaction between conditions of integration and patterns of integration, in other words the structural conditions related to processes of integration and normalization of every day life. This is done with concrete reference to Bosnian refugees living in Malmö and Umeå during 1996-1997, having received permanent permission to stay in Sweden during 1992-1995. How do refugees under different conditions arrange their lives, perceive their own life situation, manage the course of daily life and develop individual life patterns? The study shows that processes of integration and normalisation depend on and has an impact on involvement and participation in social, economic, political and cultural life in general. Background statistics, official documents and local daily press material together with intense interviews with Bosnian refugees and key-informants constitute the empirical base of the study. The theoretical base consists of a holistic perspective on integration, including aspects of ethnicity, culture and gender. The focus is on the double-sided processes of integration among refugees in relation to the established population. Refugees’ processes of integration and normalization are described and discussed with reference to patterns of living conditions, patterns of integration, patterns of action and patterns of attitudes. The general conclusion is that refugees’ life patterns are very fragile. Processes of integration and normalization depend on conditions of involvement and of participation as well as the openness of the society at large and specifically on how civil, political and social rights are supplied for. This in turn raises the question of the importance of not only formal but also substantial citizenship rights. Integration is also closely related to possible changes towards more flexible gendered spaces of action. The more equal gender relations in the family become the more it opens up for possibilities of integration and normalization for both women and men. Encompassing possibilities to integration into the society at large combined with increased potentials of altering conventional power relations between women and men are vital for the processes of integration and normalization among refugees.
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| 5. |
- Johansson, Lars M., 1963-
(författare)
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Studies of the relationship between aid and trade and the fiscal implications of emigration and HIV/AIDS interventions
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis consists of three studies; two on fiscal effects of demographic change and one on the correlation between international aid and trade flows. Fiscal Implications of Emigration. This study examines the fiscal effects of emigration. A dynamic macroeconomic framework is used. The net present value of the fiscal effects of different types of individuals' emigration decisions is calculated. Individuals are differentiated with relation to age, gender, education, being immigrants or born in Sweden and how long they choose to stay abroad in case of emigration. The study explores how the fiscal effects of emigration are contingent on these different personal characteristics and it is applied to the case of emigration from Sweden in 1998. The estimated aggregate fiscal cost is 0.62% of GDP. This cost is significantly larger than the cost of immigration. Fiscal Implications of AIDS in South Africa. In this paper, I study the fiscal implications of the HIV/AIDS epidemic in South Africa in a standard neoclassical growth model. I find that an antiretroviral program is to a large extent self financing. An improvement in dependency ratios and health care cost savings would pay for Rand 144 billion of a full epidemiological intervention. The indirect effect through the changing demographic structure will be more important than the direct health care cost saving effect. Tied Aid, Trade-Facilitating Aid or Trade-Diverting Aid? Donor aid is often regarded as being informally tied (aid increases donor-recipient exports). However, in this paper, using a gravity model, we show that aid is also positively associated with recipient-donor exports. That is, aid increases bilateral trade flows in both directions. Our interpretation is that an intensified aid relation reduces the effective cost of geographic distance. We find a particularly strong relation between aid in the form of technical assistance and exports in both directions.
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| 6. |
- Lövheim, Hugo, 1981-
(författare)
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Psychotropic and analgesic drug use among old people : with special focus on people living in institutional geriatric care
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Old people in general, and those affected by dementia disorders in particular, are more sensitive to drug side effects than younger people. Despite this, the use of nervous system drugs and analgesics among old people is common, and has increased in recent years.Institutional geriatric care accommodates people who need round-the-clock supervision and care, due to somatic, psychiatric, cognitive or behavioral symptomatology. A majority of those living in institutional geriatric care suffers from dementia disorders.This thesis is based on three different data collections. Two large cross-sectional studies, the AC1982 and AC2000 data collections, including all those living in institutional geriatric care in the county of Västerbotten in May 1982 and 2000 respectively (n=3195 and n=3669) and one study, the GERDA/Umeå 85+ data collection, including a sample of very old people, living at home and in institutions (n=546), in the municipalities of Umeå, Sweden and Vaasa and Mustasaari, Finland, in 2005-2006.The use of psychotropic drugs and analgesics was common among old people living in geriatric care and among very old people in general. A higher proportion of people with dementia received certain nervous system drugs, such as antipsychotic drugs. The use of antipsychotic drugs among people with cognitive impairment living in geriatric care was found to be correlated to several behaviors and symptoms that are not proper indications for antipsychotic drug use, and also factors related more to the staff and the caring situation.Over the course of eighteen years, from 1982 to 2000, there has been a manifold increase in the use of antidepressants, anxiolytics and hypnotics in geriatric care, but the use of antipsychotics had decreased slightly. During the same time, the prevalence of several depressive symptoms decreased significantly, correcting for demographical changes. One analysis of calculated numbers needed to treat, however, indicated poor remission rates, suggesting that even better results might be achievable. The prevalence of depressive symptoms among people with moderate cognitive impairment remained unchanged between 1982 and 2000, despite the fact that about 50% were receiving treatment with antidepressants in 2000. One possible explanation might be that depressive symptoms have different etiologies in different stages of a dementia disorder.Approximately a quarter of the people experiencing pain in geriatric care were not receiving any regular analgesic treatment. One possible reason might be misconceptions among the caring staff regarding whether or not the residents were receiving analgesic treatment. Such misconceptions were found to be common.In conclusion, psychotropic and analgesic drug use among old people in geriatric care, and very old people in general, was found to be common and in many cases possibly inappropriate. The use of antipsychotics among people with dementia deserves particular concern, because of the high risk of severe adverse events and the limited evidence for positive effects. The use of antidepressants, on the other hand, might have contributed to a lower prevalence of depressive symptoms among old people.
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| 7. |
- Rosendahl, Erik
(författare)
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Fall prediction and a high-intensity functional exercise programme to improve physical functions and to prevent falls among older people living in residential care facilities
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Impairments in balance, mobility, and lower-limb strength are common in the growing population of older people and can lead to dramatic consequences for the individual, such as dependency in activities of daily living, admission to nursing home, falls, and fractures. The main purposes of this thesis were, among older people in residential care facilities, to validate a fall-risk assessment tool and to evaluate a high-intensity functional weight-bearing exercise pro-gramme regarding its applicability as well as its effect on physical functions and falls. The prediction accuracy of the Downton fall risk index within 3, 6 and 12 months was evaluated among 78 residents, aged 65 years or more, at one residential care facility. The participants were assessed as having either a low or high fall risk according to the index and were followed-up for falls using two different fall definitions related to the cause of the fall. With all falls included, a significant prognostic separation was found between the low- and the high-risk group at 3, 6 and 12 months. A definition in which falls precipitated by acute illness, acute disease, or drug side-effects were excluded did not improve the accuracy of the fall prediction. The effect on physical functions of a high-intensity functional exercise programme was evaluated in a randomised controlled trial among 191 older people, dependent in activities of daily living, with a Mini-Mental State Examination score of ten or more, and living in nine residential care facilities. Participants were randomised to an exercise programme or a control activity, including 29 supervised sessions over 3 months, as well as to an intake of a milk-based 200 ml protein-enriched energy supplement (7.4 g protein per 100 g) or a placebo drink immediately after each session. The Berg Balance Scale, usual and maximum gait speed, and one-repetition maximum in lower-limb strength in a leg press machine were followed up at 3 and 6 months by blinded assessors and analysed using the intention-to-treat principle. Significant long-term effects of the high-intensity functional exercise programme were seen in balance, gait ability and lower-limb strength in comparison with the control activity. The intake of the protein-enriched energy supplement did not increase the effect of the training. The evaluation of the applicability of the exercise programme showed that there was a high rate of attendance, a relatively high achieved intensity in the exercises, and only two serious adverse events, neither of which led to manifest injury or disease, despite that most of the participants had severe cognitive or physical impairments. The applicability of the programme was not associated with the participants’ cognitive function. The evaluation of the fall-prevention effect of the exercise programme, during the 6 months following the intervention, showed that neither fall rate nor proportion of participants who sustained a fall differed between the exercise programme and the control activity, when all participants were compared. However, among participants who improved their balance during the intervention period, a significant reduction in fall rate was seen in favour of the exercise group. In conclusion, among older people living in residential care facilities, the Downton fall risk index appears to be a useful tool for predicting residents sustaining a fall, irrespective of the cause of the fall, even with a perspective of only a few months. A high-intensity functional exercise programme is applicable for use, regardless of cognitive function, and has positive long-term effects on balance, gait ability, and lower-limb strength. An intake of a protein-enriched energy supplement immediately after the exercise does not appear to increase the effect of the training. Participants who improve their balance function due to the exercise programme may reduce their risk of falling.
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| 8. |
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| 9. |
- Stenvall, Michael, 1966-
(författare)
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Hip fractures among old people : their prevalence, consequences and complications, and the evaluation of a multi-factorial intervention program designed to prevent falls and injuries and enhance performance of activities of daily living
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The number of old people is growing and will increase future demands on healthcare services for old people. Hip fracture is one of the diagnoses that increases with age and it has become a major problem, both for those suffering a fracture and for society due to the large numbers involved, the morbidity with complications such as falls, functional decline, and the high mortality rate among those affected. The main purposes of this thesis were, to study the impact of previous hip fractures on their life among the very old, to study in-patient falls, fall-related injuries and fall-risk factors, and to evaluate a multidisciplinary, multi-factorial intervention program designed to reduce in-patient falls and to enhance functional performance among old people who have sustained a femoral neck fracture. The impact of a hip fracture was examined in a cross-sectional population-based study, among the very old (Umeå 85+). After adjustment for potential covariates, participants with a history of hip fracture were found to be more dependent in the performance of Personal/Primary Activities of Daily Living (P-ADL) (p=0.024), walked less independently (p=0.040) and used a wheelchair more frequently (p=0.017). Most of the participants with earlier hip fractures who had moved to institutional care or begun using mobility aids, as compared to before the fracture, had started to do so permanently in connection with the fracture incident. In-patient falls, fall-related injuries and fall-risk factors were studied in 97 participants, aged 70 or more, treated for a femoral neck fracture. There were 60 postoperative falls occurring among 26/97 participants (27%). Thirty-two percent of the falls resulted in injuries, 25 % were minor, and 7 % were serious. Delirium after day seven, (Hazard Rate Ratio (HRR) with a 95% Confidence Interval (CI)), 4.62 (1.30-16.37), male sex 3.92 (1.58-9.73), and sleeping disturbances 3.49 (1.24-9.86), were associated with in-patient falls. Forty-five percent of the participants were delirious on the day they fell. The effects of a multidisciplinary, multi-factorial intervention program on in-hospital falls and injuries as well as the short- and long-term effects on living conditions, walking ability and performance of activities of daily living were evaluated in a randomised controlled trial among 199 participants with femoral neck fracture, aged ≥70 years. Participants were randomised to care in a geriatric ward (intervention, n=102) or to conventional postoperative routines (control, n=97). The intervention consisted of staff education, individualized care planning and rehabilitation, systematic assessment and treatment of fall-risk factors, active prevention, and detection and treatment of postoperative complications and an intervention follow up at four-months. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation. Twelve participants fell a total 18 times in the intervention group compared to 26 participants suffering a total 60 falls in the control group. Only one participant with dementia fell in the intervention group compared to 11 participants with dementia in the control group. The fall incidence rate was 6.29/1000 days vs. 16.28/1000 for the intervention and control groups respectively. The Incidence Rate Ratio (IRR) was 0.38 (95% CI: 0.20-0.76, p=0.006) for the total sample and 0.07 (95% CI: 0.01-0.57, p=0.013) among participants with dementia. No new fractures were incurred in the intervention group but there were four in the control group. In addition, despite shorter hospitalization, significantly more people from the intervention group had regained independence in P-ADL performance at the four- and twelve-month follow ups, Odds Ratios (OR), with 95% CI, were 2.51 (1.00-6.30) and 3.49 (1.31-9.23) respectively. More participants in the intervention group had also regained the ability to walk independently without walking aids indoors, at the end of the study period, 3.01 (1.18-7.61). In conclusion, hip fracture among the very old seems to be associated with poorer P-ADL performance and poorer mobility. Falls and injuries are common during in-patient rehabilitation after a femoral neck fracture, delirium and sleep disturbances and male gender are factors associated with in-patient falls. Having a team apply comprehensive geriatric assessments and rehabilitation, including the prevention, detection and treatment of fall-risk factors, can successfully prevent in-patient falls and fall-related injuries, even among participants with dementia, and can also enhance the performance of Activities of Daily Living (ADL) and mobility after a hip fracture, in both short- and long-term perspectives.
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