| 1. |
- Backman, Annica, 1972-
(författare)
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Leadership : person-centred care and the work situation of staff in Swedish nursing homes
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Swedish nursing home managers, who constitute the empirical focus of this thesis, hold overall operational responsibility for the nursing homes, which includes the care of residents, direct care staff and work environment. Aged care organisations are also expected to provide person-centred care. Working towards a person-centred approach poses new demands and leads to challenges for leaders, and there is currently limited knowledge of what characterises leadership that promotes a person-centred approach. In addition, an ongoing demographic shift in the aged care workforce entails further challenges, as the proportion of professional workers is decreasing. Leading a healthy work environment is therefore important for ensuring and protecting staff health. Based on this, it is important to explore nursing home managers’ leadership in relation to person-centred care and the work situation of staff.Aim: The overall aim was to explore leadership in relation to person-centred care and the work situation of staff in Swedish nursing homes.Methods: This thesis is based on data from two data collections. First, it includes cross-sectional baseline data from a national inventory of health and care in Swedish nursing homes (SWENIS) collected in 2013-2014. The SWENIS dataset consists of a sample of staff n=3605 from 169 nursing homes in 35 municipalities, and nursing home managers n=191. The second data collection consists of 11 semi-structured interviews with 12 nursing home managers in highly person-centred nursing homes that already participated in SWENIS. Data were explored via descriptive statistics, simple and multiple regression analyses, and qualitative content analysis.Results: Leadership was positively associated with person-centred care and psychosocial climate. Highly rated leadership behaviors’ among nursing homes managers was characterized by experimenting with new ideas, controlling work closely, relying on his/her subordinates, coaching and giving direct feedback, and handling conflicts constructively. Leading person-centred care can be outlined by four leadership processes: embodying person-centred being and doing; promoting a person-centred atmosphere; maximizing person-centred team potential and optimising person-centred support structures. Leadership was also positively associated with social support and negatively associated with job strain. Further, the variation in leadership was to a very small extent explained by the nursing home managers’ educational qualification, operational form of the nursing home and the number of employees in a unit.Conclusions: All findings point in the same direction: that leadership, as it is characterized and measured in this thesis, is significantly associated with person-centred care provision as well as with the work situation of staff. This suggests that nursing managers have a central leadership role in developing and supporting person-centred care practices, and also in creating a healthy work environment. The results also highlight five specific leadership behaviours that are most characteristic of highly rated leadership, thereby adding concrete descriptions of behaviours to the literature on existing leadership theories. The findings also include four central processes for leading towards person-centred care in nursing homes. Taken together, it seems important for managers to translate the person-centred philosophy into actions and to promote an atmosphere pervaded by innovation and trust, in which cultural change is enhanced by positive cultural bearers. Utilizing the overall knowledge and competencies among staff and potentiating care teams was also considered important for leading person-centred care, along with optimising supportive structures for supporting and maintaining person-centred care. If aged care organisations are to be committed to person-centred care, an important implication seems to be to organise nursing homes in a way that allows nursing home managers to be close and present in clinical practice and actively lead towards person-centred care. The findings of this thesis contribute to our understanding of leadership in relation to person-centre care and the work situation of staff. These findings can be used in leadership educations and nursing curriculum. Longitudinal studies would be valuable for following leadership, person-centred care and the work situation of staff over time.
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| 2. |
- Baxter, Rebecca, 1989-
(författare)
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“Life is for living” : exploring thriving for older people living in nursing homes
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Demand for formal care in nursing homes has steadily increased in recent decades, prompting calls for exploration of health-promoting and salutogenic concepts that support people not only to survive in older age, but to thrive. The concept of thriving has been described as a holistic experience of place-related well-being resulting from interactions between the person and their lived-environment. However, detailed understandings of thriving among nursing home residents and staff are lacking, and little is known about the variables that influence thriving, how thriving is regarded outside of Scandinavia, or the extent to which thriving may change over time.Aim: The overall aim of this thesis was to explore meanings, expressions, measurements, and associations for thriving in nursing homes. Study I aimed to illuminate the meanings of thriving as narrated by persons living in an Australian nursing home. Study II aimed to explore how Australian nursing home staff recognise expressions of thriving among persons living in nursing homes. Study III aimed to further test and describe the psychometric properties and performance of the 32-item Thriving of Older People Assessment Scale (TOPAS) and to develop a short-form TOPAS. Study IV aimed to describe longitudinal changes in Swedish nursing home thriving over a five-year period and describe changes in associated factors. Methods: For studies I and II data were collected in the form of qualitative interviews with Australian nursing home residents (N=21; study I) and staff (N=14; study II). Qualitative data were analysed using phenomenological hermeneutical analysis and qualitative content analysis respectively. For studies III and IV cross-sectional baseline (i.e., 2013/2014) and follow-up (i.e., 2018/2019) data were collected from a nationally representative sample of Swedish nursing homes for the Swedish National Inventory of Care and Health in Residential Aged Care (SWENIS) study. The baseline SWENIS I sample consisted of 4,831 proxy-rated resident surveys from 35 municipalities (study III) and the follow-up SWENIS II sample consisted of 3,894 proxy-rated resident surveys from 43 municipalities (study IV). Quantitative data were analysed using descriptive statistics, validity testing, item response theory-based analysis, and simple linear regression.Results: The meanings of thriving for nursing home residents were understood as encompassing elements of acceptance, balance, and contentment in relation to the person’s living situation, as well as their social and physical environment (study I). These meanings were interpreted as having options and choices, and the agency to make decisions where possible, in relation to the care and living environment. Nursing home staff were found to recognise expressions of thriving through a combination of understanding, observing, and sensing (study II). Staff described recognising thriving through reflective assessment processes that involved comparing and contrasting their personal and professional interpretations of thriving with their overall sense of the resident. Psychometric testing of the 32-item and short-form versions of the TOPAS showed good validity and reliability to measure thriving among nursing home residents (study III). Population characteristics were relatively consistent between the SWENIS I baseline and SWENIS II follow-up samples (study IV). A sub-sample of nursing homes that participated in both baseline and follow-up data collections reported a statistically significant increase for thriving and a decrease in the prevalence of neuropsychiatric symptoms. Higher and lower thriving was associated with several neuropsychiatric symptoms.Conclusions: Thriving appeared to be a relevant and meaningful phenomenon with shared understandings among nursing home residents and staff, providing valuable support for the ongoing assessment and application of thriving in international and cross-cultural nursing home settings. The TOPAS appeared valid and reliable to facilitate proxy-rated measurement of thriving among nursing home residents, and the short-form TOPAS could have enhanced use for assessment of thriving in research and practice. Changes to the overall thriving scores between baseline and follow-up provides important information that may be used as a reference point for future measurements and comparisons of thriving and its associated variables over time. This thesis highlights the importance of considering the various experiences, perceptions, and interpretations of thriving if such a concept is to be effectively embedded in person-centred care, policy, and practice.
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| 3. |
- Brännström, Jon, 1977-
(författare)
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Adverse effects of psychotropic drugs in old age
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: With increasing age, the body and mind transform. Many of our organs gradually lose capacity, making them more sensitive to the effects of several drugs. In parallel, many of us accumulate an increasing burden of disease and other conditions warranting the use of medications. Hence, the use of most classes of drugs increases with age, especially so in elderly women.At the same time, medical science is lagging behind due to the fact that the oldest people in society often are excluded from pharmacological studies, where young males are the most coveted subjects.In the absence of strong evidence, much of the knowledge about the clinical and adverse effects of several drugs in the elderly is derived from observational studies, prone to bias and confounding. The use of psychotropic drugs in elderly people is particularly controversial, and even more so in people suffering from major neurocognitive disorders (NCD). Psychotropics have been associated with several adverse effects as well as limited clinical effect. Still, they are frequently prescribed to elderly patients.Aims: This thesis aims to explore the associations between several types of psychotropic drugs and two of the most severe adversities attributed to their use, increased mortality and the risk of hip fracture. It aims to explore mortality in data from well-controlled studies. It also aims to employ novel statistical methods to investigate the associations between drug exposure and hip fracture, in an attempt to gain information on possible causality from observational data.Methods: This thesis uses quantitative, comparative and epidemiological methods, prospective as well as retrospective. Two of the four papers are based on data collections conducted by the Department of Community Medicine and Rehabilitation, Umeå University, and include 992 and 1,037 individuals, respectively. The other two papers are based on Swedish nationwide registers and include 408,144 and 255,274 subjects, respectively. In all four papers multivariable regression models were used to investigate the associations between the exposures and outcomes, adjusted for possible confounding variables.Results: In a population-based sample of very old people, and in old people with major NCD, ongoing use of psychotropic drugs was not independently associated with increased mortality. Analyses did show, however, a significant impact of sex on the mortality risk, with tendencies for antidepressant drug use to be protective in men, but not in women, and for benzodiazepines to increase the mortality risk in men, but not in women. In two cohorts of old people, based on several nationwide registers, investigating the associations between psychotropic drug use and hip fracture revealed that users of antidepressants, as well as users of antipsychotics, had significantly increased risks of hip fracture, independent of a wide range of covariates. However, when studying how the risk changed over time, the strongest associations were found before the initiation of treatment with the respective drug, and no dose-response relationships were found.Discussion: The finding that psychotropic drug use was not independently associated with an elevated mortality risk was not in line with previous research, most of which have been based on data from large registers, and shown an increased risk of mortality. One reason for this difference is that the cohorts studied in this thesis were thoroughly investigated and characterised, making it possible to perform extensive adjusting for confounding variables. Hence, we expect a lesser amount of residual confounding, than in most other studies. Another explanation is that we studied ongoing drug use at baseline, rather than associations following initiation of treatment. This might have introduced a selection bias in our studies, where the individuals most sensitive to adverse effects would have discontinued treatment or passed away. The finding of a significant impact of sex on the risk of mortality adds to the unexplored field of sex differences in drug responses in old age, and warrants further investigation.In our register studies of psychotropic drug use and the risk of hip fracture, novel methods were applied. We have tried to overcome the hurdles of several types of confounding through the investigation of associations before and after the initiation of antidepressants, and antipsychotics, respectively. Our finding that the associations between psychotropic drug use and hip fracture were not only present, but indeed strongest, before the initiation of treatment indicates a strong presence of residual confounding and confounding by indication, and points toward the absence of a causal relationship between psychotropic drug use and hip fracture.Conclusion: The evidence supporting causal relationships between psychotropic drug use and serious adverse events in old age is insufficient. Our results point towards bias and confounding having strong influences on the observed associations between psychotropic drug use and mortality, and hip fracture, respectively.
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| 4. |
- Corneliusson, Laura, 1989-
(författare)
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Exploring resident health, wellbeing, and thriving in Swedish sheltered housing
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: As the population of older people is expected to increase in the coming decades, an increase in service demand will likely follow. Aging in place is common in Sweden, but may be associated with loneliness, anxiety, and other negative health effects. Swedish sheltered housing began to emerge around 2008, and was aimed at older people who felt socially isolated, anxious, or unsafe aging in place. Swedish sheltered housing was to be a form of independent housing, providing accommodation with increased opportunities for social participation and accessible spaces, but with no provision of health care services. Despite the emergence of such housing, and policy documents outlining anticipated benefits, the national and international scientific body of knowledge is small.Aim: The overall aim of this thesis was to explore the health, wellbeing and thriving of residents living in Swedish sheltered housing.Methods: This thesis is based on data from two data collections and registry data. The first data collection, the U-Age Sheltered Housing Survey Study, took place between October 2016 and January 2017, and consisted of surveys sent to residents living in Swedish sheltered housing, and to a matched control group. The matching criteria was age, sex and municipality of residence. The sample for the U-Age Sheltered Housing Survey Study consisted of 3,805 individuals: 1, 955 individuals living in sheltered housing, and 1,850 aging in place. The second data collection took place between April 2019 and January 2020, and consisted of semi-structured interviews in five sheltered housing accommodations which had participated in the U-age Sheltered Housing Survey Study. This data collection consisted of a total of seven group interviews with a sample of 38 residents. In addition, to enable longitudinal analyses, registry data on social services resource utilization and mortality was obtained from The Department of Health and Welfare in Sweden and Statistics Sweden. Data were analyzed using descriptive statistics, linear regression analyses with interaction variables, logistic regressions, and qualitative content analysis.Results: Residents living in Swedish sheltered housing generally reported lower self-rated health, lower health-related quality of life, lower functional status, and higher depressive mood, compared to those aging in place. With increasing level of depressive mood, and decreasing levels of self-rated health and functional status, those residing in sheltered housing generally reported higher levels of thriving, compared to those aging in place. A higher proportion of those living in Swedish sheltered housing received home care services, and received on average more home care service hours, compared to those aging in place. Furthermore, a higher proportion of residents living in sheltered housing had relocated to a nursing home and deceased over a 3-year period, compared to those aging in place. Rates of relocation to a nursing home and mortality were higher among those who lived in Swedish sheltered housing and received home care services, compared to those living in Swedish sheltered housing who did not receive home care services. Interviews with residents living in Swedish sheltered housing revealed four different levels to the experienced facilitators and barriers to thriving in Swedish sheltered housing: individual factors, social context, environmental factors and organizational context.Conclusions: There seems to be both a want, and a potential need, for health care related support among residents living in Swedish sheltered housing. Although residents in Swedish sheltered housing reported slightly lower self-rated wellbeing than older people aging in place, differences in wellbeing did not seem to be explained by type of accommodation per se. There do however seem to be aspects in Swedish sheltered housing that support thriving specifically among those with lower levels of health, lower functional status, and higher depressive mood, when compared to those aging in place. It seems possible that thriving in Swedish sheltered housing may be influenced by the interplay of various especially influential aspects, such as, but not limited to, levels of health, the services provided, the experience of the social environment, and the perceived support. Thereby, providing residents of Swedish sheltered housing with more health care related support and information could further support resident health and thriving. The findings of this thesis contribute to the currently limited pool of knowledge on health, wellbeing, and thriving in Swedish sheltered housing, and may assist in developing tailored services, support, and interventions for the demographic residing in this type of housing.
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| 5. |
- Gustafsson, Maria, 1971-
(författare)
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Optimizing drug therapy among people with dementia : the role of clinical pharmacists
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Drugs are one of the cornerstones in the management of many diseases. In general, drugs are used for diagnosis, prevention, mitigation of symptoms, and, sometimes, to cure disease. However, drug treatment in elderly people, especially those with dementia and cognitive impairments, may involve significant risk of adverse drug events. The aim of this thesis was to identify the extent of potentially inappropriate drug treatment among people with dementia and cognitive impairment and to assess the occurrence and character of drug-related problems that lead to acute hospital admissions. Another aim was to assess the potential impact of a comprehensive medication review conducted by clinical pharmacists as part of a health care team on quality of patients’ drug therapy and drug-related hospital readmission rates.Method: Long-term use of antipsychotic/psychotropic drugs and associated factors were investigated among 344 and 278 people respectively with dementia living in specialized care units. Trends in the prescribing of potentially inappropriate drugs between 2007 and 2013, comprising 2772 and 1902 people, living in nursing homes in the county of Västerbotten, were assessed using six national quality indicators. Data on drug use, function in the activities of daily living, cognitive function and behavioral and psychological symptoms were collected using the Multi-Dimensional Dementia Assessment Scale. Further, an investigation of a separate corresponding population from 2012 was done, where potentially inappropriate drug use was measured before and after a total of 895 medication reviews. Finally, a randomized, controlled trial was carried out among people 65 years or older with dementia or cognitive impairment in internal medicine and orthopedic wards at two hospitals in northern Sweden. The proportion of hospital admissions that were drug-related were estimated, and also whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team could affect the risk of drug-related hospital readmissions.Results: Antipsychotic and other psychotropic drugs were frequently prescribed to people with dementia living in specialized care units for prolonged periods. Associations were found between behavioral and psychological symptoms and different psychotropic drugs. The extent of potentially inappropriate drug use declined between 2007 and 2013. In the separate corresponding population from 2012, the frequency of potentially inappropriate drug use was significantly reduced among people who underwent medication reviews. Hospitalizations due to drug-related problems among old people with dementia or cognitive impairment were prevalent. We found that inclusion of a clinical pharmacist in the health care team significantly reduced the risk of drug-related 30-day and 180-day readmissions. However, in a subset of patients with concomitant heart failure no effect was seen.Conclusion: Among patients with dementia or cognitive impairment long-term treatment with antipsychotic and other psychotropic drugs is common. The results indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals, despite limited evidence of their efficacy and the high risk of adverse effects. Drug-related problems, such as adverse drug reactions, constituted a major cause of hospital admissions. By reducing potentially inappropriate drug use and optimizing overall drug therapy, inclusion of clinical pharmacists in a health care team might improve the quality of patient care and reduce the risk of hospital readmissions among people with dementia.
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| 6. |
- Hörnsten, Carl, 1985-
(författare)
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Stroke and depression in very old age
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background The prevalence and incidence of stroke are known to increase with age, which, combined with demographic change, means that very old patients with stroke are a growing patient group. Risk factors for incident stroke among very old people have not been widely investigated. The impact of depression on mortality in very old people who have had a stroke also remains unclear. The aim of this thesis was to investigate the risk factors for incident stroke, the epidemiology of stroke and depression, and the consequences of having had a stroke regarding the risk of depression and mortality among very old people.Methods A randomly selected half of 85-, all 90-, and all ≥95-year-olds in certain municipalities in Västerbotten County, Sweden, and Pohjanmaa County, Finland were targeted in a population-based cohort study from 2000-2012. The 65-, 70-, 75-, and 80-year-olds in all the rural and random samples from the urban municipalities in the same counties were furthermore targeted in a survey in 2010.In the cohort study patients were assessed in their homes, by means of the 15-item Geriatric Depression Scale (GDS-15) and other assessment scales, as well as blood pressure measurements, several physical tests, and a review of medical diagnoses appearing in the medical charts. Incident stroke data were collected from medical charts guided by hospital registry records, cause of death records, and reassessments after 5 years. Depression was defined as a GDS-15 score ≥5. A clinical definition of all depressive disorders, based on assessment scale scores and review of medical charts was also used. A specialist in geriatric medicine evaluated the diagnoses. The survey included yes/no questions about stroke and depression status, and the 4-item Geriatric Depression Scale. Associations with mortality and incident stroke were tested using Cox proportional-hazard models. Results In the ≥85-year-olds examined in 2005-2007 (n=601), the stroke prevalence was 21.5%, the prevalence of all depressive disorders was 37.8% and stroke was independently associated with depressive disorders (odds ratio 1.644, p=0.038). The prevalence of depression according to GDS-15 scores was 43.2% in people with stroke compared with 25.0% in people without stroke (p=0.001). However, in ≥85-year-olds examined in Sweden from 2000-2012 (n=955), from all past data collections in the study, depression was not independently associated with incident stroke. In ≥65-year-olds who responded to a survey in 2010 (n=6098), the stroke prevalence rose with age from 4.7% among the 65- to 11.6% among the 80-year-olds (p<0.001). The prevalence of depression rose from 11.0% among the 65- to 18.1% among the 80-year-olds (p<0.001). In the group with stroke, depression was independently associated with dependence in personal activities of daily living and having a life crisis the preceding year, while in the non-stroke group, depression was independently associated with several additional demographic, social and health factors.In ≥85-year-olds examined in 2005-2007 with valid GDS-15 tests (n=452), having had a stroke was associated with increased 5-year mortality [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.15-2.03]. Having had a stroke and depression was associated with increased 5-year mortality compared with having only stroke (HR 1.90, 95% CI 1.15-3.13), having only depression (HR 1.59, 95% CI 1.03-2.45), and compared with having neither stroke nor depression (HR 2.50, 95% CI 1.69-3.69). Having only stroke without a depression did not increase mortality compared with having neither stroke nor depression.In ≥85-year-olds examined in Sweden from 2000-2012 (n=955), from all past data collections in the study, the stroke incidence was 33.8/1000 person-years during a mean follow-up period of about three years. In a comprehensive multivariate model, atrial fibrillation (HR 1.85, 95% CI 1.07–3.19) and higher systolic blood pressure (SBP; HR 1.19, 95% CI 1.08–1.30 per 10-mmHg increase) were associated with incident stroke overall. In additional multivariate models, diastolic blood pressure (DBP) ≥90 mmHg (HR 2.45, 95% CI 1.47–4.08) and SBP ≥160 mmHg (v. <140 mmHg; HR 2.80, 95% CI 1.53–5.14) were associated with incident stroke.Conclusion The prevalence of both stroke and depression increased with age, and rates were especially high among very old people. Having had a stroke was independently associated with a higher prevalence of depression among very old people, however, depression was not independently associated with a higher incidence of stroke. Having had a stroke was associated with increased all-cause mortality among very old people, but only among those who were also depressed. High SBP (≥160 mmHg), DBP (≥90 mmHg) and atrial fibrillation were the only consistent independent risk factors for incident stroke among very old people.
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| 7. |
- Kindstedt, Jonas, 1986-
(författare)
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Medication-related problems and psychotropic drug use in vulnerable older populations : a focus on acute hospital admissions and cognitive impairment
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The ageing process involves several physiological changes that affect both pharmacodynamics and pharmacokinetics and that, in combination with a heavier disease burden and more extensive use of medicines, put older people at higher risk of medication-related problems and associated clinical outcomes. The older population is often treated as a homogenous group, when in fact there are factors that render certain individuals more vulnerable to adverse drug effects and other types of medication-related problems. Older people encountered in the acute medical care setting and/or individuals with varying degrees of cognitive impairment are especially vulnerable in that context. The overall aim of this thesis was to describe and understand medication use in certain vulnerable subgroups of older people, which in turn might identify suitable target populations in which medication-related problems can be prevented or managed through interventions or similar efforts.Paper I presented, in the form of a study protocol, a clinical pharmacist intervention intended to reduce the risk of medication-related readmission to hospital among people aged 75 years or older during transitions of care. Based on 300 participants from the intervention study, approximately 50% had been readmitted to hospital within 180 days of being discharged from the hospital. Both heart failure and cognitive impairment, the latter identified through a four-item test, were predictors of early readmission. Altogether, the study population seems relevant for the purpose of the intervention; whether the intervention model is effective remains to be determined.Based on the same sample of study participants, paper II found that approximately one third of the 300 index hospital admissions were possibly medication related. Moreover, possibly medication-related hospital admissions were negatively associated with the fewest positive/correct answers on the four-item screening tool for cognitive impairment, which suggests that those clinical events might be less prevalent among people with cognitive impairment when exploring the association cross-sectionally. Both papers III and IV were registry-based studies, and their overall objective can be summarized as to describe psychotropic drug use and associated factors among older people with major neurocognitive disorder (NCD). Paper III focused on differences between major NCD subtypes, whereas paper IV compared people with major NCD against matched references from the total older population. In brief, overall psychotropic drug use was notably higher among people with major NCD, although generally in line with national treatment guidelines in terms of individual drugs of choice. The use of hypnotic drugs was also extensive in the reference group, and deprescribing efforts seem warranted, although longitudinal studies that focus on long-term use could provide a better picture of the potential problem. Nursing home stay was also positively associated with psychotropic drug use for all classes of psychotropic drugs, and the difference was most prominent for antipsychotic drugs. In that context, over 1,200 people in the reference population, most of them nursing home residents, had filled prescriptions for antipsychotic drugs, a figure indicating that the management of neuropsychiatric symptoms might also be an issue among older people who, due to various circumstances, have not been examined and diagnosed with neurocognitive disorders. Regarding major NCD subtypes, individuals with Lewy body dementia had, except for antidementia drugs, higher odds of psychotropic drug use than did those with Alzheimer’s disease. For example, the odds of antipsychotic drug use were more than twice as high, which is a worrying figure given that people with Lewy body dementia are extremely sensitive to the adverse effects of those specific drugs.In conclusion, this thesis illustrates the heterogeneity of demographics and drug use among older people and indicates that certain types of medication-related problems may be more relevant in certain older subpopulations. Medicines appear to be involved in many hospital admissions of older people, and the acute medical setting and subsequent care transitions are likely an important focus of pharmaceutical interventions. However, psychotropic drugs are probably not a major issue in that specific context. Efforts to reduce psychotropic drug use are likely more relevant to people with major NCD, especially in the nursing home setting. Antipsychotic drug exposure among persons with Lewy body dementia could be one such focus, especially since there are other better-balanced pharmacological treatment options for these individuals in terms of efficacy and safety profile.
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| 8. |
- 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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| 9. |
- Mathillas, Johan, 1980-
(författare)
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Dementia, depression and delirium in the very old : prevalences and associated factors
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Emotional suffering in old age is largely caused by a variety of psychiatric disorders which are often, however, undertreated and underrecognized. This leads to reduced quality of life and functional status and increased morbidity and mortality. Dementia, delirium and depression are common disorders in the very old, and are similar in several ways. All have multiple causes and are diagnosed by means of symptomatic criteria, are challenging to diagnose and difficult to differentiate from each other in the very old. They often coexist in the same individual, and may have common risk factors.The overall aim of this thesis was to add to our knowledge about threats to successful aging, by investigating the prevalences of dementia, depression and delirium, and factors associated with these three disorders. Further aims were to measure change over time in the prevalence of dementia and depression, respectively, and to investigate the risk factors for incident depression. This thesis uses the population-based Umeå85+/GErontological Regional DAtabase (GERDA) material.In 2000-2002, every other 85-year-old, all 90-year-olds and all people ≥95 years living in six municipalities in Västerbotten, Sweden were invited to participate, and in 2005-2007 the process was repeated, with the additional inclusion of the corresponding populations of two municipalities in Österbotten, Finland. A third data collection was carried out in 2010-2012. Trained assessors carried out assessments in the form of structured interviews during one or more home visits, recorded current medication and reviewed medical records obtained from general practitioners and hospitals. In 2000-2002 the prevalence of dementia was 17% among 85-year-olds, 24% among 90-year-olds and 46% among those aged ≥95 years. In 2005-2007 dementia prevalence reached 28% among 85-year-olds, 40% among 90-yearolds and 45% among those aged ≥95 years. The prevalence of dementia in the total sample was 27% in 2000-2002 and 37% in 2005-2007 (p=0.001). In 2000-2002 the prevalence of depressive disorders was 24% among 85-yearolds, 34% among 90-year-olds and 31% among those aged ≥95 years. In 2005-2007 the prevalence of depressive disorders was 33% among 85-year-olds, 39% among 90-year-olds and 38% among those aged ≥95 years. The prevalence of depressive disorders in the total sample was 29% in 2000-2002 and 37% in 2005-2007 (p=0.025). Among participants not depressed at baseline, 26% had developed depression after five years. Factors independently associated with new cases of depression at follow-up were hypertension, a history of stroke and a higher score on the 15-item Geriatric Depression Scale at baseline. The thirtyday prevalence of delirium in 2005-2007 was 17% among 85-year-olds, 21% among 90-year-olds and 39% among participants aged ≥95 years. Delirium prevalence among individuals with dementia was higher than among those without dementia (52% vs. 5%, p<.001). Factors independently associated with delirium superimposed on dementia in a multivariate logistic regression model were depression, heart failure, living in an institution and prescribed antipsychotics.There was a high prevalence of dementia, depression and delirium in the papers comprising this thesis, and 55% had at least one of the three disorders. The prevalence of dementia and depression also increased between 2000-2002 and 2005-2007, after controlling for age and sex. Dementia and depression were important associated factors for delirium and half of those with dementia were depressed. The increasing age-specific prevalence of depression seems to be associated with the increasing age-specific prevalence of dementia. The papers presented are among the first to report a significantly increasing age-specific prevalence of dementia and depression among very old people. More knowledge about associated factors and risk factors concerning these disorders may be helpful for carers and decision-makers, as well as providing reference values for studies in other regions. Further efforts are needed in both care and research to better prevent, screen for, diagnose and treat dementia, depression and delirium, especially considering the growing number of very old people.
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- Molander, Lena, 1983-
(författare)
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Blood pressure in advanced age : with focus on epidemiology, cognitive impairment and mortality
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The general conception is that blood pressure increases with age, but that diastolic blood pressure (DBP) starts decreasing in the elderly. There are, however, indications that systolic blood pressure (SBP) might also decline in advanced age, but further studies are needed to establish whether this is true. Midlife hypertension is an acknowledged risk factor for mortality and dementia. Some research has, however, suggested more complicated associations between blood pressure and these outcomes in old age, as low blood pressure has been linked to both increased mortality and increased risk of dementia. Research on this subject, especially in very old people (≥85 years of age), is still limited. The purpose of the present thesis was to investigate blood pressure epidemiology in old age and associations between blood pressure and mortality and cognition in very old people. Subjects were mainly derived from the Umeå 85+/GERDA (GErontological Regional DAtabase) study, a study on individuals aged 85 years, 90 years or ≥95 years carried out in northern Sweden and Finland in 2000-2007. For analysis of blood pressure change with age, data from this study were combined with data from the U70 study that was carried out in the city of Umeå, Sweden between 1981-1990 and included individuals aged 70-88 years. Investigations were performed during a home visit in the Umeå 85+/GERDA study and at a geriatric centre in the U70 study. SBP and DBP were measured in the supine position in both studies and pulse pressure (PP) was calculated as SBP-DBP. Main outcome variables were 4-year mortality, Mini-Mental State Examination (MMSE) scores, dementia and blood pressure change with age and over the years. Treatment with antihypertensive drugs was also considered. Blood pressure changes with age and time were investigated using 1133 blood pressure measurements from 705 individuals aged ≥70 years performed between 1981 and 2005. DBP continually decreased with increasing age, whereas SBP and PP increased up to age 74.5 and 80.6 years, respectively, to then start decreasing. Mean SBP and DBP also decreased over the years. The prevalence of treatment with antihypertensive drugs increased during the same period and is probably one explanation for the decrease in blood pressure with time. Blood pressure also decreased in longitudinal analyses of those individuals who participated in more than one data collection. Women had higher SBP and PP than men. The association between blood pressure and 4-year mortality was investigated in a sample of 348 individuals aged ≥85 years. Results indicated a non-linear association between SBP and mortality, i.e. both lower and higher SBP were associated with increased mortality. The lowest mortality risk was associated with an SBP of 164 mmHg (95% confidence interval 154-184 mmHg). The analyses were adjusted for a number of diseases and health factors and thus suggest a negative effect of low SBP on survival, independent of health status. There was no association between DBP or PP and 4-year mortality. The impact of blood pressure on MMSE scores and dementia was investigated both in a cross-section of 575 individuals and longitudinally in two samples including 102 and 205 individuals, respectively, all ≥85 years old. Cross-sectional analysis demonstrated nonlinear associations between SBP and PP and MMSE scores, indicating poorer cognitive function with both low and high blood pressure. The association between DBP and MMSE scores was linear, higher DBP being associated with higher scores. Individuals with dementia had lower blood pressure than those without dementia. Longitudinally, over five years, no association between baseline blood pressure and incident dementia or change in MMSE scores could be demonstrated. Mean blood pressure declined over this time period, and this decline was greater in individuals who developed dementia than in those who remained dementia free. A greater decline in blood pressure was associated with a greater decline in MMSE scores. In conclusion, this study has shown a decrease in both SBP and DBP in advanced age and also that low blood pressure is associated with both increased mortality and poor cognitive function in very old people. These associations might not be fully explained by underlying disease or poor health status; the underlying mechanisms are so far mostly speculative. Very high blood pressure might also remain a risk factor for the mentioned outcomes even in very old age, at least in some people. No association between baseline blood pressure and cognitive decline or incident dementia could be demonstrated, but blood pressure decline was associated with cognitive decline and incident dementia. The direction of this association remains to be determined. Blood pressure also decreased over the years from 1981 to 2005, probably partly due to an increasing prevalence of treatment with antihypertensive drugs.
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