| 1. |
- Burman, Maria, 1983-
(författare)
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Malnutrition and obesity among older adults, assessed by Mini Nutritional Assessment and the body mass index, respectively : prevalence and associations with mortality and urinary tract infection
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- INTRODUCTION: Malnutrition and obesity are health concerns among older (aged ≥ 65 years) adults, but the combination of them have not been studied thoroughly nor have they been thoroughly investigated in very old (aged ≥ 85 years) adults. The aims of this thesis were to investigate the prevalence, trends in prevalence and associations with mortality of malnutrition and obesity, assessed by Mini Nutritional Assessment (MNA) and the body mass index (BMI), respectively, and to examine the combined effects of these conditions on mortality. Malnutrition as a risk factor for urinary tract infection (UTI) was also investigated. MATERIAL AND METHODS: The studies reported on in papers I and II were conducted with data from the Umeå85+/Gerontological Regional Database study, a population-based study of cohorts of very old adults. Data from all four Swedish cohorts (2000–2002, 2005–2007, 2010–2012 and 2015–2017), and from the 2000–2002 and 2005–2007 Swedish cohorts and a 2005–2006 Finnish cohort, respectively, were used. In the paper I study, trends in the prevalence of malnutrition (by MNA score) and obesity (by BMI) were investigated across cohorts. In the paper II study, the associations of MNA scores and BMI with 5-year mortality were investigated. The study reported on in paper III was conducted with data from the Senior Alert national quality registry; associations of Mini Nutritional Assessment–Short Form (MNA-SF) scores, BMI and 2-year mortality in older adults living in residential care facilities in Sweden were investigated. The study reported on in paper IV was conducted with data from the Frail Older People–Activity and Nutrition and Umeå Dementia and Exercise studies; risk factors for UTI among older adults in residential care facilities were investigated. RESULTS: In the paper I study, mean BMI increased between 2000–2002 and 2015–2017 and the prevalence of obesity were 13.4% and 18.3%, respectively; the prevalences of underweight were 7.6% and 3.0%, respectively. Mean MNA scores increased between 2000–2002 and 2010–2012 and were slightly lower in 2015–2017. The prevalence of malnutrition according to MNA scores in the four cohorts were 12.2%, 6.4%, 5.1% and 8.7%, respectively, and the prevalence of at risk thereof were 31.8%–37.2%. In the paper II study, 13.3% of participants were malnourished, and 40.3% at risk thereof according to MNA scores, and malnutrition was more common among women than men. Twenty-five percent of the population had BMIs ≥28.0 kg/m2. Of those with malnutrition according to MNA scores, 17.4% had BMIs ≥ 24.7 kg/m2; of those with good nutritional status according to MNA scores, 13.8% had BMIs < 22.2 kg/m2. Compared to malnutrition according to MNA, lesser mortality was found in individuals with good nutritional status. Compared to individuals with BMI <22.2 kg/m2, lesser mortality was found in those with BMI ≥28.0 kg/m2. In the paper III study, 14.6% of the population was malnourished, and 45.0% at risk of malnutrition according to MNA-SF scores and 16.0% were obese. Compared to individuals with good nutritional status, greater mortality was found in those with malnutrition according to MNA-SF. Mortality was greater among underweight than among normal-weight participants and lesser among participants with obesity, including severe obesity. Higher BMIs were also associated with reduced mortality in subgroups defined by MNA-SF scores. In the paper IV study, malnutrition according to MNA scores was not a risk factor for UTI in the whole sample or in women. In men, the MNA score was associated with UTI in univariate analysis. CONCLUSIONS: The results of this thesis highlight the importance of nutritional screening in older adults in residential care facilities and in very old adults, since malnutrition risk was common and associated with greater mortality among these populations. Malnutrition according to MNA was not a clear risk factor for UTI in older adults living in residential care facilities. Time trends indicated an increasing prevalence of obesity whereas no change in nutritional status according to MNA was observed among very old adults, although these trends need further investigation. The results also confirmed that higher BMIs were beneficial for survival in these populations, and in the residential care population this seems to apply also for BMIs reflecting severe obesity. Finally, in the residential care population, regardless of nutritional status according to MNA-SF, higher BMIs were associated with better survival.
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| 2. |
- 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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| 3. |
- Claesson Lingehall, Helena, 1965-
(författare)
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Delirium in older people after cardiac surgery : risk factors, dementia, patients’ experiences and assessments
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background:Delirium is common in older people undergoing cardiac surgery. Delirium is an acute or subacute neuro-psychiatric syndrome, characterized by a change in cognition, disturbances in consciousness; it fluctuates, develops over a short period of time and always has an underlying cause. It is associated with a disturbance in psychomotor activity, and is classified according to different clinical profiles such as hypoactive, hyperactive and mixed delirium. Delirium after cardiac surgery is not harmless, it increases the risk of complications such as prolonged stay in hospital, falls, reduced quality of life, reduced cognitive function and increased mortality.Aim:The overall aim of this thesis was to investigate postoperative delirium in older people undergoing cardiac surgery with Cardiopulmonary Bypass (CPB), focusing on risk factors, dementia and patients’ experiences; and to evaluate an assessment for screening delirium.Methods:This thesis compromises four studies. All participants (n=142) were scheduled for cardiac surgery with use of CPB at the Cardiothoracic Surgery Department, Heart Centre, Umeå University Hospital, Sweden, between February and October 2009. Six structured interviews were conducted preoperatively, day one and day four postoperatively, and in home visits, one, three and five years after surgery (2010, 2012 and 2014). The assessment scales used in Studies I, II and IV were: the Mini-Mental State Examination (MMSE) for cognition, the Organic Brain Syndrome Scale (OBS) for delirium, Geriatric Depression Scale 15 (GDS-15) for depression, Katz staircase with Activities of Daily Living (ADL) for participants’ functional status and the Numerical Rating Scale (NRS) for pain. During the hospital stay, nursing staff used the Swedish version of the Nursing Delirium Screening Scale (Nu-DESC) to assess delirium. Semi-structured interviews were also carried out (III) in the one-year follow up. Delirium, dementia and depression were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR).Results: Out of 142 participants 54.9% (78/142) developed delirium after cardiac surgery (I). Independent risk factors, predisposing and precipitating, associated with delirium were: age, diabetes, gastritis/peptic ulcer, volume load during operation, longer time on ventilator in intensive care, increased temperature and plasma sodium concentration in the intensive care unit. Out of 114 participants thirty (26.3%) developed dementia within the five years of follow-up. It was shown that a lower preoperative MMSE score and postoperative delirium were factors independently associated with development of dementia (II). One year after cardiac surgery, participants diagnosed with postoperative delirium described in detail feelings of extreme vulnerability and frailty. Despite this, the participants were grateful for the care they had received (III). Hypoactive was the most common symptom profile for delirium. The Swedish version of Nu-DESC showed high sensitivity in detecting hyperactive delirium, but low sensitivity in detecting hypoactive delirium (IV).Conclusion:Delirium was common among older patients undergoing cardiac surgery. Both predisposing and precipitating factors contributed to postoperative delirium. Preventive strategies should be considered in future randomized studies. It might also be suggested that cognitive function should be screened for preoperatively and patients who develop delirium should be followed up to enable early detection of symptoms of dementia. Whether prevention of postoperative delirium can reduce the risk of future dementia remains to be studied. To minimise unnecessary suffering, patients and next of kin should be informed about and prepared for the risk of delirium developing during hospitalization. The Swedish version of Nu-DESC should be combined with cognitive testing to improve detection of hypoactive delirium, but further research is needed. Healthcare professionals need knowledge concerning postoperative delirium in order to prevent, detect and treat delirium so as to avoid and relieve the suffering it might cause.
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| 4. |
- Eriksson, Irene, 1965-
(författare)
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Urinary tract infection : a serious health problem in old women
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Urinary tract infection (UTI) is a common bacterial infection in women of all ages but the incidence and prevalence increase with age. Despite the high incidence of UTI, little is known about its impact on morale or subjective wellbeing and daily life in old women. UTI in older people can be a complex problem in terms of approach to diagnosis, treatment and prevention because in these patients it frequently presents with a range of atypical symptoms such as delirium, gastrointestinal signs and falls. Even if UTI has been shown to be associated with delirium it has frequently been questioned whether UTI can cause delirium or if it is only accidentally detected when people with delirium are assessed. The main purpose of this thesis was to describe the prevalence of UTI, to identify factors associated with UTI among very old women and to illuminate the impact of a UTI on old women’s health and wellbeing. This thesis is based on two main studies, the GErontological Regional DAtabase (GERDA) a cross-sectional, population-based study carried out in the northern parts of Sweden and Finland during 2005-2007 and a qualitative interview study in western Sweden 2008-2009. Data were collected from structured interviews and assessments made during home visits, from medical records, care givers and relatives. UTI was diagnosed if the person had a documented symptomatic UTI, with either short- or long-term ongoing treatment with antibiotics, or symptoms and laboratory tests judged to indicate the presence of UTI by the responsible physician or the assessor. One hundred and seventeen out of 395 women (29.6%) were diagnosed as having suffered from at least one UTI during the preceding year and 233 of these 395 (60%) had had at least one diagnosed UTI during the preceding 5 years. These old women with UTI were more dependent in their activities of daily living, and had poorer cognition and nutrition. In these women, UTI during the preceding year was associated with vertebral fractures, urinary incontinence, inflammatory rheumatic disease and multi-infarct dementia. Eighty-seven of 504 women (17.3%), were diagnosed as having a UTI with or without ongoing treatment when they were assessed, and almost half (44.8%) were diagnosed as delirious or having had episodes of delirium during the past month. In all, 137 of the 504 women (27.2%) were delirious or had had episodes of delirium during the past month and 39 (28.5%) of them were diagnosed as having a UTI. Delirium was associated with Alzheimer’s disease, multi-infarct dementia, depression, heart failure and UTI. Forty-six out of 319 women (14.4%) were diagnosed as having had a UTI with or without ongoing treatment and these had a significantly lower score on the Philadelphia Geriatric Center Morale Scale (PGCMS), (10.4 vs 11.9, p=0.003) than those without UTI, indicating a significant impact on morale or subjective wellbeing among very old women. The medical diagnoses significantly and independently associated with low morale were depression, UTI and constipation. The experience of suffering from repeated UTI was described in interviews conducted with 20 old women. The interviews were analysed using qualitative content analysis. The participants described living with repeated UTI as being in a state of manageable suffering and being dependent on alleviation. Being in a state of manageable suffering was described in terms of experiencing physical and psychological inconveniences, struggling to deal with the illness and being restricted regarding daily life. Being dependent on alleviation was illustrated in terms of having access to relief but also experiencing receiving inadequate care. In conclusion, UTI is very common among old and very old women and is a serious health problem. UTI seems to be associated with delirium and to have a significant impact on the morale or subjective wellbeing of old women and those affected suffer both physically and psychologically and their social life is limited. UTI was also associated with vertebral fractures, urinary incontinence, inflammatory rheumatic disease and multi-infarct dementia which might raise the suspicion that UTI can have serious medical effects on health in old women.
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| 5. |
- 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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| 6. |
- Karlsson, Åsa, 1972-
(författare)
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Team-based home rehabilitation after hip fracture in older adults : effects, experiences and impact of dementia
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BACKGROUND: For an older adult a hip fracture may be a traumatic and life-changing event and has shown to be associated with reduced health-related quality of life, disability and increased mortality. Previous rehabilitation studies have often excluded older adults with cognitive impairment and those living in residential care facilities, groups with an additional risk of poor outcome. Moreover, there are few randomized controlled trials that have evaluated interdisciplinary home rehabilitation after hip fracture. These studies did not include older adults with severe cognitive impairment or dementia, those with serious medical conditions, or those living in residential care.OBJECTIVE: The aim of the thesis was to investigate the effects of early discharge followed by geriatric interdisciplinary home rehabilitation (GIHR) for older adults with hip fracture, and specifically among those with dementia, compared to in-hospital geriatric care according to a multifactorial rehabilitation program. An additional aim was to explore how older adults experienced their rehabilitation and recovery during the year following the fracture.METHODS: The thesis evaluated a randomized controlled trial that included 205 participants with hip fracture, 70 years or older, living in ordinary housing or residential care facilities. In hospital, both the GIHR and control groups received care and rehabilitation according to a multifactorial rehabilitation program, but with the aim of early discharge for the GIHR group. The individually designed GIHR intervention focused on walking ability indoors and outdoors, independence in activities of daily living (ADL), and multifactorial fall prevention during a maximum period of 10 weeks. Participants were assessed in-hospital and at 3- and 12-month follow-up visits. Independence in walking and use of walking aids was assessed via an interview along with gait speed tests. Independence in ADL was measured using the Barthel ADL Index, and the ADL Staircase including the Katz ADL Index, and hospital length of stay (LOS) was recorded from medical charts. The effects of GIHR intervention among participants with dementia were investigated in a post hoc subgroup analysis where additional outcomes were falls, mortality and readmissions between discharge and 12 months. Individual interviews were conducted with 20 selected participants just after the 12-month follow-up. Data were analysed using qualitative content analysis.RESULTS: The postoperative hospital LOS was significantly reduced by a median of six days in the GIHR group compared to the control group, although not significantly reduced in the GIHR group for participants with dementia. Binary logistic regression analyses revealed no significant differences between the GIHR and control groups regarding independent walking ability, the ability to walk without a walking device, or independence in ADL at 3 and 12 months. Gait speed was comparable between the two groups at 3 and 12 months. At 12 months, 56% in the GIHR group and 58% in the control group had recovered their prefracture walking ability, and 41% vs. 42% in GIHR and control groups, respectively, had regained their prefracture Barthel ADL Index score. Interaction analyses showed that the GIHR group vs. the control group had comparable effects on walking ability and ADL at 3 and 12 months, and on falls and mortality between discharge and 12 months, regardless of whether the participants had dementia or not (P≥0.05 for all). The number of readmissions and hospital days after discharge was comparable between GIHR and control groups for participants with dementia. Overall, dementia was associated with significantly impaired walking ability and greater dependence in ADL at 3 and 12 months and with increased risk of falling and increased mortality between discharge and 12 months compared to participants without dementia. The interviews revealed that access to rehabilitation, provided by skilled staff, and support from others were important for participants’ well-being and recovery. Participants experienced a fundamental change in their self-image after the fracture, and faced a number of difficulties, but strove for independence and used adaptive strategies to find contentment in their lives.CONCLUSIONS: In older adults with hip fracture, early discharge followed by interdisciplinary home rehabilitation significantly reduced postoperative hospital LOS. Functional recovery during the year following the fracture was nevertheless comparable to in-hospital geriatric care according to a multifactorial rehabilitation program. The GIHR intervention seems to be appropriate also for older adults with dementia since the effects were not different in this subgroup, except for postoperative hospital LOS, which was not significantly reduced in the GIHR group for participants with dementia. Further studies with larger samples are needed to validate these results. Overall, dementia was associated with a substantial negative impact on the outcomes. According to participants’ experiences, receiving rehabilitation and support after the hip fracture seems crucial for successful recovery. Negative psychological reactions were common, suggesting that future interventions should consider both physical and psychological aspects. Different rehabilitation alternatives were appreciated by the participants. Rehabilitation should thus be customised to suit wishes and needs of older adults and may accordingly be carried out in different settings, where rehabilitation in the home can be one suitable alternative. The findings of this thesis indicate that geriatric interdisciplinary home rehabilitation after hip fracture can be an alternative and a complement to in-hospital care and rehabilitation for older adults with and without dementia.
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| 7. |
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| 8. |
- Toots, Annika, 1971-
(författare)
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Gait speed and physical exercise in people with dementia
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of the thesis was to investigate the importance of physical function for survival in very old people, and furthermore, whether physical exercise could influence physical function, cognitive function, and dependence in activities of daily living (ADLs) in older people with dementia living in nursing homes.The world’s population is ageing. Given the age-related increase in chronic disease such as dementia and compounded by physical inactivity, the prevalence in need for assistance and are in daily activities in older people is expected to increase in the near future. Gait speed, a measure of physical function, has been shown to be associated with health and survival. However, studies of the oldest people in the population, including those dependent in ADLs, living in nursing homes and with dementia, are few. Moreover, in people with dementia physical exercise may improve physical and cognitive function and reduce dependence in ADLs. Further large studies with high methodological quality and with designs incorporating attention control groups are needed in this population. In addition, no study has compared exercise effects between dementia types.The association between gait speed and survival was investigated in a population based cohort study of 772 people aged 85 years and over. Usual gait speed was assessed over 2.4 metres and mortality followed for five years. Cox proportional hazard regression models adjusted for potential confounders were used in analyses. Effects of physical exercise in people with dementia were investigated in a randomised controlled trial that included 186 participants with various dementia types living in nursing homes. Participants were allocated to the High-Intensity Functional Exercise (HIFE) program or a seated control activity, which both lasted 45 minutes and held five times fortnightly for four months. Dependence in ADLs was assessed with Functional Independence Measure and Barthel ADL Index, and balance with Berg Balance Scale. Usual gait speed was evaluated over 4.0 metres in two tests; first using habitual walking aid if any, and thereafter without walking aid and with minimum living support. Global cognitive function was assessed using the Mini-Mental State Examination, the Alzheimer’s Disease Assessment Scale-Cognitive subscale, and executive function using Verbal fluency. Blinded testers performed assessments at baseline, four (directly after intervention completion) and seven months. Analyses used linear mixed models in agreement with the intention-to-treat principle.Gait speed was found to be an independent predictor of five-year all-cause mortality, where inability to complete the gait test or a gait speed below 0.5 iv meters per second (m/s) was associated with higher mortality risk. In analyses of exercise effects on ADLs there was no difference between groups in the complete sample. Interaction analyses showed a difference in exercise effect according to dementia type at seven months. Positive between-group exercise effects were found for dependence in ADLs in participants with non-Alzheimer’s type of dementia (non-AD) at four and seven months. In balance, a difference between groups was found at four but not at seven months in the complete sample, and interaction analyses indicated a difference in effect according to dementia type at four and seven months. Positive between-group exercise effects were found in participants with non-AD. No difference between groups in gait speed was found in the complete sample, where the majority habitually walked with a walking aid. In interaction analyses exercise effects differed according to walking aid use. Positive between-group exercise effects in gait speed were found in participants that walked unsupported at four and seven months. No difference between groups in cognitive function was found in the complete sample. The effects of exercise on gait speed and cognitive function did not differ according to sex, cognitive level, or dementia type.In conclusion, among people aged 85 or older, including those dependent in ADLs and with dementia, gait speed seems to be a useful clinical indicator of health status. Inability to complete the gait test or a gait speed below 0.5 m/s appears to be associated with higher five-year mortality risk. In older people with mild to moderate dementia living in nursing homes, a four-month high-intensity functional exercise program appeared to attenuate loss of dependence in ADLs and improve balance, albeit only in participants with non-AD type of dementia. Further studies are needed to validate this result. Furthermore, exercise had positive effects on gait speed when tested unsupported, in contrast to when walking aids or minimum support were used. The result implies that the use of walking aids in the gait speed test may conceal exercise effects. The exercise program had no superior effects on global cognition or executive function when compared with an attention control activity. This thesis suggests that, in older people with dementia, exercise effects on physical function rather than cognitive function may explain effects on dependence in ADLs.
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| 9. |
- Weidung, Bodil, 1988-
(författare)
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Blood pressure in very old age : determinants, adverse outcomes, and heterogeneity
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: High blood pressure (BP) is the leading risk factor for disease and mortality worldwide. However, risks associated with high BP in very old age (≥ 80 or ≥ 85 years) are not entirely understood, as the majority of scientific studies have been performed with younger populations and existing scientific knowledge about very old individuals is sometimes contradictory. Results of previous studies of very old individuals suggest that the associations of BP with mortality and stroke differ with levels of physical and cognitive function. More studies that are representative of very old individuals, including individuals with multimorbidity, that are of adequate size, involve proper adjustment, and investigate non-linear associations, are needed to investigate these issues.Systolic blood pressure (SBP) decline is common among very old individuals and has been shown to precede adverse events. Previous studies have shown that SBP change is associated with baseline SBP, age, and health-related factors, but determinants of SBP change have not been investigated using comprehensive, multivariate models.The three main aims of this thesis were to investigate, in a sample of individuals aged ≥ 85 years, 1) determinants of SBP change, 2) the association of BP with mortality risk and whether this association differs with respect to gait speed and/or Mini-Mental State Examination (MMSE) score, and 3) the association of BP with stroke risk and whether this association differs with respect to the Barthel Activities of Daily Living (ADL) index and/or MMSE score.Methods: The studies conducted for this thesis were based on data from the population-based Umeå 85+/Gerontological regional database study, which provided cross-sectional and longitudinal data on socioeconomic factors, medical conditions, drug prescriptions, and health-related assessments from 2000 to 2015. Participants were aged 85, 90, and ≥ 95 years, and lived in Västerbotten, Sweden, and Österbotten/Pohjanmaa, Finland. Follow-up assessments were conducted after 5 years. Mortality data were collected after 2 and 5 years, and stroke data were collected after 5 years, from death certificates, medical records, population registers, and the inpatient diagnosis register. Comprehensive multivariate models were developed to investigate determinants of SBP change using multiple linear regression, and to investigate associations of mortality and stroke risks with BP using Cox proportional-hazard regression models.Results: Average (± standard deviation) baseline SBP was 146 ± 23 mm Hg, and average diastolic blood pressure (DBP) was 74 ± 11 mm Hg. Within 5 years, 61% of participants had died and 10% had had incident strokes. Among participants followed for 5 years, the average annual SBP decline was 2.6 ± 5.4 mm Hg.In a multivariate model, SBP decline was associated with later investigation year (p = .009), higher baseline SBP (p < .001), baseline antidepressant drug use (p = .011), incident acute myocardial infarction during follow-up (p = .003), use of a new diuretic drug during follow-up (p = .044), and declining Barthel ADL index scores during follow-up (p < .001).In an age- and sex-adjusted analysis of the total sample, mortality risk was decreased in higher (vs. lower) BP categories (SBP ≥ 165 vs. ≤ 125 mm Hg: hazard ratio [HR] .50, p < .001; DBP 70–74 vs. 75–80 mm Hg: HR 1.32, p = .031). In a comprehensively adjusted analysis of the total sample, SBP was not associated significantly with mortality risk. The associations of SBP with mortality in the gait speed < .5 m/s subcohort corresponded with those found in the total sample. In comprehensively adjusted analyses in the gait speed ≥ .5 m/s subcohort, mortality risk increased independently with higher (vs. lower) BP (SBP ≥ 165 vs. 126–139 mm Hg: HR 2.13, p = .048; DBP > 80 vs. 75–80 mm Hg: HR 1.76, p = .026). In comprehensively adjusted analyses in the MMSE score subcohorts, SBP was associated significantly with mortality risk only in the 0–10 MMSE score subcohort; high and low SBP categories were associated independently with increased mortality risk, compared with an intermediary SBP category (SBP ≥ 165 vs. 126–139 mm Hg; HR 4.54, p = .007; SBP ≤ 125 vs. 126–139 mm Hg: HR 2.23, p = .023). Higher BP was associated significantly with increased stroke risk in multivariate models (SBP per 10 mm Hg increment: HR 1.19, p < .001; DBP per 10 mm Hg increment: HR 1.26, p = .013). SBP was not associated with stroke risk in participants with SBP < 140 mm Hg.Interaction effects on the association with mortality were significant between SBP and gait speed (age- and sex-adjusted model: p = .031) but not between SBP and MMSE score. No interaction in the association with stroke was found between any BP measure and Barthel ADL index or MMSE score.Conclusion: The decline in BP in very old age may be explained by health-related factors. Low BP may be a risk marker for short life expectancy, due to morbidity, in the general very old population and among very old individuals with low gait speeds. High BP seems to be an independent risk factor for mortality only in certain groups, which may be distinguished by high gait speed or very severe cognitive impairment. High SBP and DBP seem to increase stroke risk in very old age. These findings may contribute to a better understanding of the risks of adverse outcomes in very old individuals with different BP levels, the importance of comorbidity for these risks, and the etiology of SBP change.
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- Conradsson, Mia, 1981-
(författare)
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Physical exercise and mental health among older people : measurement methods and exercise effects focusing on people living in residential care facilities
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to study the effects of exercise on mental health among older people living in residential care facilities. The aim was also to study the reliability of an assessment scale for balance function and the usefulness of an assessment scale for depressive symptoms among older people, including people with cognitive impairments. The Berg Balance Scale (BBS) is frequently used to assess balance in older people, but knowledge is lacking about its absolute reliability. The BBS (0-56 points) was assessed twice among older people living in residential care facilities by the same assessor, at approximately the same time of day, and with 1-3 days in between. The absolute reliability was calculated as being 7.7 points, using 95% confidence level, and the Intra Class Correlation coefficient (ICC) was calculated to 0.97. Depression is common among older people and is often not detected and not treated adequately. The Geriatric Depression Scale 15-item version (GDS-15) was designed to assess depressive symptoms among older people, but there is limited knowledge about the usefulness of the scale among people with varying degree of cognitive impairment. A sample of people aged 85 years and over was divided into groups according to cognitive function using their Mini-Mental State Examination (MMSE) scores; 0-4, 5-9, 10-14, 15-19, 20-24, 25-27, and 28-30. In total, 650 (78%) of the 834 participants completed the GDS-15. The lower the cognitive function, the smaller the proportion who completed the GDS-15 assessment; for the two MMSE groups with scores of < 10, the proportions who completed the GDS-15 were 1% and 42%, respectively, compared to 64–95% in people with MMSE scores of ≥ 10. The level of correlation between the GDS-15 and a scale of psychological wellbeing, the Philadelphia Geriatric Center Morale Scale (PGCMS), did not differ between MMSE groups with scores of ≥5 compared to people in the group with the highest scores (MMSE 28–30). Exercise has been suggested as effective in influencing mental health among community-dwelling older people, but there is a need for a well-designed study to establish the effects among older people living in residential care facilities. A high-intensity functional exercise programme was evaluated for effects on depressive symptoms and psychological wellbeing among older people dependent in activities of daily living (ADL) and living in residential care facilities. The study was a cluster-randomised controlled study. Participants were randomised to either a high-intensity functional weight-bearing exercise program (HIFE Program) or a control activity. Sessions were held in groups, for approximately 45 minutes, five times over each two-week period for three months, a total of 29 times. The outcome measures, the GDS-15 and the PGCMS, were blindly assessed at baseline, 3- and 6-month follow-up. There were no differences between the groups at the 3- or 6-month follow-ups in the total sample. However, sub-groups analyses showed a difference in PGCMS scores in favor of the exercise group among people with dementia at the 3-month follow-up. Regarding older people living in residential care facilities, including people with cognitive impairments, there is a lack of evidence showing that exercise has a positive influence on mental health. This may either be due to a lack of effect, or an insufficient amount of effect of exercise on physical capacity or dependence in ADL, which could be two important mediating factors for influencing mental health. The association between changes in physical capacity (BBS) or dependence in ADL (Barthel ADL Index) and changes in mental health (GDS-15 and PGCMS) was evaluated. The results showed no significant associations between change in physical capacity or dependence in ADL, and change in depressive symptoms or psychological well-being. Further, interaction analyses showed no moderating effects for dementia disorder. In conclusion, despite a high ICC value, the result of the absolute reliability evaluation shows that a change of 8 BBS points is required to reveal a genuine change in function among older people who are dependent in ADL and living in residential care facilities. This knowledge is important in the clinical setting when evaluations are made of an individual’s change in balance function over time in this group of older people. The GDS-15 seems useful in assessing depressive symptoms among very old people with MMSE scores of ten or above. More studies are needed to strengthen the validity among people with MMSE scores of 10-14, and for people with lower MMSE scores than ten there may be a need to develop and validate other measurements. Furthermore, a high-intensity exercise programme offered 2-3 times/week seems not to generally influence mental health among older people living in residential care facilities. However, the exercise programme may have a short-term effect on well-being among people with dementia. A change in physical capacity or dependence in ADL does not appear to be associated with a change in depressive symptoms or psychological well-being among older people who are living in residential care facilities. These results may explain why studies of using exercise to influence mental health have not shown effects in this group of older people. In future research, there is a need for studies that evaluate whether exercise offered more frequently, or interventions that aim to increase the level of physical activity in daily life, can influence mental health among older people living in residential care facilities.
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