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- 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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| 3. |
- 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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- 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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| 5. |
- 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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- Niklasson, Johan, 1968-
(författare)
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Morale in very old people : With focus on stroke, depression and survival
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Morale is a multidimensional concept, often defined as a future-oriented optimism or pessimism regarding the problems and opportunities associated with ageing. Very old people, older than 80 years, constitute an age group that is expected to increase in Europe from 4.7% of the general population today to 12.0% in the year 2060 in Europe. The overall aim of this thesis was to explore morale among very old people.Method: The Umeå 85+/GErontological Regional Database study (GERDA) is a population-based study carried out in parts of northern Sweden and western Finland in which every second 85 year old, every 90 year old and everyone aged 95 years and older were invited to participate. The study started the year 2000 and every five years re-invites previous participants and invites new individuals to participate in the study. The Philadelphia Geriatric Center Morale Scale (PGCMS), which is widely used to measure morale in old people, has been translated into many languages.Results: There were 598 individuals who answered the PGCMS in the Umeå 85+/GERDA study. Despite respondents’ advanced age 92.6% (554/598) answered 16 or 17 of the questions. The construct validity of the Swedish version of the PGCMS was tested among the 493 individuals who answered all 17 questions using confirmatory factor analysis and the analysis showed a generally a good fit. Reliability tested with Cronbach’s alpha was 0.74. Reliability was also tested in a convenience sample of 54 individuals (mean age of 84.7±6.7 years) and the IntraClass Correlation coefficient (ICC) was 0.89.Almost 20% (91/465) of participants who could answer the PGCMS had had a stroke. Those with stroke had significantly lower PGCMS scores than those without (10.9±3.8 vs 12.1±3.0, p-value 0.008), but there were 38.5% with stroke history who had high morale. A multiple linear regression analysis showed that depression, angina pectoris and impaired hearing were independently associated with low morale among those with a stroke history.A logistic regression model showed that each point increase in PGCMS score lowered the risk of depressive disorders five years later (odds ratio 0.779, p<0.001, with each point increase in PGCMS). In a Cox model adjusted for several demographic, health- and function-related confounders, including age and gender, mortality was higher among participants with low morale (RR=1.36, p=0.032) than those with high morale. There was a similar but non-significant pattern towards increased mortality in participants with moderate morale compared to high morale (RR=1.21, p-value=0.136).Conclusion: The feasibility and psychometric properties of the Swedish version of the PGCMS seems to be satisfactory among very old people. A large proportion of very old people have had a stroke, which is associated with reduced morale. Depression, angina pectoris and impaired hearing were independently associated with low morale among those with stroke. Among very old people, a higher level of morale seems to be associated with a lower risk of suffering from depressive disorders five years later. High morale is independently associated with increased five-year survival among very old people.
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