Bakgrund: Demens förväntas öka i Sverige, cirka 130 000–150 000 personer lider idag av demens och 20 000–25 000 nya personer insjuknar årligen. Anhörigvårdare har en avgörande roll för patienter med demens, och deras behov av adekvat stöd är av yttersta vikt. Stödet till anhöriga är i nuläget ej tillräckligt. Att belysa deras situation skulle kunna ge sjuksköterskor ökade kunskaper om demens och förbättra stödet till patienter och deras anhöriga, samt att anpassa vården efter deras unika behov. Syfte: Att belysa anhörigas upplevelser av att vårda en närstående med demens. Metod: En allmän litteraturstudie, bestående av fem kvalitativa och fyra kvantitativa artiklar samt en studie med mixad metod. Resultat: Demenssjukdom innebär ett krävande ansvar för anhörigvårdare. Bristande kunskap om symtom leder till att varningssignaler förbises. Förutom det yttre stödet krävs mer hjälp för att lindra vårdansvaret. Ömsesidighet och förberedelse minskar anhörigvårdares stress. Tidig intervention och utbildning är viktigt för att förbättra situationen för både patienter och deras familjer. Konklusion/implikation: Studien belyser det akuta behovet av omfattande stöd för de anhöriga vårdarna. Anhörigstöd kräver inte bara medicinsk expertis utan även ett känslomässigt stödsystem. Att erbjuda stöd är betydande för att minska den fysiska och psykiska belastningen på de anhöriga. / Background: Dementia is expected to increase in Sweden, approximately 130,000–150,000 people suffer from dementia today and 20,000–25,000 new people become ill annually. Carers have a crucial role for patients with dementia, and their need for adequate support is of the utmost importance. Support for relatives is currently insufficient. Elucidating their situation could provide nurses with increased knowledge about dementia and improve support for patients and their relatives, as well as adapting care to their unique needs. Aim: To shed light on relatives' experiences of caring for a loved one with dementia. Method: A general literature study, consisting of five qualitative and four quantitative articles and a mixed method study. Results: Dementia entails a demanding responsibility for family caregivers. Lack of knowledge about symptoms leads to warning signs being overlooked. In addition to external support, more help is required to alleviate the care responsibilities. Reciprocity and preparation reduce caregiver stress. Early intervention and education are important to improve the situation for both patients and their families. Conclusion/implication: The study highlights the urgent need for extensive support for family caregivers. Family support requires not only medical expertise but also an emotional support system. Offering support is important in reducing the physical and psychological burden on the relatives.

Bakgrund: Demenssjukdom blir allt vanligare och risken att drabbas ökar i takt med stigande ålder. Beteendemässiga och psykiska symtom vid demenssjukdom (BPSD) förekommer ibland till följd av demenssjukdomen. BPSD delas in i fyra huvudgrupper där hyperaktivitet innebär vandring, upprepat frågande, muntligt störande beteende samt agitation och aggressivitet, som är något av det svåraste och mest utmanande att bemöta för omgivningen. Syfte: Syftet var att sammanställa omvårdnadsinterventioner vid hyperaktivitet i samband med demenssjukdom. Metod: Metoden var en systematisk litteraturöversikt enligt SBUs riktlinjer. De kvantitativa studierna analyserades med stöd i processen för manifest innehållsanalys enligt Graneheim & Lundman (2003). Resultat: I resultatet framkom två övergripande typer av omvårdnadsinterventioner: Generella omvårdnadsinterventioner med tre grupper: Musik minskar agitation och aggressivitet, Närhet till hundar kan stabilisera agitation och aggressivitet, och Ljusterapi för bättre dygnsrytm minskar agitation. Individuellt anpassade omvårdnadsinterventioner med två grupper: Interventioner utifrån patientens intressen minskar beteendeproblem och Individualiserad Montessori intervention minskar agitation. Resultatet indikerade att generella omvårdnadsinterventioner hade en kortvarig effekt på patienterna medan omvårdnadsinterventioner baserade på individens behov antydde ett bättre och mer långvarigt resultat. Konklusion: Rätt metoder är en förutsättning för att kunna hjälpa människor samt att de är utformade för rätt målgrupp och sker evidensbaserat. Eftersom omvårdnadsinterventioner vid hyperaktivitet indikerade en kortvarig effekt behöver samtlig personal arbeta aktivt och kontinuerligt med individuellt anpassade omvårdnadsinterventioner med hänsyn till patientens bakgrund, vilket överensstämmer med Socialstyrelsens riktlinjer (Socialstyrelsen 2010). / Background: Dementia is increasingly common, and the risk increases with age. Behavioral and psychological symptoms of dementia (BPSD) sometimes occur as a result of dementia. BPSD is divided into four main groups where hyperactivity containing wandering, verbal behavior and agitation/aggression, is one of the most difficult and challenging symptoms that both caregivers and family members are faced with. The purpose: The purpose was to compile nursing interventions that can limit hyperactivity in dementia care. Method: The method was a systematic literature review carried out under SBUs guidelines. The quantitative studies were analyzed with the support of the process of content analysis according to Graneheim & Lundman (2003). Results: The result revealed two main types of nursing interventions: General nursing interventions with three groups: Music reduces agitation and aggression, Dogs within close proximity can stabilize both agitation and aggression and Light therapy improves circadian rhythm and thereby decreases agitation. Personalized care interventions with two groups: Patient interest based interventions decreases behavioral problems and Montessori interventions which focus on the person as an individual reduces agitation. The result indicated that the general nursing interventions had a short term effect on patients. However, the interventions based on individualized care suggested a better and longer lasting effect. Conclusion: The right methods are a prerequisite to be able to help people and that they are formed evidence based for the right purpose. As the nursing interventions for hyperactivity only provide short term effect, the staff caring for the patient need to work actively as well as continuously with individualized interventions with respect to the patients background, which is consistent with the Social board’s guidelines (The Social board 2010).

<p>This essay is about needs assessors within public elder care. The method is a quantitative vignette study. The aim of the study is to find out whether there is an existing consensus among the needs assessors when a relative to a client with reduced cognitive functions wants to make an application even though the client does not want to. We also wanted to find out whether there are any underlying circumstances which have influence on the needs assessors’ reactions to this specific situation. We used a questionnaire which consisted of four vignettes that illustrated a meeting between a needs assessor, a client and a relative to the client. The vignettes was complemented with questions that made it possible to find underlying circumstances that determine whether the needs assessors do accept the application from the clients relative. The result shows that professional experience and education is significant for whether the needs assessors choose to accept the application or not. It is also clear that there are variations depending on which town district the needs assessors work in. In some town district the needs assessors act with great similarity while there are huge differences in other town districts.</p>

<p>The purpose with this study was to examine which opinions and knowledge the directors have about the physical residential environment's importance on accommodations for people with dementia disease and how they do to create and to maintain a good physical residential environment. The issues have been: Which opinions and knowledge the directors had about the physical residential environment's importance for the people with dementia? How did the managers work in order to create and maintain a good physical residential environment? We had four themes, homelike environment on the accommodations, priorities on the accommodation, care/nursing in the physical residential environment and the manager’s possibility to influence the physical residential environment. The study followed a qualitative method. Five managers were interviewed on four accommodations and the managers were said to work actively with the physical residential environment. The results of the study were analyzed on the basis of Antonovskys theoretical perspectives called ”the feeling of contexts”. The result showed that the managers considered that the living environment for people with dementia should be a homelike environment which is individual tailored from their previous life. The managers wanted to accomplish a living environment which stimulated involvement.</p>

<p>Tidigare forskning pekar på försämrad kommunikationsförmåga som ett av de mest uppmärksammade symtomen vid demenssjukdom. För att förmedla ett budskap till sin omgivning använder dementa som alla andra människor både verbala och icke-verbala signaler. Med tiden försämras deras verbala uttrycksätt och de börjar istället att i allt högre grad använda sig av de icke-verbala signalerna, som till exempel ansiktsuttryck, kroppsspråk, gester, paraspråk och liknande. Eftersom dementas olika kommunikativa uttryckssätt ibland kan vara väldigt svåra att tolka av andra i deras närhet, är det av stor betydelse att ta reda på de förutsättningar som påverkar detta. Syftet med denna studie är att utifrån vårdpersonalens berättelser belysa vilka faktorer som påverkar deras tolkning av dementas olika kommunikativa uttryckssätt under omvårdnadsmötet. För att svara på detta syfte har jag använt mig av fokusgruppsintervjuer som metod för att samla in data, vilken sedan analyserades med hjälp av kvalitativ innehållsanalys. Resultatet visar att de faktorer som påverkar vårdpersonalens tolkning av dementas olika kommunikativa uttryckssätt är (1) kunskap, (2) yrkeskompetens och (3) institutionella aspekter som psykosocial miljö och tid. Den föreliggande studiens resultat kommer förhoppningsvis att bidra till en bättre kommunikation mellan dementa och vårdpersonal.</p>

The purpose with this study was to examine which opinions and knowledge the directors have about the physical residential environment's importance on accommodations for people with dementia disease and how they do to create and to maintain a good physical residential environment. The issues have been: Which opinions and knowledge the directors had about the physical residential environment's importance for the people with dementia? How did the managers work in order to create and maintain a good physical residential environment? We had four themes, homelike environment on the accommodations, priorities on the accommodation, care/nursing in the physical residential environment and the manager’s possibility to influence the physical residential environment. The study followed a qualitative method. Five managers were interviewed on four accommodations and the managers were said to work actively with the physical residential environment. The results of the study were analyzed on the basis of Antonovskys theoretical perspectives called ”the feeling of contexts”. The result showed that the managers considered that the living environment for people with dementia should be a homelike environment which is individual tailored from their previous life. The managers wanted to accomplish a living environment which stimulated involvement.

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. / Umeå 85+/GERDA

This essay is about needs assessors within public elder care. The method is a quantitative vignette study. The aim of the study is to find out whether there is an existing consensus among the needs assessors when a relative to a client with reduced cognitive functions wants to make an application even though the client does not want to. We also wanted to find out whether there are any underlying circumstances which have influence on the needs assessors’ reactions to this specific situation. We used a questionnaire which consisted of four vignettes that illustrated a meeting between a needs assessor, a client and a relative to the client. The vignettes was complemented with questions that made it possible to find underlying circumstances that determine whether the needs assessors do accept the application from the clients relative. The result shows that professional experience and education is significant for whether the needs assessors choose to accept the application or not. It is also clear that there are variations depending on which town district the needs assessors work in. In some town district the needs assessors act with great similarity while there are huge differences in other town districts.

Tidigare forskning pekar på försämrad kommunikationsförmåga som ett av de mest uppmärksammade symtomen vid demenssjukdom. För att förmedla ett budskap till sin omgivning använder dementa som alla andra människor både verbala och icke-verbala signaler. Med tiden försämras deras verbala uttrycksätt och de börjar istället att i allt högre grad använda sig av de icke-verbala signalerna, som till exempel ansiktsuttryck, kroppsspråk, gester, paraspråk och liknande. Eftersom dementas olika kommunikativa uttryckssätt ibland kan vara väldigt svåra att tolka av andra i deras närhet, är det av stor betydelse att ta reda på de förutsättningar som påverkar detta. Syftet med denna studie är att utifrån vårdpersonalens berättelser belysa vilka faktorer som påverkar deras tolkning av dementas olika kommunikativa uttryckssätt under omvårdnadsmötet. För att svara på detta syfte har jag använt mig av fokusgruppsintervjuer som metod för att samla in data, vilken sedan analyserades med hjälp av kvalitativ innehållsanalys. Resultatet visar att de faktorer som påverkar vårdpersonalens tolkning av dementas olika kommunikativa uttryckssätt är (1) kunskap, (2) yrkeskompetens och (3) institutionella aspekter som psykosocial miljö och tid. Den föreliggande studiens resultat kommer förhoppningsvis att bidra till en bättre kommunikation mellan dementa och vårdpersonal.

Bakgrund: Andelen äldre i befolkningen ökar nationellt och internationellt, och med ökande ålder ökar både fysisk och psykisk ohälsa. Äldre personer med ohälsa i form av kognitiv svikt (oftast demenssjukdom) kan bli beroende av vård och omsorg i särskilda boenden för äldre för att kunna känna trygghet och välbefinnande samt ha ett gott liv, i gemenskap med andra. Dock visar utvärderingar av särskilda boenden för äldre att vården ofta kan vara uppgiftscentrerad och inte motsvara de äldres individuella behov och önskemål. Personcentrerad vård är en vårdmodell som beskrivs kunna tillgodose äldre personers multidimensionella behov och önskemål, genom att personens livshistoria, personlighet, kapacitet och perspektiv uppmärksammas, respekteras och inkluderas i vården. Den vetenskapliga litteraturen inom området visar dock att det finns begränsad kunskap om förekomsten av personcentrerad vård i särskilda boenden för äldre i Sverige och internationellt, liksom om vilka faktorer som är mest betydelsefulla för att särskilda boenden för äldre ska bedriva en personcentrerad vård. Syfte: Syftet med denna avhandling var att beskriva faktorer som samvarierar med förekomst av personcentrerad vård i särskilda boenden för äldre i Sverige. Metod: Samtliga delstudier var tvärsnittstudier och data samlades in genom enkäter till äldre med kognitiv svikt och personal i särskilda boenden för äldre i Sverige. I studie I bestod insamlad data av skattningar av personcentrerad vård från vårdpersonal (n=1465) i 182 särskilda boendeenheter. I studie II insamlades data i form av vårdpersonalens (n=1169) skattningar av personcentrerad vård och proxyskattningar av de äldres (n=1261) livskvalitet, ADL-förmågor, smärta, depressiva symtom och agitation i 151 särskilda boendeenheter. Delstudie III baserades på data i form av personalskattningar (n=1169) av personcentrerad vård, tillfredställelse med arbete och vård, samvetsstress, arbetsbelastning och psykosocialt klimat i samma 151 särskilda boendeenheter. Även delstudie IV baserades på data från de 151 särskilda boendeenheterna och inkluderade skattningar av de äldre och vårdpersonal, men också skattningar av organisation och miljö vid dessa enheter (n=151). Samtliga studiernas data analyserades med hjälp av statistiska analyser, beskrivande, bivariata och multivariata analysmetoder. Resultat: Studie I visade att enkätinstrumentet The Person-Centred Care Assessment Tool (P-CAT) har tillfredställande psykometriska egenskaper för intern konsistens och test-retest-reliabilitet. Instrumentet består av två subskalor: Individualisering av vården och Stöd från organisation och miljö. Delstudie II visade att de boendes ADL-förmågor och livskvalitet skattades bättre vid enheter som kan beskrivas som mer personcentrerade. Delstudie III visade att en mer personcentrerad vård har samband med att personalen upplever ett positivt psykosocialt klimat, mindre samvetsstress, lägre arbetsbelastning samt högre tillfredställelse med vård och arbete. Studien visade också att personcentrerad vård var positivt relaterat till i vilken omfattning vårdarna hade vidareutbildning i demensvård. Delstudie IV visade att vårdmiljön var mest betydelsefull för förekomsten av personcentrerad vård vid boendeenheterna och att en gynnsam vårdmiljö innebar att personal upplevde att det var ett positivt psykosocialt klimat på enheten, att de hade tid att prata med eller bara vara med de boende samt att de upplevde sig ha en gemensam värdegrund, låg arbetsbelastning och en fysisk miljö som var anpassad till de boendes behov. Slutsatser: Resultaten i avhandlingen visar att den svenska versionen av P-CAT kan användas för valida och reliabla utvärderingar av personcentrerad vård samt att den kan rekommenderas för fortsatt forskning och vårdutveckling inom särskilda boenden för äldre. Resultatet visar också att den vård- och arbetsmiljö som omger de äldre och vårdpersonal i särskilda boenden för äldre är betydelsefull för förekomsten av personcentrerad vård. Dessa aspekter behöver fokuseras ytterligare för att kunna erbjuda en personcentrerad vård. Vidare är det psykosociala klimatet och förekomsten av en upplevd gemensam värdegrund viktig att förstå och prioritera om vården ska utvecklas mot en ökad personcentrering. Fortsatt forskning och kliniskt utvecklingsarbete behövs för att operationalisera och implementera de komponenter som bidrar till ett positivt psykosocialt klimat och en personcentrerad värdegrund på särskilda boenden för äldre. Dessutom behövs en ökad förståelse för hur en sådan värdegrund kan omsättas i personcentrerade interaktioner, handlingar, aktiviteter och prioriteringar. Det vore alltså önskvärt att äldrevården utvecklades mot ett mer personcentrat förhållningssätt, eftersom avhandlingens resultat visar att högre grad av personcentrerad vård i särskilda boenden för äldre var positivt relaterat till välbefinnande och tillfredställelse för såväl de äldre som för vårdpersonal. / Introduction: The proportion of older people in the population increases nationally and internationally, with a declining physical and mental health often accompanying older age. Older people with health issues such as cognitive impairment or dementia often become dependent upon residential aged care to feel safe, experience well being and a good life with others. However, it has been shown that residential aged care can largely be taskoriented and not tailored to residents' needs and wishes. Person-centred care is a contemporary best practice model of care that can meet the multidimensional needs and preferences of older people dependent on care, by acknowledging, respecting and including each person’s life story, personality, capacities, and perspective in care. Nevertheless, the research literature indicates a limited knowledge on the extent to which residential aged care units are person-centred in Sweden and internationally, as well as a limited knowledge into factors of importance for person-centred care in residential aged care units. Aim: The overall aim of this thesis was to describe factors that associate with person-centred care in Swedish residential aged care units. Methods: The thesis consists of four studies with cross-sectional designs, and data was collected through resident and staff surveys in Swedish residential aged care units. Study I collected data consisting of ratings of person-centred care from staff (n=1465) in 182 residential aged care units. Study II collected data consisting of staff (n=1169) ratings of person-centred care and proxy ratings of resident (n=1261) quality of life, ADL-capacity, pain, depressive symptoms and agitated behaviours, in 151 residential aged care units. Study III was based on staff (n=1169) ratings of person-centred care, satisfaction with care and work, job strain, stress of conscience, and perceived psychosocial climate in the same 151 residential aged care units as in study II. Study IV was also based on data from the 151 residential aged care units as described in study II and III, and included ratings of resident and staff variables, as well as variables related to the organization and environment at the units. Data was analyzed using statistical analyses such as descriptive, bivariate, and multivariate methods. Results: Study I showed that the Person-Centred Care Assessment Tool (PCAT) has satisfactory psychometric properties relating to internal consistency and test-retest reliability. The tool consists of two subscales: Extent of personalizing care and Amount of organizational and environmental support. Study II showed that residents were rated as having higher quality of life and better ability to perform activities of daily living in units described as being more person-centred. Study III highlighted that person-centred care was associated with higher staff satisfaction, less job strain, less stress of conscience, and a positive psychosocial unit climate. Person-centredness of care was also positively associated with the extent to which staff had continuing education in dementia care. Study IV showed that the environment is the most influential factor for person-centred care, and that an environment facilitating person-centred care consists of a positive psychosocial unit climate, where staff perceives having time to spend being with residents, where staff perceives a shared philosophy of care, a low job strain, and a physical environment adapted to residents’ needs. Conclusions: The results of the thesis show that the Swedish version of the P-CAT can be used for valid and reliable assessment of unit personcentredness, and that it can be recommended for further research and practice development in residential aged care. The results of the thesis also show that the environment of care and work that encapsulates residents and staff in residential care units is important for person-centred care. These aspects need further focus to enable person-centred care in residential aged care units. Furthermore, the psychosocial climate and the presence and content of a shared philosophy of care are important to understand and prioritize if care is to move towards increased person-centredness. Further research and practice development work is needed to operationalize and implement the components that contribute to a positive psychosocial climate and a person-centred philosophy in residential aged care units, as well as to increase the knowledge of how such a philosophy of care can be translated into person-centred actions, interactions, activities and priorities. strive towards developing person-centredness further within aged care is desirable, as the results in this thesis indicate that residential aged care units