Comme dans la plupart des pays européens, la population française est soumise au défi du vieillissement. Au I" janvier 2016, les personnes âgées de 60 ans ou plus représentaient 23 % de la population. Selon les projections les plus récentes, cette catégorie de personnes va continuer d'augmenter et représentera 30 % de la population à l'horizon 2060.Un grand nombre d'entre elles ne disposent pas des ressources nécessaires pour supporter le coût de l'hébergement collectif devenu souvent nécessaire, ce qui pose la question du financement de cet accueil.La présente étude propose de résoudre ce problème par l'analyse du réseau d'obligations construit autour de la personne âgée, à la fois débitrice du coût de l'hébergement collectif vis-à-vis de la structure d'accueil et créancière d'aliments vis-à-vis de la collectivité et de certains membres de sa famille. Le montant des créances alimentaires doit servir à couvrir le montant de la dette d'hébergement.Ce réseau d'obligations est mobilisé par les acteurs concernés pour obtenir l'extinction totale de la créance des établissements en respectant les recours et procédures prévus par le législateur ou par le juge. Néanmoins, ces techniques légalement encadrées ne permettent pas toujours d'atteindre l'objectif visé: les règles très strictes du régime de l'obligation alimentaire restreignent significativement les montants obtenus devant le juge aux affaires familiales.Sous l'impulsion des créanciers insatisfaits, la mobilisation du réseau d'obligations a donc dépassé le cadre organisé. De l'élaboration de barèmes de calcul jusqu'à la signature de contrats en passant par l'émission de titres exécutoires, la famille de la personnes âgée est sollicitée par des techniques diversifiées, plus ou moins légales, qui la privent de la protection du régime de l'obligation alimentaire mais qui permettent aux établissements créanciers d'augmenter leurs chances d'être payés intégralement. / As in most of the European countries, the French population is facing the challenge of ageing. On January I st, 2016,23 % of the population was aged 60 years or aider. According to the most recent projections, this category is going to increase and will represent 30 % in 2060. A large number of them do not have sufficient resources to pay the price of the collective accommodation they often need.The present study proposes to salve this problem by analysing the network of obligations built around the elderly persan. She is the debtor of the cost of the collective accommodation but she also is the maintenance creditor towards the society and towards certain members ofher family. The amount of the maintenance claims has to caver the amount of the debt of accommodation. The concerned actors mobilise this network of obligations to obtain the extinction of the claim of establishments by respecting the legal remedies and proceedings planned by the legislator or by the judge. Nevertheless, these techniques legally organised do not always reach their goal : the legal regime of the maintenance obligation restrict significantly the amounts obtained in front of the family court.For this reason, the dissatisfied creditors decided to mobilise the network ofobligations in other ways. From the elaboration of calculation scales to the signature of contracts, including the issuance of enforceable titles, the family of the elderly is requested by diversified, more or less legal techniques, which deprive them of the protection of the regime of the maintenance obligation but which allow establishments creditors to increase their chances to be entirely paid.

This thesis researches the need for increased social engagement among isolated elderly population receiving home care service in Sweden. The notion of ‘social engagement’ and how to stimulate it is a central point throughout the work. The author finds that the isolation issue is related to political factors, sustainability and Swedish culture and how they interact with the individual. The theoretical framework is comprised of the field of care science and theories regarding isolation and sense of community. Using such empirical research and more in-depth own research such as interviews, the author concludes that social isolation is, in fact, a problem. The answer or suggested solution to this problem takes the shape of a design proposal: Play, Share, Connect, Repeat. Play, Share, Connect, Repeat is a game introduced by home care service that aims to create bonds and stimulate social engagement between care receivers.

Problématique : Un tiers des personnes âgées de plus de 65 ans chute chaque année. Pourtant, les recommandations professionnelles de réduction des risques domiciliaires sont peu suivies par les habitants en raison de leur résistance à des aménagements qui leur sont imposés. A l’origine de ce phénomène, nous présumons l’existence d’une identité-logement, forme d’identité spatiale construite, qui complexifierait le rapport entre l’individu et son lieu de vie. Objectifs : Cette recherche qualitative vise à modéliser les processus d’apprentissage constituant l’identité-logement pour envisager une éducation thérapeutique du patient (ETP) chuteur lui permettant de participer pleinement à l’aménagement de son domicile. Méthode : Suivant la méthode de théorisation ancrée, nous avons élaboré notre modèle grâce à une comparaison constante entre nos résultats et les données recueillies. Dix entretiens semi-directifs ont été menés auprès de seniors chuteurs avec l’utilisation d’une carte mentale du logement (CML). Résultats : L’identité-logement comprend deux sentiments. Au centre, le sentiment de continuité temporelle, se compose des routines et connaissances del’individu dans son cycle présent, liées à ses souvenirs et projections futures. Le sentiment d’unité et de cohérence contient le sentiment de continuité, et impulse chez l’habitant des stratégies de défense pour protéger son identité-logement ainsi que des processus d’apprentissage pour la faire évoluer. Discussion : L’identité-logement se traduit par un « agir compétent » en situation au domicile. Elle est rendue dynamique par des stratégies d’apprentissage « constructivistes » permettant à la personne d’assimiler de nouvelles connaissances et de s’accommoder à l’évolution de la situation. Notre modélisation permet d’envisager une ETP sous forme d’accompagnement éducatif autour du projet d’aménagement. La CML serait utilisée pour caractériser l’évolution de l’identité-logement. Conclusion : Des recherches complémentaires permettraient de valider la CML et de tester empiriquement notre modèle. / A third of adult above 65 years of age, fall every year. Nevertheless, professional recommendations to reduce home hazards are rarely followed by the inhabitants due to their reticence to accept the modification of their living space that is imposed on them. At the origin of this phenomenon, what we term Home-Identity, a form of constructed spatial identity, which would render the relation between the individual and where he/she lives more complex. Objectives: This qualitative research aims to establish the model of the learning processes constituting Home-Identity so as to envisage a Therapeutic Patient Education (TPE) which would allow elderly fallers to fully participate in the modification of his/her home. Method: Using the grounded theory method we developed our model by continually comparing our results and the acquired data. Ten older adults fallers were interviewed with semi-direct guidance and a mental map of the home (MPH). Results: Home-Identity includes two feelings. At the center, the feeling of temporal continuity arises from the individual's present cycle of routines and knowledge which are linked to memories and projections into the future. The feeling of unity and coherence contains the feeling of continuity. It creates in the inhabitant defense strategies to protect his/her Home-Identity and learning processes to make it change. Discussion: Home-Identity leads to “competently acting” in situation at home. It is made dynamic by "constructivists” learning strategies which would allow the individual to assimilate new knowledge and to accommodate the changes of situation. Our model leads to envisage TPE in the form of educational support to home hazards modification. The MPH would be used to characterize the evolution in Home-Identity. Conclusion: Additional research will allow to validate the MPH and empirically test our model.

Class of 2005 Abstract / Objectives: To determine if delivery of medications to an independent living facility increases patient adherence. Methods: Retrospective review of patient pharmacy refill records was completed using a data extraction form in order to calculate a number of days deviation from a projected refill date based on days supply. Data on the use of express pay, auto fill, and delivery service and payment type was collected as well as age and gender. Residents of The Fountains independent living facility were eligible to be included in this study if they had complete data in the pharmacy refill records for at least one scheduled maintenance medication taken for a continuous, three-month period. Results: There were 21 subjects in the delivery group and 18 in the pick-up group. Both groups were primarily women (76.2 percent and 61.1 percent respectively). Age was also similar (85.8 and 83.8, p=0.285). The delivery group had significantly more maintenance medications than the pick-up group (mean=2.8, SD=1.1 and mean=1.7, SD=1.1 respectively). Seven of the nine time deviations were greater for the pick-up group than for the delivery group (p= 0.09 for sign test). Implications: It appears that a delivery service can increase adherence, particularly in a population of advanced age.

Intra-arterial or percutaneous locoregional therapies (LRT) are often employed to maintain potential liver transplant (LT) recipients with hepatocellular carcinoma (HCC) within T2/Milan criteria. Predictors of survival when LRT is used as destination therapy in those who are either ineligible or unwilling for LT remain poorly defined. We evaluated predictors of 3-year survival with destination LRT in a population of cirrhotic patients diagnosed with HCC, presenting within T2 criteria, and either ineligible or unwilling for LT. The cohort surviving 3 years had a significantly lower model for end-stage liver disease (MELD) score at HCC diagnosis (9.7 vs. 11.4, P= 0.037) and MELD following initial locoregional therapy (10.7 vs. 13.3, P= 0.008) compared to those not surviving three years despite similar demographic, tumor, and treatment variables. LRT as destination therapy results in modest intermediate term survival, with liver function at presentation and immediately following initiation of LRT predicting intermediate survival with this approach.

Retirement transition is a major life event in later adult life. Its timing is important for older individuals for economic, personal and family reasons, as well as for aging societies contemplating a comprehensive plan for population changes, including sustainability of the labor force, pension system, and welfare services such as eldercare. This thesis explores retirement timing in contemporary Sweden, which serves as an interesting case study because of its aging population, high labor force participation of men and women, universal pension system and generous welfare services. The overarching aim of the thesis is to investigate how relationships in the private sphere associate with retirement timing by focusing on leisure engagement, family relations and intergenerational ties. The thesis consists of an introductory chapter and four empirical studies. The purpose of the introductory chapter is to place the four studies in context by focusing on the Swedish population structure, labor force participation and pension system and by highlighting some of the central theories and empirical findings related to retirement transition. Study I addresses leisure engagement before retirement and retirement timing, and how engagement in leisure changes after retirement. The study finds that retirement timing varies by both the type of preretirement activity domain and the level of engagement. For instance, occasional or frequent engagement in dance and music postponed retirement compared to no engagement in these activities. The study also finds that patterns of leisure engagement after transition into retirement tend to be a continuation of the corresponding preretirement patterns. Study II investigates the association between grandparenthood and retirement timing. The results show that grandparents at different life stages are more likely to retire compared to non-grandparents, but there is also variation among grandparents, and the more complex the family situation, the more likely grandparents are to retire. In Study III, the focus shifts to the relationship between survival of elderly parents and retirement timing. The study finds that parental survival is positively linked to retirement timing and that the effects are stronger and more consistent for women thanfor men, in particular when only one parent is still alive. Additionally, women have a higher propensity of retiring in the immediate period after parental death, especially when the father is widowed. In contrast, men have a higher propensity of retiring when either the mother or father has been widowed for some years. Study IV examines married couples’ propensity to coordinate retirement. The study finds that the likelihood that spouses will coordinate their retirement decreases as their age difference increases but that age differences have a similar effect on retirement coordination for couples with a larger age difference. The study also finds that coordination is largely gender neutral in opposite-sex couples with age differences, regardless of whether the male is the older spouse. The thesis shows that, compared to wealth or health predictors of retirement, factors concerning the private sphere are also most relevant in non-trivial ways to large shares of retirees in Sweden. Increased knowledge of these relationships is important both for individuals’ retirement planning and for decision-makers’ and policy-makers’ planning and organization. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 3: Manuscript. Paper 4: Manuscript.</p>

Background: Uninformed generalizations about how many elderly people have ever lived, based on a poor understanding of demography, are found in a surprising number of important publications. Objective: We extend the methodology applied to the controversial question "how many people have ever been born?" initiated by Fucks, Winkler, and Keyfitz, to the proportion of people who have ever reached a certain age y and are alive today (denoted as TT(y, T ))). Methods: We first analyze the fraction TT(y, T )) by using demographic data based on UN estimates. Second, we show the main mathematical properties of TT(y, T )) by age and over time. Third, we complete our analysis by using alternative population models. Results: We estimate that the proportion who have ever been over 65 that are alive today (as of 2010) ranges between 5.5 and 9.5%. We extend the formal demographic literature by considering the fraction of interest in two frequently referred models: the stable and hyperbolic growth populations. Conclusions: We show that statements claiming half of all people who have ever reached the age of 65 are alive today ranges would never be attainable, neither theoretically nor empirically, according to existing data. Contribution: We have produced for the first time a harmonized reconstruction of the human population by age throughout history. For a given contemporaneous time T, we demonstrate analytically and numerically that TT(y, T )) is nonmonotonic in age y. For a given age y, we show tthat TT(y, T) may also be nonmonotonic with respect to T.

Background: Axis fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. Knowledge of the incidence of these fractures, as well as their treatment, outcome and mortality rate, will improve knowledge and decision-making processes for this fragile group of patients. Objectives: This thesis aims (1) to review the literature on the non-surgical and surgical treatment of odontoid fractures type 2 in the elderly population, (2) to provide an updated overview of axis fracture subtypes, their incidence and their treatment in a cohort in two university cities, (3) to map the incidence of fractures and the treatment of these patients in Sweden, (4) to investigate the effect on mortality of both the surgical and non-surgical treatment of axis fractures and (5) to present the protocol for a randomized controlled trial (RCT) on the treatment of odontoid fractures type 2 in the elderly population. Methods: A systematic review was performed using the MeSH keywords “odontoid AND fracture AND elderly”. The data for the cohort study were extracted from the regional hospital information system. The radiographs were reviewed retrospectively. Data were extracted from the Swedish National Patient Registry (NPR) and the mortality registry for the national registry studies. Finally, the RCT protocol was carried out according to the SPIRIT and CONSORT statements for clinical trial reporting. Results and conclusions: So far, there has been a scarcity of existing evidence on treatment of odontoid fractures type 2 in the elderly population. In this thesis, we found in two university cities an increased incidence, and a trend towards more surgical treatment of type 2 and 3 odontoid fractures 2002-2014. Between 1997 and 2014 in Sweden, there was an increasing incidence of C2 fractures, but the treatment trend went towards more non-surgical treatment. Surgically treated patients had a greater survival rate than non-surgically treated patients. Among those over 88 years of age, surgical treatment lost its effect on survival. In the RCT we will study the function of patients with odontoid fractures type 2 and by comparing non-surgical treatment with posterior C1-C2 fusion, the cost-effectiveness of the treatment options.

La fragilisation est un processus multiforme dynamique faisant passer de l’autonomie à la dépendance. C’est une question essentielle liée au vieillissement de la population. Il est important de repérer au plus tôt les personnes à risques dans la phase de réversibilité de la fragilité afin d’engager rapidement des actions correctives. L’échelle de Fried est un outil très répandu qui permet d’identifier une personne fragile au travers de cinq indicateurs (force de préhension palmaire, fatigue, vitesse de la marche, activité physique, et perte de poids). Cependant, les approches actuelles ne permettent pas d’alimenter ces indicateurs au quotidien dans la mesure où la présence d’un professionnel de santé est nécessaire. L’objectif de la thèse est de contribuer à la réalisation d’un pack d’évaluation gérontologique ambulatoire comprenant un ensemble de dispositifs technologiques, d’utilisation très simple et totalement intuitive, visant à alimenter les indicateurs de Fried hors de l’environnement contrôlé du cabinet du professionnel de santé : la Grip-ball pour la mesure de la force de préhension, un radar Doppler pour la vitesse de la marche, un pèse-personne pour la perte de poids. De plus, le pèse-personne a la capacité d’évaluer la qualité d’équilibre. L’ensemble est intégré autour d’une tablette PC ou d’un Smartphone. Un protocole a été défini afin d’en évaluer la valeur diagnostique et la valeur d’usage / Frailty is a dynamic multifaceted process leading from independent living to dependence. This concept addresses a key issue related to an aging population for which it is crucial to identify as soon as possible people at risk of frailty in the reversible phase of that process, in order to quickly apply corrective actions. The Fried’s scale is a widespread tool to identify physical frailty in older adults through five indicators (grip strength, exhaustion, walking speed, physical activity, and weight loss). However, usual clinical approaches fail to measure these indicators on a daily basis, given that the presence of a health professional is required. The aim of the thesis is to contribute to the design of a comprehensive technological solution devoted to frailty assessment, including a set of technological devices easy to use outside the controlled environment of the office of the health professional: The Grip-ball for grip strength, a Doppler radar for walking speed, a bathroom scale for weight loss. In addition, the scale has the ability to assess quality of balance. The whole set is built around a tablet PC or a Smartphone. A protocol has been defined to evaluate the diagnostic and use value of the proposed technological solution

Background: Based on survey data from both Canada and abroad, most people would prefer to be cared for and to die in their own homes. Although 70% of elderly patients state a preference for comfort care over high technology life prolonging treatment in an inpatient setting, 54% are still admitted to intensive care units (ICUs). Understanding their wishes regarding end-of-life care, and being able to engage in evidence informed end-of-life discussions has never been so important, in order to empower patients, and to optimize scarce resource management. For the purpose of this thesis, “very old” patients will be defined as those eighty years of age and older. All three manuscripts will be based on data from the Realistic 80 study, a prospective cohort trial of 1671 critically ill very old patients admitted to 22 Canadian ICUs. Objectives: Manuscript 1: To describe the hospital outcomes of the entire cohort of Realistic 80 patients, including their ICU mortality and length of stay, their hospital mortality and length of stay, and their ultimate dispositions. Manuscript 2: To derive a clinical prediction rule for hospital mortality in the medical patient cohort. Manuscript 3: To derive a clinical prediction rule for hospital mortality in the emergency surgical patient cohort. Data Source: A prospective, multicenter cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Methods: Clinical decision rule methodology was used to analyze the data set and to create two separate clinical prediction tools, one for critically ill elderly medical patients, and one for critically ill surgical emergency patients. A third manuscript describing general clinical outcomes was also produced. Results of Manuscript 1: A total of 1671 patients were included in this section of the “Realities, Expectations and Attitudes to Life Support Technologies in Intensive Care for Octogenarians: The Realistic 80 Study (a prospective cohort of nearly 2000 critically ill Canadian patients over eighty years old enrolled from 22 ICUs across Canada) that will provide the data for this thesis. The Realistic 80 cohort had a mean age of 84.5, a baseline Apache II score of 22.4, a baseline SOFA score of 5.3, an overall ICU mortality of 21.8%, and an overall hospital mortality of 35%. The cohort had a median ICU length of stay of 3.7 days, and an overall median hospital length of stay of 16.6 days. Only 46.4% of the survivors were able to return home to live. Results of Manuscript 2: Age, renal function, level of consciousness, and serum pH were the important predictors of hospital mortality in critically ill elderly medical patients. Our clinical prediction tool is very good, particularly at the all-important extremes of prognosis, and ready for external validation. Results of Manuscript 3: Renal function and serum pH were the important predictors of hospital mortality in critically ill elderly surgical patients. Our model’s performance is very good, and will serve to inform clinical practice once validated. Conclusions: Very old medical patients have longer ICU stays and higher mortality than their surgical counterparts. Premorbid health status and severity of illness are associated with mortality. Our medical patient clinical prediction tool is very good and ready for external validation. Our surgical emergency clinical prediction tool shows promise, but will require the incorporation of more patients and a repeat derivation phase prior to external validation or clinical implementation.