The very old, aged 80 years and over, is the fastest growing age group today, and the demands for healthcare and services will be even higher in the future. It is, therefore, of great importance to advance our knowledge about this group. The main purpose of this thesis was to describe living conditions and health, with a special focus on physical ability, falls and morale, in women and men in three different age groups of very old people in northern Sweden. Half the population aged 85, and the total population aged 90 and ≥95 (-103) in the municipality of Umeå were selected for participation (n=348) in this population-based cross-sectional study, entitled the Umeå 85+ Study. Structured interviews and assessments were performed with the participants in their homes, and data were also collected from next-of-kins, caregivers and medical charts. Cognition was screened for using the Mini-Mental State Examination (MMSE), depressive symptoms using the Geriatric Depression Scale-15 (GDS-15), and nutritional status using the Mini Nutritional Assessment (MNA). Activities of Daily Living (ADL) were assessed using the Staircase of ADL (including the Katz Index of ADL) and morale using the Philadelphia Geriatric Center Morale Scale (PGCMS). Participants also rated their own health and answered a questionnaire about symptoms. Physical ability was assessed using a gait speed test over 2.4 meters (8 feet), three consecutive chair stands, and the Berg Balance Scale (BBS). A follow-up study for falls was performed during a period of six months with fall calendars and telephone calls. The very old people in this northern population have more depression, hypertension and hip fractures, as well as a higher consumption of drugs than comparable, more southern populations. In general, younger participants had lower rates of diagnoses and prescribed drugs, were less dependent in ADL and other functional variables than older participants, and men had lower rates of diagnoses and reported symptoms than women. However, there were no age or sex differences in self-rated health or morale, which were both rated as good by the majority of the participants. There was a wide range of physical ability among these very old people, especially in women, where an age-related decline was seen. The results also demonstrate that men had greater physical ability than women. The BBS had no floor or ceiling effects in the present sample. In contrast, a large proportion was unable to perform the gait speed and chair stands test, resulting in a floor effect for the timed performances, especially in women. Falling is a major public health problem in very old people. From the results of the present study, it could be predicted that every seventh participant and every third of the people who did fall would suffer a fracture over a period of one year. The independent explanatory risk factors for time to first fall in this sample of very old people were dependency in personal (P-) ADL but not bedridden, thyroid disorders, treatment with Selective Serotonin Reuptake Inhibitors (SSRIs) and occurrence of fall/s in the preceding year. These factors should all be considered in fall prevention programmes. The morale of very old people was found in this study to be rather high, with similar scores among age groups and sexes. The most important factors for high morale were the absence of depressive symptoms, living in ordinary housing, having previously had a stroke and yet still living in ordinary housing, not feeling lonely and having few symptoms. The PGCMS seems applicable in the evaluation of morale in very old people. In conclusion, there were wide variations in health status and physical ability in this northern population of very old people. Women had poorer health and physical ability than men. Falls and fractures were common and serious health problems. Morale seemed to be high, despite the fact that a large proportion of the participants suffered from many diseases and functional decline.

Normalt åldrande innebär förändringar hos individen som kan påverka tal, språk och sväljning. Ökad känslighet för inre och yttre påverkan hos den åldrande individen samt sjukdomsbild kan skapa problematik, vilken kan ge upphov till svårigheter med tal, språk och/eller sväljning, som i sin tur påverkar den upplevda livskvaliteten. Geriatriska patienter karaktäriseras av nedsatt funktionsnivå och kroniska sjukdomar, därför ställs krav på specialkompetens för vård och rehabilitering av dessa patienter. Syftet med föreliggande studie var att genom screening undersöka förekomst av tal-, språk- och sväljsvårigheter på geriatriska avdelningar i två städer i södra Sverige. Därtill undersöktes även orofacial påverkan och hälsorelaterad livskvalitet. Totalt 42 patienter från geriatriska avdelningar med inriktningarna allmängeriatrik, strokerehabilitering och ortopedi deltog. Screeninginstrument som användes var Nordiskt Orofacialt Test – Screening (NOT-S) för screening av orofaciala funktioner. Screening av tal baserades på delar ur NOT-S samt talade delar ur språklig screening. Delar ur Neurolingvistisk Afasi-undersökning (A-ning) valdes för screening av språk och Standardised Swallowing Assessment (SSA) användes för klinisk undersökning av sväljning. Hälsoenkäten the Short Form – 12 (SF-12) användes för skattning av hälsorelaterad livskvalitet. Identifierade svårigheter i patientgruppen var talsvårigheter hos 33 % (14 av 42), samt 40 % (16 av 40) och 37 % (15 av 41) språkliga svårigheter respektive sväljsvårigheter. Bland deltagarna hade 64 % svårigheter med en eller flera av de undersökta funktionerna. Förekomst av dessa svårigheter hade signifikant samband med nedsatt orofacial funktion. Lågt skattad hälsorelaterad livskvalitet hade signifikant samband med språkliga svårigheter och med orofacial dysfunktion. / Changes occur during the normal ageing process that can interfere with speech-, language- and swallowing functions. An increased occurrence of diseases increases the frailty in the ageing individual and may cause disordered speech, language and/or swallowing, in which case the health related quality of life may be negatively affected. The geriatric population is characterized by functional impairment and chronic diseases. This therefore poses special demands on specialist care and rehabilitation of these patients. The aim of this study was to examine the occurrence of speech, language and swallowing disorders in geriatric wards in two cities in the southern part ofSwedenusing screening. The orofacial influence on these functions and health related quality of life were also examined. In total 42 patients participated, from geriatric wards with general, stroke rehabilitation and orthopedic specialty. The instruments used for screening of orofacial functions was the Nordic Orofacial Test – Screening (NOT-S) and perceptual parameters for screening of speech based on speech parts from NOT-S and speech production from Neurolingvistisk Afasi-undersökning (A-ning). Parts of A-ning were also used for screening of language. Standardised Swallowing Assessment (SSA) was used for clinical examination of swallowing. The Short Form – 12 Health Survey (SF-12) was used to estimate the health related quality of life. Results showed that 33 % (14 of 42) had difficulties with speech, 40 % (16 of 40) and 37 % (15 of 41) showed difficulties with language and swallowing respectively. Of the participants, 64 % had difficulties with one or more of the examined functions. Occurrence of these difficulties associated significantly with impaired orofacial function. Language difficulties were associated with decreased mental health status and orofacial dysfunction with decreased physical health status, measured with the SF-12.

Dissertation (Ph.D.)--University of South Florida, 2008. / Includes vita. Includes bibliographical references.

Disputats, Umeå 2007. / Sammanfattning på engelska.

La réadaptation gériatrique reconnaît le loisir comme un indicateur clé des résultats de la réadaptation. Cependant, les connaissances théoriques sur le loisir sont peu développées. L’objectif de ce mémoire est de décrire et critiquer des modèles en lien avec le loisir et publiés dans les écrits scientifiques afin d’en dégager les aspects les plus pertinents pour la réadaptation gériatrique. Dix modèles ont été sélectionnés à partir d’une stratégie de recherche bibliographique. Ils ont été analysés sur la base de six critères : 1) le processus de développement du modèle, 2) les concepts, 3) les interactions entre les concepts, 4) l’aspect pratique, 5) la littérature générée et 6) la compatibilité avec les concepts-clés de la réadaptation gériatrique. Les résultats révèlent quatre modèles particulièrement intéressants pour la réadaptation gériatrique, sans pouvoir en dégager un en particulier, chacun présentant des forces et des limites qui sont discutées. De plus, les concepts rattachés au loisir les plus pertinents à retenir selon l’ensemble des modèles concernent: 1) la participation dans les loisirs, 2) la perception de soi face aux loisirs, 3) la motivation dans les loisirs, 4) la satisfaction dans les loisir, 5) les capacités en lien avec les loisirs et 6) l’environnement physique et social. Les résultats de la présente étude se traduiront par une meilleure connaissance des déterminants, caractéristiques et effets du loisir auprès des personnes âgées en processus de réadaptation. / Leisure is a key indicator of successful geriatric rehabilitation. However, there is a need for further development of theoretical knowledge of the role of leisure. The goal of this study was to describe and analyze scientific publications addressing leisure models and to extract the most relevant aspects for the rehabilitation of the elderly. A structured bibliographical search was conducted to select the most pertinent models (n=10). These models were analyzed regarding six criteria: 1) the development process of the model, 2) concepts put forward, 3) the interactions between the various concepts, 4) there practical aspects, 5) the subsequent literature generated and 6) the compatibility with key concepts of rehabilitation. It was concluded that four of the ten models were more pertinent for geriatric rehabilitation. Each model strengths and weaknesses are examined. The most relevant concepts that emerged from all the models are: 1) leisure participation, 2) leisure and self-perception, 3) leisure motivation, 4) leisure satisfaction, 5) leisure capacities and 6) physical and social environment. It is hoped that this study will be a first step in the comprehension of the determinants, characteristics and effects of leisure in the context of geriatric rehabilitation.

Hip fracture is a global and a growing public health problem. More women than men sustain hip fractures, the incidence increases exponentially with age and mean age is above 80. About one third of hip-fracture patients suffer from dementia and are prone to develop acute confusional state (delirium). Delirium is one of the most common complications after hip-fracture surgery, and seriously impacts on morbidity and mortality. Malnutrition is also common in hip-fracture patients and is associated with postoperative complications, such as delayed healing of the wound, infections and decubitus ulcers. Arthroplasty is usually preferred procedure in displaced femoral neck fractures but is, however, controversial in patients with dementia due to the fear of dislocation of the prosthesis. The aims of this thesis are to identify risk factors for delirium and the impact of delirium on rehabilitation outcome, to evaluate whether a postoperative multi-factorial intervention program could reduce delirium, to investigate the effect of a nutritional intervention and to evaluate complications, functional outcome and mortality regarding two surgical methods, hemiarthroplasty (HAP) and internal fixation (IF), in old patients with femoral neck fracture. Thirty-eight out of 61 consecutive patients (62%) were delirious on admission to hospital or developed postoperative delirium. An increased risk of postoperative delirium was found among hip-fracture patients with dementia and/or depression. Delirious patients were hospitalized longer, were more dependent in their activities of daily living, had poorer psychological well-being and suffered more complications than non-delirious patients. A postoperative multi-factorial and multidisciplinary intervention program reduced the incidence, at 55% vs 75% (p=0.003), and number of days with delirium, 5 vs 10 days (p=0.009). Postoperative complications were also reduced; decubitus ulcers 9% vs 22% (p= 0.010), urinary tract infections 31% vs 51% (p=0.005), falls 12% vs 27% (p=0.007), and the mean hospitalization period was 10 days shorter in the intervention group (p=0.030). Malnutrition was common among all these patients (53 %) and associated with postoperative complications such as decubitus ulcers and delirium. However, the nutritional intervention had no effect on nutritional parameters at four months, nevertheless men had better nutritional outcomes than women. A higher proportion of patients with dementia operated on using HAP had regained their pre-fracture ability to walk independently at the one-year follow up compared with those operated on using IF. Six of 83 patients dislocated their HAP during hospitalization and during an episode of delirium, none had dementia. No difference in mortality between the surgical methods was seen. Dementia per se should not be a reason to disqualify patients from being treated with the most appropriate surgical method. It is clinically important to discriminate between dementia and delirium, since delirium can be prevented and treated even in patients with dementia. Old patients undergoing surgery have special needs that are not always catered for in ordinary orthopaedic or surgical wards. The special care for these patients should include: a combined nursing and medical care based on comprehensive geriatric assessments, systematic prevention, detection and treatment of postoperative complications such as delirium, hypoxemia, urinary tract infections, pain, malnutrition and an active rehabilitation. It is obvious that improved quality of care reduces patient suffering and seemingly the costs for society.

Many elderly patients visiting the emergency department for minor injuries are not assessed for functional status and experience functional decline 6 months post injury. Identifying such high-risk patients can allow for interventions to prevent or minimize adverse health outcomes including loss of independence. For the purpose of a planned clinical decision rule to identify elderly patients at high risk of functional decline a survey of physicians was conducted. A random sample of 534 Canadian geriatricians, emergency and family physicians was selected with half randomly selected to receive an incentive. A response rate of 57.0% was obtained with 90% of physicians considering a drop in function of at least 2 points on the 28-point OARS ADL scale as clinically significant. A sensitivity of 90% would meet or exceed 90% of physicians' requirements for a clinical decision rule to identify injured seniors at high risk of functional decline 6 months post injury.

This research contributes to the social work understanding of mental competency assessments with older adults in healthcare settings. Utilizing a narrative research methodology, this qualitative research study analysed nine face-to-face interviews with social workers with experience assessing competency of older adults in the following Winnipeg, Manitoba healthcare settings: hospitals, personal care homes, and a number of community settings (home care, geriatric specialty programs, and private practice). Drawing from systems and ecological theories, as well as the social determinants of health, the results of this study revealed several key concerns such as the motivation behind what triggers an assessment, the specific tests and methods used to determine competency, inequitable treatment of the patient throughout the assessment depending on their cultural or socioeconomic background, and depending on the setting whether the social worker felt their role on the assessment team was valued or dismissed. Recommendations outlined implications for: enhancing the quality of the competency assessment process; expanding the role of social work in interdisciplinary settings; examining the use of methods and tests for assessment; and exploring opportunities for change in legislation, education and early detection. Potential areas of further study are discussed.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. inst., 2004. / Härtill 5 uppsatser.