SAMMANFATTNING   Sveriges befolkning blir allt äldre och antalet personer över 80 år ökar. Många vill bo kvar hemma men äldre med stora hjälpbehov flyttar till äldreboende. Syftet med studien var att belysa äldres uppfattningar om att vara äldre och deras syn på äldreboende. Vidare hur de ser på att själva bo på ett äldreboende och deras syn på att diskutera en framtida flytt till äldreboende med anhöriga eller vårdpersonal. Studien genomfördes med en kvalitativ ansats och intervjuer gjordes. Analysen av intervjumaterialet skedde med en kvalitativ manifest innehållsanalys. Resultatet visade att de äldre inte såg sig själva som äldre trots de förändringar åldrandet medfört. De äldre hade både en positiv och negativ syn på äldreboende som de grundade på erfarenheter från två äldreboenden. De ville bo kvar hemma och en flytt till äldreboende var ännu ingen aktuell fråga. Men en anledning till att i framtiden flytta till äldreboende skulle vara att inte längre kunna sköta sin hygien. De flesta informanterna hade inte diskuterat en framtida flytt till äldreboende med någon, men upplevde ändå att deras anhöriga kände till deras vilja. Flera såg det som positivt att bli kontaktade av vården och få information om äldreboende och hemtjänst. Resultatet antyder att det kan vara av vikt att veta hur äldre ser på äldreboende och hur de vill ha det den dagen deras hjälpbehov ökar.

<p>SAMMANFATTNING</p><p> </p><p>Sveriges befolkning blir allt äldre och antalet personer över 80 år ökar. Många vill bo kvar hemma men äldre med stora hjälpbehov flyttar till äldreboende. Syftet med studien var att belysa äldres uppfattningar om att vara äldre och deras syn på äldreboende. Vidare hur de ser på att själva bo på ett äldreboende och deras syn på att diskutera en framtida flytt till äldreboende med anhöriga eller vårdpersonal. Studien genomfördes med en kvalitativ ansats och intervjuer gjordes. Analysen av intervjumaterialet skedde med en kvalitativ manifest innehållsanalys. Resultatet visade att de äldre inte såg sig själva som äldre trots de förändringar åldrandet medfört. De äldre hade både en positiv och negativ syn på äldreboende som de grundade på erfarenheter från två äldreboenden. De ville bo kvar hemma och en flytt till äldreboende var ännu ingen aktuell fråga. Men en anledning till att i framtiden flytta till äldreboende skulle vara att inte längre kunna sköta sin hygien. De flesta informanterna hade inte diskuterat en framtida flytt till äldreboende med någon, men upplevde ändå att deras anhöriga kände till deras vilja. Flera såg det som positivt att bli kontaktade av vården och få information om äldreboende och hemtjänst. Resultatet antyder att det kan vara av vikt att veta hur äldre ser på äldreboende och hur de vill ha det den dagen deras hjälpbehov ökar. <em></em></p><p> </p><p> </p><p> </p>

Old people in general, and those affected by dementia disorders in particular, are more sensitive to drug side effects than younger people. Despite this, the use of nervous system drugs and analgesics among old people is common, and has increased in recent years. Institutional geriatric care accommodates people who need round-the-clock supervision and care, due to somatic, psychiatric, cognitive or behavioral symptomatology. A majority of those living in institutional geriatric care suffers from dementia disorders. This thesis is based on three different data collections. Two large cross-sectional studies, the AC1982 and AC2000 data collections, including all those living in institutional geriatric care in the county of Västerbotten in May 1982 and 2000 respectively (n=3195 and n=3669) and one study, the GERDA/Umeå 85+ data collection, including a sample of very old people, living at home and in institutions (n=546), in the municipalities of Umeå, Sweden and Vaasa and Mustasaari, Finland, in 2005-2006. The use of psychotropic drugs and analgesics was common among old people living in geriatric care and among very old people in general. A higher proportion of people with dementia received certain nervous system drugs, such as antipsychotic drugs. The use of antipsychotic drugs among people with cognitive impairment living in geriatric care was found to be correlated to several behaviors and symptoms that are not proper indications for antipsychotic drug use, and also factors related more to the staff and the caring situation. Over the course of eighteen years, from 1982 to 2000, there has been a manifold increase in the use of antidepressants, anxiolytics and hypnotics in geriatric care, but the use of antipsychotics had decreased slightly. During the same time, the prevalence of several depressive symptoms decreased significantly, correcting for demographical changes. One analysis of calculated numbers needed to treat, however, indicated poor remission rates, suggesting that even better results might be achievable. The prevalence of depressive symptoms among people with moderate cognitive impairment remained unchanged between 1982 and 2000, despite the fact that about 50% were receiving treatment with antidepressants in 2000. One possible explanation might be that depressive symptoms have different etiologies in different stages of a dementia disorder. Approximately a quarter of the people experiencing pain in geriatric care were not receiving any regular analgesic treatment. One possible reason might be misconceptions among the caring staff regarding whether or not the residents were receiving analgesic treatment. Such misconceptions were found to be common. In conclusion, psychotropic and analgesic drug use among old people in geriatric care, and very old people in general, was found to be common and in many cases possibly inappropriate. The use of antipsychotics among people with dementia deserves particular concern, because of the high risk of severe adverse events and the limited evidence for positive effects. The use of antidepressants, on the other hand, might have contributed to a lower prevalence of depressive symptoms among old people.

In the last decades our knowledge concerning cardiovascular risk factors has grown rapidly through results from longitudinal studies. However, despite new treatment, in Western countries coronary heart disease remains the leading cause of death and stroke is still the leading cause of severe disability. The studies reported in these papers examine the relationships between stroke/transient ischaemic attack (TIA) and a number of different factors measured on two different occasions in men born in Uppsala 1920-1924 and are epidemiological in their character. The findings indicate that in addition to already established risk factors, indices of an unhealthy dietary fat intake and high serum lipoprotein(a) are independent predictors of stroke/TIA. Among different glucometabolic variables a low insulin sensitivity index derived from the euglycaemic insulin clamp and proinsulin carries a high predictive value for later stroke, independently of diabetes. Moreover, cognitive test performance measured with Trail Making Test B at age 70 is a strong and independent predictor of brain infarction, indicating that the risk is already increased in the subclinical phase of milder cognitive dysfunction. Performance at a pre-stroke Trail Making Test is also of predictive value for mortality after first-ever stroke/TIA, but none of the studied pre-stroke variables or cognitive tests was found to be related to dependency after an event. In summary these studies provide further knowledge about predictors of stroke and of mortality after first-ever stroke. They also indicate the possible importance of new markers of risk, such as the level of lipoprotein(a), profile of fatty acids in the diet, low insulin sensitivity derived from clamp investigations, level of proinsulin, and cognitive performance measured with Trail Making Tests.

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.

The aim of this thesis was to study the biomarker homocysteine and other novel potential vascular risk factors for dementia. In an out-patient based study of a cohort of 926 consecutive subjects referred to our Memory Unit during 1996―2000, serum-folate was lower and total plasma homocysteine (tHcy) and serum methyl malonate were higher in subjects being prescribed with B12. In the subgroup diagnosed with dementia and with a positive family history of dementia, tHcy was higher than in the subgroup diagnosed as non-demented. It is necessary to supplement subjects with vitamin B12 deficiency with B12, but our results indicate that it is not sufficient with B12 alone because this gives rise to intracellular folate deficiency. We also found indications of a genetic component in dementia because tHcy was higher in the group with a positive family history of dementia. These findings prompted further studies of homocysteine metabolism. The frequency of mutations in the gene for folate receptor-α (FOLR-1), and the fibrinolytic pattern in dementia and non-dementia were studied in the two cohorts DGM (n=300) and AS (n=389). The DGM cohort is a consecutive series of subjects attending our Memory Care Unit for investigation of suspected cognitive problems or dementia between 2003 - 2007. The AS (= active seniors) cohort comprises retired, apparently healthy subjects from central Sweden, actively participating in study circles. A rare haplotype in the FOLR-1, with mutations in two nearby loci, was discovered, possibly associated with lower serum-folate and higher tHcy concentrations and was more frequent in the DGM group. The transport of folate to the CSF was studied in the DGM-cohort. Dementia with a vascular component was associated with a lower CSF to serum folate ratio indicative of reduced transport of folate to the CSF and further to the brain. The vascular endothelial derived fibrinolytic markers tPA, tPA/PAI-1-complex, and vWF were not only higher in vascular dementia (VaD) but also in Alzheimer’s Disease (AD) when compared to the AS group. The impaired fibrinolytic activity in both vascular dementia and in AD is a novel finding, signifying a vascular component in the development of dementia. In conclusion we found that both hereditary and nutritional background factors were linked to dementia and furthermore that a dysregulated fibrinolysis was linked to both VaD and AD.

Höftfrakturer är en vanlig ortopedisk orsak till sjukhusvård hos äldre. Att vara äldre och drabbas av höftfraktur är förknippat med hög risk för död. Stora fysiologiska avvikelser preoperativt samt försenad operation är kopplat till ökad risk för komplikationer och död. Äldre, sköra patienter har små marginaler och kan i samband med operation av höftfraktur behöva intensivvård. Det har uppmärksammats på ett sjukhus i Västra Götaland att denna patientgrupp vid ankomst till preoperativ avdelning ibland ej bedöms vara i operabelt skick, vilket medför ett förehavande där patienten förs till postoperativa intensivvårdsavdelningen för optimering inför operation. Syftet med studien är att undersöka hur det postoperativa förloppet hos äldre patienter med akuthöftfraktur påverkas efter införande av preoperativ optimering, stöttat av intensivvårdssjuksköterskan, på vårdavdelning. Studien har en kvantitativ ansats med en kombination av kvantitativ retroperspektiv registerstudie och en kvantitativ prospektiv interventionsstudie. Sammanställningen påvisar en minskning av den totala vårdtiden från 9 dagar till 6 dagar i median. Sammanfattningsvis betonas att intensivvårssjuksköterskan tillsammans med övriga professioner i teamet runt patienten har betydelse för att förbättra den äldre patientens möjlighet att återhämta sig efter akut höftfraktur.

The aim of this study is to describe situations that nurses experience as strenuous in their work with elders in institutional environment. The study focuses on the content and structure of the situations, meanings the nurses put in the situations and how they manage to handle the situations. The approach was to have a phenomenological perspective and a theoretical frame of reference in the CPT model  (CognitivePhenomenological-Transactional view) from Lazarus and Manet as well as inAntonovsky's discussion about the importance of general resistance resources against stressful events. The study is based on observations and interviews with five nurses working in three different institutions and in five different wards. The thesis states that factors in the work organisation such as lack of a common caring philosophy, ignorance of the nurses' role and function, communication problems with other organisations, imbalance between demands and resources are experienced as strenuous. Situations with pain and pain relieving, constant shouting from patients and  severe confusion were pointed out as particularly stressful in the interaction with patients. The nurses use a number of strategies in order to handle these strains, such as seeking social support, planned problemsolving, positive reappraisal and sometimes distancing. From an immediate perspective these strategi.es were efficient and the nurses were satisfied with their work.

Den här studien undersöker i vilken grad 360° video betraktad i en HMD kan ha för livskvalitetshöjande effekt på boende inom äldreomsorgen i Malmö. Ensamhet och depression är ett av de vanligaste hälsoproblemen bland personer över 65 år idag. En av anledningarna till detta är fysiska och psykiska hinder som minskar möjligheterna för dem att kontinuerligt delta i sociala sammanhang och få ett miljöbyte. Med 360° video kan vad som helst upplevas och med en HMD kan känslan av att vara närvarande på platsen förstärkas. Med hjälp av denna teknik har ett prototyptest utförts på 2 olika äldreboende i Malmö där 9 stycken deltagare har fått testa att betrakta 360° video i en HMD, i form av olika utflyktsmål i Malmö som har skapats som prototyp i denna studie. Utifrån observationer, ”think-aloud”-tekniken och enkätsvar har slutsatserna kunnat dras att prototyptestet behöver göras under en längre period för att påvisa ett säkert resultat om vilken livshöjande effekt 360° video kan ha på de boende. Resultatet av testet kunde även påvisa en ökad positivitet om deltagarna fick se en plats de besökt tidigare. / This study examines the degree to which 360 ° video viewed in an HMD can have a life-quality enhancing effect on residents of elderly care in Malmö. Loneliness and depression are one of the most common health problems today among people with an age over 65. One of the reasons for this is physical and mental barriers that reduces the opportunities for them to continuously participate in social contexts and get an environmental change. With 360° video, anything can be experienced and with an HMD the feeling of being present on the site can be enhanced. With the help of this technique, a prototype test has been performed on 2 different retirement homes in Malmö where 9 participants have been tested to view 360° video in an HMD, in the form of various excursion destinations in Malmö that have been created as a prototype in this study. Based on observations, think-aloud technology and questionnaire responses, the conclusions have been drawn that the test needs to be done for a longer period to be able to demonstrate a safe result on which life-enhancing effect 360° video can have on the residents. The result of the test could also show an increased positivity if the participants saw a place they visited in the past.

Höftfrakturer hos äldre kommer att bli ett stort globalt hälsoproblem på grund av den snabbt växande åldrande befolkningen. En höftfraktur kan medföra en rad negativa konsekvenser i det dagliga livet, därmed är det viktigt att belysa hur de äldre upplever livet efter höftfrakturen. Syftet med denna studie var att belysa de äldres upplevelse av dagligt liv efter höftfraktur. Studien är en litteraturöversikt med induktiv ansats genom manifest innehållsanalys och består av tio vetenskapliga artiklar med både kvalitativa och kvantitativa ansatser. Resultatet presenteras i tre huvudkategorier: upplevda förändringar i dagligt liv, upplevelser av behov av rehabilitering, upplevelser av behov av socialt stöd. De äldre upplever förändringar i det dagliga livet efter höftfrakturen från ett fysiskt och psykiskt samt socialt perspektiv. De behöver olika former av stöd för att kunna återvända till sin fungerande vardag. Vidare forskning bör lägga fokus på könsspecifik kunskap om förändringar i det dagliga livet hos de äldre med höftfrakturer. / Hip fractures in the elderly will be a major global health problem due to the rapidly growing elderly population. A hip fracture can result in several negative consequences in daily life, thus it is important to highlight how the elderly experience life after the hip fracture. The aim of this study was to illuminate the elderly’s experience of daily life after hip fracture. The study is a literature review with inductive approach through manifest content analysis and consists of ten scientific articles with both qualitative and quantitative approaches. The result is presented in three main categories: experienced changes in daily life, experiences of need of rehabilitation, experiences of need of social support. The elderly experience changes in the daily life after the hip fracture from a physical and mental as well as social perspective. They need different forms of support to be able to return to their functional daily life. Further research should focus on gender-specific knowledge regarding changes in the daily life of the elderly with hip fractures.