Medelåldern bland personer över 65 år som bor hemma och har hemsjukvård eller bor på särskilda boenden för äldre i Sverige ökar och parallellt med detta ökar också antalet personer med demenssjukdom. Samtidigt sker en generell ökning av problematiska beteenden, som är vanliga bland personer med demenssjukdom. Problematiska beteenden är en utmaning för personalen på äldreboenden och de har till viss del har varierade uppfattningar om orsaker till problematiska beteenden samt hur beteendena kan minskas och bemötas. Eftersom området är komplext finns det ytterligare behov av att undersöka vårdpersonals uppfattningar inom detta område. Syftet med studien var att beskriva vårdpersonals uppfattningar om orsaker till aggression, vandringsbeteende och överdrivet verbalt beteende hos personer med demenssjukdom, samt åtgärder som kan lindra dessa beteenden. Metoden som använts för datainsamling är semistrukturerade intervjuer med 13 personer verksamma vid äldreboenden i en svensk medelstor stad. Det transkriberade datamaterialet analyserades genom kvalitativ innehållsanalys med manifest ansats. Analysen fokuserade på att besvara de specifika frågeställningarna och utfördes stegvis. Studien är godkänd av Etikkommittén vid Luleå Tekniska Universitet. Resultatet pekar på att de omvårdnadsåtgärder som personalen använder har ofta en nära koppling till hur de tänker om orsaker. Studiens resultat kan förstås som att personalen både använder en biomedicinsk förklaringsmodell där beteenden ses som symptom på en förändring i hjärnan och en psykosocial förklaringsmodell där beteenden är logiska resultat av hur individen upplever sin situation och kan betraktas som reaktioner på samspelet med omgivning, andra människor och fysiska besvär. Slutsats: förekomst av problematiska beteenden hos personer med demenssjukdom samt personalens upplevelse av stress kan minskas genom implementering av personcentrerad omvårdnad.

This dissertation aims at analyzing mindfulness as a concept and a multidimensional phenomenon in its historic and primordial but also contemporary contexts. In the course of examining this more general question, this dissertation targets four specific objectives: 1) classifying existing definitions of mindfulness, 2) critically analyzing and interpreting the Buddhist and Western interpretations and practices of mindfulness, 3) elaborating on the social and existential dimensions of mindfulness, and 4) applying these dimensions in advancing the notion of mindful sustainable aging in the context of successful aging. Paper I examines and assesses the numerous definitions of mindfulness that have been presented over the years by a wide range of scholars from a variety of disciplines. Paper II traces the roots of modern mindfulness in Buddhism. It continues by exploring the utility and practices of mindfulness in the context of social work. The definitions provided in Paper I and the Buddhist underpinnings discussed in Paper II call attention to the fact that in addition to the more commonly considered physical and mental dimensions, mindfulness contains a social and an existential dimension as well – dimensions that remain under-researched and not well understood. To redress this imbalance, Paper III elaborates on these two latter dimensions, emphasizing their potential to enhance health, wellbeing and meaning in life. Paper III further argues that a more nuanced understanding of physical, mental, social and existential mindfulness can be obtained by examining the interconnectedness of all four fields. Paper IV continues the discussion of the social and the existential dimensions of mindfulness with specific emphasis on their utility for successful aging, and advances the notion of mindful sustainable aging. Paper IV highlights the potential of mindfulness for living a meaningful life and boosting the elderly’s capacity to find deeper meaning in their final stage of life.

Anxiety disorders share the feature of excessive fear, anxiety and related behavioural disturbances. Fear is defined as the emotional response to a real or a perceived imminent threat and anxiety is the anticipation of a future threat. The anxiety disorders covered in this thesis are panic disorder with or without agoraphobia, social phobia, post-traumatic stress disorder, generalized anxiety disorder and anxiety disorder not otherwise specified. Cognitive behavioural treatment protocols are typically designed to target one specific disorder and falls under the definition of disorder-specific cognitive behavioural therapy. It is however unclear if this is the most optimal approach in regards to the high comorbidity between anxiety disorders and depressive disorders. Internet-based cognitive behavioural therapy has in the past generally been disorder-specific and from above mentioned predicament two alternative treatment approaches emerged, the tailored and the transdiagnostic approach that aims to simultaneously treat both principal and comorbid disorders. Previous trials on internet-based cognitive behavioural therapy have targeted adults in general and relatively few target adolescents, young adults and older adults. The aims of this thesis were to further develop and test the effects of tailored internet-based cognitive behavioural therapy on the basis of age, for adolescents, young adults and older adults. Specifically by developing and testing the effects of individually tailored internet-based cognitive behavioural therapy for adolescents with anxiety and comorbid depressive symptoms and by adapting and testing the effects of individually tailored internet-based cognitive behavioural therapy for young adults and older adults with anxiety and comorbid depressive symptoms. These aims were tested in two pilot effectiveness studies (Paper I and III) and two efficacy randomised controlled trials (Paper II and IV). The results from these four trials showed significant results across all outcome measures with overall moderate to large effect sizes. The tentative conclusion based on these results is that tailoring internet-based cognitive behavioural therapy can be a feasible approach in the treatment of anxiety symptoms and comorbid depressive symptoms for adolescents, young adults and older adults. Despite the positive findings of the studies in this thesis, there is a need for more research examining the acceptability and effectiveness of internet-based cognitive behavioural therapy for adolescents, young adults and older adults with anxiety and depression before implementation on a larger scale.

Bakgrund: Omkring 100 000 svenskar beräknas lida av bensår vilka kräver långa behandlingstider och medför ekonomiska kostnader för samhället. Olika sjukdomstillstånd såsom trauma och försämrad blodcirkulation anses som riskfaktorer. Att leva med bensår kan ha negativ inverkan på människors dagliga liv. Det är viktigt för sjuksköterskor att informera patienterna kring behandlingen, ge stöd samt ha förmågan att bemöta dem med respekt och empati. Syfte: Syftet med föreliggande studie var att beskriva hur patienter med bensår upplever sin livskvalitet samt att beskriva undersökningsgrupperna som ingick i de inkluderade artiklarna. Metod: Beskrivande litteratur studie som inkluderade tolv vetenskapliga artiklar som söktes fram i databasen Cinahl. Huvudresultat: Patienterna beskrev smärta som påverkade deras dagliga liv både fysiskt och psykiskt. Sömnproblem påverkade det psykiska måendet negativt. Rädslan för att skada sig begränsade patienterna fysiskt och man beskrev även känslan av skam, missmod, ensamhet, oro, ångest, depression och förlust av hopp. Bensår upplevdes tidssamt energikrävande och brister i kunskap hos sjukvårdpersonalen hade negativ påverkan på patienternas livskvalité. Undersökningsgrupperna varierade i antal från 5 till 247 deltagare, majoriteten var kvinnor, åldern var mellan 18 till 99 år. De flesta deltagarna hade haft venösa bensår, vilka varade mellan 6 veckor till 43 år. Slutsats: Att leva med bensår påverkade livskvaliteten. Relationen mellan sjuksköterska – patient hade stort betydelse för sårläkningen och välbefinnande. Det är viktigt att sjuksköterskor har tillräcklig kunskap om denna patientgrupp samt att ge ett professionellt bemötande, stöd och information om en egenvård.

<p>Att vårda en närstående person med demens innebär en stor börda för anhörigvårdaren vilket kan resultera i psykisk ohälsa. Stöd är en viktig del för att minska bördan. Syftet med studien var att ur ett omvårdnadsperspektiv belysa anhörigas upplevelse av psykosocial börda och psykosocialt stöd vid vård av en person med demens i hemmet. Studien var en systematisk litteraturstudie som baserades på 15 vetenskapliga artiklar. I resultatet framkom att anhöriga som vårdar en person med demens upplevde en psykisk och fysisk börda. Den tyngsta psykiska bördan uppgavs vara brist på egen tid och att känna sig isolerad från omvärlden. Anhörigvårdarens individuella uppfattning om sig själv och förhållandet till personen med demens påverkade bördan. Informellt socialt stöd visade sig viktigt och minskade risken för depression. Det framkom att socialt stöd och stödgrupper var betydelsefullt för den anhörige. De anhöriga kände att de inte fick det stöd som behövdes från hälso- och sjukvårdpersonal. Därför behövs mer kunskap hos formella vårdgivare för att kunna möta behovet av stöd för anhöriga till en person med demens. Ökad kunskap och förståelse om psykosocial börda ger sjuksköterskan större förutsättningar att kunna ge anhörigvårdaren ett adekvat stöd. Ytterligare forskning krävs för att utvärdera sjuksköterskans roll som psykosocialt stöd.</p>

Att vårda en närstående person med demens innebär en stor börda för anhörigvårdaren vilket kan resultera i psykisk ohälsa. Stöd är en viktig del för att minska bördan. Syftet med studien var att ur ett omvårdnadsperspektiv belysa anhörigas upplevelse av psykosocial börda och psykosocialt stöd vid vård av en person med demens i hemmet. Studien var en systematisk litteraturstudie som baserades på 15 vetenskapliga artiklar. I resultatet framkom att anhöriga som vårdar en person med demens upplevde en psykisk och fysisk börda. Den tyngsta psykiska bördan uppgavs vara brist på egen tid och att känna sig isolerad från omvärlden. Anhörigvårdarens individuella uppfattning om sig själv och förhållandet till personen med demens påverkade bördan. Informellt socialt stöd visade sig viktigt och minskade risken för depression. Det framkom att socialt stöd och stödgrupper var betydelsefullt för den anhörige. De anhöriga kände att de inte fick det stöd som behövdes från hälso- och sjukvårdpersonal. Därför behövs mer kunskap hos formella vårdgivare för att kunna möta behovet av stöd för anhöriga till en person med demens. Ökad kunskap och förståelse om psykosocial börda ger sjuksköterskan större förutsättningar att kunna ge anhörigvårdaren ett adekvat stöd. Ytterligare forskning krävs för att utvärdera sjuksköterskans roll som psykosocialt stöd.

Falls and concomitant injuries are common problems among large groups of the elderly population, leading to immobility and mortality. These problems are even more pronounced among people suffering from dementia. This thesis targets fall risk factors for people with dementia in institutions. The overall aim of this thesis was to investigate risk factors for falls, predisposing as well as related to circumstances surrounding falls, and to do this as efficiently as possible. In a prospective cohort study including residents of residential care facilities with and without dementia, the fall rate was higher for those with dementia, the crude incidence rate ratio (IRR) was 2.55 (95% CI 1.60–4.08) and the adjusted IRR was 3.79 (95% CI 1.95–7.36). In the group of people suffering from dementia, including 103 residents, a total of 197 falls resulted in 11 fractures during the 6-months follow-up period. From the same baseline measurements 26% and 55%, respectively, of the variation in falls could be explained in the group of residents with and without dementia. Fall predictors significantly and independently associated with an increased risk of falls in the group of people suffering from dementia were the category “man walking with an aid” and the use of more than four drugs. In a prospective cohort study, including 204 patients in a psychogeriatric ward, a total of 244 falls resulted in 14 fractures. Fall predictors significantly and independently associated with an increased risk of falls were male sex, failure to copy a design, use of clomethiazole, and walking difficulties. Treatment with statins was associated with a reduced risk of falls. With these fall predictors in the negative binomial regression (Nbreg) model, 48% of the variation in falls was explained. The data from the psychogeriatric ward were also analysed with the use of partial least squares regression (PLS) and regression tree to be compared with the results of the Nbreg analysis. PLS and regression tree are techniques based on combinations of variables. They both showed similar patterns, that a combination of a more severe level of dementia, behavioral complications and medication related to these complications is associated with an increased fall rate. Thirty-two percent and 38%, respectively, of the variation in fall rate were explained in the PLS and regression tree analysis. The circumstances surrounding the falls in the psychogeriatric ward were analysed. It was found that the fall rate was equally high during the night and the day. A large proportion of the falls was sustained in the patients’ own room and a small proportion of the falls was witnessed by the staff. This pattern was even more pronounced during the night. The proportion of diurnal rhythm disturbances and activity disturbances was higher for falls at night than for falls during the day. Circumstances associated with an increased risk of falls, as shown by a short time to first fall, were anxiety, darkness, not wearing any shoes and, for women, urinary tract infection. The proportion of urinary tract infection was also higher in connection to falls sustained by women than to falls sustained by men. This thesis confirms that people suffering from dementia are prone to fall. Walking difficulties, male sex and impaired visual perception are factors that should be considered in the work of reducing falls among people suffering from dementia. Furthermore, falls at night, behavioral complications and medication related to these complications should also be considered in this work, especially as the dementia disease progresses. A larger portion of the variation of the outcome variable was explained by the Nbreg model than the regression tree and PLS. However, these statistical methods, based on combinations of variables, gave a complementary perspective on how the fall predictors were related to falls.

The number of old people is growing and will increase future demands on healthcare services for old people. Hip fracture is one of the diagnoses that increases with age and it has become a major problem, both for those suffering a fracture and for society due to the large numbers involved, the morbidity with complications such as falls, functional decline, and the high mortality rate among those affected. The main purposes of this thesis were, to study the impact of previous hip fractures on their life among the very old, to study in-patient falls, fall-related injuries and fall-risk factors, and to evaluate a multidisciplinary, multi-factorial intervention program designed to reduce in-patient falls and to enhance functional performance among old people who have sustained a femoral neck fracture. The impact of a hip fracture was examined in a cross-sectional population-based study, among the very old (Umeå 85+). After adjustment for potential covariates, participants with a history of hip fracture were found to be more dependent in the performance of Personal/Primary Activities of Daily Living (P-ADL) (p=0.024), walked less independently (p=0.040) and used a wheelchair more frequently (p=0.017). Most of the participants with earlier hip fractures who had moved to institutional care or begun using mobility aids, as compared to before the fracture, had started to do so permanently in connection with the fracture incident. In-patient falls, fall-related injuries and fall-risk factors were studied in 97 participants, aged 70 or more, treated for a femoral neck fracture. There were 60 postoperative falls occurring among 26/97 participants (27%). Thirty-two percent of the falls resulted in injuries, 25 % were minor, and 7 % were serious. Delirium after day seven, (Hazard Rate Ratio (HRR) with a 95% Confidence Interval (CI)), 4.62 (1.30-16.37), male sex 3.92 (1.58-9.73), and sleeping disturbances 3.49 (1.24-9.86), were associated with in-patient falls. Forty-five percent of the participants were delirious on the day they fell. The effects of a multidisciplinary, multi-factorial intervention program on in-hospital falls and injuries as well as the short- and long-term effects on living conditions, walking ability and performance of activities of daily living were evaluated in a randomised controlled trial among 199 participants with femoral neck fracture, aged ≥70 years. Participants were randomised to care in a geriatric ward (intervention, n=102) or to conventional postoperative routines (control, n=97). The intervention consisted of staff education, individualized care planning and rehabilitation, systematic assessment and treatment of fall-risk factors, active prevention, and detection and treatment of postoperative complications and an intervention follow up at four-months. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation. Twelve participants fell a total 18 times in the intervention group compared to 26 participants suffering a total 60 falls in the control group. Only one participant with dementia fell in the intervention group compared to 11 participants with dementia in the control group. The fall incidence rate was 6.29/1000 days vs. 16.28/1000 for the intervention and control groups respectively. The Incidence Rate Ratio (IRR) was 0.38 (95% CI: 0.20-0.76, p=0.006) for the total sample and 0.07 (95% CI: 0.01-0.57, p=0.013) among participants with dementia. No new fractures were incurred in the intervention group but there were four in the control group. In addition, despite shorter hospitalization, significantly more people from the intervention group had regained independence in P-ADL performance at the four- and twelve-month follow ups, Odds Ratios (OR), with 95% CI, were 2.51 (1.00-6.30) and 3.49 (1.31-9.23) respectively. More participants in the intervention group had also regained the ability to walk independently without walking aids indoors, at the end of the study period, 3.01 (1.18-7.61). In conclusion, hip fracture among the very old seems to be associated with poorer P-ADL performance and poorer mobility. Falls and injuries are common during in-patient rehabilitation after a femoral neck fracture, delirium and sleep disturbances and male gender are factors associated with in-patient falls. Having a team apply comprehensive geriatric assessments and rehabilitation, including the prevention, detection and treatment of fall-risk factors, can successfully prevent in-patient falls and fall-related injuries, even among participants with dementia, and can also enhance the performance of Activities of Daily Living (ADL) and mobility after a hip fracture, in both short- and long-term perspectives.

Physical restraint use and falls are common in institutional care of old people and various attempts have been made to reduce their occurrence. Falls and concomitant injuries are a major problem due to their negative effect on morbidity and mortality. Prevention of falls and injuries is the most common reason for physically restraining old people in institutional care. Its use has, however, been questioned both from an ethical perspective, since restraints can be perceived as coercive and also because of the lack of sound evidence of their effectiveness in preventing falls, as well as the adverse effects associated with their use. The main purposes of this thesis were to investigate differences in the us of physical restraints over time, to identifify risk factors for falls among people with dementia, to evaluate the effects of a restraint minimization program on staff knowledge, attitudes, and work environment and use of physical restraints and the quality of care. The present thesis is based on three main data collections, two census surveys conducted within institutional care for old people in the county of Västerbotten in 2000 (n=3,804) and 2007 (n=2,970) and one cluster-Randomized Controlled Trial (RCT) including 40 group dwellings for people suffering from dementia where the intervention consisted of staff education. The use of physical restraints increased slightly between 2000 and 2007 (16.2% to 18.4%, p=0.016). Analyses suggest that the increase might be independent of any change in resident characteristics. Restrained residents were also subjected to restraints for longer times in 2007. During a six-month follow-up 64/160 (40.0%) residents in group dwellings for those with dementia sustained at least one fall. Independent risk factors for falls were ‘requiring help with hygiene’, ‘displaying verbally disruptive/attention-seeking behavior’, ‘able to rise from a chair’, ‘walking with assistive devices’, and ‘participating in outdoor walks’, which explained 36.1% of the falls. The majority of the 191 falls were un-witnessed, 35% occurred during the night and anxiety and confusion were the most common symptoms preceding the falls. A six-month restraint minimization program showed a positive impact on staff knowledge, attitudes and work environment as well as on the use of physical restraints and subjectively estimated quality of care. Residents in the intervention group present throughout the entire study period had lower odds, relative to the residents in the control group of being physically restrained at follow-up (OR= 0.21, CI 95%=0.08-0.57) after controlling for potential confounders and the cluster effect. Adjusted analyses including all residents present at either baseline or follow-up also showed that the use of physical restraints was less in the intervention group relative to the control group at follow-up. There was no change in the occurrence of falls or use of psychoactive drugs. The intervention also reduced stress of conscience, job demands and strain in the staff, and improved their job control and the caring climate. Subgroup analysis indicated a greater effect in units where the use of physical restraints had been reduced or remained constant. In conclusion, physical restraint use and falls remains common in institutional care of old people. The practice of physical restraint seems to have changed. In the RCT it was found that it is possible to change restraint practice and also to improve staff work environment. Falls among residents with dementia require a certain mobility function and anxiety and confusion are common symptoms preceding falls.

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