An increasingly older population will most likely lead to greater demands on the health care system, as older age is associated with an increased risk of having acute and chronic conditions. The number of diseases or disabilities is not the only marker of the amount of health care utilized, as persons may seek hospitalization without a disease and/or illness that requires hospital healthcare. Hospitalization may pose a severe risk to older persons, as exposure to the hospital environment may lead to increased risks of iatrogenic disorders, confusion, falls and nosocomial infections, i.e., disorders that may involve unnecessary suffering and lead to serious consequences. Aims: The overall aim of this thesis was to describe and explore individual trajectories of cognitive development in relation to hospitalization and risk factors for hospitalization among older persons living in different accommodations in Sweden and to explore older persons' reasons for being transferred to a hospital. Methods: The study designs were longitudinal, prospective and descriptive, and both quantitative and qualitative methods were used. Specifically, latent growth curve modelling was used to assess the association of cognitive development with hospitalization. The Cox proportional hazards regression model was used to analyse factors associated with hospitalization risk overtime. In addition, an explorative descriptive design was used to explore how home health care patients experienced and perceived their decision to seek hospital care. Results: The most common reasons for hospitalization were cardiovascular diseases, which caused more than one-quarter of first hospitalizations among the persons living in ordinary housing and nursing home residents (NHRs). The persons who had been hospitalized had a lower mean level of cognitive performance in general cognition, verbal, spatial/fluid, memory and processing speed abilities compared to those who had not been hospitalized. Significantly steeper declines in general cognition, spatial/fluid and processing speed abilities were observed among the persons who had been hospitalized. Cox proportional hazards regression analysis showed that the number of diseases, number of drugs used, having experienced a fall and being assessed as malnourished according to the Mini Nutritional Assessment scale were related to an increased hospitalization risk among the NHRs. Among the older persons living in ordinary housing, the risk factors for hospitalization were related to marital status, i.e., unmarried persons and widows/widowers had a decreased hospitalization risk. In addition, among social factors, receipt of support from relatives was related to an increased hospitalization risk, while receipt of support from friends was related to a decreased risk. The number of illnesses was not associated with the hospitalization risk for older persons in any age group or for those of either sex, when controlling for other variables. The older persons who received home health care described different reasons for their decisions to seek hospital care. The underlying theme of the home health care patients’ perceptions of their transfer to a hospital involved trust in hospitals. This trust was shared by the home health care patients, their relatives and the home health care staff, according to the patients. Conclusions: This thesis revealed that middle-aged and older persons who had been hospitalized exhibited a steeper decline in cognition. Specifically, spatial/fluid, processing speed, and general cognitive abilities were affected. The steeper decline in cognition among those who had been hospitalized remained even after controlling for comorbidities. The most common causes of hospitalization among the older persons living in ordinary housing and in nursing homes were cardiovascular diseases, tumours and falls. Not only health-related factors, such as the number of diseases, number of drugs used, and being assessed as malnourished, but also social factors and marital status were related to the hospitalization risk among the older persons living in ordinary housing and in nursing homes. Some risk factors associated with hospitalization differed not only between the men and women but also among the different age groups. The information provided in this thesis could be applied in care settings by professionals who interact with older persons before they decide to seek hospital care. To meet the needs of an older population, health care systems need to offer the proper health care at the most appropriate level, and they need to increase integration and coordination among health care delivered by different care services.

Bakgrund: Alla, som vårdas inom rättspsykiatrisk vård, har någon form av psykiskt funktionshinder och har också begått ett eller flera brott. Vården regleras av ett antal lagar. I rehabiliteringen ingår utslussning av patienten till öppna vårdformer genom så kallad permission. Ett antal av de patienter som har permission återintas emellanåt till slutenvården av olika orsaker. De benämns ibland som svängdörrspatienter. Syfte: Syftet var att belysa olika berörda personalgruppers syn på och erfarenheter av vad som har betydelse för om en patient som vårdas enligt lagen om rättspsykiatrisk vård, lyckas eller misslyckas med sin permission. Metod: En kvalitativ ansats valdes och två fokusgruppsintervjuer med sex deltagare i varje grupp genomfördes. Texten analyserades med hjälp av en kvalitativ innehållsanalys. Resultat: Tre huvudteman som hade betydelse för om en permission lyckades framkom: samsjuklighet, hur grundläggande behov mötts och samverkan runt patienten. Under dessa framkom 14 subteman: rätt psykiatrisk diagnos, samtidigt missbruk, följsamhet i medicinering, socialt nätverk, sysselsättning, tryggt boende, patientens ekonomi, se patientens behov, tydlig planering, kunskap och motivation, otydlig ansvarsfördelning, samverkan inför permission, kontaktmannaskap och uppföljning i öppenvård. Konklusion: Mycket fungerar bra i vården runt patienten inom rättspsykiatrisk vård. Brister finns dock som behöver förbättras och utvecklas. Det är viktigt att patienterna är delaktiga i vården och att olika instanser skapar individuella förutsättningar och flexibla lösningar för att permissionen ska lyckas. Ordnad ekonomi är av stor betydelse för att permissionen ska lyckas, då det påverkar många delar i patientens vardag. När patienten misslyckas med permissionen kan orsaken vara att man inte har tagit reda på dennes verkliga behov eller inte tagit tillräcklig hänsyn till dessa i permissionsplaneringen. Bristande resurser i samhället bidrar ibland till att patienter inom rättspsykiatrisk vård inte får rätt eller tillräckliga insatser, vilket är ett problem. / Background: Everyone in forensic care has some type of psychiatric disability and has carried out one or more criminal acts. The care is regulated in a number of laws. One part of the patient’s rehabilitation is the transition from closed to open care by so-called leave. A number of the patients that are on leave are sometimes readmitted to closed care for different reasons. These patients are sometimes referred to as “revolving door patients”. Aim: The aim was to determine different concerned personnel groups’ opinions and experiences of what is important, if a patient that is cared for according to the law of forensic care, is to be successful or unsuccessful with his/her leave. Method: A qualitative approach was chosen and two focus group interviews, with six participants in each group, were performed. The text was analyzed with the help of a qualitative content analysis. Results: Three main themes came to light that have significance as to how successful a leave is: comorbidity, how fundamental needs are taken care of and collaboration concerning the patient. 14 subthemes were found under the three main themes: correct psychiatric diagnosis, concurrent misuses, compliance in medication, social networks, employment, safe accommodation, the patient’s economy, seeing the patients needs, clear planning, knowledge and motivation, indistinct line of responsibility, collaboration prior to leave, contacts and follow-up in open care. Conclusion: Many functions are adequate in the care of patients within forensic care. Though there are deficiencies that need to be improved and developed. It is important that the patients participate in the care and that different authorities create individual conditions and flexible solutions if a leave is to be successful. Arranged economy is important if a leave is to be successful, as much of the patient’s everyday existence is affected. When the patient is unsuccessful with a leave, the reason could be that the patient’s real needs are not known, or not enough consideration has been taken to the patients needs when planning the leave. Inadequate public recourses sometimes contribute to patients, in forensic care, not receiving correct or sufficient measures (help), which is a problem.