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Geriatric Aspects of Frail Nursing Home Residents: A Swedish cohort study
Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0002-2491-4232
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The number and proportion of older people are increasing in Sweden as well as throughout the western world. Older people with increasing assistance needs that can no longer be met in their own home need institutional long-term care in nursing homes. A successive reduction of nursing home beds in combination with a future demographic development with a rapidly increasing number of older people will lead to higher demands on future medical care in nursing homes. Consequently, increased knowledge about the medical needs of nursing home residents is of great value.

Objectives: This thesis explores some important geriatric aspects of frail nursing home residents. The specific aims was to characterise the population of nursing home residents, to explore the prevalence of anaemia, paying particular attention to risk factors and mortality, to investigate associations between falls and use of possible fall risk drug classes and to estimate the prevalence of diagnostic failure of cognitive impairment and to investigate whether diagnostic failure was associated with impaired medical care.

Methods: All data originate from SHADES (the Study of Health and Drugs in Elderly nursing home residents in Sweden), a prospective cohort study that included nursing home residents at 12 nursing homes situated in three municipalities in southern Sweden between 2008 and 2011. The subjects were followed every six months with data collection from medical records concerning medications, diagnoses, hospital referrals and mortality, examinations including blood sample analyses, assessments with validated rating scales for cognitive evaluation, depression, risk of pressure ulcers, malnutrition or falls, and the need for care was rated through a questionnaire.

Results: SHADES included a total of 428 subjects with a mean age of 85 years, of whom 71% were women. They demonstrated comorbidity with a mean of three registered medical diagnoses, and polypharmacy with a mean of seven regularly used drugs. More than half of the sample (60%) were at risk of malnutrition and one third were at risk of developing pressure ulcers. A set of single items from the performed risk assessments was found to be important in understanding frailty and need for care. One third of the women and half of the men had anaemia. For the men, anaemia was associated with significantly higher mortality. Haemoglobin decline was also associated with higher mortality. Almost everyone (93%) had an increased fall risk and 62% had fallen during the last year. There was an association between falls during the last year and regular use of non-benzodiazepine hypnotics. In the older age group there was also an association between these drugs and serious falls the next 6 months. Dementia was previously diagnosed in 42%. However, among subjects without a dementia diagnosis, 72% were cognitively impaired (Mini Mental State Examination <24). These subjects were significantly older, did not get anti-dementia treatment and had higher levels of brain natriuretic peptide compared to the diagnosed dementia group, possibly indicating heart failure. Their risks of malnutrition and pressure ulcers were similar to the dementia group.

Conclusions: Nursing home residents are generally frail. Anaemia is associated with higher mortality among men. The fall risk is generally high and use of non-benzodiazepine hypnotics is associated with a higher occurrence of falls. Cognitive impairment is undiagnosed in half of the cases and may indicate underlying heart failure. Consequently, regular medical follow-ups in this population are proposed to include blood count, drug review, and cognitive evaluation. In the case of cognitive impairment, exclusion of underlying disease such as heart failure should be considered.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1674
National Category
Geriatrics
Identifiers
URN: urn:nbn:se:liu:diva-155641DOI: 10.3384/diss.diva-155641ISBN: 978-91-7685-101-2 (print)OAI: oai:DiVA.org:liu-155641DiVA, id: diva2:1298126
Public defence
2019-05-03, Originalet, Qulturum, Hus B4, Länssjukhuset Ryhov, Jönköping, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2019-03-25 Created: 2019-03-21 Last updated: 2019-07-25Bibliographically approved
List of papers
1. How to assess frailty and the need for care? Report from the Study of Health and Drugs in the Elderly (SHADES) in community dwellings in Sweden
Open this publication in new window or tab >>How to assess frailty and the need for care? Report from the Study of Health and Drugs in the Elderly (SHADES) in community dwellings in Sweden
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2011 (English)In: Archives of gerontology and geriatrics (Print), ISSN 0167-4943, E-ISSN 1872-6976, Vol. 53, no 1, p. 40-45Article in journal (Refereed) Published
Abstract [en]

Abstract

Knowledge about the need for care of elderly individuals in community dwellings and the factors affecting their needs and support is limited. The aim of this study was to characterize the frailty of a population of elderly individuals living in community dwellings in Sweden in relation to co-morbidity, use of drugs, and risk of severe conditions such as malnutrition, pressure ulcers, and falls. In 2008, 315 elderly individuals living in community dwellings were interviewed and examined as part of the SHADES-study. The elderly demonstrated co-morbidity (a mean of three diseases) and polypharmacy (an average of seven drugs). More than half the sample was at risk for malnutrition, one third was at risk for developing pressure ulcers, and nearly all (93%) had an increased risk of falling and a great majority had cognitive problems. Age, pulse pressure, body mass index, and specific items from the modified Norton scale (MNS), the Downton fall risk index (DFRI), and the mini nutritional assessment (MNA-SF) were related to different outcomes, defining the need for care and frailty. Based on the results of this study, we suggest a single set of items useful for understanding the need for care and to improve individual based care in community dwellings.

 

Place, publisher, year, edition, pages
Elsevier, 2011
Keywords
Frailty; Community dwellings; Risk-assessments; Cognitive function
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-66914 (URN)10.1016/j.archger.2010.06.011 (DOI)
Available from: 2011-03-21 Created: 2011-03-21 Last updated: 2019-03-21Bibliographically approved
2. Prevalence and predictive importance of anemia in Swedish nursing home residents - a longitudinal study
Open this publication in new window or tab >>Prevalence and predictive importance of anemia in Swedish nursing home residents - a longitudinal study
2016 (English)In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 16, article id 206Article in journal (Refereed) Published
Abstract [en]

Background: Anemia is common in elderly people and especially in nursing home residents. Few studies have been performed on the consequences of anemia in a nursing home population. This study explored the prevalence of anemia in nursing homes in Sweden, including risk factors and mortality associated with anemia or hemoglobin (Hb) decline. Methods: Three hundred ninety patients from 12 nursing homes were included during 2008-2011. Information about medication, blood samples, questionnaire responses and information about physical and social activities was recorded. The baseline characteristics of the patients were compared for subjects with and without anemia. Vital status was ascertained during the following 7 years from baseline to compare the survival. Hb levels amp;lt;120 g/L in women and amp;lt;130 g/L in men were used to define anemia. For 220 of the subjects Hb change during one year was registered and the quartiles in Hb change were compared in terms of baseline characteristics and mortality. Results: The prevalence of anemia at baseline was 52% among men and 32% among women. The men with anemia had a two-year mortality significantly higher (61%) than the men without anemia (29%, p = 0.001) but there was no statistical difference in two- year survival in women. In anemic men there was a higher mortality (Hazard Ratio = 1.58) during a total follow-up period of up to 7 years after adjustment for age, increased B-type natriuretic peptide (BNP) and decreased estimated Glomerular Filtration Rate (eGFR). Among men, but not women, we found baseline correlations between anemia and elevated BNP (amp;gt;100 ng/L) and severely reduced eGFR (amp;lt;30 ml/min). When the lowest quartile of Hb change (decline amp;gt;9 g/L) was compared with the highest (improvement amp;gt;6 g/L) the mortality was higher in the lowest quartile (p = 0.03). Conclusions: Anemia is common in nursing home residents in Sweden, especially among men for whom it is related to higher mortality. A rapid Hb drop is associated with higher mortality. Regardless of earlier Hb values, monitoring Hb regularly in a nursing home population seems important for catching rapid Hb decline correlated with higher mortality.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2016
Keywords
Anemia; Mortality; Elderly; Nursing homes; Longitudinal study
National Category
Geriatrics
Identifiers
urn:nbn:se:liu:diva-133780 (URN)10.1186/s12877-016-0375-2 (DOI)000389385600001 ()27912734 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden (FORSS); Futurum - academy of health and care, Region Jonkoping county; Swedish Society of Medicine; Fromma Foundation; ALF funding from Region Skane

Available from: 2017-01-09 Created: 2017-01-09 Last updated: 2019-03-21
3. Use of non-benzodiazepine hypnotics is associated with falls in nursing home residents: a longitudinal cohort study
Open this publication in new window or tab >>Use of non-benzodiazepine hypnotics is associated with falls in nursing home residents: a longitudinal cohort study
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2019 (English)In: Aging Clinical and Experimental Research, ISSN 1594-0667, E-ISSN 1720-8319, Vol. 31, no 8, p. 1078-1095Article in journal (Refereed) Published
Abstract [en]

Background

Falls and related injuries are common among older people, and several drug classes are considered to increase fall risk.

Aims

This study aimed to investigate the association between the use of certain drug classes and falls in older nursing home residents in Sweden, and relate these to different age groups.

Methods

Information on falls that occurred in the previous year and regular use of possible fall risk drugs including non-benzodiazepine hypnotics (zopiclone and zolpidem) was collected from 331 nursing home residents during 2008–2011. Over the following 6 months, the occurrence of serious falls, requiring a physician visit or hospital care, was registered. Association between serious falls and drug use was compared between an older (≥ 85 years) and a younger group.

Results

An increased fall risk (Downton Fall Risk Index ≥ 3) was found in 93% of the study subjects (aged 65–101 years). Baseline data indicated an association between falls that occurred in the previous year and regular use of non-benzodiazepine hypnotics (p = 0.005), but not with the other studied drug classes. During the following 6 months, an association between use of non-benzodiazepine hypnotics and serious falls in the older group (p = 0.017, odds ratio 4.311) was found. No association was found between the other studied drug classes and serious falls.

Discussion

These results indicate an association between falls and the use of non-benzodiazepine hypnotics, compounds that previously have been considered generally well-tolerated in older people.

Conclusions

Caution is advocated when using non-benzodiazepine hypnotics regularly in older people living in nursing homes.

Place, publisher, year, edition, pages
Springer, 2019
Keywords
Accidental falls, Frail elderly, Nursing homes, Hypnotics and sedatives, Adverse effects, Longitudinal study
National Category
Rheumatology and Autoimmunity Geriatrics Pharmacology and Toxicology
Identifiers
urn:nbn:se:liu:diva-156240 (URN)10.1007/s40520-018-1056-0 (DOI)000477664800007 ()30341643 (PubMedID)2-s2.0-85055751099 (Scopus ID)
Note

Funding agencies:  Medical Research Council of Southeast Sweden (FORSS); Futurum-Academy of Health and Care, Region Jonkoping County

Available from: 2019-04-09 Created: 2019-04-09 Last updated: 2019-08-12Bibliographically approved
4. Diagnostic Failure of Cognitive Impairment in Nursing Home Residents May Lead to Impaired Medical Care
Open this publication in new window or tab >>Diagnostic Failure of Cognitive Impairment in Nursing Home Residents May Lead to Impaired Medical Care
2019 (English)In: Dementia and Geriatric Cognitive Disorders, ISSN 1420-8008, E-ISSN 1421-9824Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background/Objectives: Dementia and cognitive impairment are common in nursing homes. Few studies have studied the impact of unnoted cognitive impairment on medical care. This study aimed to estimate the prevalence of diagnostic failure of cognitive impairment in a sample of Swedish nursing home residents and to analyze whether diagnostic failure was associated with impaired medical care. 

Method: A total of 428 nursing home residents were investigated during 2008–2011. Subjects without dementia diagnosis were grouped by result of the Mini Mental State Examination (MMSE), where subjects with <24 points formed a possible dementia group and the remaining subjects a control group. A third group consisted of subjects with diagnosed dementia. These three groups were compared according to baseline data, laboratory findings, drug use, and mortality. 

Results: Dementia was previously diagnosed in 181 subjects (42%). Among subjects without a dementia diagnosis, 72% were cognitively impaired with possible dementia (MMSE <24). These subjects were significantly older, did not get anti-dementia treatment, and had higher levels of brain natriuretic peptide compared to the diagnosed dementia group, but the risks of malnutrition and pressure ulcers were similar to the dementia group. 

Conclusions: Unnoted cognitive impairment is common in nursing home residents and may conceal other potentially treatable conditions such as heart failure. The results highlight a need to pay increased attention to cognitive impairment among nursing home residents.

Place, publisher, year, edition, pages
S. Karger, 2019
Keywords
Cognitive impairment, Nursing homes, Morbidity, Dementia, Heart failure
National Category
Geriatrics
Identifiers
urn:nbn:se:liu:diva-159107 (URN)10.1159/000499671 (DOI)31269489 (PubMedID)2-s2.0-85068515589 (Scopus ID)
Available from: 2019-07-25 Created: 2019-07-25 Last updated: 2019-09-04Bibliographically approved

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Westerlind, Björn

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