Background: Combining National Quality Registries (NQRs) with existing National Health Registries (NHRs) might make it possible to get a wider picture of older adults health situation. The aim was to examine the feasibility of aggregating data across different NQRs and existing NHRs to explore the possibility to investigate trajectories and patterns of disease and care, specifically for the most ill older adults.

Method: A Swedish twin population (N = 44,816) was linked to nine NQRs and four NHRs. A descriptive mixed-method study was performed. A manifest content analysis identified which health parameters were collected from each NQR. Factor analysis identified patterns in representation across NQRs. Two case studies illustrated individual trajectories of care by using NQRs and NHRs.

Results: About 36% of the population was registered in one or more NQRs. NQRs included 1849 variables that were sorted into 13 categories with extensive overlap across the NQRs. Health and function variables were identified, but few social or cognitive variables. Even though most individuals demonstrated unique patterns of multi-morbidities, factor analysis identified three clusters of representation in the NQRs with sufficient sample sizes for future investigations. The two cases illustrated the possibility of following patterns of disease and trajectories of care.

Conclusions: NQRs seem to be a significant source for collecting data about a population that may be underrepresented in most research on aging because of their age and poor health. However, NQRs are primarily disease related, and further development of the registries to maximize coverage and utility is needed. 

BACKGROUND: In the last years of life, burden of disease and disability and need of health- and social care often increase. Social, functional and psychological factors may be important in regard to social- and health care utilization. This study aims to describe use of health- and social care during the last year of life among persons living in ordinary housing or in assisted living facilities.

METHODS: A retrospective study examining health- and social care utilization during their last year of life, using a subsample from the Swedish twin registries individually linked to several Swedish national quality registries (NQR). Persons that died during 2008-2009 and 2011-2012 (n = 1518) were selected.

RESULTS: Mean age at death was 85.9 ± 7.3 (range 65.1-109.0). Among the 1518 participants (women n = 888, 58.5%), of which 741 (49%) were living in assisted living facilities and 1061 (69.9%) had at least one hospitalization during last year of life. The most common causes of death were cardiovascular disease (43.8%) and tumors (15.3%). A multivariable logistic regression revealed that living in ordinary housing, younger age and higher numbers of NQR's increased the likelihood of hospitalization.

CONCLUSIONS: Persons in their last year of life consumed high amount of health- and social care although 12% did not receive any home care. Married persons received less home care than never married. Persons living in ordinary housing had higher numbers of hospitalizations compared to participants in assisted living facilities. Older persons and persons registered in fewer NQR's were less hospitalized.

Background: Older people living in nursing homes are at a high risk of becoming malnourished, falling and developing pressure ulcers. In Sweden the national quality registry Senior Alert was developed to support prevention in these areas. Prevention according to Senior Alert follows a preventive care process of four steps, including risk assessment, analysis of the causes of risk, to determine and perform appropriate actions, and finally, to evaluate the care given.

Aim: The overall aims of this thesis were to investigate how the preventive care process in Senior Alert functions as a tool for preventive work among older persons living in nursing homes, and to investigate the results of risk assessments and actions.

Design: The thesis is based on three longitudinal quantitative studies (I, III, and IV) and one qualitative study (II). In Studies I and III, process- and patient results were compared among different groups of nursing home residents, with a follow-up time of 6 months. In Study IV, associations between the assessment instruments and the outcomes of weight loss, falls and pressure ulcers were investigated. The qualitative study (II) was based on focus group interviews with healthcare professionals and was analyzed using content analysis.

Results: The residents included in the registry during the later years (2013-2014) had a higher proportion of registered preventive actions in the three areas, and were followed up more frequently regarding weight and new assessments than residents included during the earlier years (2010-2012). Nevertheless, regardless of risk, only 30% were reassessed, and 44% of the residents at risk for malnutrition were followed up for body weight within 6 months. No difference in weight change was found between a group of residents included in Senior Alert and a second group receiving ‘care as usual’. Generally, the mobility variables in the risk assessment instruments had the strongest associations with the tested outcomes of weight loss, fall and pressure ulcers, albeit in different ways. Healthcare professionals described that Senior Alert stimulated better teamwork while at the same time they experienced the increased documentation and time constraints as aggravating circumstances. They also described a lack of reliability of the assessment instruments in that they overrated the risks compared to their own clinical judgement. Healthcare professional’s knowledge about the evaluation part of the process was low.

Conclusion: The evaluation and follow-up step of the preventive care process was not sufficiently applied. This was expressed by the participants in the focus groups and was also reflected in registry data by the varying time to follow-up and the poor event registration. As a consequence, the sample to measure outcomes within 6 months became small. Therefore, larger samples are needed to study longitudinal outcomes, if a fixed system-mandatory time point for follow-up is not implemented. A committed leadership is important to improve the preventive work and to stimulate follow-up of results.

AIMS AND OBJECTIVES: To explore the association between oral health and nutritional status in the context of daily care for older people.

BACKGROUND: Oral problems often increase with age and affect a person's ability to chew and swallow. They might also influence the ability to maintain a satisfactory nutritional status. Oral health awareness is therefore of great importance in nursing care for older people.

DESIGN: A retrospective cross-sectional study.

METHODS: Data from the Swedish quality register, Senior Alert, were used, including structured assessments of both oral and nutritional status using the Revised Oral Assessment Guide-Jönköping and the Mini Nutritional Assessment. In total, 1,156 persons (mean age: 82.8 ± 7.9) had both oral and nutritional assessments registered by the nursing staff in daily care.

RESULTS: Approximately 29% of participants had moderate oral health problems. Another 12% had severe problems. Over 60% of the persons were considered at risk of malnutrition or were malnourished. There was a weak correlation between poor nutritional status and poor oral health, and approximately one-third of the persons who were at risk or malnourished had simultaneous oral problems. A multivariate logistic regression revealed that when problems involving voice and swallowing were present, there was also a greater possibility of being assessed as at risk of malnourishment or being malnourished.

CONCLUSION: There is a relationship between oral health problems and nutritional status, indicating the importance of evaluating oral health status in older persons with nutritional problems.

RELEVANCE TO CLINICAL PRACTICE: Nursing staff involved in care for older people should be aware of the importance of including regular oral health check-ups in their work. There is also a need for nursing staff members and oral health professionals to exchange knowledge.

A structured and systematic care process for preventive work, aimed to reduce falls, pressure ulcers and malnutrition among older people, has been developed in Sweden. The process involves risk assessment, teambased interventions and evaluation of results. Since development, this structured work process has become web-based and has been implemented in a national quality registry called ‘Senior Alert’ and used countrywide. The aim of this study was to describe nursing staff’s experience of preventive work by using the structured preventive care process as outlined by Senior Alert. Eight focus group interviews were conducted during 2015 including staff from nursing homes and homebased nursing care in three municipalities. The interview material was subjected to qualitative content analysis. In this study, both positive and negative opinions were expressed about the process. The systematic and structured work flow seemed to only partly facilitate care providers to improve care quality by making better clinical assessments, performing team-based planned interventions and learning from results. Participants described lack of reliability in the assessments and varying opinions about the structure. Furthermore, organisational structures limited the preventive work.

Objective: Malnutrition with consequent weight loss is a well-known problem among older frail persons living in nursing homes. The objective of this study was to examine the effect of a structured preventive care programme including an individualized nutrition plan. Design: A retrospective study, based on already collected data from two different nursing home populations. One population constituted a group of nursing home residents receiving the nutritional care programme (ncp-group), including individually performed nutritions actions. The ncp-group (N=135) was registered in the national quality registry Senior Alert (SA), a platform for following of this preventive care process. The other population constituted a group of nursing home residents receiving “care as usual” (n=186), ie not using the nutritional care programme, collected from the study SHADES. The two populations was compared by a quasi-experimental pre-posttest design with a follow-up time of 5–7 months.

Settings: Nursing homes in Sweden.

Participants: Two populations of nursing home residents assessed to be at risk for malnutrition, or to be already malnourished, according to the short form of the Mini Nutritional Assessment (MNA-SF).

Intervention: The ncp-group received a structured, individually targeted care programme including risk assessments, team-based decisions on actions, and evaluation of results.

Measurements: Body weight and weight changes were monitored over time. Additionally, nutritional status was described using the MNA-SF scores and body mass index (BMI).

Results: No statistically significant differences in body weight, MNA-SF or BMI between the groups were found at follow-up. However, within-group analyses in the group followed in SA showed improved outcomes.

Conclusion: This suggest small differences in nutritional care provided at nursing homes working with SA and “care as usual” in nursing homes, not working with SA.

It is well known that malnutrition is common among older persons and has a negative impact on health. Even though there is a growing literature on nutrition and aging, few studies focus on longitudinal changes in later life. The aims of this study are to characterize general nutritional status development over time, to identify clusters of nutritional status trajectories, as well as to study the association between the nutritional status trajectories and death. The baseline sample is drawn from the Screening Across the Lifespan Twins (SALT) study. All participants of SALT that had at least 3 assessments according to Mini Nutritional Status Shortform (MNA-SF) documented in the Senior Alert quality register between 2008 and 2015 were included for analyses (N=1509). At the first registration, mean age was 82.4 ± 7.5. According to MNA-SF, 13.3% persons were malnourished, 44.9% were at risk of malnutrition, and 41.8 % were well nourished. Preliminary analysis indicate that despite a general decline in nutritional status in old age, there is a large variability in the sample, making the data suitable for latent class trajectory analyses. Initial analyses also indicate that decrease in nutritional status is associated with decreased survival. Consequently, deterioration in nutritional status seems to be associated with mortality. Detecting malnutrition in older age is important in order to avoid premature death.