Predictors of Institutionalization at the Age of 70

Existing knowledge about institutionalization of elderly individuals is mainly based on cross-sectional data and does not give good indications of the cumulative risk of institutionalization. The purpose of this study was to analyze longitudinal data prospectively, to estimate the cumulative risk of ending up in elder care institutions at some point in life. Methods: The study was based on a longitudinal investigation of a random sample of 70-year-old persons living in Gothenburg, Sweden (H70). The sample was followed from age 70 to age 100. Results: The prospective analysis showed that 50% of the subjects eventually moved to some kind of elder care institution. Significantly more women than men relocated although women moved later in life. In a Cox regression model at the age of 70, gender was a strong predictor of future institutionalization together with SES (Socioeconomic Situation), objective health, objective social network and ADL (Activities in Daily Life) functions. Discussion: The proportion of elderly relocating to institutions was significantly higher than proportions generally found in cross-sectional studies. It is noteworthy that, already at age 70 it was possible to find variables that predicted future institutionalization. Our findings confirm that longitudinal analyses give more in depth understanding of institutionalization than cross-sectional designs.

Purpose: The concept of security is related to the experience of health but has ever so often been argued from a risk perspective rather than from a promotional perspective. The experience of older persons’ sense of security in private homes and in nursing homes seems to be missing when it comes to promote aging well throughout the life span. This study aimed to describe and analyze factors related to the sense of security of older persons receiving care in nursing homes in Sweden. Design and Methods: The study was based on a questionnaire from a total of 495 persons aged ≥ 65 in private homes (n = 350) or nursing homes (n = 145) in Sweden. Results: Secure relationships, sense of control, and perceived health were significantly related to the subjects’ sense of security. No significant relationships were found between sense of security and having a personal emergency response alarm. Implications: Experience of sense of security from the older person perspective differs depending on the context. To promote the sense of security within the care of older persons, methods on how to establish secure relations as well as the sense of control and knowledge need to be further tested, developed and analyzed together with older persons.

De flesta kan kanske känna igen sig i en situation då flytt till särskilt boende blir aktuellt, oavsett om det gäller en nära anhörigs flytt eller sin egen. Våra skäl och orsaker till flytten kan variera men behovet av vård och omsorg är ofta detsamma. I en tid av livet då skörheten gör sig påmind och behovet av hjälp och stöd ökar, kan flytten bli ett känslosamt möte mellan det förflutna och en oviss framtid. Att arbeta för att få den äldre personen att känna trygghet under hela flyttprocessen och även under den första tiden på det särskilda boendet blir därför viktigt. Socialtjänsten och Hälsohögskolan har sedan 2013 genomfört ett samverkansprojekt i syfte att fördjupa kunskapen om äldres upplevelse av trygghet i flyttprocessen, för att på så vis förbättra och stärka den.

Sense of security is important throughout the lifespan not at least in advanced age with increased risks of functional declines and decreased social capital. Despite this, knowledge concerning older person’s perceptions and experiences of sense of security when moving into nursing homes is scarce. This study is a longitudinal, descriptive, exploratory case study with in-depth interviews and observations of three older persons in the age of 87, 88, and 91 years in a mid-sized municipality in the south of Sweden, in order to highlight how sense of security is experienced when moving into and living in a nursing home. Data were analysed using qualitative content analysis, which resulted in one main theme and four categories. The main theme, ‘Adaptation and sense of security’, indicates older persons’ need to adapt to the new context of the nursing home, and how this relates to their sense of security. The categories – ‘Control’, ‘Struggling for understanding’, ‘Lack of influence’, and ‘Grasping’ – suggest that older persons’ sense of security is reduced when they must adjust to routines without sufficient management and understanding. When able to maintain control over daily routines, and felt as a part of the new context, they perceived a sense of security.

BACKGROUND: The concept of deinstitutionalization started in the 1960s in the US to describe closing down or reducing the number of beds in mental hospitals. The same process has been going on in many countries but with different names and in various forms. In Europe, countries like Italy prescribed by law an immediate ban on admitting patients to mental hospitals while in some other European countries psychiatric care was reorganized into a sectorized psychiatry characterized by open psychiatric care. This sectorization has not been studied to the same extent as the radical closures of mental hospitals, even though it entailed major changes in the organization of care. The deinstitutionalization in Sweden is connected to the sectorization of psychiatric care, a protracted process taking years to implement.

METHODS: Older people, with their first admission to psychiatric care before or after the sectorization process, were followed using three different time metrics: (a) year of first entry into a mental hospital, (b) total years of institutionalization, and (c) changes resulting from aging. Data from surveys in 1996, 2001, 2006, and 2011 were used, together with National registers.

RESULTS: Examination of date of first institutionalization and length of stay indicates a clear break in 1985, the year when the sectorization was completed in the studied municipality. The results show that the two groups, despite belonging to the same age group (birthyears 1910-1951, mean birthyear 1937), represented two different patient generations. The pre-sectorization group was institutionalized at an earlier age and accumulated more time in institutions than the post-sectorization group. Compared to the post-sectorization group, the pre-sectorization group were found to be disadvantaged in that their level of functioning was lower, and they had more unmet needs, even when diagnosis was taken into account.

CONCLUSIONS: Sectorization is an important divide which explains differences in two groups of the same age but with different institutional history: "modern" and "traditional" patient generations that received radically different types of care. The results indicate that the sectorization of psychiatric care might be as important as the Mental Health Care Reform of 1995, although a relatively quiet revolution.

Background: Current recommendations from the World Health Organization (WHO) are that individuals should seek to maintain a body mass index (BMI) between 18.5-25 kg/m², independent of age. However, there is an ongoing discussion whether the WHO recommendations apply to old (70 ≥ 80 years) and very old persons (80+ years). In the present study we examine how BMI status and change in BMI are associated with mortality among old and very old individuals.

Design: Pooled data from three multidisciplinary prospective population-based studies OCTO-twin, GENDER, and NONA.

Setting: Sweden.

Participants: 882 individuals aged 70 to 95 years.

Measurements: Body Mass Index was calculated from measured height and weight as kg/m². Information about survival status and time of death was obtained from Swedish Civil Registration System

Results: Mortality hazard was 20% lower for the overweight group relative to the normal/underweight group (RR = 0.80, p < .05), and the mortality hazard for the obese group did not differ significantly from the normal/underweight group (RR = 0.93, > .10), independent of age, education, and multimorbidity. Furthermore, mortality hazard was 141% higher for the BMI loss group relative to the BMI stable group (RR = 1.65, p < .05); and 178% higher for the BMI gain group relative to BMI stable group (RR = 1.53, p < .05).  However, the BMI change differences were moderated by age, i.e. the higher mortality risks associated with both loss in BMI and BMI gain were less severe in very old age.

Conclusion: Old persons who were overweight had a decreased mortality risk compared to old persons having a BMI below 25, even after controlling for weight change and multimorbidity. Compared to persons who had a stable BMI those who increased or decreased in BMI had a higher mortality risk, particularly among people aged 70 to 80. This study lends further support for the opinion that the WHO guidelines are overly restrictive in old age.

Personer som bor och vårdas på särskilt boende (säbo) har omfattande omvårdnadsbehov och ofta nedsatt kognitiv funktion, de är ofta multisjuka och har många olika läkemedel samtidigt.

Om en god vårdkvalitet ska kunna garanteras, måste kompetensen bland vårdpersonalen höjas, framför allt avseende specifik geriatrisk kompetens.

En betydande andel av de äldre som bor och vårdas på säbo avlider också där, trots att förutsättningarna för att ge en god palliativ vård vid livets slut är begränsade.

This thesis demonstrates relations among health, social network, ADL and patterns of care in the oldest old guided by a resource theoretical model.

The analyzed data are based on two studies: the Nona study, a longitudinal study of 157 individuals aged 86 to 94 years, and the H70 study, a longitudinal study of 964 individuals aged 70 at baseline. Data were collected by interviews and to some extent in the H70 study, medical exams and medical records.

The results demonstrate that perceived resources seem to affect patterns of care to a higher extent than the more objective resources in the sample of the oldest old. On the other hand, sociodemographic variables such as gender, marital status and SES, in addition to the more objective resources of having children nearby and the number of symptoms of illness predicted institutionalization during a subsequent 30-year period from the age of 70. The proportion of elderly persons’ institutionalization was further significantly higher than that generally found in cross-sectional studies. ADL was one of the strongest predictors for both use of formal care and institutionalization in both samples, indicating an effective targeting of the formal care system in Sweden. The care at end of life in the oldest old is challenged by the problems with progressive declines in ADL and health, which makes it hard to fit in the dying oldest old in the palliative care system. There is a need to increase the knowledge and the possibility for care staff to support and encourage social network factors and for decision-making staff to consider factors beyond ADL.

There are surprisingly few longitudinal studies of the oldest old, but these studies are of high importance because the number of oldest old continues to increase in most countries and because of the uniqueness in this population. The aims of this study were to investigate how health, Activities of Daily Living (ADL), and use of care change over time in the oldest old and to seek how differences in health and ADL affect survival of the oldest old. The study was longitudinal in design, and the participants were interviewed by trained nurses. A group of 300 persons was randomly selected from three age-groups; 86, 90, and 94. For the first phase, in 1999, 157 persons could and wanted to participate; from these 98 persons continued to participate in the second phase and 62 in the third. Repeated Measures (GLM) from the oldest old showed a decline in objective health and ADL functioning with increasing age, but subjective health remained positive and stable. The use of formal help increased with age, and once the oldest old entered the old-age care system, it was rare that they returned to independent living. Analysis using a Cox regression model showed that health and ADL functioning significantly predicted survival, but age did not.

Background and aims: Existing information about institutionalization of elderly individuals is mainly based on cross-sectional data and does not address the cumulative risk of institutionalization. The purpose of the present study was to analyze longitudinal data prospectively and estimate the risk of placement in an elder care institution for individuals aged 70 years or older. Methods: The study was based on a longitudinal investigation (the H70 study) of a random sample of 70-year-olds living in Gothenburg, Sweden, in 1971. Individuals were followed from age 70-100 years. Three different analyses were performed: a descriptive prospective analysis, cross-sectional analyses at ages 70, 79 and 85 years, and a longitudinal analysis of predictors for institutionalization. Results: The prospective analysis indicated that 50% of the individuals eventually moved to an elder care institution. Significantly more women than men were institutionalized, although for women the move occurred later in life. Cross-sectional analyses demonstrated that various factors were important to institutionalization at different ages. The Cox regression model with time-varying covariates indicated that gender, socio-economic situation, marital status, number of symptoms, having children living nearby, and activities in daily life were related to institutionalization. Conclusions: The proportion of elderly persons relocating to institutions was significantly higher than that generally found in cross-sectional studies. It was possible to identify variables that predict institutionalization during a subsequent 30-year period, but different analyses revealed different effects from the factors evaluated.

Introduction

Research indicates gender differences in functional performance at advanced ages, but little is known about their impact on longevity for men and women.

Objective

To derive a set of motor function factors from a battery of functional performance measures and examine their associations with mortality, incorporating possible gender interactions.

Method

Analyses were performed on the longitudinal Swedish Adoption/Twin Study of Aging (SATSA) including twenty-four assessments of motor function up to six times over a 19-year period. Three motor factors were derived from several factor analyses; fine motor, balance/upper strength, and flexibility. A latent growth curve model was used to capture longitudinal age changes in the motor factors and generated estimates of intercept at age 70 (I), rates of change before (S1) and after age 70 (S2) for each factor. Cox regression models were used to determine how gender in interaction with the motor factors was related to mortality.

Results

Females demonstrated lower functional performance in all motor functions relative to men. Cox regression survival analyses demonstrated that both balance/upper strength, and fine motor function were significantly related to mortality. Gender specific analyses revealed that this was true for women only. For men, none of the motor factors were related to mortality.

Conclusion

Women demonstrated more difficulties in all functioning facets, and only among women were motor functioning (balance/upper strength and fine motor function) associated with mortality. These results provide evidence for the importance of considering motor functioning, and foremost observed gender differences when planning for individualized treatment and rehabilitation.

Introduction: As populations continue to age, the need for formal care is increasing. As criteria for formal care services become stricter, older adults with greater health problems may remain at home longer and become increasingly reliant on help from their social networks. Knowledge on how different social network factors affect use of care is limited. This study aimed to analyze 1) how personal outlook and objective and subjective social network factors change over time and 2) how these factors are associated to the use of care among older adults. Methods: Data from 7 follow-up questionnaires from the Swedish Adoption Twin Study of Aging (SATSA) were used, spanning a 23-year period. Individuals older than 55 years at baseline were included. Objective social network measures included: number of neighbors, acquaintances, close friends, confidants, and caregivers. Subjective social networks were measured as the satisfaction with these different contacts. Personal outlook included feelings of loneliness and satisfaction with life. The outcome was measured as self-reported receipt of weekly care. Multivariate logistic regression explored the relationship between social network factors and weekly care. Results: Among the 1,065 older individuals in the sample, changes in social networks were most concentrated in the oldest individuals (85+ years at baseline). Increasing age (p<0.0001) was associated with an increased likelihood of weekly care, while never feeling lonely was associated with a much lower likelihood of weekly care (p=0.034). Conclusion: Age and personal outlook factors are important considerations in formal care needs among older populations.

Introduction: The aging population is often considered as a threat that will deplete family and societal resources. Yet older people may be a resource, giving support and care to their family. The aim of this study is to analyze patterns of giving and receiving support by the oldest old with their family. Method: Data were used from the OCTO2- study, a Swedish population-based sample of 171 women and 156 men, 75–90  years. Respondents completed the Intergenerational Support Index to examine patterns of receiving and giving care and support and factors associated with support exchanges. Results: Results showed that the oldest old gave as much support as they received within the family. Most of the older persons receiving formal help from the community (79%) continued giving support to family. The most common types of support given and received within the family were emotional (89% given, 90% received) and practical (44% given, 46% received). Older persons gave more financial support (26%) than they received (2%). Age, gender, functioning in daily life activities and satisfaction with life were associated with giving different types of family support. Conclusion: Old-old people in Sweden are not just consumers of care, but are involved in reciprocal patterns as receivers and providers of care and support. It is not a simple opposition between being a giver and receiver of informal support simultaneously, but more knowledge is needed about the complex interplay between various form of care and support.

Trycksår orsakas av många olika faktorer, så kallade direkta och indirekta riskfaktorer som blir vanligare med stigande ålder. En tidigare undersökning i Jönköpings kommun 1995 (Socialstyrelsen 1996) visade att prevalensen av trycksår var på sjukhem 4,9 %, på serviceboende med helinackordering 0,9 %, på servicehus 0,8 % och på gruppboende slutligen 0,6 %. En något senare undersökning från 1996 visade att prevalens trycksår på distrikt Öster i Jönköping var 6 % (Malmberg et al 1997). I undersökningen var samtliga äldreboende inkluderade men inte uppdelade på olika boendeformer såsom i undersökningen från Socialstyrelsen (1996). Alla faktorer som exponerar huden för tryck eller försämrar hudens tolerans för tryck ska beaktas som en riskfaktor för trycksår. Syftet med att använda ett instrument eller en skala för identifiering av personer som löper risk att utveckla trycksår är att i ett tidigt skede kunna sätta in preventiva åtgärder. De mest använda instrumenten är Norton Risk Assessment Score, the Waterlow Risk Assessment Card och the Braden Scale (Murray et al 2001). Ek (1989) har utarbetat en modifierad Nortonskala som använts i svenska studier av riskfaktorer vid trycksår. Den skattar födointag och vätskeintag, förutom variablerna i ursprungsskalan (Norton Risk Assessment Score). Var och en av de sju variablerna graderas från 1 till 4. Totalt kan en person erhålla högst 28 poäng och lägst 7 poäng (Ek et al 1989).

Syftet med den här undersökningen var att med hjälp av den modifierade Norton-skalan uppskatta hur många vårdtagare på särskilda boendeformer för äldre som befann sig i riskzonen för att utveckla trycksår för att få ett underlag för förebyggande åtgärder. Undersökningen riktade sig till samtliga vårdtagare som bodde på särskilda boendeformer för äldre inom ett distrikt/kommundel i Jönköpings kommun, som skattades med den modifierade Nortonskalan under tre år i följd (1999, 2000 och 2001).

Enligt skalan anses personer som har 21 poäng eller lägre vara i riskzonen för att utveckla trycksår. Medelvärdet för samtliga bedömda personer låg mellan 22 och 23. De flesta vårdtagarna (mellan 58 och 65 %) hade mer än 21 poäng. Mellan 35 % och 42 % bedömdes vara i riskzonen att drabbas av trycksår enligt den modifierade Nortonskalan. Av de vårdtagare som låg i riskzonen att drabbas av trycksår var det få (mellan 2 % och 4 % av samtliga bedömda) som hade så låga poäng som 7 – 14. De flesta av dem som låg i riskzonen hade mellan 15 och 21 poäng. År 1999 var det 38 personer som hade någon typ av trycksår, det vill säga 7,9 %, år 2000 var det 35 personer, 9,3 %, och år 2001 var det 32 personer som hade trycksår, vilket innebar 8,5 % av de bedömda. Personerna som hade utvecklat trycksår hade överlag lägre totalpoäng på den modifierade Nortonskalan. Det var dock varje mätår en fem - sex personer som hade över 21 poäng och alltså inte bedömdes vara i riskzonen att utveckla trycksår enligt den modifierade Nortonskalan som trots allt hade trycksår. Detta innebär att 14 – 19 % av dem som utvecklar trycksår inte bedömdes att vara i riskzonen enligt den modifierade Nortonskalan. De så kallade speciella riskfaktorerna, som beskrivs närmare i rapporten, ”träffade rätt” i högre grad men går heller inte att helt förlita sig på. Trycksår ger ett stort lidande för den som drabbas och en känsla av misslyckande bland personalen. Kontinuerliga skattningar av trycksårsrisken kan ha stor betydelse för att ständigt hålla dessa frågeställningar aktuella och därigenom minimera risken för att någon skall utveckla trycksår.

OBJECTIVE: The aim of this study was to describe the last year of life of a sample of the oldest old, focusing on care trajectories, health, social networks, and function in daily life activities.

METHOD: Data originated from the NONA study, a longitudinal study of 193 individuals among the oldest old living in a Swedish municipality. During this longitudinal study, 109 participants died. Approximately one month after their death, a relative was asked to participate in a telephone interview concerning their relative's last year of life. One hundred two relatives agreed to participate.

RESULTS: Most of the elderly in this sample of the oldest old (74.5%) died at an institution and the relatives were mostly satisfied with the end-of-life care. The oldest old relatives estimated that the health steadily declined during the last year of life, and that there was a decline in performing of daily life activities. They also estimated that those dying in institutions had fewer social contacts than those dying in a hospital or at home.

SIGNIFICANCE OF RESULTS: Care at end of life for the oldest old is challenged by problems with progressive declines in ability to perform activities of daily living and health. The findings also highlight the need to support social networks at eldercare institutions.