We used national surveys to study how older persons’ changing household patterns influence the gender balance of caregiving in two countries with distinct household structures and cultures, Spain and Sweden. In both countries, men and women provide care equally often for their partner in couple-only households. This has become the most common household type among older persons in Spain and prevails altogether in Sweden. This challenges the traditional dominance of young or middle-aged women as primary caregivers in Spain. In Sweden, many caregivers are old themselves. We focus attention to partners as caregivers and the consequences of changing household structures for caregiving, which may be on the way to gender equality in both countries, with implications for families and for the public services.

We linked individual-level data from the 2004 wave of the National Long-Term Care Survey with state-level data from the National Aging Program Information Systems (NAPIS) State Program Reports to predict care mix and unmet need for assistance. Our sample consisted of 2422 community-dwelling individuals aged 65 and older (69% women, 8% nonwhite) who reported at least one limitation in an instrumental or basic activity of daily living. We used the data to predict the mix of formal and informal support received, and the probability of having at least one unmet need from individual (predisposing, enabling, and need) characteristics with state-level home help coverage rates, intensity of home help services, and proportion of population aged 60+ residing in institutional settings. Consistent with past research, a majority (52.6%) of the disabled sample reported unmet need. At the individual level, enabling (availability of kin support) and need (number of basic and instrumental activity of daily living impairments, BADLs and IADLs) were most strongly associated with care mix and unmet need. State-level services were not associated with receipt of informal supports. In states providing home help services to a higher proportion of elders, women were more likely to receive formal help. In states providing more intensive services, women were less likely and individuals living alone more likely to receive formal supports. In states where a higher proportion of elders lived in nursing homes, individuals living alone were more likely to receive formal assistance, less likely overall to report unmet needs, but the oldest-old were more likely to report unmet need.

Social isolation and loneliness are often considered to be important and frequent problems in old age. However, the empirical support for this notion is weak. Results from Swedish studies show that rather extensive social networks continue into old age. Only a small minority can be said to be isolated and suffering from feelings of loneliness. This minority, however, reports a lower life satisfaction, which can also produce physical and psychological problems. Increased attention must be directed toward such negative consequences of weak social networks. This is especially important in discussions of how to alter a social situation characterized by loneliness and isolation. It is emphasized that further research within this field must be based on more explicit theories.

(PERS) alarms have been used in Sweden since 1974 to enable older people to age safely at home. Despite this long use, we found no studies describing independent older users’ opinions of these devices.

Aim Our aim was to describe how people living in Swedish independent senior housing perceive the alarms and to highlight their wishes for further developments and innovations.

Methods We conducted five focus group interviews with residents of senior housing who used or had used a PERS alarm and analysed the data qualitatively for latent content.

Results The data analysis revealed five themes in participants’ opinions and feelings about the PERS alarms: (i) safety, (ii) anxiety, (iii) satisfaction, (iv) being informed, and (v) older persons as active innovators.

Conclusion The 40-year-old Swedish PERS used in senior housing seems to limit rather than liberate users in their daily lives and cause feelings of insecurity rather than security. Older Swedish people require a more personalized alarm with a built-in positioning system that would allow them a greater range of movement beyond their homes.

Aging in Sweden has been uniquely shaped by its history—most notably the long tradition of locally controlled services for older adults. We considered how local variations and local control shape the experience of aging in Sweden and organized the paper into 3 sections. First, we examine aging in Sweden along demography, economy, and housing. Next, we trace the origins and development of the Swedish welfare state to consider formal supports (service provision) and informal supports (caregiving and receipt of care). Finally, we direct researchers to additional data resources for understanding aging in Sweden in greater depth. Sweden was one of the first countries to experience rapid population aging. Quality of life for a majority of older Swedes is high. Local control permits a flexible and adaptive set of services and programs, where emphasis is placed on improving the quality and targeting of services that have already reached a plateau as a function of population and expenditures.

Background and aims: This study examines gender-specific behavioral correlates of depressive symptoms using a secondary data analysis of a cross-sectional, population-based sample of older unlike-sex twins.

Methods: Unlike-sex twins aged 69–88 were identified through a national Swedish registry and sent a survey about health, including depressive symptoms (CES-D) and the frequency of engaging in physical, social and mental activities. A total of 605 complete twin pairs responded.

Results: Depressive symptom scores were associated with frequency of engagement in physical and mental activities, but only in men. No statistically significant associations with depressive symptom scores for any of the three types of activities were found in women.

Conclusions: The results suggest that engaging in physical and mental activities may protect older men from developing depressive symptoms, but longitudinal data are needed to offer more conclusive findings on the role that physical, mental, and social activities play in the maintenance of psychological health in older men and women.

Aim.  To develop a test of cognitive performance in persons with moderate-to-severe dementia.

Background.  Various instruments are used to assess the course of dementia and to evaluate treatments in persons with dementia. Most neuropsychological assessments are inappropriate for measuring cognitive abilities in persons with severe dementia, because these persons perform at floor level in such measurements.

Design.  A cross-sectional research design.

Methods.  The test (Clinical Evaluation of Moderate-to-Severe Dementia; Swedish acronym: KUD) was developed from a pool of 25 test items with the final KUD consisting of 15 items. Reliability and validity were established using 220 subjects (with various dementia diagnoses) with scores of Mini-Mental State Examination between 0–20. Approximately two weeks after the first test, 116 of the original 220 subjects were retested.

Results.  A factor analysis with the 15-item scale revealed an interaction factor comprising three items and a cognitive performance factor with 12 items. The internal consistence reliability was 0·93 for the KUD (Cronbach’s alpha). Test–retest reliability was also high (0·92) and correlation between the KUD and the MMSE (≤20) was high (r = 0·80).

Conclusion.  The KUD seems to be a valid, reliable performance-based assessment scale for measuring cognitive performance in persons with MMSE score below 12 or 15 points.

Relevance to clinical practice.  It is of outmost interest that cognitive performance can be easily followed for persons with moderate-to-severe dementia in, for example, drug therapies and other therapies, but also in terms of treatment of and support to the person based on his or her abilities.

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.

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.

Developmental processes are inherently time-related, with various time metrics and transition points being used to proxy how change is organized with respect to the theoretically underlying mechanisms. Using data from 4 Swedish studies of individuals aged 70-100+ (N = 453) who were measured every 2 years for up to 5 waves, we tested whether depressive symptoms (according to the Center for Epidemiologic Studies Depression Scale; Radloff, 1977) are primarily driven by aging-, disablement-, or mortality-related processes, as operationally defined by time-from-birth, time-to/from-disability-onset (1st reported impairment in Personal Activities of Daily Living; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963), and time-to-death metrics. Using an approach based on Akaike weights, we tested whether developmental trajectories (for each time metric) of depressive symptoms in late life are more efficiently described as a single continuous process or as a 2-phase process. Comparing fits of linear and multiphase growth models, we found that 2-phase models demonstrated better fit than did single-phase models across all time metrics. Time-to-death and time-to/from-disability-onset models provided more efficient descriptions of changes in depressive symptoms than did time-from-birth models, with time-to-death models representing the best overall fit. Our findings support prior research that late-life changes in depressive symptoms are driven by disablement and, particularly, mortality processes, rather than advancing chronological age. From a practical standpoint, time-to/from-disability-onset and, particularly, time-to-death metrics may provide better "base" models from which to examine changes in late-life depressive symptoms and determine modifiable risk and protective factors. Developmental researchers across content areas can compare age with other relevant time metrics to determine if chronological age or other processes drive the underlying developmental change in their construct of interest.

Gender and Patterns of Cardiovascular Diagnoses and Year of Diagnoses in an Unlike-Sex Twin Sample in Sweden

Cardiovascular disease is the number one cause of death for men and women. This study examined diagnoses in health records in a sample of older-unlike-sex twins in Sweden (N=249 pairs). A physician in Sweden has examined these twins’ medical records going back as far as 50 years and compiled a database with diagnoses based on ICD-10 codes and the year of diagnosis. A subsample of twinpairs was created in which both members had been diagnosed with at least one cardiovascular condition (N=140 pairs). The number of these conditions ranged from 1-8, with men having more than women (chi-square = 15.349, 7 d.f., p<.05). Analyses of the 4 most frequent conditions were conducted. We found 59 subjects with a diagnosis of myocardial infarction (45 men; 14 women), but only 4 concordant twinpairs; of those 2 brothers preceded their sister in year of diagnosis. We found 72 cases of congestive heart failure (43 men; 29 women), but only 12 concordant twinpairs; in half of those cases, the brother preceded his sister. We found 61 cases of stroke (34 men; 27 women), but only 12 concordant twinpairs; in 5 cases the brother preceded his sister. We found 181 subjects with arterial hypertension (77 men; 104 women), and 66 concordant twinpairs; in 31 of those twinpairs, the brother preceded his sister, and in 35 the sister preceded her brother. Additional pattern analyses will be presented that describe the arrays of cardiovascular co-morbidities and their year of diagnosis within twinpairs and the whole sample.

Benefits and Learning Objectives

To present pattern analyses of cardiovascular conditions in an unlike-sex twin sample

Background: Nursing home residents are at a higher risk of hospital care as they represent the oldest and most frail segment of the population. At the same time, hospitalization is associated with a greater risk of various diseases, such as iatrogenic disorders, physical impairments and other adverse outcomes. Knowledge about factors associated with greater risk of hospitalization among nursing home residents is scarce. The aim of this study was to identify predictors of hospitalization among nursing home residents. Methods: Four hundred twenty-nine Swedish nursing home residents (mean age 84.9 years, ± 7.27, 71% females) were followed during three years in the longitudinal SHADES study. Participants were examined on physical, psychological, and social functioning, and information about hospitalization was recorded across the study period. Results: Of the 429 participants, 196 (45.7%) had at least one hospital admission during the three year follow-up period. The most common cause of admission was cardiovascular diseases (CVD) and complications due to falls.  Cox proportional hazard regression model controlling for dependency within nursing homes and municipalities showed that nursing home residents with previous falls (HR=1.59, p=.000), cognitive impairment (HR=1.28, p=.008) and malnutrition (HR=1.51, p=.018) were at a greater risk of hospitalization. Discussion: The results suggest that nursing home residents are at high risk of hospitalization, especially due to CVD and falls. Several modifiable factors associated with an increased risk of hospitalization were identified, including nutritional status and falls. Hospital admissions for older people could potentially be reduced by preventive measures aiming at fall reduction and malnutrition. 

Anhörigomsorg är del av en komplex väv med olika nivåer, individuella, familjemässiga och övergripande samhälleliga, där åtminstone de senare har begränsade resurser. Denna rapport presenterar och diskuterar kunskapsläget inom svensk och internationell forskning om anhöriga till äldre. Vi sätter den svenska anhörigomsorgen i ett större sammanhang genom resonemang om demografiska förutsättningar, historiska tillbakablickar och internationella utblickar. Nutid belyses med aktuella undersökningar och vi tror att framtiden kan klaras tack vare den allt större överlappning vi redan ser mellan många olika former av hjälp, service, omsorg och vård. Vi ställer frågan om dessa mönster kanske förbises i de ofta dystra, rent demografisk-ekonomiska framskrivningarna. Rapporten redovisar många svenska undersökningar av anhörigomsorg, både i befolkningen i stort och bland äldre. Det förefaller klart att det skett en faktisk ökning av anhörigomsorgens omfattning från 1990-talet och början av 2000- talet, något som flera studier visar. Resultat från en europeisk undersökning med gemensamma frågor och svarsalternativ tyder på att anhörigomsorg är vanligare i Nordeuropa än i Sydeuropa vilket nog strider mot gängse föreställningar. Kanske är det i Norden vanligare att vara hjälpgivare men inte med lika omfattande engagemang eller lika länge och man bor sällan tillsammans. Då fördelas nog omsorgen på fler händer. I Sverige angav mindre än 1 procent att de gav omsorg på heltid, i Spanien 5 procent. Sammantaget har, i Sverige liksom i övriga Europa, mer än 4 av 10 i befolkningen en aktuell eller tidigare personlig erfarenhet av att ge omsorg, och på befolkningsnivå är anhörigomsorgen klart större än den offentliga. De flesta svenska studier visar att det är ungefär lika vanligt bland kvinnor och män att vara givare av anhörigomsorg. Kvinnor ger dock oftare personlig omvårdnad och de ger fler timmar omsorg än männen. De flesta omsorgsgivare ger ganska få hjälptimmar, men timinsatserna ökar med stigande ålder och är högst bland de äldsta. I genomsnitt ger omkring 30 procent av omsorgsgivarna daglig hjälp, men den andelen stiger till nästan 40 procent för anhörigvårdare i 65–80 årsåldern och till 80 procent för dem som är ännu äldre. Äldre utgör således 30 procent av alla som ger omsorg, oftast till andra äldre, men utför ungefär 4 av 10 omsorgstimmar. Äldre personer är inte bara mottagare av omsorg utan minst lika ofta också givare. De flesta givare av anhörigomsorg ger ”lättare” former av insatser (skjutsning, passning, tillsyn etc.), insatser som många gånger säkerligen är viktiga och kan vara avgörande för mottagaren. Det är viktigt att se det stora spektret av anhörigomsorg och att det också finns grupper av anhöriga (ofta äldre personer) som gör omfattande insatser som kan påverka såväl egen hälsa som arbetsliv. Vid små hjälpbehov – fallet för de flesta – får man lite hjälp främst av anhöriga, vid större behov mer hjälp och då av både anhöriga och av kommunen. Delat ansvar är vanligt och även vad omsorgsgivare och mottagare önskar. Få önskar bära ansvaret ensamma och få önskar att ansvaret helt ligger på det offentliga. Historiskt utgör barn och andra anhöriga en viss trygghet på ålderdomen, något som inte tillhör det förflutna, utan snarare kommer att få större betydelse framöver. Anledningen är demografisk: allt fler har nära anhöriga i form av en egen familj. Familjens relativa betydelse har ökat, inte minskat som man ibland föreställer sig. Detta accentueras av att den offentliga omsorgen visserligen är väl utbyggd i Sverige, men tycks ha nått gränsen för vad den kan uträtta, praktiskt och finansiellt. Anhörigomsorgen har även socialpolitiska aspekter. Den som är eller varit anhörigvårdare vill helst inte själv vara mottagare av omfattande anhörigvård, utan hellre få huvuddelen av omsorgen från det offentliga. Man kan nog förutse ännu strängare ransonering av offentliga tjänster i framtiden, där anhöriga och marknadsbaserade tjänster är alternativen, möjligen tillsammans med växande insatser från ideella organisationer.