Disparities in Coronavirus Disease 2019 Mortality by Country of Birth in Stockholm, Sweden: A Total-Population-Based Cohort Study.

Preliminary evidence points to higher morbidity and mortality from coronavirus disease 2019 (COVID-19) in certain racial and ethnic groups, but population-based studies using microlevel data are lacking so far. We used register-based cohort data including all adults living in Stockholm, Sweden, between January 31, 2020 (the date of the first confirmed case of COVID-19) and May 4, 2020 (n = 1,778,670) to conduct Poisson regression analyses with region/country of birth as the exposure and underlying cause of COVID-19 death as the outcome, estimating relative risks and 95% confidence intervals. Migrants from Middle Eastern countries (relative risk (RR) = 3.2, 95% confidence interval (CI): 2.6, 3.8), Africa (RR = 3.0, 95% CI: 2.2, 4.3), and non-Sweden Nordic countries (RR = 1.5, 95% CI: 1.2, 1.8) had higher mortality from COVID-19 than persons born in Sweden. Especially high mortality risks from COVID-19 were found among persons born in Somalia, Lebanon, Syria, Turkey, Iran, and Iraq. Socioeconomic status, number of working-age household members, and neighborhood population density attenuated up to half of the increased COVID-19 mortality risks among the foreign-born. Disadvantaged socioeconomic and living conditions may increase infection rates in migrants and contribute to their higher risk of COVID-19 mortality.

Residential Segregation of European and Non-European Migrants in Sweden: 1990-2012.

In this paper, we analyse how a migrant population that is both expanding and changing in composition has affected the composition of Swedish neighbourhoods at different scales. The analysis is based on Swedish geocoded individual-level register data for the years 1990, 1997, 2005, and 2012. This allows us to compute and analyse the demographic composition of neighbourhoods that range in size from encompassing the nearest 100 individuals to the nearest 409,600 individuals. First, the results confirm earlier findings that migrants, especially those from non-European countries, face high levels of segregation in Sweden. Second, large increases in the non-European populations in combination with high levels of segregation have increased the proportion of non-European migrants living in neighbourhoods that already have high proportions of non-European migrants. Third, in contrast to what has been the established image of segregation trends in Sweden, and in an apparent contrast to the finding that non-European migrants increasingly live in migrant-dense neighbourhoods, our results show that segregation, when defined as an uneven distribution of different populations across residential contexts, is not increasing. On the contrary, for both European migrants from 1990 and non-European migrants from 1997, there is a downward trend in unevenness as measured by the dissimilarity index at all scale levels. However, if segregation is measured as differences in the neighbourhood concentration of migrants, segregation has increased.

A Comparative Study of Segregation Patterns in Belgium, Denmark, the Netherlands and Sweden: Neighbourhood Concentration and Representation of Non-European Migrants.

In this paper, we use geo-coded, individual-level register data on four European countries to compute comparative measures of segregation that are independent of existing geographical sub-divisions. The focus is on non-European migrants, for whom aggregates of egocentric neighbourhoods (with different population counts) are used to assess small-scale, medium-scale, and large-scale segregation patterns. At the smallest scale level, corresponding to neighbourhoods with 200 persons, patterns of over- and under-representation are strikingly similar. At larger-scale levels, Belgium stands out as having relatively strong over- and under-representation. More than 55% of the Belgian population lives in large-scale neighbourhoods with moderate under- or over-representation of non-European migrants. In the other countries, the corresponding figures are between 30 and 40%. Possible explanations for the variation across countries are differences in housing policies and refugee placement policies. Sweden has the largest and Denmark the smallest non-European migrant population, in relative terms. Thus, in both migrant-dense and native-born-dense areas, Swedish neighbourhoods have a higher concentration and Denmark a lower concentration of non-European migrants than the other countries. For large-scale, migrant-dense neighbourhoods, however, levels of concentration are similar in Belgium, the Netherlands, and Sweden. Thus, to the extent that such concentrations contribute to spatial inequalities, these countries are facing similar policy challenges.

IGEMS: the consortium on Interplay of Genes and Environment across Multiple Studies.

The Interplay of Genes and Environment across Multiple Studies (IGEMS) group is a consortium of eight longitudinal twin studies established to explore the nature of social context effects and gene-environment interplay in late-life functioning. The resulting analysis of the combined data from over 17,500 participants aged 25-102 at baseline (including nearly 2,600 monogygotic and 4,300 dizygotic twin pairs and over 1,700 family members) aims to understand why early life adversity, and social factors such as isolation and loneliness, are associated with diverse outcomes including mortality, physical functioning (health, functional ability), and psychological functioning (well-being, cognition), particularly in later life.

Behavioral correlates of depressive symptoms in older unlike-sex twin pairs.

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.

Analysis of lipid pathway genes indicates association of sequence variation near SREBF1/TOM1L2/ATPAF2 with dementia risk.

We conducted dense linkage disequilibrium (LD) mapping of a series of 25 genes putatively involved in lipid metabolism in 1567 dementia cases [including 1270 with Alzheimer disease (AD)] and 2203 Swedish controls. Across a total of 448 tested genetic markers, the strongest evidence of association was as anticipated for APOE (rs429358 at P approximately 10(-72)) followed by a previously reported association of ABCA1 (rs2230805 at P approximately 10(-8)). In the present study, we report two additional markers near the SREBF1 locus on chromosome 17p that were also significant after multiple testing correction (best P = 3.1 x 10(-6) for marker rs3183702). There was no convincing evidence of association for remaining genes, including candidates highlighted from recent genome-wide association studies of plasma lipids (CELSR2/PSRC1/SORT1, MLXIPL, PCSK9, GALNT2 and GCKR). The associated markers near SREBF1 reside in a large LD block, extending more than 400 kb across seven candidate genes. Secondary analyses of gene expression levels of candidates spanning the LD region together with an investigation of gene network context highlighted two possible susceptibility genes including ATPAF2 and TOM1L2. Several markers in strong LD (r(2) > 0.7) with rs3183702 were found to be significantly associated with AD risk in recent genome-wide association studies with similar effect sizes, providing independent support of the current findings.

Needs and care of older people living at home in Iceland.

BACKGROUND: The Icelandic old-age care system is universal and the official goal is to support older people live independently for as long as possible. The aim of this study is to analyse living conditions and use of formal and informal care of older people in Iceland. METHODS: The results are based on the new study ICEOLD, a telephone survey which included questions on social network, health, activities of daily living, and received support from the community and/or from relatives, neighbours, and friends. RESULTS: Almost half of the sample (47%) receives some kind of care, with 27% of them receiving only informal care, which is understood to mean that informal care is of great importance and families are the main providers of help. For hypothetical future long-term care, older people wish to be cared for in their homes, but those already in need of assistance prefer to be cared for in institutions. DISCUSSION: Caring relatives are the main providers of support to older people in their homes and it is important to provide them with suitable formal support when the care responsibility increases. CONCLUSIONS: As the care system in Iceland is now under reconstruction, the important contribution of informal carers must be recognised and taken into account when planning the care of older people.

KUD--a scale for clinical evaluation of moderate-to-severe dementia.

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.

Sequence variation in SORL1 and dementia risk in Swedes.

The gene encoding the neuronal sortilin-related receptor SORL1 has been claimed to be associated with Alzheimer's disease (AD) by independent groups and across various human populations. We evaluated six genetic markers in SORL1 in a sample of 1,558 Swedish dementia cases (including 1,270 AD cases) and 2,179 controls. For both single-marker-based and haplotype-based analyses, we found no strong support for SORL1 as a dementia or AD risk-modifying gene in our sample in isolation nor did we observe association with AD/dementia-related traits, including cerebrospinal fluid beta-amyloid(1-42), tau levels, or age at onset. However, meta-analyses of markers in this study together with previously published studies on SORL1 encompassing in excess of 13,000 individuals does suggest significant association with AD (best odds ratio = 1.097; 95% confidence interval = 1.038-1.158, p = 0.001). All six markers were significant in meta-analyses and it is notable that they occur in two distinct linkage disequilibrium blocks. These data are consistent with either allelic heterogeneity or the existence of as yet untested functional variants and these will be important considerations in further attempts to evaluate the importance of sequence variation in SORL1 with AD risk.

End-of-life care in the oldest old.

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.

[Loneliness among the elderly in Spain and Sweden: context and culture]. / La soledad de las personas mayores en España y Suecia: contexto y cultura.

OBJECTIVES: Older people in Spain and other Southern European countries are reported to feel lonelier than the older people in the North of Europe. Data from the 1970s and onwards consistently show this. The present study explores feelings of loneliness as a product of both cultural and situational determining factors, by comparing survey data for Spain and Sweden. MATERIAL AND METHOD: Data derived from several national surveys of the older people in Spain and Sweden with questions about loneliness. For closer analysis we use the Spanish 2006 Encuesta de Condiciones de Vida (Living conditions Questionnaire), and the Swedish 2002-2003 Survey of Living Conditions. RESULTS: On average, 24% of older people in Spain and 10% of elderly Swedish people expressed sentiments of loneliness in the surveys used here (2006 and 2002-03 respectively). Living arrangements and perceived health are related with factors of loneliness in both countries, although levels differ. For example, people in good health who live alone are five times more likely to feel lonely in Spain (45%) than in Sweden (9%) and two-three times more likely when living alone in poor health (82% and 32% respectively). People in good health who live with their spouse/partner only are equally unlikely in both Spain and Sweden to express loneliness (4-5%). It often seems--when it occurs--to be due to caring for a spouse/partner, or problems in the relationship. CONCLUSIONS: Results highlight the importance of contextual features--health and living arrangements--and cultural expectations in interpreting reported loneliness.

Neighbourhood Concentration and Representation of Non-European Migrants: New Results from Norway.

In a previous study, Andersson et al. (A comparative study of segregation patterns in Belgium, Denmark, the Netherlands and Sweden: neighbourhood concentration and representation of non-European migrants. Eur J Popul 34:1-25, 2018) compared the patterns of residential segregation between non-European immigrants and the rest of the population in four European countries, using the k-nearest neighbours approach to compute comparable measures of segregation. This approach relies on detailed geo-coded data and can be used to assess segregation levels at different neighbourhood scales. This paper updates these findings with results from Norway. Using similar data and methods, we document both similarities and striking differences between the segregation patterns in Norway and Belgium, Denmark, the Netherlands and Sweden. While the segregation patterns in Norway at larger scales are roughly comparable to those found in Denmark, but with higher concentrations of non-European immigrants in the most immigrant-dense large-scale neighbourhoods, the micro-level segregation is much lower in Norway than in the other countries. While an important finding by Andersson et al. (2018) was that segregation levels at the micro-scale of 200 nearest neighbours fell within a narrow band, with a dissimilarity index between 0.475 and 0.512 in the four countries under study, segregation levels at this scale are clearly lower in Norway, with a dissimilarity index of 0.429. We discuss possible explanations for these patterns.

A population-based cohort study of socio-demographic risk factors for COVID-19 deaths in Sweden.

As global deaths from COVID-19 continue to rise, the world's governments, institutions, and agencies are still working toward an understanding of who is most at risk of death. In this study, data on all recorded COVID-19 deaths in Sweden up to May 7, 2020 are linked to high-quality and accurate individual-level background data from administrative registers of the total population. By means of individual-level survival analysis we demonstrate that being male, having less individual income, lower education, not being married all independently predict a higher risk of death from COVID-19 and from all other causes of death. Being an immigrant from a low- or middle-income country predicts higher risk of death from COVID-19 but not for all other causes of death. The main message of this work is that the interaction of the virus causing COVID-19 and its social environment exerts an unequal burden on the most disadvantaged members of society.

Residential context and COVID-19 mortality among adults aged 70 years and older in Stockholm: a population-based, observational study using individual-level data.

BACKGROUND: Housing characteristics and neighbourhood context are considered risk factors for COVID-19 mortality among older adults. The aim of this study was to investigate how individual-level housing and neighbourhood characteristics are associated with COVID-19 mortality in older adults. METHODS: For this population-based, observational study, we used data from the cause-of-death register held by the Swedish National Board of Health and Welfare to identify recorded COVID-19 mortality and mortality from other causes among individuals (aged ≥70 years) in Stockholm county, Sweden, between March 12 and May 8, 2020. This information was linked to population-register data from December, 2019, including socioeconomic, demographic, and residential characteristics. We ran Cox proportional hazards regressions for the risk of dying from COVID-19 and from all other causes. The independent variables were area (m2) per individual in the household, the age structure of the household, type of housing, confirmed cases of COVID-19 in the borough, and neighbourhood population density. All models were adjusted for individual age, sex, country of birth, income, and education. FINDINGS: Of 279 961 individuals identified to be aged 70 years or older on March 12, 2020, and residing in Stockholm in December, 2019, 274 712 met the eligibility criteria and were included in the study population. Between March 12 and May 8, 2020, 3386 deaths occurred, of which 1301 were reported as COVID-19 deaths. In fully adjusted models, household and neighbourhood characteristics were independently associated with COVID-19 mortality among older adults. Compared with living in a household with individuals aged 66 years or older, living with someone of working age (<66 years) was associated with increased COVID-19 mortality (hazard ratio 1·6; 95% CI 1·3-2·0). Living in a care home was associated with an increased risk of COVID-19 mortality (4·1; 3·5-4·9) compared with living in independent housing. Living in neighbourhoods with the highest population density (≥5000 individuals per km2) was associated with higher COVID-19 mortality (1·7; 1·1-2·4) compared with living in the least densely populated neighbourhoods (0 to <150 individuals per km2). INTERPRETATION: Close exposure to working-age household members and neighbours is associated with increased COVID-19 mortality among older adults. Similarly, living in a care home is associated with increased mortality, potentially through exposure to visitors and care workers, but also due to poor underlying health among care-home residents. These factors should be considered when developing strategies to protect this group. FUNDING: Swedish Research Council for Health, Working Life and Welfare (FORTE), Swedish Foundation for Humanities and Social Sciences.

A survey of ABCA1 sequence variation confirms association with dementia.

We and others have conducted targeted genetic association analyses of ABCA1 in relation to Alzheimer disease risk with a resultant mixture of both support and refutation, but all previous studies have been based upon only a few markers. Here, a detailed survey of genetic variation in the ABCA1 region has been performed in a total of 1,567 Swedish dementia cases (including 1,275 with Alzheimer disease) and 2,203 controls, providing evidence of association with maximum significance at marker rs2230805 (odds ratio [OR]=1.39; 95% confidence interval [CI] 1.23-1.57, p=7.7x10(-8)). Haplotype-based tests confirmed association of this genomic region after excluding rs2230805, and imputation did not reveal additional markers with greater support. Significantly associating markers reside in two distinct linkage disequilibrium blocks with maxima near the promoter and in the terminal exon of a truncated ABCA1 splice form. The putative risk allele of rs2230805 was also found to be associated with reduced cerebrospinal fluid levels of beta-amyloid. The strongest evidence of association was obtained when all forms of dementia were considered together, but effect sizes were similar when only confirmed Alzheimer disease cases were assessed. Results further implicate ABCA1 in dementia, reinforcing the putative involvement of lipid transport in neurodegenerative disease.

Health, functional capacity, formal care, and survival in the oldest old: a longitudinal study.

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 (general linear model=GLM) from the oldest old showed a decline in objective health and ADL 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 significantly predicted survival, but age did not.

Physical, cognitive, and psychosocial variables from the Disablement Process Model predict patterns of independence and the transition into disability for the oldest-old.

PURPOSE: This study used the Disablement Process Model to predict whether a sample of the oldest-old maintained their disability or disability-free status over a 2- and 4-year follow-up, or whether they transitioned into a state of disability during this time. DESIGN AND METHODS: We followed a sample of 149 Swedish adults who were 86 years of age or older over a period of 4 years; we grouped them by ability in activities of daily living as being functional survivors (nondisabled over time), increasingly disabled (initially nondisabled but later disabled), chronically disabled (disabled at all waves), or deceased. We used variables from baseline to predict group membership into these four longitudinal outcome groups. RESULTS: Results indicated that demographic factors, physical impairments, physical and cognitive limitations, and psychosocial variables at baseline predicted membership into the functional survivor group after 2 years and most continued to distinguish between functional survivors and other groups after 4 years. IMPLICATIONS: These findings indicate key variables that may be useful in predicting shorter term longitudinal changes in disability. By understanding the physical, cognitive, and psychological variables that predict whether a person develops a disability within the next 2 or 4 years, we may be better able to plan for care or implement appropriate interventions.

Sex differences after all those years? Heritability of cognitive abilities in old age.

We investigated sex differences in genetic and environmental effects on cognitive abilities among older adult twins. We drew participants from the Swedish Twin Registry; our sample included 647 twin pairs. Our cognitive measures included Synonyms, Block Design, Digit Span, Thurstone's Picture Memory, Symbol Digit, and general cognitive ability tests. Higher age was related to lower performance in all cognitive measures, except synonyms. For digit span forward, symbol digit, and general cognitive ability tasks, there was a Sex x Age interaction, with greater deficits in the performance of women compared with those of men at higher ages. We found no sex-specific genetic influences. In other words, the same genetic effects were operating for men and women. Furthermore, the magnitude of genetic effect was similar for men and women.

Multi-scalar residential context and recovery from illness: An analysis using Swedish register data.

The aim of this paper is to analyse if recovery from ill-health is influenced by geographical context using a multi-scalar approach to context measurement and Swedish longitudinal register-based data on sickness benefit recipiency as an indicator of onset of and recovery from illness. Our sample consists of individuals that have stayed healthy and in work for a three-year period (2000-2002) and then falls ill during the fourth year (2003), some of who recover to good health in the fifth year (2004). The results show that in areas with above-average percentages of people receiving sickness-benefit there is a reduced probability of recovery. In contrast, high levels of employment in the neighbourhood and in the local area have a positive effect on the chances of recovery. These contextual effects are statistically significant but relatively weak in comparison to the influence of individual level factors such as age, sex, marital status, and income. Our conclusion is that individualised scalable neighbourhoods constitute a potentially valuable addition to the toolbox used in neighbourhood effect studies.

Angels of the night: evening and night patrols for homebound elders in Sweden.

PURPOSE: The purpose of this study was to describe the work of evening and night home care patrols in Swedish old-age care by examining how staff members view their work and the specific work content. DESIGN AND METHODS: The authors developed two questionnaires: one that was to be answered jointly by the patrol teams, and one to be completed by each individual member of a team. All patrols in the municipality of Jönköping, Sweden, were asked to participate. RESULTS: The most frequent kind of help provided by evening and night patrols involves personal care, but help with medications and injections are also frequent. The staff reported that it is becoming more common for the patrols to assist people with terminal illnesses. The patrols also increasingly assist people with psychiatric problems. The staff feels that the job may be becoming too diverse and that they need further education for the range of tasks they are asked to perform. IMPLICATIONS: The patrols are very flexible in the services provided. Without the patrols, the staff members believe that many persons would have to leave their homes to go to institutions.