Impact of tooth loss on walking speed decline over time in older adults: a population-based cohort study.

BACKGROUND: Tooth loss has been linked to poor health such as chronic diseases and mobility limitations. Prospective evidence on the association between tooth loss and walking speed decline is however lacking. AIMS: To examine the impact of tooth loss on walking speed over time and explore whether inflammation may account for this association. METHODS: This study included 2695 persons aged 60 years and older, who were free from severe mobility limitation at baseline. Information on dental status was assessed through self-report during the nurse interview at baseline. Walking speed baseline and at 3- and 6-year follow-ups was assessed when participants walked at their usual pace. Covariates included age, sex, education, lifestyle-related factors, and chronic diseases. Blood samples were taken, and C-reactive protein (CRP) was tested. RESULTS: At baseline, 389 (13.1 %) participants had partial tooth loss and 204 (6.9 %) had complete tooth loss. Mixed-effects models showed that tooth loss was associated with a greater decline in walking speed over time after adjustment for lifestyle-related factors and chronic diseases (p = 0.001 for interaction between time and tooth loss on walking speed decline); however, when further adjusting for inflammation (CRP), the association was attenuated and no longer significant. CONCLUSION: Tooth loss was associated with an accelerated decline in walking speed in older adults. Inflammation may play a role in the association between tooth loss and walking speed decline.

Inequalities in health care use among older adults in Sweden 1992-2011: a repeated cross-sectional study of Swedes aged 77 years and older.

AIMS: In the last decades, the Swedish health care system was reformed to promote free choice; however, it has been questioned whether older adults benefit from these reforms. It has also been proposed that reforms promoting free choice might increase inequalities in health care use. Thus, the aim of this study is to investigate socioeconomic differences in health care use among older adults in Sweden, from 1992 to 2011. METHODS: The Swedish Panel Study of the Living Conditions of the Oldest Old (SWEOLD) is a nationally representative study of Swedes over 76 years old, including both institutionalized and community-dwelling persons. We analyzed cross-sectional data from SWEOLD waves in 1992, 2002 and 2011 (n ≈ 600/wave); and performed multivariate analyses to investigate whether socioeconomic position was associated with health care use (inpatient, outpatient and dental services) after need was accounted for. RESULTS: For the period of 1992-2011, we found that higher education was associated with more use of outpatient and dental care, both before and after adjustment for need. The association between education and inpatient or outpatient care use did not change over time. There was an increase in the proportion of older adults whom used dental care over the 19-year period, and there was a tendency for the socioeconomic differences regarding dentist visits to decrease over time. CONCLUSIONS: Our study covering 19 years showed relatively stable findings for socioeconomic differences in health care use among older adults in Sweden. We found there was a slight decrease in inequality in dental care; but unchanged socioeconomic differences in outpatient care, regardless of the changes that occurred in the Swedish health care system.

Drug use in centenarians compared with nonagenarians and octogenarians in Sweden: a nationwide register-based study.

BACKGROUND: the number of centenarians increases rapidly. Yet, little is known about their health and use of medications. OBJECTIVE: to investigate pharmacological drug use in community-dwelling and institutionalised centenarians compared with nonagenarians and octogenarians. METHODS: we analysed data on dispensed drugs for centenarians (n = 1,672), nonagenarians (n = 76,584) and octogenarians (n = 383,878) from the Swedish Prescribed Drug Register, record-linked to the Swedish Social Services Register. Multivariate logistic regression analysis was used to analyse whether age was associated with use of drugs, after adjustment for sex, living situation and co-morbidity. RESULTS: in the adjusted analysis, centenarians were more likely to use analgesics, hypnotics/sedatives and anxiolytics, but less likely to use antidepressants than nonagenarians and octogenarians. Moreover, centenarians were more likely to use high-ceiling diuretics, but less likely to use beta-blockers and ACE-inhibitors. CONCLUSIONS: centenarians high use of analgesics, hypnotics/sedatives and anxiolytics either reflects a palliative approach to drug treatment in centenarians or that pain and mental health problems increase into extreme old age. Also, centenarians do not seem to be prescribed cardiovascular drug therapy according to guidelines to the same extent as nonagenarians and octogenarians. Whether this reflects an age or cohort effect should be evaluated in longitudinal studies.

Baseline leisure time activity and cognition more than two decades later.

OBJECTIVE: Many studies of the relation between factors earlier in life and late-life cognition have a short follow-up time, often less than 10 years. Since cognitive decline can be present up to 20 years prior to dementia it is difficult to distinguish the direction of the relationships without a long follow-up. We analyzed the association between different types of leisure time activity at baseline and cognition more than 20 years later. A wide range of activities was included-political, mental, socio-cultural, social, physical, and organizational activities. METHODS: Baseline studies were random Swedish samples aged 46-75 years (mean 57.4) (n=1643) interviewed in 1968 or 1981. Activities were measured at baseline. Cognition was measured with items from the Mini-Mental State Examination in 1992, 2002, or 2004. RESULTS: There was a significant association between later cognition and earlier political, mental, and socio-cultural activities controlling for age, age-square, sex, follow-up-time, mobility problems, symptoms of mental distress, employment status, education, adult and childhood socioeconomic status, income, smoking, and drinking. Physical activities had a significant association with cognition only among women. Organizational activities were not significant when controlling for all covariates. Social activities had no significant association. Including all covariates and all leisure activities simultaneously, only mid-life political and mental activities remained significantly related to later life cognition. CONCLUSIONS: These findings add support to the theory that various forms of engagement in mid-life can have a protective effect with respect to cognition in later life.

Informal caregiving for elders in Sweden: an analysis of current policy developments.

In Sweden, care of elderly people is a public responsibility. There are comprehensive public policies and programs providing health care, social services, pensions, and other forms of social insurance. Even so, families are still the major providers of care for older people. In the 1990s, the family was "rediscovered" regarding eldercare in Sweden. New policies and legislative changes were promoted to support family caregivers. The development of services and support for caregivers at the municipal level has been stimulated through the use of national grants. As a result, family caregivers have received more recognition and are now more visible. However, the "Swedish model" of publicly financed services and universal care has difficulty addressing caregivers. Reductions in institutional care and cutbacks in public services have had negative repercussions for caregivers and may explain why research shows that family caregiving is expanding. At the same time, a growing "caregivers movement" is lobbying local and national governments to provide more easily accessible, flexible, and tailored support. In 2009, the Swedish Parliament passed a new law that states: "Municipalities are obliged to offer support to persons caring for people with chronic illnesses, elderly people, or people with functional disabilities." The question is whether the new legislation represents a paradigm shift from a welfare system focused on the individual to a more family-oriented system. If so, what are the driving forces, motives, and consequences of this development for the different stakeholders? This will be the starting point for a policy analysis of current developments in family caregiving of elderly people in Sweden.

Mentally stimulating activities at work during midlife and dementia risk after age 75: follow-up study from the Kungsholmen Project.

OBJECTIVES: Previous research has suggested that mental stimulation in different life periods may protect against dementia or delay disease onset. This study aimed to explore the association between work complexity factors at midlife and dementia risk in late life under the hypothesis that high work complexity may modulate the increased dementia risk due to low education. DESIGN: Population-based follow-up study. SETTING: Urban. PARTICIPANTS: A cohort of 931 nondemented subjects, aged 75+ years from the Kungsholmen Project, Stockholm, examined twice over 6 years. MEASUREMENTS: Incident dementia cases were identified using Diagnostic and Statistical Manual of Mental Disorders, 3rd-Edition Revised criteria. Primary occupations were assigned into categories according to the Nordic Occupational Classification and matched to the 1970 U.S. Census to score the level of work complexity with data, people, and things by using a preformed matrix. RESULTS: Lower dementia risk was associated with complexity of work with both data (age and gender adjusted relative risk [aRR]: 0.85, 95% confidence interval [CI]: 0.75-0.95) and with people (aRR: 0.88, 95% CI: 0.80-0.97). Adjusting for education led to similar results, although no longer statistically significant. Further, the highest degrees of complexity of work with data that involves analyzing, coordinating, and synthesizing data were associated with lower dementia risk even among lower educated subjects (relative risk: 0.52, 95% CI: 0.29-0.95). No gender differences were detected. CONCLUSIONS: This study suggests that work complexity with data and people is related to lower risk of dementia and that the highest levels of work complexity may modulate the higher dementia risk due to low education.

Leisure activities and mortality: does gender matter?

OBJECTIVES: This study examines the association between participation in leisure activities and mortality risk among older men and women. METHODS: A representative sample of 1,246 men and women ages 65 to 95, interviewed in 1991-1992, were followed for 12 years. Cox regressions analyzed mortality risk. RESULTS: Participating in only a few activities doubled mortality risk compared to those with the highest participation levels, even after controlling for age, education, walking ability, and other health indicators. Women had a dose-response relationship between overall participation and survival. Strong associations with survival were found for engagement in organizational activities and study circles among women and hobby activities and gardening among men. DISCUSSION: Results suggest gender differences in the association between leisure activities and mortality. Women display a decreasing mortality risk for each additional activity. Social activities have the strongest effects on survival among women, whereas men seem to benefit from solitary activities.

Health trends in the elderly population: getting better and getting worse.

Health trends in the fastest growing sector of the population, the oldest old, have received much attention during the past decade because of the rising costs of medical and long-term care. Many studies have suggested a compression of morbidity in this sector, implying that the future care needs of elderly people will not follow the demographic prognoses. Most of these studies have used health indicators based on disability, a concept that is contextually embedded. We have taken a closer look at health-trend surveys with a focus on the health indicator used. Our findings reveal that although disability measures often show improvement, there is a simultaneous increase in chronic disease and functional impairments-health components that require care resources. That is, an expansion of other health problems may accompany a compression of disability. Therefore, a concept of general morbidity is not sufficient when discussing health trends and the need for care services in the elderly population. Because different indicators do not show the same trends over time, we suggest a more refined discussion that distinguishes between different health components. In addition, different components have different implications for the amount and kind of care resources needed. If the current positive trends in disability continue, future need for social services and long-term care may not parallel demographic projections. Trends in disease and functional limitations seem to have taken a different direction, suggesting a parallel or increased need for resources in medical care, rehabilitation, and compensatory interventions such as assistive technology.

Complexity of primary lifetime occupation and cognition in advanced old age.

OBJECTIVE: The authors explored the association between complexity of primary lifetime occupation and cognition in older adulthood. METHOD: The study included 386 participants from the Swedish Panel Study of Living Conditions of the Oldest Old, a nationally representative sample aged 77 years or older. The authors examined complexity of work with data, people, and things in relation to cognitive functioning, measured with a shortened version of Mini-Mental State Examination (MMSE) and cognitive impairment based on MMSE score cutoff. RESULTS: Complexity of work with data and people were associated with better MMSE scores, controlling for age, sex, childhood socioeconomic status, and education. The association between complexity of work with data and MMSE remained statistically significant when adult occupational status was substituted for education as a covariate. DISCUSSION: Complexity of primary lifetime occupation may be reflected in cognitive functioning even in advanced old age. This effect may be independent of education or occupational status.

Validation of abridged mini-mental state examination scales using population-based data from Sweden and USA.

The objective of this study is to validate two abridged versions of the mini-mental state examination (MMSE): one intended for use in face-to-face interviews, and the other developed for telephonic interviews, using data from Sweden and the US to validate the abridged scales against dementia diagnoses as well as to compare their performance to that of the full MMSE scale. The abridged versions were based on eight domains from the original MMSE scale. The domains included in the MMSE-SF were registration, orientation, delayed recall, attention, and visual spatial ability. In the MMSE-SF-C, the visual spatial ability item was excluded, and instead, one additional orientation item was added. There were 794 participants from the Swedish HARMONY study [mean age 81.8 (4.8); the proportion of cognitively impaired was 51 %] and 576 participants from the US ADAMS study [mean age 83.2 (5.7); the proportion of cognitively impaired was 65 %] where it was possible to compare abridged MMSE scales to dementia diagnoses and to the full MMSE scale. We estimated the sensitivity and specificity levels of the abridged tests, using clinical diagnoses as reference. Analyses with both the HARMONY and the ADAMS data indicated comparable levels of sensitivity and specificity in detecting cognitive impairment for the two abridged scales relative to the full MMSE. Receiver operating characteristic curves indicated that the two abridged scales corresponded well to those of the full MMSE. The two abridged tests have adequate validity and correspond well with the full MMSE. The abridged versions could therefore be alternatives to consider in larger population studies where interview length is restricted, and the respondent burden is high.

Continuity of leisure participation from middle age to old age.

OBJECTIVE: Continuity in habits, activities, and roles is important upon entering old age according to the continuity theory of aging. Few studies have investigated patterns of leisure participation over an extended period of time among older adults. This study examines changes in nine different leisure activities in a nationally representative sample of individuals followed over a 34-year period in Sweden. METHODS: We used longitudinal data from three waves of an interview survey that followed 495 individuals from 1968 to 2002. Individuals were aged 43-65 in 1968 and 77-99 in 2002. We conducted logistic regression analyses on each of the leisure activities. RESULT: For the panel followed, a decline in participation rates was the most common pattern over time. Analyses at the individual level showed that late-life participation was generally preceded by participation earlier in life. Previous participation, both 10 and 34 years earlier, predicted late-life participation. The modifying effect of functional status in late life was small. DISCUSSION: In accordance with the continuity theory of aging, leisure participation in old age is often a continuation of previous participation. However, there is considerable variation among both activities and individuals.

Health changes among Swedish oldest old: prevalence rates from 1992 and 2002 show increasing health problems.

BACKGROUND: The health of the elderly population is of utmost importance for planning policy and resources for care services. Most surveys of the health of the elderly population show improvement, suggesting support for the compression of morbidity hypothesis. This study examines changes in the health of the Swedish population (aged 77+) from 1992 to 2002. METHODS: Two nationally representative surveys of the elderly population (n = 537 and 563, respectively), including both community-based and institutionalized persons were used. Outcomes include self-reported diseases, symptoms, and activities of daily living, as well as objective tests of physical capacity, lung function, vision, and cognition. RESULTS: None of the indicators showed improvement. A number of health indicators showed significant worsening, with or without adjustment for changes in the age and sex distribution from 1992 to 2002. Among self-reported indicators, there were significant increases in several diseases and symptoms. The objective function tests also showed significantly worse results in 2002 compared to 1992 for physical capacity, lung function, and cognition. No significant differences in activities of daily living limitations were found. CONCLUSIONS: In light of several recent studies, we expected to observe improvements in the health of the elderly population. However, this study showed no signs of improvement. On the contrary, we found a pattern of worsening health. The study included objective tests of function, implying that results are not due solely to raised expectations or changes in reporting. Possible explanations are discussed.

Can elderly people take their medicine?

This study used performance tests to assess the cognitive, visual and physical abilities related to taking medicines in the elderly population. The study population consisted of the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD II), a nationally representative interview survey. SWEOLD II is a random sample of all community-based and institutionalized persons aged 77+ in Sweden. Five tests related to medication management were administered in the direct interviews (n=492): hand function (opening bottle), vision (reading label), and medication competence (comprehension and calculation). Results showed that 9.4% could not read instructions on a medicine container and 14.6% had difficulty opening a plastic flip-top medicine bottle. The three cognitive tests related to taking medicine resulted in 30.7, 47.4 and 20.1% errors. Combining all the tests revealed that 66.3% of the sample had at least one limitation of capacity related to taking medicine. There were no significant gender differences. Among those people who did not pass all the tests, 31.8% lived alone with no home-help. Taking medicines is a complex task and a large proportion of the Swedish elderly population has cognitive, visual or physical limitations that may hinder their ability to take medicines accurately. Awareness of these limitations is essential to concordance.

[How do the elderly feel actually? Contradictory research results indicate both improved and impaired health]. / Hur mår egentligen de aldre? Motstridiga forskningsresultat tyder på både förbättrad och försämrad hälsa.

As expected life span increases, researchers are asking if the years added to life are healthy or characterized by illness and disability. The question of compression or expansion of morbidity is complex and entails numerous methodological challenges. International and Swedish health trends in elderly populations are reviewed. Differences in methods concerning sampling, time period and health indicators make comparisons difficult and can explain why studies have divergent results. Despite the differences, a general trend can be seen showing an increase in poor health during the late nineties. However, the trend is seen primarily in disease and functional limitations, but not disability. If this is the case and this trend continues, the future may bring less disability than would be expected according to today's calculations based on demographic development. But at the same time, demands for medical care may increase due to increases in chronic illnesses that can be managed but not cured.

Complex health problems among the oldest old in Sweden: increased prevalence rates between 1992 and 2002 and stable rates thereafter.

Studies of health trends in older populations usually focus on single health indicators. We include multiple medical and functional indicators, which together indicate the broader impact of health problems experienced by individuals and the need for integrated care from several providers of medical and long-term care. The study identified severe problems in three health domains (diseases/symptoms, mobility, and cognition/communication) in three nationally representative samples of the Swedish population aged 77+ in 1992, 2002, and 2011 (n ≈ 1900; response rate >85 %). Institutionalized people and proxy interviews were included. People with severe problems in two or three domains were considered to have complex health problems. Results showed a significant increase of older adults with complex health problems from 19 % in 1992 to 26 % in 2002 and no change thereafter. Changes over time remained when controlling for age and sex. When stratified by education, complex health problems increased significantly for people with lower education between 1992 and 2002 and did not change significantly between 2002 and 2011. For higher-educated people, there was no significant change over time. Among the people with severe problems in the symptoms/disease domain, about half had no severe problems in the other domains. People with severe mobility problems, on the other hand, were more likely to also have severe problems in other domains. Even stable rates may imply an increasing number of very old people with complex health problems, resulting in a need for improved coordination between providers of medical care and social services.

The prevalence of pain among the oldest old in Sweden.

Although there is information available about pain in elderly persons, there have been very few studies about pain among the oldest old. In Sweden, 8% of the population is older than 74 years, and 2% is older than 84 years. It is the group over 74 which is growing fastest in proportion to the entire population. The aims of the present study are (a) to analyze if pain increases or decreases with age in the oldest age groups and (b) to study gender differences regarding pain. The present study of a random sample (n = 537) of the oldest old in Sweden shows that there is some evidence of decreased musculoskeletal pain with age. Among women, total reported pain decreases with age. Among men, there is an increase of reported severe pain with age. Including the results from another Swedish population survey of individuals aged 18-84, there is evidence that the prevalence of pain among the older elderly is comparable to the prevalence of pain among the middle-aged (45-64) and is higher than the prevalence among the younger elderly (65-75). Musculoskeletal pain is more common among old women than old men but for chest pain and abdominal pain there is no difference. The sex difference is more pronounced for multiple and severe pain complaints. The prevalence of mild or severe pain in any of the studied locations in the whole study group (77+) was 73% and for individuals over 85 years, 68%. For multiple pain, the figures were 47% for all older elderly (77+) and 46% for individuals over 85 years of age. For severe pain in at least one location, corresponding figures were 33% and 35%.

Mobility limitations 1974-1991: period changes explaining improvement in the population.

The proportion of people with mobility limitations (difficulties with running, walking and stairs) decreased between 1968 and 1991 in the Swedish population aged 18-75. The distribution of predictors of late life morbidity, e.g., social class, health behaviour and childhood conditions, also changed during this period. This study explored whether the changes in these predictors over time were related to the decrease in the proportion of the population with mobility limitations. In two nationally representative interview samples (n=4468) from 1974 and 1991 of persons aged 45-71 the odds for limitations were cross-sectionally compared in ordered logistic regression models. In addition, predictors for the mobility outcome in 1974 were collected from an earlier 1968 survey and predictors for the 1991 outcome were collected from 1981. In 1974 the odds for limitations in the population was 50% higher than in 1991. Had the population composition regarding social class and housewives in 1991 been identical to 1974, the odds for limitations would have been similar in 1974 and 1991. Period improvement in social classes with poorer mobility also contributed to the overall period improvement. Health behaviours were examined as possible mediating factors. The increase of physically active people between 1968 and 1974 was related to the period improvement in mobility between 1974 and 1991. Smoking showed an increased association with mobility limitations during the period, indicating that mobility improvement would have been greater if everyone had been a non-smoker. Results indicate how sensitive disability rates may be for cohort or period effects.

The effect of the duration of follow-up in mortality analysis: the temporal pattern of different predictors.

OBJECTIVES: This study presents a model of the mechanisms affecting how time since baseline affects the correlation between mortality and commonly used predictors. METHODS: In 1986, 421 persons (aged 75 years or older) in a Swedish community were interviewed. Fifteen-year mortality rates were analyzed by using hazard regressions. Rather than using average risk over the whole follow-up time, this study looks at temporal differences in predictor strength. RESULTS: All studied health variables, living conditions, and life satisfaction were much stronger predictors of mortality during the first 1 or 2 years of follow-up than during later years. Gender, social contacts, and mental status were about equally correlated to mortality throughout the period. DISCUSSION: Of the presented mechanisms affecting predictive strength, results suggest the importance of the instability of predictors over time. Especially in old populations, predictors that can change rapidly (e.g., health) are strongest for the short term, revealing a lower average mortality risk for longer follow-ups. Rather stable variables (e.g., gender or social contacts) are not affected by the length of follow-up. When average risk is studied over a longer follow-up, insignificant results may hide significant effects during a part of the follow-up. These findings are relevant for studies that examine any kind of outcome after a follow-up.