High prevalence of diabetes mellitus, hypertension and obesity among persons with a recorded diagnosis of intellectual disability or autism spectrum disorder.

BACKGROUND: Obesity and lack of physical activity are frequently reported in persons with intellectual disability (ID) or autism spectrum disorder (ASD). We hypothesised a higher prevalence of diabetes and hypertension in this population. METHOD: We used administrative data for all primary and specialist outpatient and inpatient healthcare consultations for people with at least one recorded diagnosis of diabetes mellitus, hypertension or obesity from 1998 to 2015. Data were drawn from the central administrative database for Stockholm County, Sweden. It was not possible to separate data for type 1 and type 2 diabetes. We stratified 26 988 individuals with IDs or ASD into three groups, with Down syndrome treated separately, and compared these groups with 1 996 140 people from the general population. RESULTS: Compared with the general population, men and women with ID/ASD had 1.6-3.4-fold higher age-adjusted odds of having a registered diagnosis of obesity or diabetes mellitus, with the exception of diabetes among men with Down syndrome. A registered diagnosis of hypertension was only more common among men with ID/ASD than in the general population. CONCLUSIONS: Diabetes and blood pressure health screening, along with efforts to prevent development of obesity already in childhood, are necessary for individuals with IDs and ASD. We believe that there is a need for adapted community-based health promotion programmes to ensure more equitable health for these populations.

Drug and treatment costs in Parkinson's disease patients in Sweden.

BACKGROUND: Parkinson's disease (PD) is a chronic neurodegenerative disease expected to cause great costs. The aim of this study was to calculate drug and treatment costs in patients with PD in Sweden. METHOD: All healthcare contacts of patients with PD in Stockholm County, Sweden, were extracted from registers together with information on reimbursements from the authorities to the caregivers. PD-related costs were calculated together with non-PD-related costs. Cost per patient was calculated and extrapolated to the whole Swedish population, taking population demographics into consideration. In addition, nationwide PD drug sales statistics were included. RESULTS: The PD prevalence of Stockholm County was estimated to 196 per 100,000 inhabitants, resulting in an estimated total of about 22,000 patients with PD in Sweden. The cost per patient was estimated to SEK 76,000 of which drug costs accounted for SEK 15,880. The annual direct costs in patients with PD in Sweden were SEK 1.7 billion in 2009. CONCLUSION: Our study estimates high direct costs in patients with PD in Sweden, SEK 1.7 billion, 52% for inpatient care, 27% for outpatient care and 21% for drugs. With an ageing population and the medical progress, the financial burden on society will most probably increase in the future. This study might initiate and provide information for discussions about future cost allocations and healthcare priorities.

No ticking time bomb: hospital utilisation of 28,528 hip fracture patients in Stockholm during 1998-2007.

AIM: The objectives were to show how utilisation of hospital care among hip fracture patients has changed in Stockholm during 1998-2007 and to explore changes in some demographic and clinical characteristics as well as surgical treatment of the patients. METHODS: The Stockholm County Patient Care Register covers all public healthcare services in the region. All patients from 1998 to 2007 who had a hospital stay due to a hip fracture (ICD-10 codes S72.0, S72.1, S72.2) and had undergone hip surgery (NCSP codes NFB09-99 and NFJ39-99) were identified. Number of hospital stays, surgical procedures, deaths, and length of hospital stay were categorised according to age and sex, and presented as absolute and relative numbers year by year. Age- and sex-standardised annual incidence figures were calculated. RESULTS: A total of 28,528 patients (72.2% women, 27.8% men) were hospitalised due to a hip fracture. The annual numbers decreased during the study period in all age groups except men 85 years and older. The age- and sex-standardised hip fracture incidence fell with 16%. Mortality was slightly reduced. The acute care hospital length of stay fell with 1.4 days to 7.0 days, and the whole hospital episode increased by 1.4 days to 17.3 days. CONCLUSIONS: Despite a continued increase in the numbers of elderly during 1998-2007, the number of patients and their utilisation of hospital services remained constant and showed a marked decrease in women over 65 years of age. Comparisons with national statistics indicate that the results can be generalised to Sweden.

Unintended weight loss in the elderly living at home: the aged in Home Care Project (AdHOC).

OBJECTIVE: To describe associations between unintended weight loss (UWL) and characteristics of nutritional status. DESIGN: A comparative cross-sectional assessment study at 11 sites in Europe. The target population was a stratified random sample of 4,455 recipients of home care (405 in each random sample from 11 urban areas) aged 65 years and older. MEASUREMENTS: the Resident Assessment Instrument for Home Care, version 2.0. Epidemiological and medical characteristics of clients and service utilisation were recorded in a standardized, comparative manner. UWL was defined as information of 5% or more weight loss in the last 30 days (or 10% or more in the last 180 days). RESULTS: The final sample consisted of 4,010 persons; 74% were female. The mean ages were 80.9 +/- 7.5 years (males) and 82.8 +/- 7.3 years (females). No associations were found between single diagnoses and UWL, except for cancer. Cancer patients were excluded from further analyses. Persons with a Cognitive Performance Scale value (CPS) superior 3 (impaired) had increased risk of UWL (OR = 2.0) compared with those scoring inferior or egal 3 (less impaired). Only in the oldest group did we find a significant association between UWL and reduction in ADL and IADL functions, comparing those who scored 3 or less with those who scored more than 3 (disabled). A binary logistic regression model explained 26% of UWL: less than one meal/day, reduced appetite, malnutrition, reduced social activity, experiencing a flare-up of a recurrent or chronic problem, and hospitalisation were important indicators. CONCLUSION: We recommend a regular comprehensive assessment in home care to identify clients with potential risk factors for weight loss and malnutrition, in particular those discharged from hospital, and those with physical dependency or cognitive problems. This study may provide incentives to create tailored preventive strategies.

Underweight, weight loss and related risk factors among older adults in sheltered housing--a Swedish follow-up study.

BACKGROUND: Underweight and weight loss are important factors in detecting malnutrition. OBJECTIVE: To describe underweight, weight loss and related nutritional factors after 12 months among individuals 75 years or older and living in sheltered housing. A further aim was to identify possible risk factors associated with underweight and weight loss. DESIGN: This is a part of a cross-sectional follow-up study from a county in Sweden, examining the disabilities, resources and needs of 719 older adults in sheltered housing units. Data were collected twice, with a 12-month interval using the Resident Assessment Instrument. RESULTS: Among the 503 remaining chronically ill individuals with cognitive and functional disabilities, 35% were classified as underweight at the initial assessment and 38% at the second, a non-significant difference. A further analysis showed 39% had decreased weight, 27% remained stable and 28% gained weight. A weight loss of 5% occurred in 27% of the older adults and a loss of 10% occurred in 14%. Risk factors associated with being underweight and weight loss, using scales derived from the instrument were cognitive and functional decline. Dementia and Parkinson's disease, eating dependencies and constipation were the strongest risk factors when analyzed as single items. CONCLUSION: A high percentage was underweight or exhibited weight loss and several risk factors were identified. Ensuring adequate nutritional status in individuals with a variety of diseases and declining health status is challenging. Increased combined efforts using a wide range of measures, nutritional programs and routines need to be regularly implemented.

Cytokine induced modulation of MHC class I and class II molecules on human cervical epithelial cells.

Our purpose was to determine the expression of the major histocompatibility complex (MHC) class I and class II gene products as well as the costimulatory molecules B7-1 and B7-2 on cervical epithelial cells, and to determine to what extent inflammatory cytokines regulate their expression. Immunohistology and flow cytometry techniques were used to identify and quantify MHC class I and class II molecules, and the costimulatory molecules B7.1 and B7.2, on sections and primary epithelial cell cultures of human endo- and ectocervix. MHC class I but not class II molecules were constitutively expressed on tissue sections and primary epithelial cell cultures derived from endo- and ectocervix. Expression of MHC class I and class II was upregulated in vitro by IFN-gamma in a time and dose dependent fashion. The induction of class II expression was more pronounced on ectocervical cells than on endocervical cells. MHC class I but not class II expression was also enhanced by IFN-alpha as well as TNF-alpha. TNF-alpha and TGF-beta1 inhibited the IFN-gamma induced MHC class II expression. Expression of the costimulatory molecules B7-1 and B7-2 were not detected in tissue sections or on resting or cytokine-treated cervical epithelial cells in vitro. The present results support the concept that endo- and ectocervical epithelial cells, like their counterparts at other mucosal sites. constitutively express MHC class I molecules and can express MHC class II upon cytokine stimulation, indicating that they are capable of presenting antigens to T-cells.

International comparison of long-term care: the need for resident-level classification.

Differences between long-term care facilities in Stockholm (1134 residents) and New York (95,000 residents statewide) were examined. The comparison employed a resident classification system, Resource Utilization Groups (RUG-II), which links individuals' characteristics to resource use. Distributions of Activity of Daily Living functionality and RUG-II categories demonstrated significant differences between these two populations, with the Stockholm facilities more akin to the heavier care skilled nursing facilities in New York. These differences may indicate different uses of long-term care beds in the United States and Sweden and demonstrate the need for resident-level classification systems in cross-national studies.

The impact of legislation on psychotropic drug use in nursing homes: a cross-national perspective.

OBJECTIVES: To quantify the impact of legislation on nursing home residents, psychotropic drug use, and the occurrence of falls in the US compared with five countries with no such regulation. DESIGN: A retrospective cross-sectional study SETTING: Nursing homes in five US states and selected nursing homes in Denmark, Iceland, Italy, Japan, and Sweden. PARTICIPANTS: Residents in nursing homes in five US states and the aforementioned countries during 1993-1996. MAIN OUTCOME MEASURES: Using data collected using the Minimum Data Set, logistic regression provided estimates of the legislative effects on the use of antipsychotics and antianxiety/hypnotics while simultaneously adjusting for potential confounders. The occurrence of falls was evaluated similarly. RESULTS: Prevalence of antipsychotic and/or antianxiety/ hypnotic use varied substantially across countries. After adjustment for differences in age, gender, presence of psychiatric/neurologic conditions, and physical and cognitive functioning, residents in Denmark, Italy, and Sweden were at least twice as likely to receive these drugs (Denmark Odds Ratio (OR)=2.32; 95% Confidence Intervals (CI), 2.15-2.51; Italy OR=2.05; 95% CI, 1.78-2.34; Sweden OR=2.50; 95% CI, 2.16-2.90); in Iceland, the risk was increased to greater than 6 times (OR=6.54; 95% CI, 5.75-7.44) that of the US. Residents were less likely to fall in Italy, Iceland, and Japan compared with the US, despite more extensive use of psychotropic medication, whereas residents in Sweden and Denmark were more likely to fall. CONCLUSIONS: Policy has had an impact on the prescribing of psychotropic medication in US nursing homes compared with other countries, but it is unclear if this is translated into better outcomes for residents.

Quality of diagnoses and cost of managing anemia in four countries.

An earlier study of non-hospitalized Swedish patients suggested frequent overprescribing of iron tablets and frequently uncertain diagnoses of iron deficiency. For this reason, a record audit was performed of 202 patients hospitalized because of iron deficiency anaemia or pernicious anemia in an English, a French, three Swedish, and a US teaching hospitals. Results are difficult to interpret because of the limited extent of this study and because differences between hospitals are as great as those between countries. Nevertheless, the Swedish hospital seemed to have 37% longer duration of stays (p less than 0.05), it spent only 16% of the total hospitalization cost for diagnostic studies as compared to 22-35% for the other hospitals, and it had numerically, but not significantly increased percentages both of uncertain diagnoses and of unidentified causes of the iron deficiency. For comparable time periods the hospitals with the longest length of stay also had the highest percentage of uncertain diagnoses (p less than 0.001). After the local publication of the first reports in 1978-1981, an improvement in the percentage of uncertain diagnoses was found in the Swedish hospital, which suggests that quality evaluation can lead to quality assurance.

Stroke patients ready for discharge from acute care--a multi-dimensional assessment of functions and further care.

PURPOSE: The aim of this study was to describe actual functions, performance of activities and needs of further care in patients with stroke in acute care wards at the time the physicians decided that the patients were ready for discharge, in relation to placement after discharge and the motives for the decision. METHOD: Thus 114 stroke patients in Stockholm County were assessed with the Resident Assessment Instrument, and the motives for further care were reviewed in the patients' case records. RESULTS: The results showed that the oldest, most severely impaired stroke patients had the shortest mean length of stay before the physician considered the patients ready for discharge to nursing homes, where resources for long-term rehabilitation and stroke care vary. CONCLUSION: It is important to secure continuing adequate care and rehabilitation for elderly severely impaired stroke patients being discharged early from acute care hospitals.

The RAI-PC: an assessment instrument for palliative care in all settings.

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in counjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH). The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The "clinician friendly" RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.

Observer ratings of perceived exertion in relation to self ratings and heart rate.

The results from a comparison made between observers' estimations of a bicycling subject's exertion and the self-raters' perceived exertion show that one can draw conclusions of an individual's exertion at physical work by using observer ratings. Six bicycling subjects (self-raters) cycled on a bicycle ergometer at six different power levels presented in random order. The estimations were made simultaneously by the observers and the self-rater during the last half minute at each power level. At the same time the self-rater's heart rate was registered. In accordance with earlier findings on physical work, the relation between heart rate and power level was linear. The estimations were made on a category-ratio scale as well as with magnitude estimation. The observers found the category-ratio scale easier to use and it seems as if the category-ratio scale is as reliable as magnitude estimation for these kinds of ratings.

Perceived exertion during a self-imposed pace of work for a group of cleaners.

Nine cleaners were monitored for four hours while performing their ordinary work. They rated their perceived exertion on Borg's CR-10 scale every five minutes and their heart rates were recorded every minute. It was found that the subjects worked on a physiological 'steady-state' level, meaning that their heart rates were about the same regardless of the work performed. Their ratings of perceived exertion varied, however, but were all 'fairly strong' or stronger. During more than 80% of the time, the work periods on the different tasks were shorter than 15 min. On the basis of the results of a bicycle ergometer test, it was determined that the actual level of exertion during the ordinary work corresponded to about 35% of the subjects' estimated maximal oxygen uptake. Most subjects had back symptoms and more than half of them reported symptoms involving the neck, shoulders, wrists and hands. The varying intensities indicate where the problems are most critical.