Trends in polypharmacy and potential drug-drug interactions across educational groups in elderly patients in Sweden for the period 1992 - 2002.

OBJECTIVE: This study investigates the changes in drug use, polypharmacy and potential drug-drug interactions (DDIs) between educational groups of Swedish elderly over a 10-year period from 1992 - 2002. METHODS: We used data from SWEOLD I (n = 512) from 1992 and SWEOLD II from 2002 (n = 561), which are nationally representative surveys of the elderly population in Sweden aged 77 years and older. Both community-based and institutionalized persons were included. Information on drug use was based on personal interviews and all drugs used in the two weeks prior to the studies were recorded. The three outcomes under study were drug use, polypharmacy (concurrent use of five or more drugs), and potential DDIs. RESULTS: In the SWEOLD data from 1992 - 2002, the mean number of drugs used per person increased from 2.5 - 4.4. Overall, 81% of the study participants were drug users in 1992 as compared to 88% in 2002. The prevalence of polypharmacy increased 3-fold (from 18% in 1992 to 42% in 2002) after controlling for age and gender. In both SWEOLD surveys, the less educated reported polypharmacy more often (19% in 1992 and 46% in 2002) than the higher educated (12% in 1992 and 36% in 2002). Potential DDIs also increased, both among the less educated (14% in 1992 to 26% in 2002) and the higher educated (18% in 1992 to 24% in 2002). The most pronounced changes in the consumption of specific drug groups were observed in antithrombotic agents, beta-blocking agents, ACE inhibitors, and vitamin B12 and folic acid. In general, the use of most therapeutic classes increased more among the well educated compared to less educated men between 1992 and 2002, whereas the opposite relationship prevailed among women. CONCLUSION: This study indicates that the use of drugs, polypharmacy and potential DDIs have increased during 1992 to 2002 among the elderly. These changes were most prominent among the less educated women. Polypharmacy and potential DDIs represent potential health hazards for the elderly. Therefore, the trends of increasing polypharmacy and drug-drug interactions deserve attention and the mechanisms behind should be investigated further.

The use of medicines with anticholinergic effects in older people: a population study in an urban area of Sweden.

OBJECTIVE: To investigate the use of medicines with anticholinergic properties among older people in an urban population in Sweden. DESIGN: A cross-sectional survey. SETTING: Ordinary homes, sheltered accommodations, nursing homes, and geriatric departments. PARTICIPANTS: All residents aged 75 and older in a district of Stockholm, Sweden. MEASUREMENTS: Structured interviews with older persons, their relatives and/or health care personnel; prescription forms; medical records. RESULTS: The overall use of medicines with anticholinergic effects was comparatively low. Doses of these medicines were also generally low. Concurrent use of several such medicines was uncommon. The most prevalent therapeutic/pharmacological group was neuroleptics. In contrast, antidepressants were used by few older people. The prevalence of medicines with anticholinergic effects was highest at institutions, where neuroleptics were frequent and use of low-potency neuroleptics was not uncommon. CONCLUSION: Our results indicate that the risk of anticholinergic side effects may be quite low in the present population as a whole. However, there may be grounds for revising the therapy in institutions, where the use of neuroleptics was shown to be high and low-potency neuroleptics, known to have a higher incidence of anticholinergic side effects, were not avoided.

Use of cardiovascular drugs in an older Swedish population.

OBJECTIVE: To describe the use of cardiovascular drugs in an older population with respect to age, sex, housing type, and creatinine clearance. DESIGN: A cross-sectional survey. PARTICIPANTS: All residents of a district of Stockholm (Kungsholmen), Sweden, aged 75 and older, living in institutions or at home. MEASUREMENTS: Cardiovascular drug use, serum creatinine, electrolytes, height, weight, and symptoms. RESULTS: A total of 43 cardiovascular (CV) drugs were used. The most common drugs were digoxin (used by 18.2%), furosemide (16.4%), and glyceryl trinitrate (12.4%). Drugs with an antihypertensive effect accounted for 61% of all CV drugs. CV drug use increased with age for cardiac glycosides and diuretics, but decreased with age for calcium antagonists and beta-blockers. Drug doses tended to be less than the recommended daily dose except for a few drugs, e.g., furosemide. There was a trend toward decreasing dose with increasing age, but this was not significant. Diuretics were the only CV drugs used more often in women. People living in institutional care used the least amount of CV drugs. The dose of drugs taken did not appear to be related to estimated creatinine clearance. Comparisons between drug use and complaint of symptoms showed a strong correlation between the use of cardiac glycosides and anorexia, calcium antagonists and constipation, and nitrates and vertigo. There were weaker correlations with cardiac glycosides and visual disturbances and with potassium sparing diuretics and a high potassium. CONCLUSIONS: CV drugs are used commonly in older people. We suggest that the symptoms correlating with cardiac glycoside use may be signs of unrecognized toxicity, and this may relate to our finding that drug use is often not tailored to renal function as measured by creatinine clearance.

The appropriateness of drug use in an older nondemented and demented population.

OBJECTIVE: To assess the extent of inappropriateness of drug use in an older nondemented and demented population. DESIGN: Descriptive analysis based on data from a sample of older subjects age 81 years and older. Data were collected from the second follow-up conducted in 1994-1996. SETTING: A population-based study of the Kungsholmen project in Stockholm, Sweden. PARTICIPANTS: Drug information was obtained from 681 subjects with a mean age of 86.9 years. The subjects were predominantly women (78%). Thirteen percent resided in institutions and 27.6% were diagnosed with dementia. MEASUREMENTS: Dementia diagnosis based on DSM III-R. Criteria for inappropriateness of drug use: use of drugs with potent anticholinergic properties, drug duplication, potential drug-drug and drug-disease interactions, and inappropriate drug dosage. RESULTS: The mean number of drugs used was 4.6: 4.5 drugs for nondemented and 4.8 for demented subjects. Nondemented subjects more commonly used cardiovascular-system drugs and demented subjects used nervous-system drugs. Demented subjects were more commonly exposed to drug duplication and to drugs with potent anticholinergic properties, both involving the use of psychotropic drugs. Nondemented subjects were more commonly exposed to potential drug-disease interactions, mostly with the use of cardiovascular drugs. The most common drug combination leading to a potential interaction was the use of digoxin with furosemide, occurring more frequently among nondemented subjects. The most common drug-disease interaction was the use of beta-blockers and calcium antagonists in subjects with congestive heart failure. The doses of drugs taken by both nondemented and demented subjects were mostly lower than the defined daily dose. CONCLUSION: There was substantial exposure to presumptive inappropriateness of drug use in this very old nondemented and demented population. The exposure of demented subjects to psychotropic drugs and nondemented subjects to cardiovascular drugs reflect the high frequency of prescribing these drugs in this population.

The validity of a pain questionnaire for postal surveys.

A postal survey aimed at studying the prevalence of chronic pain and the need for care because of pain was carried out in a representative sample of a Swedish population. A random sample of the study population has been interviewed and assessed clinically to determine whether a questionnaire method gives the same results as clinical assessment. The agreement between estimates based on the questionnaire and those based on the clinical assessments varied depending on the questions used. By creating questions more independent of language habits and values, it was shown that it is possible to get better agreement between different descriptions. The best agreement was shown when answers to questions regarding different dimensions of pain were combined in a model for selecting individuals with more serious pain problems.

A longitudinal study of pain: reported pain from middle age to old age.

OBJECTIVE: Describe patterns of pain reporting over a span of 24 years. DESIGN: Individuals were interviewed on four occasions (1968, 1974, 1981, 1992). PARTICIPANTS: Representative sample (n = 321) of the Swedish population aged 53-63 at baseline. MEASURES: Self-reported pain in the chest, abdomen, and musculoskeletal system (back or hips, shoulders, hands, elbows, legs, or knees). RESULTS: Less than 1% reported chest or abdominal pain on all four occasions. Whereas 21.8% of the sample reported musculoskeletal pain on all four occasions. More than half of the sample reported some kind of pain on three or four occasions. Women reported more severe and more persistent pain compared with men. There were more people who developed pain during the 24-year period than there were who became pain free. An increase in pain was equally common for chest and musculoskeletal pain, but a decrease in pain was much more common for musculoskeletal pain than chest pain. CONCLUSIONS: Cross-sectional studies have shown differing age patterns in pain. This longitudinal study demonstrates different patterns for men and women and for different pain localities.

The increasing number of very old people will change the Swedish model of the welfare state.

In Sweden as well as many other welfare states, society has assumed--or been given--a number of functions formerly performed by the family. Child care and care of the elderly are here two significant examples. Since 1960 the number of institutional beds for the care of the elderly has doubled. The number of personnel working within the home-help and home-care systems has increased sharply. In spite of this, the demand for service and care is today increasing faster than the input of new resources. Many have been worried that the increasing number of very old people will create (too) heavy a strain on the Swedish economy. But the main problem will be not the economy but rather the scarcity of personnel. Even the most optimistic prognosis indicates that within the next 10 years, the number of personnel employed in the care of the elderly will no longer be sufficient. Heavy burdens will be placed on families and on women. The potential labour force of the newly retired will be needed, the private sector will expand, etc. Sweden will still be a welfare state, but the fundamental concept of a society where services and care are provided for all citizens on equal terms will change.

Smoking behaviour among pregnant women prior to antenatal care registration.

Changes in smoking behaviour during early pregnancy and factors influencing such changes were studied in an unselected, area-based population. During 1987, all women registered at the antenatal care clinics in Uppsala county. Sweden, received a self-administered questionnaire regarding past and present smoking habits. Thirty-two per cent (n = 1160) were daily smokers at the time of conception. Almost one-fourth of the smokers (n = 263) had quit smoking at the first visit to antenatal care 6-10 weeks later. Using logistic regression analyses, we found that low education, not living with infants's father and whether others smoked at home or at work were factors that were independently associated with increased risks of smoking at time of conception as well as continued smoking in early pregnancy. Continued smoking was also significantly more common among women with previous births, women who started smoking at an early age and women who smoked heavily.

The use of common pain experiences in designing a pain intensity scale for epidemiological purposes.

The planning of services for the treatment of chronic pain does not seem to be based on adequate information. Although some epidemiological studies exist already, there is a need for more epidemiological knowledge. We have tried to develop a mail questionnaire which may, to some extent, separate pain sensory intensity from pain affect and behaviour. In this paper we refer to the development and testing of a pain sensory intensity scale based on common pain experience. 155 subjects classified the intensity of 15 common pain states. The classifications were then compared. The results indicate that there are pain states which many people have experienced and which they are able to rank according to pain intensity. The pain sensory intensity scale we based on five of these pain experiences or groups of pain experience.

The utilization of home help in Sweden: a multivariate analysis.

We estimated the effect of a variety of factors on the utilization of home help among the elderly in Sweden using a sample (N = 421) of people 75 years and older. A regression analysis singled out two factors as the most important: physical functioning (instrumental activities of daily living) and living alone. Calculations of attributable fractions substantiated this result. Implications for planning and allocating home help are discussed.

The de-institutionalization of care of the elderly: some notes about implementation and outcome of a Swedish case-study.

During the 1980s the number of institutional beds in Sweden has decreased in relation to the number of elderly in the population. In some communities this development has been drastic. The present paper describes how the implementation of this process in one of these communities was based on action research design. Initially most people regarded the development as a success: more elderly people were able to stay in their homes and institutional places were used more effectively. The situation today is more complicated. Elderly patients finally ending up in institutions are in greater need of care than before. Over-occupation of beds is again common, making the situation more "heavy-going" for the staff. Staff outside the institutions are also experiencing a heavier workload. In view of this, the wisdom of further de-institutionalization is now questioned.

'Bed-blockers': delayed discharge of hospital patients in a nationwide perspective in Sweden.

Between 1989 and 1992 the number of 'bed-blocking' patients in Sweden decreased from 15 to 7% according to national registers containing approx. 4000 patients. Part of this reduction can be explained by the 1992 Elderly Reform, which placed economic responsibility for bed-blockers on municipalities. However, the decrease began before the economic reform, implying that other factors are also involved, such as access to alternative institutional beds and other forms of care. An in-depth study of one district has provided a description of these often elderly patients, their heavy hospital utilization both before and after the bed-blocking period and their mortality. Nearly half the patients were dead within a year. Bed-blocking is a poorly defined concept requiring urgent discussion. Other related topics to which attention should be drawn are the administrative costs of economic control systems and efficient utilization of public resources as a whole.

Health and inequalities among the oldest old.

The elderly, and especially the oldest old, have generally been overlooked in research on social class inequalities in health. On the basis of nationally representative data from Sweden for the age group 77 to 98 (N=537), we have been able to demonstrate clear differences in health between social classes. These inequalities were found both for men and women. It should be noticed, however, that the patterns of class differences varied depending on the health indicator used. The often employed global measure of self-rated health showed the smallest class gradient when controlling for age and sex, whereas larger differences were found with more concrete and descriptive measures such as peak flow rate.

Predictors of physical function among the oldest old: a comparison of three outcome variables in a 24-year follow-up.

This study has measured physical function in a nationally representative sample of persons aged 77 to 98 (N = 508) in 1992. Three measures of function are used: activities of daily living (ADL), an index of mobility, and performance tests. These are used as outcomes and analyzed in relation to variables gathered in a survey in 1968. Variables from 1968 include education, mobility, smoking, and an index of circulation problems. All four variables predict some limitations in physical function in old age. However, there are different patterns of predictors found for the three outcome measures. All three outcomes are associated with age, education, and previous circulation problems. ADL limitations are also associated with poor previous mobility and smoking; mobility limitations are also associated with sex and smoking; performance limitations are also associated with sex.

Surveying the elderly about health, medical care and living conditions. Some issues of response inconsistency.

A sample of elderly persons (75-84 years old) in Sweden was surveyed twice on home conditions, health and medical care. Two data collection methods were used: interviews and a mail survey. It has been shown that it is possible to carry out a mail survey (with low non-response) among the elderly in this group. However, what about other aspects of quality? Is it really possible to use a mail survey instead of the much more expensive and complicated techniques involved in interviewing? The results show that for certain groups of variables there are fairly large differences between how respondents reply in the mail survey and in personal interviews carried out by district nurses. These differences apply both to the degree of inconsistency in answers and to shifts in marginal distributions. Among other things, more ailments are mentioned at interview. The demand for information on the elderly and the differences between the methods in the cost of gathering this information make reliability and validity studies of methods of surveying the elderly increasingly important.

Predictors of mortality for the oldest old. A 4-year follow-up of community-based elderly in Sweden.

The aim of this study is to investigate predictors for mortality in two age groups, 75-84 years old and 85 years and older. Interviews were carried out on 161 community-based persons aged 75-84 and 260 persons aged 85 and over. Predictors for mortality 4 years later were analyzed using logistic regression. Different models to predict mortality were found for the two age groups. Gender and IADL (Instrumental Activities of Daily Living) were found to be significant for the older group while ADL (Primary Activities of Daily Living), mobility and life satisfaction were significant for the younger group. Eliminating variables based on the nurse's evaluations did not change the model for the 85+ age group; in the 75-84 age group the nurse's assessment of ADL was replaced by a self-reported IADL index. Results confirm the heterogeneity of the elderly population and the importance of ADL and subjective measures for predicting mortality.

Nursing load in different care alternatives in Sweden during 18 years.

In a repeated cross-sectional study, changes in nursing load and changes in care organisation (1978-1996) were studied in Sundsvall, Sweden. A total of 4555 nursing load measurements on elderly people were performed on four occasions (1978, 1988, 1993 and 1996). The nursing load has increased considerably at the nursing homes and at the homes for the aged during the whole period. In home care, the nursing load did not increase between 1978 and 1993, but it increased considerably between 1993 and 1996. The mean age of the residents, the number of persons with dementia, as well as the mean age, also increased. Between 1978 and 1996, the number of institutional resources decreased by 38%, while home care resources increased by 421%. The considerable increase in nursing load presents a worrying scenario when it is combined with the expected increase of the oldest old.

Musculoskeletal pain and analgesic therapy in a very old population.

The aim of this study was to examine the prevalence of musculoskeletal pain and use of analgesic drugs in a population of very old people. The investigation is based on data from the Kungsholmen project. Of the 2638 inhabitants aged 75 or more in a parish of central Stockholm 1800 were examined. Of the subjects. 60% reported trouble with pain at musculoskeletal locations, while only 40% of the pain reporting subjects used analgesics, one third of which were non-prescription minor analgesics. Prescription analgesics (non-steroidal antiinflammatory drugs or centrally acting drugs) were used by one fourth of the pain reporting subjects, and taken on a regular basis in only half of the cases. Potent opioids were used by less than 1% of the population. There was no increase in pain with increasing age, but an increase in use of minor analgesics with age >85. Women more often reported pain and had a higher consumption of analgesics. Light opioids were more often used by subjects with multifocal pain. Subjects living in sheltered accommodation used more analgesics, particularly light opioids, than did those living in their own homes or in institutions. Subjects with low or intermediate educational status more often reported pain and used light opioids to a larger extent than did the highly educated. These results indicate that musculoskeletal pain is relatively common among the very old, but does not seem to be a severe problem for the majority, considering the low proportion of subjects using prescription analgesics regularly. However, the very low use of potent opioids indicates that some of the elderly suffering from cancer and other severe pain causing diseases might be undertreated.

'Misplacement' of elderly people in the caring organisation: reasons and alternatives.

The degree of misplacement in the care organisation was studied in a repeated cross-sectional study (788 persons in 1993 and 1538 in 1988, 65 years and older) in Sundsvall, an industrial city in the middle of Sweden. The overall misplacements were 23% both in 1988 and 1993. Misplacements were most frequent in the homes for the aged (about 50%). At the nursing homes, misplacement decreased from 27 to 12% between 1988 and 1993, while it has increased in home care from 8 to 27%. Almost half of the misplacements in home care needed nursing home or psychogeriatric care. The main conclusion is that the care organisation is not working optimally. The number of misplacements reflects an exhausted care situation. The concept of misplacement is probably valuable, but its usefulness must be evaluated in further studies.

: prevalence and association with drug use.

In a cross-sectional study, we have investigated the prevalence of self-reported symptoms and their association with medicinal drug use in elderly people. Data from the Kungsholmen Project were used, a population-based study of elderly people aged 75 years and over in Stockholm, Sweden. The study sample comprised 1800 persons. Information on the occurrence of 22 different symptoms and the actual drug use was obtained at interviews with the participants. The relation of symptoms to age, gender and housing, and their association with drug use was analysed using logistic regression. The most commonly reported symptoms were pain and tiredness. In general, symptoms were more common in women and at higher ages. Many of the associations between symptoms and drug use reflected established treatments. However, some were suggestive of inappropriate treatment or dosage; for example, the association between tiredness and the use of anxiolytics and hypnotics-sedatives.