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.

Patient educational level and use of newly marketed drugs: a register-based study of over 600,000 older people.

OBJECTIVE: To examine the association between educational level and the use of newly marketed drugs (NMD) among elderly persons. METHODS: We conducted a register-based, retrospective, cross-sectional study of 626,258 people aged 75-89 years who filled at least one drug prescription from August to October 2005 and who, consequently, were registered in the Swedish Prescribed Drug Register (SPDR). Data from the SPDR were record-linked to the Swedish National Inpatient Register and the Education Register. Newly marketed drugs were defined as new chemical entities that had been approved in Sweden between 2000 and 2004. RESULTS: Overall, NMD were prescribed to 7.3% of the study population. The use of NMD increased with increasing educational level (6.9% for the lowest educated elderly and 8.1% for the highest educated elderly), and education was associated with NMD [odds ratio (OR) 0.82; 95% confidence interval (CI)] 0.80-0.88 for <9 compared with > or =13 years of education) after adjustment for age, sex, type of residential area and number of dispensed drugs. Decreasing educational level was associated with a lower probability of using most of the NMD, especially oseltamivir (adjusted OR 0.16; 95% CI 0.12-0.22 for <9 years of education compared with > or =13 years of education) and ezetimibe. CONCLUSIONS: This study suggests that education-related inequalities in NMD use may exist even in a healthcare system that claims to ensure a high degree of equity. Future research is required to explain why educational level influences the selection of new drugs and whether it has any impact on health outcomes.

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.

Does day care also provide care for the caregiver?

People caring for relatives with dementia may need respite to be able to cope and maintain some quality of life. With the aim to investigate whether day care is an effective form of respite for caregivers of dementia sufferers, 115 new day care clients were invited and 90 caregivers agreed to participate. Of these, 51 fulfilled the inclusion criteria and were asked to assess feelings of worry, depression, overload and role captivity before using day care and again 4 months later. The study group comprised both co-residing (CR) and non-co-residing (NCR) caregivers and care recipients. Those NCR caregivers whose elderly relative dropped out of day care had significantly higher values for worry, overload and role captivity, and a higher level of depression than the caregivers in the NCR group whose care recipient continued day care. Although this study is of an explorative character, some conclusions may be drawn from it. Dementia sufferers seem to need an informal caregiver to help them when they are not at day care. Day care is probably a form of support most suitable for caregivers, who are looking after relatives in the early stages of the illness and are not yet too exhausted.

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.

Enduring inequality: educational disparities in health among the oldest old in Sweden 1992-2011.

OBJECTIVES: Although the past two decades have involved changes in the living conditions of the oldest old in Sweden, little is known about how health inequalities have developed in this group during the period. This study explores the educational disparities in a wide range of health outcomes among the oldest old in Sweden between 1992 and 2011. METHODS: The study uses the repeated cross-sectional design of the SWEOLD survey, a nationally representative survey of the oldest old in Sweden with comparable data from 1992, 2002, and 2011. The development of educational disparities in health was tracked across the three waves. RESULTS: The results show that although the prevalence of most health problems increased during the period, the prevalence of disability in activities of daily living decreased. Despite these changes, educational disparities in health remained largely unaffected. CONCLUSIONS: The results of the study suggest that the association between education and health is remarkably robust. It prevailed into the oldest age groups, was consistently found for a wide range of health problems, and tended to be stable over extended periods of time.

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 in a general population. The results of a postal survey in a county of Sweden.

In a postal survey, we asked 1009 randomly chosen individuals, age 18-84, about their pain problems. The pain prevalence depended on what types of questions were asked. Any pain or discomfort, including even a problem of short duration, was reported by 66% of those questioned. Forty percent reported 'obvious pain' (pain which affected them 'to quite a high degree' or more and was 'like being stiff after exercise' or worse) lasting more than 6 months. Pain problems of more than 6 months duration were reported far more often than short-lasting problems. Continuous or nearly continuous pain problems were reported as frequently as problems recurring regularly or irregularly. Pains in the neck, shoulders, arms, lower back and legs were most frequent. The prevalence of 'obvious pain' in these localizations was 15-20%. Pain was reported most frequently in the age group 45-64, where the prevalence of 'obvious pain' was 50% among males as well as females. Over 65 years of age the prevalence was less.

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%.

Sleep problems in a very old population: drug use and clinical correlates.

BACKGROUND: Complaints of disturbed or dissatisfied sleep are common among older people. This study aimed to evaluate the prevalence of sleep problems in very old persons and its relation to physical and mental health and drug use. METHODS: This is a cross-sectional analysis of sleep problems in a population of old persons living in Stockholm, Sweden. There were 641 subjects aged 81+ years; 77.8% were women, 91.4% were noninstitutionalized, and 68.6% lived alone. All persons underwent a comprehensive medical and psychiatric interview and examination. Sleep problems were assessed using the Clinical Psychopathological Rating Scale (CPRS). Covariates included chronic medical conditions, depression, dementia, pain, self-rated health, activities of daily living, use of hypnotics-sedatives, use of other psychotropic drugs, and use of nonpsychotropic drugs. RESULTS: More than one third of subjects were identified with sleep problems. They were more common among women and persons using a higher number of drugs. Poor self-rated health, depression, and pain were related to the presence of sleep problems. Among persons with sleep problems and depression, only 19.2% used antidepressants, and 46.2% used hypnotics-sedatives. Among persons with sleep problems and pain, 63.2% used analgesics, and 47.0% used hypnotics-sedatives. One or more chronic diseases, use of hypnotics-sedatives, use of other psychotropic drugs, and use of nonpsychotropic drugs were also related to sleep problems. After multivariate analysis, factors significantly related to sleep problems were female gender, depression, pain, and hypnotic-sedative use. CONCLUSIONS: Sleep problems were common in this very old population. These results suggest the importance of carefully assessing an older person's complaints to accurately diagnose and effectively treat sleep problems.

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.

Dementia and depressive symptoms as predictors of home help utilization among the oldest old: population-based study in an urban area of Sweden.

OBJECTIVE: The objective of this article is to investigate predictors of public home help utilization, particularly mental health problems such as dementia and depressive symptoms. METHODS: A population-based sample of community-dwelling people aged 81-100 was interviewed and assessed with medical examinations (N = 502). RESULTS: Dementia increased the odds of receiving public home help among people residing alone. Among coresiding people, it increased the odds of receiving home help, but only among those who had extra residential care. Depressive symptoms decreased the odds of receiving home help among people with lower levels of education who lived alone. Depressive symptoms among highly educated people who lived alone and among coresiding people of any educational level were not related to receipt of home help. DISCUSSION: Improvement of screening activities for public home help needs of community-dwelling elders might allow better targeting of limited social resources to the most needy.

Care utilisation in the last years of life in Sweden: the effects of gender and marital status differ by type of care.

The effects of gender and marital status on care utilisation in the last years of life are highly correlated. This study analysed whether gender differences in use of eldercare (home help services or institutional care) or hospital care in the last 5 years of life, and the place of death, could be attributed to differences in marital status and thereby to potential access to informal care. A longitudinal Swedish study provided register data on 567 participants (aged 83 +) who died between 1995 and 2004. A higher proportion of unmarried than married people used home help services; this was true of both men and women. The likelihood of receiving home help was lower for those living with their spouse (OR = 0.38) and for those with children (OR = 0.60). In the 2 years preceding death, the proportion receiving home help services decreased and the proportion in institutional care increased. Women were significantly more likely to die in institutional care (OR = 1.88) than men. Although men were less likely to live in institutional care than women and more likely to be inpatients in the 3 months preceding death, after controlling for residence in institutional care, neither gender nor marital status was statistically significant when included in the same model. In summary, the determining factor for home help utilisation seemed to be access to informal care, whereas gender differences in health status could explain women's higher probability of dying in institutional care.

Data resource profile: The Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD).

As the number and proportion of very old people in the population increase, there is a need for improved knowledge about their health and living conditions. The SWEOLD interview surveys are based on random samples of the population aged 77+years. The low non-response rates, the inclusion of institutionalized persons and the use of proxy informants for people unable to be interviewed directly ensure a representative portrayal of this age group in Sweden. SWEOLD began in 1992 and has been repeated in 2002, 2004 and 2011. The survey is based on another national survey, the Swedish Level of Living Survey (LNU), started in 1968 with 10-year follow-up waves. This longitudinal design provides additional data collected when SWEOLD participants were in middle age and early old age. The SWEOLD interviews cover a wide range of areas including health and health behaviour, work history, family, leisure activities and use of health and social care services. Socio-economic factors include education, previous occupation and available cash margin. Health indicators include symptoms, diseases, mobility and activities of daily living (ADL). In addition to self-reported data, the interview includes objective tests of lung function, physical function, grip strength and cognition. The data have been linked to register data, for example for income and mortality follow-ups. Data are available to the scientific community on request. More information about the study, data access rules and how to apply for data are available at the website (www.sweold.se).

Sampling and non-response bias on health-outcomes in surveys of the oldest old.

Surveys of the oldest old population are associated with several design issues. Place of residence and possible physical or cognitive impairments make it difficult to maintain a representative study population. Based on a Swedish nationally representative survey among individuals 77+, the present study analyze the potential bias of not using proxy interviews and excluding the institutionalized part of the population in surveys of the oldest old. The results show that compared to directly interviewed people living at home, institutionalized and proxy interviewed individuals were older, less educated and more likely to be female. They had more problems with health, mobility and ADL, and a significantly increased mortality risk. If the study had excluded the institutionalized part of the population and/or failed to use proxy interviews, the result would have been severely biased and resulted in underestimated prevalence rates for ADL, physical mobility and psychologic problems. This could not be compensated for weighting the data by age and sex. The results from this study imply that accurate population estimates require a representative study population, in which all individuals are included regardless of their living conditions, health status, and cognitive ability.