Dementia and road traffic accidents among non-institutionalized older people in Denmark: A Danish register-based nested case-control study.

AIM: We used register-based data to estimate the effect of all-type dementia on road traffic accidents (RTAs) risk, combined with comorbidities or sedative medicines, among non-institutionalized older people in Denmark. METHODS: The source population was all residents in Denmark aged 65 years and older, alive as of January 1, 2008 ( n = 853,228). Cases were those who had any type of RTA in 2009-2014. Each case was matched for age, sex and geographic location to 4-6 controls. All-type dementia was ascertained using the International Classification of Diseases version 10 (ICD-10) diagnosis supplemented with prescribed medicine records. Eight chronic diseases were selected to assess comorbidities. Four types of medicines were categorized as sedative medicines for analysis. Conditional logistic regression with adjustment for education and marital status as well as either the number of comorbidities or sedative medications use was performed using STATA software. RESULTS: Older people with dementia had lower RTAs risk compared to their controls (odds ratio = 0.43, 95% confidence interval (0.32-0.60), p < 0.001). Significant interaction was observed between dementia and the number of comorbidities for RTAs estimation. CONCLUSIONS: The significantly lower RTAs risk for older individuals with dementia observed in our study may be due to people with dementia living at home having a lower frequency of outdoor activities; that is, less exposure to traffic. However, this, together with the interaction between dementia and comorbidities as well as sedative medications, should be investigated further.

Hypnotics and mortality--partial confounding by disease, substance abuse and socioeconomic factors?

PURPOSE: The aim of this Cohort study of 10 527 Danish men was to investigate the extent to which the association between hypnotics and mortality is confounded by several markers of disease and living conditions. METHODS: Exposure was purchases of hypnotics 1995-1999 ("low users" (150 or less defined daily dose (DDD)) or "high users" (151 or more DDD)). Follow-up for all-cause mortality was from 1 Jan 2000 to 19 June 2010. Cox proportional hazard models were used to study the association. Covariates were entered one at a time and simultaneously. Results were reported using hazard ratio (HR) and 95% confidence intervals (CI). RESULTS: When covariates were entered one at a time, the changes in HR estimates showed that psychiatric disease, socioeconomic position and substance abuse reduced the excess risk by 17-36% in the low user group and by 45-52% in the high user group. Somatic disease, intelligence score and cohabitation reduced the excess risk by 2-11% in the low user group and 8-24% in the high user group. When adjusting for all covariates, the HR was reduced to 1.22 95% CI (0.97-1.54) in the low user group and 1.43 95% CI (1.11-1.85) in the high user group. CONCLUSIONS: The results of this study point at psychiatric disease, substance abuse and socioeconomic position as potential confounding factors partly explaining the association between use of hypnotics and all-cause mortality.

Educational intervention and functional decline among older people: the modifying effects of social capital.

AIM: To analyse if social capital modifies the effect of educational intervention of home visitors on mobility disability. Earlier studies have found that educational intervention of home visitors has a positive effect of older peoples' functional decline, but how social capital might modify this effect is still unknown. METHODS: We used the Danish Intervention Study on Preventive Home Visits - a prospective cohort study including 2863 75-year-olds and 1171 80-year-olds in 34 Danish municipalities - to analyse the modifying effect of different aspects of social capital on the effect of educational intervention of home visitors on functional decline. The three measures of social capital (bonding, bridging, and linking) were measured at contextual level. Data was analysed with multivariate linear regression model using generalised estimating equations to account for repeated measurements. RESULTS: We found that 80-year-olds living in municipalities with high bonding (B=0.089, p=0.0279) and high linking (B=0.0929; p=0.0217) had significant better mobility disability in average at 3-year follow up if their municipality had received intervention. CONCLUSIONS: With the unique design of the Danish Intervention Study on Preventive Home Visits and with theory-based measures of social capital that distinguish between three aspects of social capital with focus on older people, this study contributes to the literature about the role of social capital for interventions on mobility disability.

Are acceptance rates of a national preventive home visit programme for older people socially imbalanced?: a cross sectional study in Denmark.

BACKGROUND: Preventive home visits are offered to community dwelling older people in Denmark aimed at maintaining their functional ability for as long as possible, but only two thirds of older people accept the offer from the municipalities. The purpose of this study is to investigate 1) whether socioeconomic status was associated with acceptance of preventive home visits among older people and 2) whether municipality invitational procedures for the preventive home visits modified the association. METHODS: The study population included 1,023 community dwelling 80-year-old individuals from the Danish intervention study on preventive home visits. Information on preventive home visit acceptance rates was obtained from questionnaires. Socioeconomic status was measured by financial assets obtained from national registry data, and invitational procedures were identified through the municipalities. Logistic regression analyses were used, adjusted by gender. RESULTS: Older persons with high financial assets accepted preventive home visits more frequently than persons with low assets (adjusted OR = 1.5 (CI95%: 1.1-2.0)). However, the association was attenuated when adjusted by the invitational procedures. The odds ratio for accepting preventive home visits was larger among persons with low financial assets invited by a letter with a proposed date than among persons with high financial assets invited by other procedures, though these estimates had wide confidence intervals. CONCLUSION: High socioeconomic status was associated with a higher acceptance rate of preventive home visits, but the association was attenuated by invitational procedures. The results indicate that the social inequality in acceptance of publicly offered preventive services might decrease if municipalities adopt more proactive invitational procedures.

Cost effectiveness of preventive home visits to the elderly: economic evaluation alongside randomized controlled study.

We evaluated the cost effectiveness of preventive home visits to elderly persons in Denmark alongside a 3-year randomized controlled study. The main outcome measure was incremental costs per active life-year gained. The number of active life-years was defined as those during which the person is able independently to transfer, walk indoors, go outdoors, walk outdoors in both pleasant and poor weather, and climb stairs. In 17 of 34 municipalities health visitors and general practitioners were offered geriatric training, which focused on early signs of disability, physical activity, and interdisciplinary follow-up. The remaining 17 municipalities offered preventive home visits as usual. Outcomes were measured in 4,034 persons aged 75 or 80 years old and dwelling at home. The difference in mean total costs between the intervention and the control group discounted at 3% was -856 euro (95% CI -2,455 to 744) in 75-year-olds and 694 euro (-2,684 to 4,071) in 80-year-olds. The discounted difference in mean active life-years was 0.034 (-0.058 to 0.125) and 0.197 (0.013 to 0.380), respectively. The study did not provide conclusive evidence on the cost effectiveness of the programs under consideration.

[In Denmark, there is a lack of consensus in the definition of frailty].

Emerging evidence demonstrates the value of frailty as a predictor of adverse outcomes in older persons. Identification of early stages of frailty offers the opportunity to reverse the development of frailty through targeted interventions. Awareness of the vulnerability in frailty can guide appropriate counselling of patients and their families when considering medical interventions. Recognition of frailty may also help identify and optimize the management of coexisting conditions. There is a lack of consensus in Denmark to use frailty and how to best identify, assess and diagnose frailty.

Dementia and Traffic Accidents: A Danish Register-Based Cohort Study.

BACKGROUND: As a consequence of a rapid growth of an ageing population, more people with dementia are expected on the roads. Little is known about whether these people are at increased risk of road traffic-related accidents. OBJECTIVE: Our study aims to investigate the risk of road traffic-related accidents for people aged 65 years or older with a diagnosis of dementia in Denmark. METHODS: We will conduct a nationwide population-based cohort study consisting of Danish people aged 65 or older living in Denmark as of January 1, 2008. The cohort is followed for 7 years (2008-2014). Individual's personal data are available in Danish registers and can be linked using a unique personal identification number. A person is identified with dementia if the person meets at least one of the following criteria: (1) a diagnosis of the disease in the Danish National Patient Register or in the Danish Psychiatric Central Research Register, and/or (2) at least one dementia diagnosis-related drug prescription registration in the Danish National Prescription Registry. Police-, hospital-, and emergency room-reported road traffic-related accidents occurred within the study follow-up are defined as the study outcome. Cox proportional hazard regression models are used for the main analysis. RESULTS: Our study protocol has 3 phases including data collection, data analysis, and reporting. The first phase of register-based data collection of 853,228 individual's personal information was completed in August, 2016. The next phase is data analysis, which is expected to be finished before December 2016, and thereafter writing publications based on the findings. The study started in January 2016 and will end in December 2018. DISCUSSION: This study covers the entire elderly population of Denmark, and thereby will avoid selection bias due to nonparticipation and loss to follow-up. Furthermore, this ensures that the study results are reliable and generalizable. However, underreporting of traffic-related accidents may occur, which will limit estimation of absolute risks.

Feasible model for prevention of functional decline in older people: municipality-randomized, controlled trial.

OBJECTIVES: To investigate the effect of an educational program for preventive healthcare professionals in routine primary care on functional ability, nursing home admissions, and mortality in older adults. DESIGN: A prospective, controlled 3-year follow-up study (1999-2001) in primary care with randomization and intervention at the municipality level and outcomes measured at the individual level in two age cohorts. SETTING: Primary care. PARTICIPANTS: Of 81 eligible municipalities in four counties, 34 agreed to participate. A total study population of 5,788 home-dwelling subjects aged 75 and 80 were asked to participate. Written consent was obtained from 4,060 persons (70.1%), of whom 2,104 were living in 17 intervention municipalities and 1,956 were living in 17 matched control municipalities. INTERVENTION: Intervention municipality visitors received ongoing education, and local general practitioners were introduced to a short geriatric assessment program early in the study period. Control municipalities visitors and general practitioners received no education. MEASUREMENTS: At the 3-year follow-up, the outcome measures of mortality and nursing home admissions were obtained from all, and the outcome measure of functional ability was obtained from 3,383 (95.6%) of 3,540 surviving participants. RESULTS: Education improved functional ability (odds ratio=1.20, 95% confidence interval (CI)=1.01-1.42, P=.04) in intervention municipality participants, notably in the 80-year-olds. There were no differences in mortality (relative risk (RR)=1.06, 95% CI=0.87-1.28, P=.59) or rates of nursing home admissions after 3 years (RR=0.74, 95% CI=0.50-1.09, P=.13). Subjects aged 80 benefited from accepting and receiving in-home assessment with regular follow-ups. CONCLUSION: A brief, feasible educational program for primary care professionals helps preserve older people's functional ability.

[Uncertain efficiency of follow-up home visits among older patients after hospital discharge]. / Usikker effekt af opfølgende hjemmebesøg til ældre medicinske patienter efter hospitalsindlæggelse.

Improving the vulnerable hospital discharge process among older people has been in focus for decades. The economic impact and ease of measurement of all-cause hospital readmission rates have questioned whether they are reducible. This review aimed to identify the efficiency of follow-up home visits after hospital discharge by district nurses in coordination with general practice. Six settings in Denmark have been evaluated in different controlled designs. Results are inconsistent and inconclusive due to selection bias and methods chosen. Targeting and management organisation need further research.

Mobility decline in old age: the combined effect of mobility-related fatigue and socioeconomic position.

BACKGROUND: Mobility-related fatigue and low socioeconomic position predicts mobility limitations and disability in old age, but the interplay between these two factors is unknown. To evaluate whether mobility-related fatigue is a stronger risk factor for mobility limitations in certain socioeconomic groups, the aim of this study was to examine the combined effect of mobility-related fatigue and socioeconomic position on mobility limitations in a prospective study among older Danish men and women. METHODS: Multivariate linear regression models with combined exposure variables using generalised estimating equations were performed using four waves of data on 2874 individuals without mobility limitations at baseline from The Danish Intervention Study on Preventive Home Visits. RESULTS: Low socioeconomic position and mobility-related fatigue are risk factors for mobility limitations in old age. The combined exposure to both factors additionally increased the risk, but there was no synergy effect between the two. Notably, fatigue predicted mobility decline at 3-year follow-up among those aged 80 years at baseline with a mean difference in number of mobility limitations from the joint reference category (high socioeconomic position and no fatigue) of -0.52, p<0.0001 among those in high socioeconomic position and -0.96, p<0.0001 among those in low socioeconomic position. CONCLUSIONS: Mobility-related fatigue is not a significantly stronger risk factor for subsequent mobility limitations among those with concomitant exposure to low socioeconomic position, compared with those with high socioeconomic position. Preventive strategies must focus on vulnerable groups of older people with low socioeconomic position as well as on individuals with fatigue.

Childhood socioeconomic position, young adult intelligence and fillings of prescribed medicine for prevention of cardiovascular disease in middle-aged men.

OBJECTIVES: To explore the relationship between childhood socioeconomic position (SEP) and filling of medicine prescriptions for prevention of cardiovascular diseases (CVDs), with young adult intelligence (IQ) as a potential mediator. DESIGN: Birth cohort study with logistic and Cox-proportional hazard regression analyses of associations between childhood SEP, retrieved from birth certificates, and prevalence, initiation of and refill persistency for CVD preventive medicine. SETTING: Denmark. PARTICIPANTS: 8736 Danish men born in 1953, who had no CVD at the start of follow-up in 1995, were followed in the Danish National Prescription Register for initiation of and refill persistency for antihypertensives and statins, until the end of 2007 (age 54 years). RESULTS: Low childhood SEP at age 18 was not associated with prescription fillings of antihypertensives, but was weakly associated with initiation of statins (HR = 1.19 (95% CI 1.00 to1.42)). This estimate was attenuated when IQ was entered into the model (HR=1.10 (95% CI 0.91 to 1.23)). Low childhood SEP was also associated with decreased refill persistency for statins (HR=2.23 (95% CI 1.13 to 4.40)). Thus, the HR for SEP only changed slightly (HR=2.24 (95% CI 1.11 to 4.52)) when IQ was entered into the model, but entering other covariates (education and body mass index in young adulthood and income in midlife) into the model attenuated the HR to 2.04 (95% CI 1.00 to 4.16). CONCLUSIONS: Low childhood SEP was related to more frequent initiation of and poorer refill persistency for statins. IQ in young adulthood explained most of the association between childhood SEP and initiation of statins, but had no impact on refill persistency.

Statin utilization according to indication and age: a Danish cohort study on changing prescribing and purchasing behaviour.

OBJECTIVE: Introduced to reduce mortality after myocardial infarction (MI), statins are now recommended for a range of other conditions, including asymptomatic individuals without cardiovascular disease or diabetes. The aim was to describe trends in Danish statin utilization according to indication and age during 1996-2009, and to analyse changing prescribing and purchasing behaviour during time intervals (driver periods) a priori defined by potential influential factors. METHODS: A nationwide cohort (N=4,998,580) was followed in Danish individual-level registries. Based on a hierarchy of register markers of indications for statin prescribing, we analysed incidence and prevalence of use by age and indication (age ≥ 40). Applying Poisson regression, we calculated Incidence Rate Ratios (IRR) of statin treatment for the last year of each driver period, applying the first year as reference. RESULTS: Treatment prevalence increased from 7/1000 to 187/1000, representing a shift towards lower-level indications and increased relatively more in individuals aged 75+. While treatment prevalence in MI-patients reached 780/1000, asymptomatic individuals represented 50% of incident statin-users in 2009. A marked increase in incidence of statin use occurred during 1999-2003 (IRR=3.05) across all indications, followed by a more moderate rise during 2003-2006 (IRR=1.29) and 2006-2008 (IRR=1.15) - most marked increases in asymptomatic individuals. A sudden decrease was observed in 2009 (IRR=0.82) for all indications and ages. CONCLUSION: While patent expiry and lower prices most likely boosted the general increase in statin utilization, the gradually altered indication and age pattern seems to be driven by guidelines, influencing both reimbursement rules and general healthcare policies. A media debate on statin side effects may have modified the general attitudes.

Low confidence among general practitioners in end-of-life care and subcutaneous administration of medicine.

INTRODUCTION: Most terminally ill patients prefer to die at home, and the general practitioner (GP) is central in making this possible. However, knowledge is needed about the GP's level of confidence in assuming this task and with subcutaneous (SC) administration of medicine in end-of-life care. The aim of this study was to determine if GPs used SC needle and medication in end-of-life care, if they felt confident about being principally responsible for palliative trajectories and whether such confidence was associated with GP characteristics. MATERIAL AND METHODS: This was a cross-sectional questionnaire survey of all 332 GPs practising in Copenhagen, Denmark. Questions covered the GPs' use of SC medication/needle and their confidence in being principally responsible for palliative trajectories. RESULTS: The survey response rate was 61%. 43% of the respondents had been principally responsible for a minimum of one palliative trajectory, and only 11% of these GPs had used a SC needle during this process. 57% felt very or somewhat confident being principally responsible and 27% felt very or somewhat confident administrating SC medicine. Confidence as principally responsible was positively associated with the number of palliative trajectories for which the GP had been responsible, but no significant associations with the GPs' age, gender or practice organisation were found. CONCLUSION: We found that few GPs in Copenhagen feel very confident about being responsible for terminal care and that very few used SC needles. Hence, more education and training in this field is warranted. Further research is needed into how GPs may best become involved and supported in end-of-life care. FUNDING: Danish General Practitioners' Educational and Development Fund. TRIAL REGISTRATION: not relevant.

Formal home help services and institutionalization.

The effect of home help services has been inconsistent. Raising the hypothesis that receiving small amounts of home help may postpone or prevent institutionalization, the aim of the present study is to analyze how light and heavy use of home help services was related to the risk for institutionalization. The study was a secondary analysis of a Danish intervention study on preventive home visits in 34 municipalities from 1999 to 2003, including 2642 home-dwelling older people who were nondisabled and did not receive public home help services at baseline in 1999 and who lived at home 18 months after baseline. Cox regression analysis showed that those who received home help services during the first 18 months after baseline were at higher risk of being institutionalized during the subsequent three years than those who did not receive such services. However, receiving home help for less than 1h per week during the first 18 months after baseline was not associated with an increased risk of institutionalization during the study period among those with physical or mental decline. Receiving public home help services was a strong indicator for institutionalization in Denmark. Receiving small amounts of home help and experiencing physical or mental decline was not associated with higher hazard for institutionalization compared with those who received no help.

Impact of social capital on 8-year mortality among older people in 34 Danish municipalities.

OBJECTIVE: To analyze the impact of social capital measures (bonding, bridging, and linking) on all-cause mortality at 8-year follow-up among older people aged 75 and 80 at baseline. METHOD: Prospective cohort study on preventive home visits including 2,863 seventy-five-year-olds and 1,171 eighty-year-olds in 34 Danish municipalities. The associations of the three aspects of social capital measures with mortality were tested in Cox regression models on time to death. RESULTS: In the 80-year-old cohort significant associations were seen between mortality and both bridging (hazards ratio (HR)=1.24, 95% CI [1.07, 1.45]) and linking (HR=1.21, 95% CI [1.03, 1.43]), but the associations attenuated when controlling for relevant confounders. None of the social capital measures were associated with mortality among the 75-year-olds. CONCLUSION: The measures of social capital used in the present study include key aspects of social capital that are associated to mortality in older populations via physical activity and mobility disability.

Collaborative relationship in preventive home visits to older people.

AIM: To describe what characterizes preventive home visits with collaborative relationships among non-disabled home-dwelling older people in Japan. BACKGROUND: Preventive home visits have the potential to result in improved health outcomes among older people. Collaboration, mutual understanding and trust between visitor and the visited person seem to work as a vehicle, but little is known about which part of the encounters contributes to a collaborative relationship. METHODS: We performed a retrospective qualitative analysis of visiting records written by preventive home visitors immediately after the visits were made. A collaborative relationship was predefined as a favourable change in behaviour seen in the visited person during the study period. Visitor characteristics were analysed from 248 records where 37 cases of collaborative relationships were documented. RESULTS: The three most important elements associated with a collaborative relationship were (i) visitor communication skills i.e. mastering 'enhancing motivation' and 'having patience and coping with frustrations' in difficult and problematic situations, (ii) professionalism, which includes 'professional instruction and guidance' based on documented knowledge in health and social domains combined with an overall 'caring approach' and (iii) practical actions which imply an 'immediate concrete response to identified needs or problems' and 'individually tailored advice' to suit the older person's daily life. CONCLUSIONS: Preventive home visitor communication skills and professionalism, and practical actions after the visits characterized cases, where favourable changes in behaviour were obtained in non-disabled home-dwelling older people in Japan. RELEVANCE TO CLINICAL PRACTICE: Education should be emphasized, because preventive home visitor competence may be the most important element of proactive assessment schemes to obtain beneficial outcomes.