Symptomatic diagnoses in primary care: an observational cohort study.

BACKGROUND: Among primary health care patients, it is sometimes impossible to assign a definitive diagnosis for the patient's reported or observed symptoms. Therefore, symptomatic diagnoses are often used. AIM: The aim of the present study was to examine the proportion of symptomatic diagnoses among primary health care patients. We also explored which symptomatic diagnoses were most frequently recorded as well as their age and gender distribution. DESIGN & SETTING: This is a register-based study in the public primary health care of the city of Vantaa, Finland. METHOD: Diagnoses were entered according to the 10th revision of the International Classification of Diseases (ICD-10). The data consisted of every diagnosis entered into the electronic health record between January first 2016 and December 31st 2018. Both absolute numbers and relative proportions of various symptomatic diagnosis recordings (chapter 'R') were reported. RESULTS: Of all the recorded diagnoses (N=503,001), the proportion of R-diagnoses was 13.5% (N=67,905). Diagnoses of symptoms and signs involving the digestive system and abdomen (R10-19) (4.1% of all; n=18,550), the circulatory and respiratory systems (R00-09) (3.9%; n=17,426), general symptoms and signs (R50-69) (3.4%; n=15,165), and the skin and subcutaneous tissue (R20-23) (2.2%; n=9,812) were the most prevalent. Age was also a major factor determining how the symptomatic diagnoses were distributed between women and men. Overall, the symptomatic diagnoses were more common among women than men (14.1% and 12.4%, respectively). The major symptomatic diagnosis categories, including symptoms and signs involving the digestive system and abdomen, the skin and the subcutaneous tissue, and general symptoms and signs, were more predominant among women, while symptoms and signs involving the circulatory and respiratory systems were more common among men. CONCLUSION: A symptomatic diagnosis code was recorded in about one eighth of the GP appointments, although there were significant sex differences in the prevalence within and between diagnosis groups.

Sleep duration in midlife and old age and risk of mortality over a 48-year follow-up: The Helsinki businessmen study (HBS) cohort.

OBJECTIVES: Both short and long sleep duration have been associated with increased mortality, but there are few truly long-term studies. STUDY DESIGN: This is a cohort study of 2504 men born between 1919 and 1934. In 1974-1975 (mean age 48), participants underwent baseline clinical examinations and sleep duration assessments. A follow-up examination took place 35 years later, in 2010 (mean age 82). MAIN OUTCOME MEASURE: All-cause mortality data from baseline and from old age were collected through to December 31, 2022. RESULTS: At baseline, short sleep duration (≤6 h per night), normal sleep duration (>6 and ≤ 8 h), and long sleep duration (>8 h) was reported by 266, 2019 and 219 men, respectively. Men with short sleep duration had higher levels of smoking, alcohol consumption, body mass index, and poorer self-rated health than those with normal sleep duration. During the 48-year follow-up, 2287 men died. The unadjusted hazard ratio for mortality was 1.20 (95 % confidence interval [CI] 1.05-1.37) for short compared with normal sleep duration, but this association vanished after adjustments (1.01, 95 % CI 0.87-1.17). In old age, the corresponding hazard ratios were 1.41 (1.16-1.72) and 1.19 (0.94-1.51) for short sleep duration and 1.33 (1.09-1.63) and 1.31 (1.02-1.67) for long sleep duration. CONCLUSIONS: In a comprehensive lifespan follow-up, the modestly increased mortality among men with short sleep duration in midlife was attributed to unhealthy lifestyle factors. In old age both long and short sleep duration seemed to be associated with modestly increased mortality. CLINICALTRIALS: gov identifier for the HBS: NCT02526082.

Nature-based social interventions to address loneliness among vulnerable populations: a common study protocol for three related randomized controlled trials in Barcelona, Helsinki, and Prague within the RECETAS European project.

BACKGROUND: The negative effects of loneliness on population health and wellbeing requires interventions that transcend the medical system and leverage social, cultural, and public health system resources. Group-based social interventions are a potential method to alleviate loneliness. Moreover, nature, as part of our social and health infrastructure, may be an important part of the solutions that are needed to address loneliness. The RECETAS European project H2020 (Re-imagining Environments for Connection and Engagement: Testing Actions for Social Prescribing in Natural Spaces) is an international research project aiming to develop and test the effectiveness of nature-based social interventions to reduce loneliness and increase health-related quality of life. METHODS: This article describes the three related randomized controlled trials (RCTs) that will be implemented: the RECETAS-BCN Trial in Barcelona (Spain) is targeting people 18+ from low socio-economic urban areas; the RECETAS-PRG Trial in Prague (Czech Republic) is addressing community-dwelling older adults over 60 years of age, and the RECETAS-HLSNK trial is reaching older people in assisted living facilities. Each trial will recruit 316 adults suffering from loneliness at least sometimes and randomize them to nature-based social interventions called "Friends in Nature" or to the control group. "Friends in Nature" uses modifications of the "Circle of Friends" methodology based on group processes of peer support and empowerment but including activities in nature. Participants will be assessed at baseline, at post-intervention (3 months), and at 6- and 12-month follow-up after baseline. Primary outcomes are the health-related quality-of-life according to 15D measure and The De Jong Gierveld 11-item loneliness scale. Secondary outcomes are health and psychosocial variables tailored to the specific target population. Nature exposure will be collected throughout the intervention period. Process evaluation will explore context, implementation, and mechanism of impact. Additionally, health economic evaluations will be performed. DISCUSSION: The three RECETAS trials will explore the effectiveness of nature-based social interventions among lonely people from various ages, social, economic, and cultural backgrounds. RECETAS meets the growing need of solid evidence for programs addressing loneliness by harnessing the beneficial impact of nature on enhancing wellbeing and social connections. TRIAL REGISTRATION: Barcelona (Spain) trial: ClinicalTrials.gov, ID: NCT05488496. Registered 29 July 2022. Prague (Czech Republic) trial: ClinicalTrials.gov, ID: NCT05522140. Registered August 25, 2022. Helsinki (Finland) trial: ClinicalTrials.gov, ID: NCT05507684. Registered August 12, 2022.

Health-related quality of life after hip fracture: effects of a 12-month home-based exercise intervention-secondary analyses of an RCT.

PURPOSE: In this randomized controlled trial, we analyzed the effects of a 12-month home-based exercise intervention on the health-related quality of life (HRQoL) of patients with a hip fracture. METHODS: Participants (n = 121) aged ≥ 60 years, with a Mini-Mental State Examination (MMSE) score of ≥ 12 and an operated hip fracture, were placed into Exercise (n = 61) or Usual care (n = 60) groups. Physiotherapist-supervised, home-based training was given twice a week over 12 months. HRQoL was assessed using the 15D instrument at baseline and at 3, 6, and 12 months. The total 15D scores and dimension scores were analyzed and compared to national age- and sex-matched reference data. RESULTS: The participants' mean age was 81 years (SD 7), 75% were women, and 61% had a femoral neck fracture. The mean within-group change in total 15D score over 12 months was 0.023 (95% CI: -0.003 to 0.048) in the Usual care group, and 0.028 (CI: 0.003 to 0.054) in the Exercise group (between-group p = 0.76). We found a statistically significant change in total 15D score in the Exercise group, as well as in the dimension scores of mobility and usual activities in both groups. All 15D scores remained below the general population reference level. CONCLUSION: Exercise training for 12 months did not enhance the HRQoL of home-dwelling patients with hip fractures any more than usual care. In addition, HRQoL remained below the population level in both groups.

Relationship between oral frailty, health-related quality of life, and survival among long-term care residents.

PURPOSE: We evaluated oral frailty (OFr) and its association with health-related quality of life (HRQoL), energy and protein intake, and survival among older long-term care residents. METHODS: This cross-sectional study with a 3-year follow-up for survival assessed 349 residents in long-term care facilities (73% female, mean age 82 years). We defined OFr with six signs (dry mouth, food residue on oral surfaces, unclear speech, inability to keep mouth open or pain expression during the clinical oral examination, diet pureed/soft) and OFr severity was categorized as Group 1, (mild) = 0-1 signs, Group 2 (moderate) = 2-4 signs, and Group 3 (severe) = 5-6 signs. We measured HRQoL with 15D instrument, and energy and protein intake by a 1- to 2-day food record. Mortality was retrieved from central registers on March 2021. RESULTS: Of the residents, 15% had 0-1, 67% 2-4 and 18% 5-6 OFr signs. HRQoL decreased linearly from Group 1 to Group 3. OFr correlated with such dimensions of HRQoL as mobility, eating, speech, excretion, usual activities, mental function, and vitality. We found no association between OFr categories and energy and protein intake. Survival decreased linearly from Group 1 to Group 3. CONCLUSIONS: OFr was common among older long-term care residents and OFr severity predicts poorer outcomes. The six oral signs denoting OFr may be used at the bedside to screen residents at risk for OFr.

Effect of Milk Fat Globule Membrane- and Protein-Containing Snack Product on Physical Performance of Older Women-A Randomized Controlled Trial.

INTRODUCTION: Sarcopenia is common in people 70+ years of age, and its prevalence increases with further aging. Insufficient energy and protein intake accelerates muscle loss, whereas sufficient protein intake and milk fat globule membrane (MFGM) may suppress age-associated deterioration of muscle mass and strength. Our objective was to test whether a snack product high in MFGM and protein would improve physical performance in older women. METHODS: In this 12-week randomized controlled trial, women ≥ 70 years, with protein intake < 1.2 g/body weight (BW) kg/day (d), were randomized into intervention (n = 51) and control (n = 50) groups. The intervention group received a daily snack product containing ≥ 23 g of milk protein and 3.6-3.9 g of MFGM. Both groups were advised to perform a five-movement exercise routine. The primary outcome was the change in the five-time-sit-to-stand test between the groups. Secondary outcomes included changes in physical performance, cognition, hand grip strength, and health-related quality of life. RESULTS: The change in the five-time-sit-to-stand test did not differ between the intervention and the control groups. The change in the total Short Physical Performance Battery score differed significantly, favoring the intervention group (p = 0.020), and the balance test showed the largest difference. Protein intake increased significantly in the intervention group (+14 g) compared to the control group (+2 g). No other significant changes were observed. CONCLUSIONS: Our results indicate that the combination of MFGM and protein may improve the physical performance-related balance of older women.

Association of medication use with falls and mortality among long-term care residents: a longitudinal cohort study.

BACKGROUND: Falls in long-term care are common. The aim of our study was to explore how medication use is associated with incidence of falls, related consequences, and all-cause mortality among long-term care residents. METHODS: Five hundred thirty two long-term care residents aged 65 years or older participated in this longitudinal cohort study in 2018-2021. Data on medication use were retrieved from medical records. Polypharmacy was defined as use of 5-10 medications and excessive polypharmacy as use of > 10 medications. The numbers of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment. Participants were followed for three years for mortality. All analysis were adjusted for age, sex, Charlson Comorbidity Index, Clinical dementia rating, and mobility. RESULTS: A total of 606 falls occurred during the follow-up. Falls increased significantly with the number of medications used. Fall rate was 0.84/person-years (pyrs) (95% CI 0.56 to 1.13) for the non-polypharmacy group, 1.13/pyrs (95% CI 1.01 to 1.26) for the polypharmacy group, and 1.84/pyrs (95% CI 1.60 to 2.09) for the excessive polypharmacy group. Incidence rate ratio for falls was 1.73 (95% CI 1.44 to 2.10) for opioids, 1.48 (95% CI 1.23 to 1.78) for anticholinergic medication, 0.93 (95% CI 0.70 to 1.25) for psychotropics, and 0.91 (95% CI 0.77 to 1.08) for Alzheimer medication. The three-year follow-up showed significant differences in mortality between the groups, the lowest survival rate (25%) being in the excessive polypharmacy group. CONCLUSION: Polypharmacy, opioid and anticholinergic medication use predicted incidence of falls in long-term care. The use of more than 10 medications predicted all-cause mortality. Special attention should be paid to both number and type of medications when prescribing in long-term care.

The feasibility of a 6-month dietary intervention aiming to increase protein intake among community-dwelling older adults with low habitual protein intake: A secondary analysis of the PROMISS randomised controlled trial.

BACKGROUND: The PROMISS randomised controlled trial showed that personalised dietary advice increased protein intake and improved 400-m walk time and leg strength among community-dwelling older adults with a low habitual protein intake. This secondary analysis describes and further evaluates the methods and feasibility of the model used to carry out dietary intervention in the PROMISS randomised controlled trial. METHODS: In total, 185 participants (≥65 years, 54% women) with a habitual low protein intake (<1.0 g/kg adjusted body weight/day) in Finland and the Netherlands received personalised dietary advice and complimentary protein-enriched food products for 6 months with two main objectives: (1) to increase protein intake to ≥1.2 g/kg adjusted body weight/day (energy-neutral) and (2) to include each day a 'high-protein meal' containing ≥ 30-35 g of protein. The feasibility of the model was evaluated by the adoption of the advice, feedback from the participants, and practical experiences by the nutritionists. RESULTS: In all, 174 participants (93.5%) completed the intervention. At the 6-month follow-up, 41.8% reached both main objectives of the advice. The participants' general rating for the dietary advice was 8.6 (SD 1.0) (on a scale of 1-10; 10 indicating very good). Sticking to the advice was (very) easy for 79.2% of the participants. The nutritionists perceived the model feasible for the participants except for those with low food intake. CONCLUSIONS: The methods used in this model are mainly feasible, well-received and effective in increasing protein intake among community-dwelling older adults with low habitual protein intake.

Being actively engaged in life in old age: determinants, temporal trends, and prognostic value.

PURPOSE: Recently, the concept of successful ageing has shifted from healthy ageing to active ageing, the latter emphasising even more the subjective perspective. Active agency is a marker for better functioning. However, the concept of active ageing lacks a clear definition so far. The specific aims of the study were to identify the determinants of being actively engaged in life (BAEL), to explore the changes in BAEL over 3 decades, and to explore the prognostic value of BAEL. METHODS: This is a repeated cross-sectional cohort study of older (≥ 75 years) community-dwelling people in Helsinki in 1989 (N = 552), 1999 (N = 2396), 2009 (N = 1492), and 2019 (N = 1614). The data were gathered by a postal questionnaire at each time point. Being actively engaged in life was defined by two questions "Do you feel needed?" and "Do you have plans for the future?", which was further converted into BAEL score. RESULTS: An increasing temporal trend in BAEL score was observed through the study years. Male sex, good physical functioning and subjective health, and meaningful social contacts were determinants for higher BAEL score. Active agency measured by BAEL score predicted lower 15-year mortality. CONCLUSIONS: Older home-dwelling, urban Finnish people have become more actively engaged in recent years. The underlying causes are diverse but improved socioeconomic status observed over the study years was one of them. Social contacts and not feeling lonely were found to be determinants for being actively engaged. Two simple questions describing active engagement in life may help to predict mortality among older people.

Comparison of two GP service provider models in older adults: a register-based follow-up study.

BACKGROUND: In Finland, there have been various strategies attempting to provide access to GPs. The 'restricted-List General Practitioner model' (rLGP) was launched in primary health care (PHC) in the city of Vantaa after the 'named General Practitioner model' (nGP) failed to provide sufficient access to GPs. This was done to improve access to GP appointments for those most needing care. AIM: To evaluate the impact of the transition from nGP to rLGP on access to non-urgent scheduled appointments among patients aged ≥75 years. DESIGN & SETTING: A register-based follow-up study in public PHC in Vantaa, Finland. METHOD: The study focused on patients aged ≥75 years who used PHC from 2004-2008. It looked at the number of non-urgent and urgent scheduled appointments, patient contacts, home visits, PHC emergency department appointments, and cancelled appointments, which were recorded 7 years before and after the transition from nGP to rLGP in 2011 and adjusted to patient-years. Non-urgent appointments were booked to the patient's own nGP or rLGP in public PHC, whereas urgent appointments could be to any GP. RESULTS: The number of non-urgent scheduled appointments to GPs was halved during the time of nGP, before launching the rLGP. Simultaneously, the number of urgent scheduled appointments more than tripled. The number of both started to plateau a year before the rLGP was launched. The number of both non-urgent and urgent scheduled appointments remained mainly at that level after rLGP was implemented. CONCLUSION: The rLGP model was unsuccessful in improving access to non-urgent scheduled appointments to GPs.

Changes in symptom burden from 2019 to 2021 amongst community-dwelling older adults in Finland.

BACKGROUND: Symptom burden causes suffering amongst older adults and is associated with healthcare visits and prognosis. AIMS: We evaluated the prevalence of 10 symptoms and changes in symptom burden amongst home-dwelling older adults in 2019 and 2021 using Finnish cohort data. We analysed factors associated with symptom burden increase during follow-up. METHODS: Altogether 1,637 people aged 75+ participated in the Helsinki Ageing Study postal survey in 2019, where they reported the presence of 10 common symptoms over the past 2 weeks. Of them, 785 participated in a follow-up in 2021, where the same symptoms were queried. We compared the prevalence of various symptoms and symptom burden scores in the 2-year interval and evaluated factors associated with increased symptom burden during this time. RESULTS: Of participants, 33% reported at least one daily symptom in 2019 versus 44% in 2021. Symptom burden increased by a mean ratio of 1.29 between 2019 and 2021. The most common symptoms were joint pain, back pain, urinary incontinence and fatigue. The prevalence of four symptoms increased between 2019 and 2021: joint pain, urinary incontinence, dizziness and shortness of breath. Higher age, reduced functional capacity and comorbidities were associated with higher odds of symptom burden increase during follow-up. Psychological well-being (PWB) was strongly associated with lower odds of symptom burden increase in the logistic regression model. CONCLUSIONS: Symptom burden increased in our cohort aged 75+ between 2019 and 2021 before and during the COVID-19 pandemic. PWB was associated with lower odds of acquiring additional symptoms over time.

Determinants of a sense of insecurity among home-dwelling older people.

Aims: A sense of insecurity may have an impact on older people's well-being and their courage to engage actively in meaningful activities. Studies on a sense of insecurity among older people are scarce. The aim of this study was to determine the extent to which home-dwelling older adults perceive their life as being insecure and how a sense of insecurity is associated with their health, functional status, active social engagement, well-being and perceptions of the societal treatment of older people. Methods: This study is part of the Helsinki Aging Study, a cohort study ongoing since 1989. Data were collected using a postal questionnaire that was mailed in 2019 to a random sample of home-dwelling older people ⩾75 years of age living in Helsinki (N=2917; response rate 74%). The questionnaire inquired about the respondents' sense of security/insecurity, and they were subcategorised into those feeling secure and those feeling insecure based on their answers. Results: Seven per cent of respondents felt insecure in their lives. In a stepwise logistic regression analysis, loneliness, living alone and perceived poor societal treatment of older people were associated with a sense of insecurity, while having good self-rated health, having children and meeting friends at least weekly were associated with lower odds of insecurity. Conclusions: Our findings highlight the importance of recognising and combating loneliness, social isolation and societal ageism in order to reduce insecurity among older people and to support their active engagement in life.

Temporal Trends Over Two Decades in the Use of Anticholinergic Drugs Among Older Community-Dwelling People in Helsinki, Finland.

BACKGROUND: Knowledge of the adverse effects of drugs with anticholinergic properties (DAPs) has increased in recent decades. However, research on the temporal trends of the clinical use of DAPs is still sparse. OBJECTIVES: The aim of this study was to investigate the temporal trends of DAP use over two decades in the older community-dwelling population and to explore the medication classes contributing to the use of DAPs. METHODS: The study involved random samples of ≥ 75-year-old community-dwelling Helsinki citizens in 1999, 2009, and 2019 from the Helsinki Ageing Study. A postal questionnaire inquired about their health, functioning, and medications. The medications were categorized as DAPs according to Duran's list. In addition, we grouped DAPs into various medication groups. RESULTS: The prevalence and burden of DAPs on Duran's list showed a decreasing trend over the years. In 1999 the prevalence was 20% and the burden 0.35, in 2009 they were 22% and 0.35, respectively, and in 2019 they were 16% and 0.23, respectively. There were no differences in how the 75- and 80-year-olds used DAPs compared with those aged 85 years and older. The proportion of typical antipsychotics, benzodiazepines, hypnotics, urinary antispasmodics, and asthma/chronic obstructive pulmonary disease medications decreased, whereas the proportion of atypical antipsychotics, antidepressants, strong opioids, and antihistamines increased. In particular the use of mirtazapine increased-to 3.9% in 2019. In 2019 the three most prevalent groups of DAPs were antidepressants (7.4%), opioids (2.7%), and antihistamines (2.4%). CONCLUSIONS: The decrease in the use of DAPs on Duran's list is a welcome change. Although the use of old, strong DAPs has decreased, new DAPs have simultaneously emerged. Physicians need continuous education in prescribing DAPs and more recent information on the use and effects of DAPs is needed in order to decrease their exposure among the rapidly growing older population.

Effects of a 12-month home-based exercise program on functioning after hip fracture - Secondary analyses of an RCT.

BACKGROUND: Long-term functional limitations are common after hip fractures. Exercise may alleviate these negative consequences but there is no consensus on an optimal training program. The objective was to study the effects of a 12-month home-based supervised, progressive exercise program on functioning, physical performance, and physical activity. METHODS: Secondary analysis of a randomized controlled trial targeting patients with surgical repair of a hip fracture, aged ≥60 years, Mini-Mental State Examination (MMSE) score of ≥12. The participants were randomized into Exercise (n = 61) or Usual care (n = 60). Assessments at baseline, 3, 6, and 12 months included Lawton's Instrumental Activities of Daily Living (IADL), Short Physical Performance Battery (SPPB), handgrip strength, and self-reported frequency of sessions of leisure-time physical activity. Analyzed using mixed-effects models. RESULTS: Participants' (n = 121) mean age was 81 years (SD 7), and 75% were women. The mean IADL score at baseline was 17.1 (SD 4.5) in the exercise group, and 17.4 (5.1) in the usual care group. The mean SPPB scores were 3.9 (1.6) and 4.2 (1.8), and handgrip strength was 17.7 (8.9) kg and 20.8 (8.0) kg, respectively. The age- and sex-adjusted mean changes in IADL over 12 months were 3.7 (95% CI 2.8-4.7) in the exercise and 2.0 (1.0-3.0) in the usual care group (between-group difference, p = 0.016); changes in SPPB 4.3 (3.6-4.9) and 2.1 (1.5-2.7) (p < 0.001); and changes in handgrip strength 1.2 kg (0.3-2.0) and 1.0 kg (-1.9 to -0.2) (p < 0.001), respectively. We found no between-group differences in changes in the frequency of leisure-time activity sessions. CONCLUSION: A 12-month home-based supervised, progressive exercise program improved functioning and physical performance more than usual care among patients with hip fractures. However, the training did not increase leisure-time physical activity.

Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication.

BACKGROUND: Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs). METHODS: The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants' healthcare service use costs and costs for the intervention were estimated for a 12 month period.Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates. RESULTS: The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs -€1,629, confidence interval (CI) -€5,489 to €2,240; incremental effect -0.02, CI -0.06 to 0.02]. The base case ICER was >€80,000/QALY. CONCLUSION: The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.

Clinical trials in older people.

Randomised controlled trials (RCTs) usually provide the best evidence for treatments and management. Historically, older people have often been excluded from clinical medication trials due to age, multimorbidity and disabilities. The situation is improving, but still the external validity of many trials may be questioned. Individuals participating in trials are generally less complex than many patients seen in geriatric clinics. Recruitment and retention of older participants are particular challenges in clinical trials. Multiple channels are needed for successful recruitment, and especially individuals experiencing frailty, multimorbidity and disabilities require support to participate. Cognitive decline is common, and often proxies are needed to sign informed consent forms. Older people may fall ill or become tired during the trial, and therefore, special support and empathic study personnel are necessary for the successful retention of participants. Besides the risk of participants dropping out, several other pitfalls may result in underestimating or overestimating the intervention effects. In nonpharmacological trials, imperfect blinding is often unavoidable. Interventions must be designed intensively and be long enough to reveal differences between the intervention and control groups, as control participants must still receive the best normal care available. Outcome measures should be relevant to older people, sensitive to change and targeted to the specific population in the trial. Missing values in measurements are common and should be accounted for when designing the trial. Despite the obstacles, RCTs in geriatrics must be promoted. Reliable evidence is needed for the successful treatment, management and care of older people.

Dietary fat intake and quality in long-term care residents in two cohorts assessed 10 years apart.

PURPOSE: To describe and compare detailed dietary fat intake, fat quality and associative factors between two measuring points 10 years apart of residents living in long-term care facilities, and to reflect how fat composition and fat quality corresponds to current nutrition recommendations. METHODS: In 2007 long-term care residents (n = 374) of 25 assisted-living facilities and nursing homes and in 2017-18 long-term care residents (n = 486) of 17 respective facilities in Helsinki metropolitan area were recruited for this study. Information on the residents' heights, demographic information and use of calcium and vitamin D supplementation were retrieved from medical records. Residents' clinical assessment included Clinical Dementia Rating (CDR), the Mini Nutritional Assessment (MNA) and questionnaire related to nutrition care. Participants' energy and fat intake were determined from 1--2-day food diaries kept by the ward nurses, and fat quality indicators calculated. RESULTS: Age, gender distribution, MNA score or body mass index did not differ between the two cohorts. Residents' cognitive status, subjective health and mobility were poorer in 2017 compared to 2007. Total fat and saturated fatty acid (SFA) intakes were higher and fat quality indicators lower in the 2017 cohort residents than in the 2007 cohort residents. Sugar intake, male gender, eating independently, eating larger amounts and not having dry mouth predicted higher SFA intake in the 2017 cohort. CONCLUSIONS: The fat quality in long-term care residents in our study worsened in spite of official recommendations between the two measurement points.