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

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

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

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

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

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

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

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

Home care needs of extremely obese elderly European women.

OBJECTIVE: To examine the health and needs of extremely obese women aged over 65 years receiving home care in Europe. STUDY DESIGN: A cross-sectional assessment study based on the Aged in Home Care (AdHOC) project recruited 2974 women aged 65 or over who were receiving home care at 11 sites in European countries. Extreme obesity was defined as 'Obesity of such a degree as to interfere with normal activities, including respiration'. MAIN OUTCOME MEASURES: Resident Assessment Instrument for Home Care (RAI-HC version 2.0); Activity of Daily Living Scale; Instrumental Activity of Daily Living Scale; the Minimum Data Set Cognitive Performance Scale; and a health profile. RESULTS: One hundred and twenty women (4.0%) were extremely obese. They were younger than their thinner counterparts, with a median age of 78.3 versus 83.3 years, and they more often had multiple health complaints and needed more help with mobility outside the home. The extremely obese had received home care longer than the non-extremely obese (median 28.7 versus 36.6 months). Extremely obese women also needed more help with personal care than the other group and, due to lower age, they were less cognitively impaired. CONCLUSIONS: Extreme obesity is a problem that increasingly affects home care of elderly women.

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

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

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

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

Oral status, cognitive and functional capacity versus oral treatment need in nursing home residents: a comparison between assessments by dental and ward staff.

OBJECTIVES: The aim of this study was to study the relationships between cognitive and functional capacity versus oral health and treatment need and to compare oral status assessments and oral treatment need, assessed by nurses and dental professionals, respectively. DESIGN: Cross-sectional survey. SETTING: Nursing home. SUBJECTS: One hundred and ninety-two nursing home residents were examined in 1997. MAIN OUTCOME MEASURES: Cognitive and functional capacity in different groups of residents regarding oral health and treatment need, measured by a comprehensive assessment with the Resident Assessment Instrument (RAI) and dental status in a separate examination protocol, recorded by a dentist. RESULTS: There was a significant correlation between being dentate and having need of oral treatment. Those who were able to chew also had significantly better cognitive and functional capacity. Oral treatment need was identified most often by the dentist, intermediately by the RAI assessment and least frequently by the residents themselves. CONCLUSIONS: Being dentate and having a loss of cognitive and functional capacity is predictive of oral treatment need among nursing home residents. Enhanced interaction between nurses and dental professionals needs to be promoted for better awareness of preventive measures and better regular oral care for frail and dependent elderly persons.

Nutritional status and chewing capacity in nursing home residents.

Chronically ill elderly persons sustain a high risk for protein-energy malnutrition (PEM). In this study we explored some of the complex associations between nutritional status, dental health and cognitive and physical function in 192 nursing home residents (mean age 84+/-8 years, 80% female). Nutrition-related data from the Resident Assessment Instrument (RAI) were compiled into a Nutrition Score (NuSc; 0-1 = non-PEM, 2 = risk for PEM, and 3-7 = PEM). Chewing capacity, according to number and condition of occlusal contacts, was determined by a Clinical Dental Functionality score (CDF). The Cognitive Performance Scale (CPS) and activities of daily living (ADL) were determined according to the RAI. Fifty percent of the residents had NuSc > or = 2, and 25% had NuSc > or = 3. One third did not have the dental prerequisites for chewing. i.e., < 4 occlusal contacts. Almost half of the residents had severe cognitive dysfunction, and over two thirds were severely limited in their ADL activities. Subjects with > or = 4 occlusal contacts, i.e., technical chewing capacity, had better NuSc (1.5+/-1.4) than those not able to chew (2.4+/-1.6, p=0.0005). In univariate logistic regression, the odds for NuSc > or = 2 increased with reduced ADL functions. inability to chew and poor cognition. In multivariate logistic regression, ADL and chewing capacity were significantly related to NuSc > or = 2. When NuSc > or = 3 was chosen as cut-off, only ADL was related to malnutrition. In conclusion, half of this group of nursing home residents appeared to be malnourished, or were at risk for PEM. Reduced physical function was the strongest predictor of PEM, while impaired chewing capacity was associated with risk for PEM.

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

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

Review of nursing documentation in nursing home wards - changes after intervention for individualized care.

Using standardized assessment instruments may help staff identify needs, problems and resources which could be a basis for nursing care, and facilitate and improve the quality of documentation. The Resident Assessment Instrument/Minimum Data Set (RAI/MDS) especially developed for the care of elderly people, was used as a basis for individualized and documented nursing care. This study was carried out to compare nursing documentation in three nursing home wards in Sweden, before and after a one-year period of supervised intervention. The review of documentation focused on structure and content in both nursing care plans and daily notes. The greatest change seen after intervention was the writing of care plans for the individual patients. Daily notes increased both in total and within parts of the nursing process used, but reflected mostly temporary situations. Even though the documentation of nursing care increased the most, it was the theme medical treatment which was the most extensive overall. A difference was seen between computer-triggered Resident Assessment Protocol (RAP) items, obtained from the RAI/MDS assessments, and items in the nursing care plans; the former could be regarded as a means of quality assurance and of making staff aware of the need for further discussions. The RAI/MDS instrument seems to be a useful tool for the dynamic process in nursing care delivered and as a basis for documentation. The documentation should communicate a patient's situation and progress, and if staff are to be able to use it in their everyday nursing care activity, it must be well-structured and freely available. The importance of continuing education and supervision in nursing documentation for development of a reliable source of information was confirmed by the present study.

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

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

Staff views on the Resident Assessment Instrument, RAI/MDS, in nursing homes, and the use of the Cognitive Performance Scale, CPS, in different levels of care in Stockholm, Sweden.

Multidimensional functional assessment is the basis of individualized care. It is especially important in the care of elderly, with the complexity of symptomatology and often with cognitive impairment present. An assessment instrument for elderly persons, used in this study, is the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) and its incorporated MDS Cognitive Performance Scale (CPS). The purposes of the study were to demonstrate the cognitive performance in elderly persons in different levels of care by using the CPS and to elicit the views of staff on use of the RAI/MDS. Cognitive impairment was found in 1276 elderly persons in six levels of care studied, an important factor to consider when organizing care of elderly. An intervention study was carried out for 1 year in three nursing home wards, with training and supervision in implementation of the RAI/MDS including individualized and documented care. Part of a questionnaire was used to evaluate staff (n = 50) views on using the instrument. A majority of the staff thought that the RAI/MDS could contribute to the improvement of quality of care, documentation in nursing records, and in co-operation and engagement. Further research is necessary to elicit more knowledge on the usefulness and benefits of the instrument.

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

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

Costs of dementia and dementia care: a review.

Costs of dementia care constitute a great part of the total costs of care for elderly. Because the prevalence of dementia is linked to increasing age, and the number of the oldest old is rising, the costs of dementia care will increase considerably in the forthcoming decades. In this review, research describing costs of dementia care has been analysed and classified. The available database in this field is small, though expanding, and the methodological problems are obvious. Differences between countries, and between different periods of time, are difficult to analyse due to different methods of financing and organizing care. The main result of the present study is that the costs of dementia care differ considerably in the literature. One important reason for this variability is that the number of included cost categories vary, leading to a wide range of costs. Unpaid informal care forms a major part of the total costs, but the theory of costing informal care is complicated.

Nursing homes in 10 nations: a comparison between countries and settings.

AIM: to illustrate demographic differences and recent trends in the provision and structure of long-term care systems in the 10 countries participating in the Resident Assessment Instrument studies (Denmark, France, Iceland, Italy, Japan, The Netherlands, Sweden, Switzerland, the UK and the USA). METHOD: data were assembled from government documents, statistical yearbooks and articles from journals; supplemental data on long-term care and nursing homes were solicited from colleagues. RESULTS: All 10 countries are developed nations with high life-expectancies. Sweden has the oldest and Iceland the youngest population in this study, with Japan showing the highest ageing rates over the next three decades. Between 2 and 5% of elderly people reside in nursing homes. Interestingly, Iceland, as the 'youngest country' in this study, has the highest rate of institutionalization (living in residential or nursing homes), while the 'oldest country' (Sweden) has a low rate of institutionalization. In all countries the support ratio (number of elderly people per 100 younger adults) is high and increasing rapidly. CONCLUSIONS: no relation appears to exist between the ageing status of a country and the number of nursing home beds. Institutionalization rates among the nations studied differ even more, due at least in part to differences in the organization and financing of long-term care services, in the amount of responsibility assumed in the care for disabled elderly people by each sector and the availability of long-term care beds. Facing a rapid ageing of their population, many countries are in the process of health and social care reforms.

Efforts to establish the reliability of the Resident Assessment Instrument.

BACKGROUND: since its original implementation in the USA, the Resident Assessment Instrument (RAI) has been used in many countries in languages other than English. This paper describes the efforts that have been made to test the inter-rater reliability of the core set of items forming the minimum data set items in the USA and in non-English speaking countries (Denmark, Iceland, Italy, Japan, Sweden and Switzerland). RESULTS: a large proportion (from 70 to 96%) of the items in the RAI achieved an adequate to excellent level of reliability, with no substantial differences across countries. The RAI met the standard for good reliability (i.e. a kappa value of 0.6 or higher) in crucial areas of functional status, such as memory, activities of daily living self-performance and support, and bowel and bladder continence in most of the countries. Indicators of mood and behavioural problems achieved adequate reliability levels of 0.4 or higher.