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  • 1.
    Abramsson, Linnea
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Gustafsson, Maria
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Adherence to Bisphosphonates among People Admitted to an Orthopaedic and Geriatric Ward at a University Hospital in Sweden2018In: Pharmacy, E-ISSN 2226-4787, Vol. 6, no 1, article id 20Article in journal (Refereed)
    Abstract [en]

    Oral bisphosphonates are the first choice of therapy to reduce the risk of osteoporotic fractures. These medications have generally poor oral bioavailability, which may further be reduced by concomitant intake of certain foods and drugs; therefore, it is vital to follow specific instructions. The aim with this study was to assess general adherence to oral bisphosphonates and adherence to specific administration instructions among people admitted to two wards at Umeå University hospital in Sweden. This interview study focuses on elderly patients living at home and prescribed oral bisphosphonates. Invited were 27 patients admitted to an orthopaedic ward and a geriatric ward during the period 28 March 2017 and 5 December 2017. In total, 21 patients were interviewed regarding their adherence to oral bisphosphonates. Out of 21 patients, 13 (62%) were considered non-adherent. The most common reason was calcium intake less than 2 h after oral administration of bisphosphonate (54%). The number of regularly prescribed drugs was significantly higher among patients rated non-adherent to bisphosphonates compared to those rated adherent (p = 0.004). Adherence to bisphosphonates administration instruction among elderly people living at home was limited. More research is needed to confirm these results and to investigate the reasons for non-adherence and how adherence to bisphosphonates can be improved.

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  • 2.
    Abramsson, Linnea
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Gustafsson, Maria
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Prevalence of drug-related problems using STOPP/START and medication reviews in elderly patients with dementia2020In: Research in Social and Administrative Pharmacy, ISSN 1551-7411, E-ISSN 1934-8150, Vol. 16, no 3, p. 308-314Article in journal (Refereed)
    Abstract [en]

    Background: Drug-related problems (DRPs) are common among elderly patients with dementia. STOPP/START is an explicit tool that has been used to detect DRPs among elderly patients.

    Objectives: The objective of this study was to compare prevalence and type of DRPs identified by STOPP/START with DRPs identified by clinical pharmacists among the same population. Secondary objectives were to investigate factors associated with the use of DRPs using the two methods.

    Method: Extracts from medical records were used to identify DRPs in 212 patients by using STOPP/START. The patients were ≥65 years of age with dementia or cognitive impairment. An earlier study was performed in the same study population in 2012–2014, where DRPs were identified by clinical pharmacists in order to decrease the number of rehospitalizations.

    Results: STOPP/START identified DRPs in 72.2% of the patients compared with 66.0% identified by the clinical pharmacists. The numbers of DRPs identified by the different methods were 326 and 310, respectively. Different types of DRPs were identified with the different tools. STOPP/START mainly identified DRPs in the categories “ineffective/inappropriate drug” and “needs additional drug therapy”, whereas the clinical pharmacists identified DRPs in several categories.

    Conclusion: Even though STOPP/START was able to identify a similar number of DRPs compared with DRPs identified by clinical pharmacists, STOPP/START failed to identify DRPs in several important categories. To cover all DRPs, STOPP/START might be used as a complement to implicit criteria.

  • 3. Ahman, Hanna B.
    et al.
    Cedervall, Ylva
    Kilander, Lena
    Giedraitis, Vilmantas
    Berglund, Lars
    McKee, Kevin J.
    Rosendahl, Erik
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Ingelsson, Martin
    Aberg, Anna Cristina
    Dual-task tests discriminate between dementia, mild cognitive impairment, subjective cognitive impairment, and healthy controls: a cross-sectional cohort study2020In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 20, no 1, article id 258Article in journal (Refereed)
    Abstract [en]

    BackgroundDiscrimination between early-stage dementia and other cognitive impairment diagnoses is central to enable appropriate interventions. Previous studies indicate that dual-task testing may be useful in such differentiation. The objective of this study was to investigate whether dual-task test outcomes discriminate between groups of individuals with dementia disorder, mild cognitive impairment, subjective cognitive impairment, and healthy controls.MethodsA total of 464 individuals (mean age 71years, 47% women) were included in the study, of which 298 were patients undergoing memory assessment and 166 were cognitively healthy controls. Patients were grouped according to the diagnosis received: dementia disorder, mild cognitive impairment, or subjective cognitive impairment. Data collection included participants' demographic characteristics. The patients' cognitive test results and diagnoses were collected from their medical records. Healthy controls underwent the same cognitive tests as the patients. The mobility test Timed Up-and-Go (TUG single-task) and two dual-task tests including TUG (TUGdt) were carried out: TUGdt naming animals and TUGdt months backwards. The outcomes registered were: time scores for TUG single-task and both TUGdt tests, TUGdt costs (relative time difference between TUG single-task and TUGdt), number of different animals named, number of months recited in correct order, number of animals per 10s, and number of months per 10s. Logistic regression models examined associations between TUG outcomes pairwise between groups.ResultsThe TUGdt outcomes "animals/10s" and "months/10s" discriminated significantly (p <0.001) between individuals with an early-stage dementia diagnosis, mild cognitive impairment, subjective cognitive impairment, and healthy controls. The TUGdt outcome "animals/10s" showed an odds ratio of 3.3 (95% confidence interval 2.0-5.4) for the groups dementia disorders vs. mild cognitive impairment. TUGdt cost outcomes, however, did not discriminate between any of the groups.ConclusionsThe novel TUGdt outcomes "words per time unit", i.e. "animals/10s" and "months/10s", demonstrate high levels of discrimination between all investigated groups. Thus, the TUGdt tests in the current study could be useful as complementary tools in diagnostic assessments. Future studies will be focused on the predictive value of TUGdt outcomes concerning dementia risk for individuals with mild cognitive impairment or subjective cognitive impairment.

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  • 4.
    Aidanpää, Oliver
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Varför utförs färre trombektomier på hjärninfarktspatienter från Norrbotten jämfört med riket? - En retrospektiv kvalitetsgranskningsstudie2020Independent thesis Basic level (professional degree), 20 credits / 30 HE creditsStudent thesis
  • 5.
    Akner, G.
    et al.
    School of Health and Medical Sciences, Örebro University, 70185 Örebro, Sweden.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Personalized geriatric medicine2014In: European Geriatric Medicine, ISSN 1878-7649, E-ISSN 1878-7657, Vol. 5, no 3, p. 145-146Article in journal (Other academic)
  • 6.
    Alafuzoff, Irina
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Histopathological and immunocytochemical studies in age-associated dementias: the importance of rigorous histopathological criteria for classification of progressive dementia disorders1985Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Dementia is an age-associated organic brain disorder, recogniz­able by the essential features of psychological or behavioral abnormality associated with permanent dysfunction of the brain interfering with social and occupational functioning.

    There are two clinical and three histopathological forms of dementia 1) primary degenerative dementia, (PDD), or Alzhei­mer's dementia/Senile dementia of Alzheimers type (AD/SDAT) which is associated with clinical features of uniform progres­sion and insidious onset of symptoms and histopathologically i- dentified by the occurrence of neurofibrillary tangles (NFT) and senile/neuritic plaques (SP/NP) in various cortical and subcor- tical regions; 2) vascular dementia, or multi-infarct dementia (MID), which is associated with clinical features of stepwise progress and patchy distribution of deficits, and histopatholo­gically identified by the occurrence of multiple large and/or small haemorrhagic and/or ischaemic infarcts in various cortical and subcortical regions and 3) intermediate form of dementia or "mixed” ("combined") dementia (AD-MID), which is histopatho- logically associated with the coexistance of symptoms and le­sions observed in AD/SDAT and MID, and clinically referred to the MID group. The DSM-III criteria separate the demented into two groups, AD/SDAT and MID, while there are no unique clinical criteria for the AD-MID patients. The clinical diagnosis of dementia according to the DSM-III criteria was shown to be in­sufficient . Histopathological diagnostic criteria were postu­lated by us for 1) pathological changes developing in mentallyunimpaired ageing, 2) AD/ SPAT, 3) MID and 4) AD-MID.

    These histopathological classes could be separated, by means of multivariate data analysis. The pathology in AD-MID was shown not to be merely a linear combination of the AD/SDATand MID pathology.

    Intrathecal synthesis of Ig, oligoclonal bands or other abnormal proteins in the CSF could not be demonstrated in aged non-demen- ted and demented patients.

    The blood-cerebrospinal barrier (B-CSF-B) or blood-brain barrier (BBB) function alters with age and this alteration was shown to be more pronounced in MID and AD-MID patients. In MID and AD-MID patients the BBB alteration involves primarily the grey matter while in AD/SDAT patients the alteration would appear to involve only the white matter. The BBB dysfunction and a possible complement activation, either through antibody-anti- gen activation or other complement activators, was visualized in MID and AD-MID patients as perivascular serum protein depo­sits in the grey matter, always with a capillary in the center. The occurrence of some serum proteins in plaques, and the previously descibed localization of plaques in close relation­ship to the capillaries, suggest that altered BBB function and serum factors may be involved in the etiology and maturation of plaques while the etiology and maturation of tangles may not be directly dependent on these factors, as they were never labelled with any of the antisera studied.

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  • 7.
    Aléx, Lena
    et al.
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Lundman, Berit
    Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Reflections of men and women in advanced old age on being the other sex2010In: Ageing & Society, ISSN 0144-686X, E-ISSN 1469-1779, Vol. 30, no 2, p. 193-206Article in journal (Refereed)
    Abstract [en]

    The study reported in this paper is part of the Umeå 85+ project in Sweden. The aim was to investigate gender perspectives among ‘the oldest old’, by asking men and women in advanced old age living in a sparsely populated area of northern Sweden to reflect on how life might have been if they had been born the other sex. Thematic narratives from nine men and seven women were analysed using qualitative content analysis. The content of these narratives was resolved into eight categories in two domains, respectively men's and women's reflections about being born the opposite sex. The narratives of both the men and women indicated that they were satisfied with their actual birth sex. The men were aware that if they had been born female, they would probably have experienced more hard work and had a more restricted life, and they were conscious of both women's relative powerlessness and their greater ability to manage and organise work within the home. The women's narratives described a femininity characterised by longing for a state of being unconcerned when young, and their narratives also displayed awareness of women's physical strength and that men's lives had also been hard.

  • 8.
    Andersson, Johanna
    et al.
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Rosell, Michelle
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Kockum, Karin
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Lilja-Lund, Otto
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Soderstrom, Lars
    Laurell, Katarina
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Prevalence of idiopathic normal pressure hydrocephalus: A prospective, population-based study2019In: PLOS ONE, E-ISSN 1932-6203, Vol. 14, no 5, article id e0217705Article in journal (Refereed)
    Abstract [en]

    Background: Idiopathic normal pressure hydrocephalus (iNPH) causing gait impairment, dementia and urinary incontinence among the elderly, is probably under-diagnosed and under-treated. Despite being known since the 1960s, there is still a lack of prospective, population-based studies on the prevalence of iNPH. Such studies are warranted to minimize selection bias and estimate the true prevalence of the disease.

    Methods: The prevalence of iNPH was determined in a randomly selected sample of residents, aged 65 years and older, in the Swedish county of Jämtland. Out of 1,000 individuals invited to participate, 673 (67.3%) completed a questionnaire with seven questions on iNPH symptoms. A subgroup, with and without self-reported symptoms, participated in clinical and radiological evaluations and were diagnosed according to international guidelines. Measurement of cerebrospinal fluid opening pressure was not performed as it was considered too invasive.

    Results: Those who reported at least two symptoms in the questionnaire (n = 117) and 51 randomly selected individuals with 0–1 symptom participated in further examinations. Out of them, 25 individuals received the diagnosis probable iNPH according to American-European guidelines (except for the criterion of CSF opening pressure) corresponding to a prevalence of 3.7%. The prevalence of iNPH was four times higher among those aged 80 years and older (8.9%) than among those aged 65–79 years (2.1%) (p <0.001). The difference in prevalence between men (4.6%) and women (2.9%) was not significant (p = 0.24). When iNPH was diagnosed according to the Japanese guidelines the prevalence was 1.5%

    Conclusions: In this prospective, population-based study the prevalence of iNPH was 3.7% among individuals 65 years and older, and more common in the higher age group, 80 years and above. INPH should be increasingly recognized since it is a fairly common condition and an important cause of gait impairment and dementia among the elderly that can be effectively treated by shunt surgery.

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  • 9.
    Anjomshoae, Sule
    et al.
    Umeå University, Faculty of Science and Technology, Department of Computing Science. Umeå University.
    Pudas, Sara
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB). Umeå University, Faculty of Medicine, Umeå Centre for Functional Brain Imaging (UFBI).
    Explaining graph convolutional network predictions for clinicians: an explainable AI approach to Alzheimer’s disease classification2024In: Frontiers in Artificial Intelligence, E-ISSN 2624-8212, Vol. 6, article id 1334613Article in journal (Refereed)
    Abstract [en]

    Introduction: Graph-based representations are becoming more common in the medical domain, where each node defines a patient, and the edges signify associations between patients, relating individuals with disease and symptoms in a node classification task. In this study, a Graph Convolutional Networks (GCN) model was utilized to capture differences in neurocognitive, genetic, and brain atrophy patterns that can predict cognitive status, ranging from Normal Cognition (NC) to Mild Cognitive Impairment (MCI) and Alzheimer's Disease (AD), on the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. Elucidating model predictions is vital in medical applications to promote clinical adoption and establish physician trust. Therefore, we introduce a decomposition-based explanation method for individual patient classification.

    Methods: Our method involves analyzing the output variations resulting from decomposing input values, which allows us to determine the degree of impact on the prediction. Through this process, we gain insight into how each feature from various modalities, both at the individual and group levels, contributes to the diagnostic result. Given that graph data contains critical information in edges, we studied relational data by silencing all the edges of a particular class, thereby obtaining explanations at the neighborhood level.

    Results: Our functional evaluation showed that the explanations remain stable with minor changes in input values, specifically for edge weights exceeding 0.80. Additionally, our comparative analysis against SHAP values yielded comparable results with significantly reduced computational time. To further validate the model's explanations, we conducted a survey study with 11 domain experts. The majority (71%) of the responses confirmed the correctness of the explanations, with a rating of above six on a 10-point scale for the understandability of the explanations.

    Discussion: Strategies to overcome perceived limitations, such as the GCN's overreliance on demographic information, were discussed to facilitate future adoption into clinical practice and gain clinicians' trust as a diagnostic decision support system.

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  • 10. Arkkukangas, Marina
    et al.
    Söderlund, Anne
    Eriksson, Staffan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation. Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden; Department of Neuroscience, Physiotherapy, Uppsala University, Uppsala, Sweden.
    Johansson, Ann-Christin
    Fall Preventive Exercise With or Without Behavior Change Support for Community-Dwelling Older Adults: A Randomized Controlled Trial With Short-Term Follow-up2019In: Journal of Geriatric Physical Therapy, ISSN 1539-8412, E-ISSN 2152-0895, Vol. 42, no 1, p. 9-17Article in journal (Refereed)
    Abstract [en]

    Background and Purpose: In Western countries, falls and fall-related injuries are a well-known threat to health in the aging population. Studies indicate that regular exercise improves strength and balance and can therefore decrease the incidence of falls and fall-related injuries. The challenge, however, is to provide exercise programs that are safe, effective, and attractive to the older population. The aim of this study was to investigate the short-term effect of a home-based exercise program with or without motivational interviewing (MI) compared with standard care on physical performance, fall self-efficacy, balance, activity level, handgrip strength, adherence to the exercise, and fall frequency.

    Method: A total of 175 older adults participated in this randomized controlled study. They were randomly allocated for the Otago Exercise Program (OEP) (n = 61), OEP combined with MI (n = 58), or a control group (n = 56). The participants' mean age was 83 years. The recruitment period was from October 2012 to May 2015. Measurements of physical performance, fall self-efficacy, balance, activity level, handgrip strength, adherence to the exercise, and fall frequency were done before and 12 weeks after randomization.

    Results and Discussion: A total of 161 participants were followed up, and there were no significant differences between groups after a period of 12 weeks of regular exercise. Within the OEP + MI group, physical performance, fall self-efficacy, physical activity level, and handgrip strength improved significantly; likewise, improved physical performance and fall self-efficacy were found in the control group. A corresponding difference did not occur in the OEP group. Adherence to the exercise was generally high in both exercise groups.

    Conclusion: In the short-term perspective, there were no benefits of an exercise program with or without MI regarding physical performance, fall self-efficacy, activity level, handgrip strength, adherence to the exercise, and fall frequency in comparison to a control group. However, some small effects occurred within the OEP + MI group, indicating that there may be some possible value in behavioral change support combined with exercise in older adults that requires further evaluation in both short- and long-term studies.

  • 11.
    Axenhus, Michael
    et al.
    Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet, Solna, Sweden; Theme Inflammation and Aging, Karolinska University Hospital, Huddinge, Sweden.
    Schedin-Weiss, Sophia
    Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet, Solna, Sweden.
    Tjernberg, Lars
    Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet, Solna, Sweden.
    Wimo, Anders
    Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet, Solna, Sweden; The primary care of Hudiksvall-Nordanstig, the Region of Gävleborg, Gävle, Sweden.
    Eriksdotter, Maria
    Theme Inflammation and Aging, Karolinska University Hospital, Huddinge, Sweden; Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden.
    Bucht, Gösta
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Winblad, Bengt
    Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet, Solna, Sweden; Theme Inflammation and Aging, Karolinska University Hospital, Huddinge, Sweden.
    Changes in dementia diagnoses in Sweden during the COVID-19 pandemic2022In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 22, no 1, article id 365Article in journal (Refereed)
    Abstract [en]

    Introduction: The COVID-19 pandemic has caused large disruptions to healthcare systems. Refocus on COVID-19 related care might have contributed to indirect effects on other healthcare areas. Care focused on acute conditions have been negatively affected although research into the effects on chronic and care intensive patient groups such as patients with dementia diseases is lacking. In this study we evaluated dementia diagnosis trends in Sweden during 2015–2020 according to International Classification of Disease version 10 coding of common dementia diseases.

    Methods: Regional and national statistics in the form of International Classification of Disease version 10 coding, COVID-19 incidence, mortality data, and population census data were collected from the National Institute of Health and Welfare. Logistic regression analysis was performed to identify trends of dementia diagnosis during 2015–2020. Correlation test was performed between COVID-19 incidence, mortality rates, and dementia coding.

    Results: Dementia diagnosis incidence has been declining since 2015 and further decline was noted in many regions in Sweden during 2020. As COVID-19 incidence increased, fewer cases of dementia were diagnosed, a decrease that differentially impacted women and those who were advanced in age.

    Conclusions: Dementia diagnosis incidence in Sweden has been on a decline since 2015. The COVID-19 pandemic caused a further larger decline in dementia diagnosis incidence during 2020. COVID-19 incidence, but not mortality, was associated with decrease in dementia diagnosis incidence. There might be a large number of undiagnosed patients with dementia and healthcare reforms should be enacted to address this. Women and elderly are particularly vulnerable groups.

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  • 12.
    Backman, Annica C.
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lövheim, Hugo
    Sjögren, Karin
    Umeå University, Faculty of Medicine, Department of Nursing.
    Edvardsson, David
    Umeå University, Faculty of Medicine, Department of Nursing. La Trobe Univ, Melbourne, Vic, Australia.
    Leadership behavior in relation to person-centeredness and person-centered climate - a cross-sectional study in residential aged care in Sweden2015In: The Gerontologist, ISSN 0016-9013, E-ISSN 1758-5341, Vol. 55, p. 806-807Article in journal (Other academic)
  • 13.
    Backman, Annica
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lövheim, Hugo
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Sjögren, Karin
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edvardsson, David
    Umeå University, Faculty of Medicine, Department of Nursing.  School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia.
    Characteristics of highly rated leadership in Swedish nursing homes2016In: The Gerontologist, ISSN 0016-9013, E-ISSN 1758-5341, Vol. 56, p. 283-283Article in journal (Other academic)
  • 14.
    Bajraktari, Saranda
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Zingmark, Magnus
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Municipality of Östersund, Health and Social Care Administration, Östersund, Sweden.
    Pettersson, Beatrice
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Rosendahl, Erik
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Lundin-Olsson, Lillemor
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Sandlund, Marlene
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.
    Reaching older people with a digital fall prevention intervention in a Swedish municipality context: an observational study2022In: Frontiers In Public Health, ISSN 2296-2565, Vol. 10, article id 857652Article in journal (Refereed)
    Abstract [en]

    Background: There is robust evidence that falls in old age can be prevented by exercise programs that include balance training, functional exercises, and strength training. For the interventions to have a population health impact, outreach to the population of focus with suitable interventions is needed. While digital interventions are promising there is limited knowledge on the characteristics of who is reached. The aim of this study was to describe the recruitment process, estimate reach rate at the population level and to describe participants characteristics and representativeness in a digital fall prevention intervention study.

    Methods: In a municipality-based observational study, reach of a digital fall prevention intervention was evaluated. The intervention included a digital exercise programme (Safe Step) and optional supportive strategies, complemented with a range of recruitment strategies to optimize reach. Recruitment during a period of 6 months was open to people 70 years or older who had experienced a fall or a decline in balance the past year. Reach was based on data from the baseline questionnaire including health and demographic characteristics of participants. Representativeness was estimated by comparing participants to a sample of older people from the Swedish National Public Health Survey.

    Results: The recruitment rate was 4.7% (n = 173) in relation to the estimated population of focus (n = 3,706). Most participants signed up within the first month of the intervention (n = 131). The intervention attracted primarily women, older people with high education, individuals who used the internet or digital applications almost every day and those perceiving their balance as fair or poor. Safe step participants lived more commonly alone and had higher education and better walking ability in comparison to the Swedish National Public Health Survey.

    Conclusions: With a range of recruitment strategies most participants were recruited to a digital fall intervention during the first month. The intervention attracted primarily highly educated women who frequently used the internet or smart technologies. In addition to digital fall prevention interventions, a higher diversity of intervention types (digital and non-digital) is more likely to reach a larger group of older people with different needs.

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  • 15.
    Ballesteros, Soledad
    et al.
    Studies on Aging and Neurodegenerative Diseases Research Group, Department of Basic Psychology II, Universidad Nacional de Educación a Distancia, Madrid, Spain.
    Prieto, Antonio
    Studies on Aging and Neurodegenerative Diseases Research Group, Department of Basic Psychology II, Universidad Nacional de Educación a Distancia, Madrid, Spain.
    Mayes, Julia
    Studies on Aging and Neurodegenerative Diseases Research Group, Department of Basic Psychology II, Universidad Nacional de Educación a Distancia, Madrid, Spain.
    Toril, Pilar
    Studies on Aging and Neurodegenerative Diseases Research Group, Department of Basic Psychology II, Universidad Nacional de Educación a Distancia, Madrid, Spain.
    Pita, Carmen
    Studies on Aging and Neurodegenerative Diseases Research Group, Department of Basic Psychology II, Universidad Nacional de Educación a Distancia, Madrid, Spain.
    Ponce de León, Laura
    Studies on Aging and Neurodegenerative Diseases Research Group, Department of Basic Psychology II, Universidad Nacional de Educación a Distancia, Madrid, Spain.
    Reales, José
    Studies on Aging and Neurodegenerative Diseases Research Group, Department of Basic Psychology II, Universidad Nacional de Educación a Distancia, Madrid, Spain.
    Waterworth, John
    Umeå University, Faculty of Social Sciences, Department of Informatics.
    Brain training with non-action video games enhances aspects of cognition in older adults: a randomized controlled trial2014In: Frontiers in Aging Neuroscience, ISSN 1663-4365, E-ISSN 1663-4365, Vol. 6, article id 277Article in journal (Refereed)
    Abstract [en]

    Age-related cognitive and brain declines can result in functional deterioration in many cognitive domains, dependency, and dementia. A major goal of aging research is to investigate methods that help to maintain brain health, cognition, independent living and wellbeing in older adults. This randomized controlled study investigated the effects of 20 1-hr non-action video game training sessions with games selected from a commercially available package (Lumosity) on a series of age-declined cognitive functions and subjective wellbeing. Two groups of healthy older adults participated in the study, the experimental group who received the training and the control group who attended two meetings with the research team along the study. Groups were similar at baseline on demographics, vocabulary, global cognition, and depression status. All participants were assessed individually before and after the intervention, or a similar period of time, using neuropsychological tests and laboratory tasks to investigate possible transfer effects. The results showed significant improvements in the trained group, and no variation in the control group, in processing speed (choice reaction time), attention (reduction of distraction and increase of alertness), immediate and delayed visual recognition memory, as well as a trend to improve in Affection and Assertivity, two dimensions of the Wellbeing Scale. Visuospatial working memory (WM) and executive control (shifting strategy) did not improve. Overall, the current results support the idea that training healthy older adults with non-action video games will enhance some cognitive abilities but not others.

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  • 16.
    Ballin, Marcel
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Physical activity, visceral adipose tissue, and cardiovascular disease in older adults: associations and effects2023Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    BACKGROUND: Cardiovascular disease (CVD) poses a substantial public health burden and is the leading cause of mortality in older adults. With the population aging rapidly, interventions aimed at improving modifiable risk factors for CVD, such as physical inactivity and visceral obesity, could play an important role in reducing its burden, provided they are proven effective.

    PURPOSE AND AIMS: The overall purpose of this thesis was to create a deeper understanding of the links between physical activity, visceral adipose tissue (VAT), and CVD in older adults, by studying it from both an observational and an interventional perspective. The specific aims were to investigate the associations of objectively measured physical activity and VAT with the risk of CVD and all-cause mortality, to investigate the effect of structured physical activity (exercise) on VAT, and to review the effects of exercise on CVD and all-cause mortality based on evidence from randomized controlled trials (RCTs).

    METHODS: This thesis comprised two prospective cohort studies, one RCT, and one narrative review of evidence from RCTs. The cohort studies included about 3,300 men and women aged 70 years with baseline data on physical activity and VAT mass, as obtained using accelerometry and dual-energy X-ray absorptiometry, respectively. Cases of stroke, myocardial infarction, and all-cause mortality during follow-up were collected from Swedish nationwide registers. The RCT included 77 men and women aged 70 years with visceral obesity who were randomly allocated to either 10 weeks of supervised vigorous-intensity exercise or to no exercise, with VAT mass measured before and after the intervention. In the review, evidence from published RCTs and meta-analyses of RCTs reporting on the effects of exercise on CVD (N=19,162) and all-cause mortality (N=37,443) in general older adults and in individuals with chronic conditions (such as obesity, type 2 diabetes, and preexisting CVD) were reviewed.

    MAIN FINDINGS: In the cohort studies, greater amounts of physical activity of any intensity, but especially that of moderate to vigorous intensity, were associated with lower risk of stroke, myocardial infarction, and all-cause mortality. Conversely, greater VAT mass was associated with higher risk of stroke or myocardial infarction. In the RCT, short-term vigorous-intensity exercise seemed to decrease VAT mass slightly, but the effect was not statistically significant. Finally, the review showed that there is currently no convincing evidence from RCTs that exercise effectively reduces the risk of CVD or all-cause mortality, which stands in sharp contrast to the strong associations typically reported in observational studies. The reasons for the conflicting findings are likely complex and multifactorial. In the RCTs, a lack of statistical power could partly explain why no effects have been detected in the general population of older adults, but it is unlikely to explain the null findings in clinical populations, as some of these trials, including meta-analyses of such trials, have been large. Other potential explanations could be a ceiling effect due to the inclusion of participants who were healthier and more physically active than the general population, or that an effect of exercise was masked by the use of effective medications such as antihypertensives and lipid-lowering agents. On the other hand, observational studies have likely overestimated the benefits of physical activity, because these studies are vulnerable to selection bias, reverse causation, and unmeasured confounding, such as from heritable influences.

    CONCLUSIONS AND IMPLICATIONS: Despite strong associations, the protective effect of physical activity as a single intervention against CVD and all-cause mortality in older adults is probably not as substantial as is commonly presumed. To uncover the true role of physical activity in preventing CVD, further high-quality trials would be valuable. However, because these trials are very difficult and resource demanding, they should be complemented by innovative observational studies that seek to strengthen causal inference through addressing sources of bias and confounding that are often incompletely accounted for in conventional observational studies. This could include a variety of methodologies, such as utilizing negative control outcomes, instrumental variables, sibling comparisons, and other genetically informed designs. As the aging population continues to grow, it becomes increasingly important to take these scientific steps in order to provide a more definitive answer to the question of the extent to which physical activity alone can reduce the risk of CVD.

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  • 17.
    Ballin, Marcel
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Hult, Andreas
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Sports Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Björk, Sabine
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Lundberg, Emmy
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Nordström, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. School of Sport Sciences, UiT The Arctic University of Norway, Tromsø, Norway..
    Web-based exercise versus supervised exercise for decreasing visceral adipose tissue in older adults with central obesity: a randomized controlled trial2020In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 20, no 1, article id 173Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Visceral adipose tissue (VAT) is a strong risk factor for cardiovascular disease and increases with age. While supervised exercise (SE) may be an effective approach, web-based exercise (WE) have other advantages such as being more readily accessible. Therefore, we evaluated the effects of WE on VAT, body composition and cardiometabolic risk markers in centrally obese older adults and compared the effects of WE to SE. We also explored the feasibility of WE.

    METHODS: In a randomized controlled trial conducted in Umeå, Sweden during January 2018 - November 2018, N = 77, 70-year-old men and women with central obesity (> 1 kg VAT for women, > 2 kg for men) were randomized to an intervention group (n = 38) and a wait-list control group (n = 39). The intervention group received 10 weeks of SE while the wait-list control group lived as usual. Following a 10-week wash-out-period, the wait-list control group received 10 weeks of WE. The primary outcome was changes in VAT. Secondary outcomes included changes in fat mass (FM), lean body mass (LBM), blood lipids, fasting blood glucose. Additionally, we explored the feasibility of WE defined as adherence and participant experiences.

    RESULTS: WE had no significant effect on VAT (P = 0.5), although it decreased FM by 450 g (95% confidence interval [CI], 37 to 836, P < 0.05). The adherence to WE was 85% and 87-97% of the participants rated aspects of the WE intervention > 4 on a scale of 1-5. Comparing SE to WE, there was no significant difference in decrease of VAT (Cohen's δ effect size [ES], 0.5, 95% CI, - 24 to 223, P = 0.11), although SE decreased FM by 619 g (ES, 0.5, 95% CI, 22 to 1215, P < 0.05) compared to WE.

    CONCLUSIONS: Ten weeks of vigorous WE is insufficient to decrease VAT in centrally obese older adults, but sufficient to decrease FM while preserving LBM. The high adherence and positive experiences of the WE intervention implies that it could serve as an alternative exercise strategy for older adults with central obesity, with increased availability for a larger population.

    TRIAL REGISTRATION: ClinicalTrials.gov (NCT03450655), retrospectively registered February 28, 2018.

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  • 18.
    Ballin, Marcel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Lundberg, Emmy
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Sörlén, Niklas
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Hult, Andreas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Nordström, Anna
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. School of Sport Sciences, The Arctic University of Norway, Tromsø, Norway..
    Effects of Interval Training on Visceral Adipose Tissue in Centrally Obese 70-Year-Old Individuals: A Randomized Controlled Trial2019In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 67, no 8, p. 1625-1631Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate the effects of 10 weeks of progressive vigorous-intensity interval training as a single intervention on body composition among 70-year-old individuals with central obesity.

    DESIGN: Randomized controlled trial (ClinicalTrials.gov registration No. NCT03450655).

    SETTING: Community-dwelling 70-year-old men and women living in the Umeå municipality in Sweden.

    PARTICIPANTS: Seventy-seven 70-year-old men and women with central obesity (greater than 1 kg visceral adipose tissue [VAT] for women and greater than 2 kg VAT for men).

    INTERVENTION: Participants allocated to the intervention group were offered a 10-week progressive concurrent exercise program performed three times per week. All participants in both groups had received tailored lifestyle recommendations focused on diet and physical activity at one occasion within 12 months prior to trial initiation.

    MEASUREMENTS: The primary outcome was changes in VAT, and secondary outcomes included changes in total fat mass (FM), total lean body mass (LBM), and body mass index.

    RESULTS: Comparing the groups, there were no significant differences in decrease of VAT mass (P = .10), although the intervention group significantly decreased FM by 716 g (P = .01) and gained LBM by 508 g (P = .03), compared to the control group. Furthermore, the effects of the training were significantly greater in the male subcohort (P < .05 for interaction), with positive effects also on VAT and FM, where men in the intervention group decreased VAT by 175 g (P < .05) and FM by 1364 g (P = .004), compared to the male controls.

    CONCLUSIONS: The present trial demonstrates that 10 weeks of progressive vigorous interval training is sufficient to significantly decrease FM in older adults with central obesity, with positive effects also on LBM.

  • 19.
    Ballin, Marcel
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Niklasson, Johan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Nordström, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. School of Sport Sciences, UiT The Arctic University of Norway, Tromsø, Norway.
    Associations of Objectively Measured Physical Activity and Sedentary Time with the Risk of Stroke, Myocardial Infarction or All‑Cause Mortality in 70‑Year‑Old Men and Women: A Prospective Cohort Study2020In: Sports Medicine, ISSN 0112-1642, E-ISSN 1179-2035, Vol. 51, no 2, p. 339-349Article in journal (Refereed)
    Abstract [en]

    Objective: To study the associations of objectively measured physical activity (PA) and sedentary time (ST) with the combined outcome of incident stroke, myocardial infarction (MI) or all-cause mortality in older adults.

    Methods: N = 3343 men and women aged 70 who participated in a health survey between 2012 and 2017 were included. Actigraph GT3X+ accelerometers were used to measure light-intensity PA (LPA), moderate-intensity PA (MPA) and ST for 1 week. Incident cases of cardiovascular disease (CVD) in terms of stroke or MI, and all-cause mortality were identified using national registers. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using multivariable-adjusted Cox regressions.

    Results: During a mean follow-up of 2.7 years (0.1–5.6), there were 124 events of CVD or all-cause mortality. After adjusting for potential confounders and mediators, every 30-min/day increment in LPA was associated with 11% lower risk of CVD or all-cause mortality (HR 0.89, 95% CI 0.82–0.97), and every 30-min/day increment in MPA was associated with 36% lower risk (HR 0.64, 95% CI 0.48–0.84). Every 1-h/day increment in ST increased the risk of the outcomes by 33% (HR 1.33, 95% CI 1.14–1.56), although there was no significant association among participants who performed ≥ 30 min/day MPA (HR 1.11, 95% CI 0.82–1.50, P = 0.034 for interaction). None of the associations were modified by sex (P > 0.4 for all).

    Conclusion: Objectively measured LPA and MPA are each associated with lower risk of stroke, MI or all-cause mortality in 70-year-old individuals, while ST is associated with increased risk. The greatest risk reduction is observed for MPA, which also appears to attenuate some of the increased risks associated with ST.

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  • 20. Bamia, Christina
    et al.
    Orfanos, Philippos
    Juerges, Hendrik
    Schoettker, Ben
    Brenner, Hermann
    Lorbeer, Roberto
    Aadahl, Mette
    Matthews, Charles E.
    Klinaki, Eleni
    Katsoulis, Michael
    Lagiou, Pagona
    Bueno-de-mesquita, H. B.
    Eriksson, Sture
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Mons, Ute
    Saum, Kai-Uwe
    Kubinova, Ruzena
    Pajak, Andrzej
    Tamosiunas, Abdonas
    Malyutina, Sofia
    Gardiner, Julian
    Peasey, Anne
    de Groot, Lisette C. P. G. M.
    Wilsgaard, Tom
    Boffetta, Paolo
    Trichopoulou, Antonia
    Trichopoulos, Dimitrios
    Self-rated health and all-cause and cause-specific mortality of older adults: Individual data meta-analysis of prospective cohort studies in the CHANCES Consortium2017In: Maturitas, ISSN 0378-5122, E-ISSN 1873-4111, Vol. 103, p. 37-44Article in journal (Refereed)
    Abstract [en]

    Objectives: To evaluate, among the elderly, the association of self-rated health (SRH) with mortality, and to identify determinants of self-rating health as “at-least-good”.

    Study design: Individual data on SRH and important covariates were obtained for 424,791 European and United States residents, ≥60 years at recruitment (1982–2008), in eight prospective studies in the Consortium on Health and Ageing: Network of Cohorts in Europe and the United States (CHANCES). In each study, adjusted mortality ratios (hazard ratios, HRs) in relation to SRH were calculated and subsequently combined with random-effect meta-analyses.

    Main outcome measures: All-cause, cardiovascular and cancer mortality.

    Results: Within the median 12.5 years of follow-up, 93,014 (22%) deaths occurred. SRH “fair” or “poor” vs. “at-least-good” was associated with increased mortality: HRs 1.46 (95% CI 1·23–1.74) and 2.31 (1.79–2.99), respectively. These associations were evident: for cardiovascular and, to a lesser extent, cancer mortality, and within-study, within-subgroup analyses. Accounting for lifestyle, sociodemographic, somatometric factors and, subsequently, for medical history explained only a modest amount of the unadjusted associations. Factors favourably associated with SRH were: sex (males), age (younger-old), education (high), marital status (married/cohabiting), physical activity (active), body mass index (non-obese), alcohol consumption (low to moderate) and previous morbidity (absence).

    Conclusion: SRH provides a quick and simple tool for assessing health and identifying groups of elders at risk of early mortality that may be useful also in clinical settings. Modifying determinants of favourably rating health, e.g. by increasing physical activity and/or by eliminating obesity, may be important for older adults to “feel healthy” and “be healthy”.

  • 21. Bellelli, Giuseppe
    et al.
    Mazzola, Paolo
    Morandi, Alessandro
    Bruni, Adriana
    Carnevali, Lucio
    Corsi, Maurizio
    Zatti, Giovanni
    Zambon, Antonella
    Corrao, Giovanni
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Annoni, Giorgio
    Duration of Postoperative Delirium Is an Independent Predictor of 6-Month Mortality in Older Adults After Hip Fracture2014In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 62, no 7, p. 1335-1340Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To evaluate the association between number of days with delirium and 6-month mortality in elderly adults after hip fracture surgery. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: Orthogeriatric Unit (OGU). PARTICIPANTS: Individuals (mean age = 84.3 +/- 6.4) admitted to the OGU between October 2011 and April 2013 with hip fracture (N = 199). MEASUREMENTS: Postoperative delirium (POD) was assessed daily using the Confusion Assessment Method algorithm and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria. Multivariable Cox regression models were used to evaluate the association between POD of and 6-month mortality after surgery, after adjustment for covariates including age, prefracture residence, Katz activity of daily living score, New Mobility score, diagnosis of prefracture dementia, American Society of Anesthesiologists score, albumin serum levels, Charlson Comorbidity Index, and length of OGU stay. RESULTS: Fifty-seven participants (28.6%) developed POD. In the 6-month period after surgery, 35 (17.6%) participants died: 16 of 57 (28.1%) with POD and 19 / of 142 (13.4%) with no POD. The average duration of POD was 2.0 +/- 3.2 days for participants who died and 0.7 +/- 1.8 days for those who survived (P < .001). After adjusting for covariates, each day of POD in the OGU increased the hazard of dying at 6 months by 17% (hazard ratio = 1.17, 95% confidence interval = 1.07-1.28). CONCLUSION: In older adults undergoing hip fracture surgery, duration of POD is an important prognostic factor for 6-month mortality. Efforts to reduce duration of POD are therefore crucial for these individuals.

  • 22. Benetou, V.
    et al.
    Orfanos, P
    Feskanich, D
    Michaëlsson, K
    Pettersson-Kymmer, Ulrika
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Ahmed, L A
    Peasey, A
    Wolk, A
    Brenner, H
    Bobak, M
    Wilsgaard, T
    Schöttker, B
    Saum, K-U
    Bellavia, A
    Grodstein, F
    Klinaki, E
    Valanou, E
    Papatesta, E-M
    Boffetta, P
    Trichopoulou, A
    Education, marital status, and risk of hip fractures in older men and women: the CHANCES project2015In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 26, no 6, p. 1733-1746Article in journal (Refereed)
    Abstract [en]

    The role of socioeconomic status in hip fracture incidence is unclear. In a diverse population of elderly, higher education was found to be associated with lower, whereas living alone, compared to being married/cohabiting, with higher hip fracture risk. Educational level and marital status may contribute to hip fracture risk.

    INTRODUCTION: The evidence on the association between socioeconomic status and hip fracture incidence is limited and inconsistent. We investigated the potential association of education and marital status with hip fracture incidence in older individuals from Europe and USA.

    METHODS: A total of 155,940 participants (79 % women) aged 60 years and older from seven cohorts were followed up accumulating 6456 incident hip fractures. Information on education and marital status was harmonized across cohorts. Hip fractures were ascertained through telephone interviews/questionnaires or through record linkage with registries. Associations were assessed through Cox proportional hazard regression adjusting for several factors. Summary estimates were derived using random effects models.

    RESULTS: Individuals with higher education, compared to those with low education, had lower hip fracture risk [hazard ratio (HR) = 0.84, 95 % confidence interval (CI) 0.72-0.95]. Respective HRs were 0.97 (95 % CI 0.82-1.13) for men and 0.75 (95 % CI 0.65-0.85) for women. Overall, individuals living alone, especially those aged 60-69 years, compared to those being married/cohabiting, tended to have a higher hip fracture risk (HR = 1.12, 95 % CI 1.02-1.22). There was no suggestion for heterogeneity across cohorts (P heterogeneity > 0.05).

    CONCLUSIONS: The combined data from >150,000 individuals 60 years and older suggest that higher education may contribute to lower hip fracture risk. Furthermore, this risk may be higher among individuals living alone, especially among the age group 60-69 years, when compared to those being married/cohabiting.

  • 23. Benetou, V.
    et al.
    Orfanos, P.
    Feskanich, D.
    Michaëlsson, K.
    Pettersson-Kymmer, Ulrika
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research. Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
    Byberg, L.
    Eriksson, Sture
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Grodstein, F.
    Wolk, A.
    Jankovic, N.
    de Groot, L. C. P. G. M.
    Boffetta, P.
    Trichopoulou, A.
    Mediterranean diet and hip fracture incidence among older adults: the CHANCES project2018In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 29, no 7, p. 1591-1599Article in journal (Refereed)
    Abstract [en]

    The association between adherence to Mediterranean diet (MD) and hip fracture incidence is not yet established. In a diverse population of elderly, increased adherence to MD was associated with lower hip fracture incidence. Except preventing major chronic diseases, adhering to MD might have additional benefits in lowering hip fracture risk.

    INTRODUCTION: Hip fractures constitute a major public health problem among older adults. Latest evidence links adherence to Mediterranean diet (MD) with reduced hip fracture risk, but still more research is needed to elucidate this relationship. The potential association of adherence to MD with hip fracture incidence was explored among older adults.

    METHODS: A total of 140,775 adults (116,176 women, 24,599 men) 60 years and older, from five cohorts from Europe and the USA, were followed-up for 1,896,219 person-years experiencing 5454 hip fractures. Diet was assessed at baseline by validated, cohort-specific, food-frequency questionnaires, and hip fractures were ascertained through patient registers or telephone interviews/questionnaires. Adherence to MD was evaluated by a scoring system on a 10-point scale modified to be applied also to non-Mediterranean populations. In order to evaluate the association between MD and hip fracture incidence, cohort-specific hazard ratios (HR), adjusted for potential confounders, were estimated using Cox proportional-hazards regression and pooled estimates were subsequently derived implementing random-effects meta-analysis.

    RESULTS: A two-point increase in the score was associated with a significant 4% decrease in hip fracture risk (pooled adjusted HR 0.96; 95% confidence interval (95% CI) 0.92-0.99, pheterogeneity = 0.446). In categorical analyses, hip fracture risk was lower among men and women with moderate (HR 0.93; 95% CI 0.87-0.99) and high (HR 0.94; 95% CI 0.87-1.01) adherence to the score compared with those with low adherence.

    CONCLUSIONS: In this large sample of older adults from Europe and the USA, increased adherence to MD was associated with lower hip fracture incidence.

  • 24. Benetou, V
    et al.
    Orfanos, P
    Zylis, D
    Sieri, S
    Contiero, P
    Tumino, R
    Giurdanella, M C
    Peeters, P H M
    Linseisen, J
    Nieters, A
    Boeing, H
    Weikert, C
    Pettersson, U
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Pharmacology.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology, Cariology.
    Bueno-de-Mesquita, H B
    Dorronsoro, M
    Boffetta, P
    Trichopoulou, A
    Diet and hip fractures among elderly Europeans in the EPIC cohort2011In: European Journal of Clinical Nutrition, ISSN 0954-3007, E-ISSN 1476-5640, Vol. 65, no 1, p. 132-139Article in journal (Refereed)
    Abstract [en]

    In a prospective study of the elderly, diet, including consumption of dairy products, alcohol and vitamin D, did not appear to play a major role in hip fracture incidence. There is however, weak and statistically non-significant evidence that vegetable and fish consumption and intake of polyunsaturated lipids may have a beneficial, whereas saturated lipid intake a detrimental effect.

  • 25.
    Bergdahl, Ellinor
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Allard, Per
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Depression among the very old with dementia2011In: International psychogeriatrics, ISSN 1041-6102, E-ISSN 1741-203X, Vol. 23, no 5, p. 756-763Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of this study was to investigate the prevalence of depression among very old individuals with dementia compared to those without dementia and to examine if there were any differences regarding associated factors between people with or without depression in these conditions.

    Methods: In a population-based study in Sweden, 363 participants aged 85 years and above, were evaluated for depression and dementia.

    Results: The prevalence of depression was significantly higher among the people with dementia than without dementia, 43% vs. 24% (p < 0.001). Approximately 2/3 of the depressed in both groups used antidepressants and of those, approximately 50% had responded. Depression in the group without dementia was, among other factors, associated with higher total number of medication, the use of significant more analgesics and benzodiazepines, loneliness, inability of going outside and recent loss of child. The loss of a child was the only factor that was independently associated with depression in those with dementia.

    Conclusions: The present study confirms that in the very old, depression is more common among people with dementia than without dementia. A large proportion, both with and without dementia, are under-diagnosed and untreated, and in addition many subjects in both groups studied were non-responders to treatment. Many of the factors associated with depression among people without dementia in this study were not associated with depression among those with dementia, thus supporting the theory that the spectrum of associated factors for depression in dementia seems to be different from that for depression in people without dementia.

  • 26.
    Berggren, Monica
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Karlsson, Åsa
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Lindelöf, Nina
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Englund, Undis
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics. Umeå University, Faculty of Medicine, Department of Nursing.
    Nordstöm, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Stenvall, Michael
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Effects of geriatric interdisciplinary home rehabilitation on complications and readmissions after hip fracture: a randomized controlled trial2019In: Clinical Rehabilitation, ISSN 0269-2155, E-ISSN 1477-0873, Vol. 33, no 1, p. 64-73Article in journal (Refereed)
    Abstract [en]

    Objective: This pre-planned secondary analysis of geriatric interdisciplinary home rehabilitation, which was initially found to shorten the postoperative length of stay in hospital for older individuals following hip fracture, investigated whether such rehabilitation reduced the numbers of complications, readmissions, and total days spent in hospital after discharge during a 12-month follow-up period compared with conventional geriatric care and rehabilitation.

    Design: Randomized controlled trial.

    Setting: Geriatric department, participants' residential care facilities, and ordinary housing.

    Subjects: Individuals aged ⩾70 years with acute hip fracture (n = 205) were included.

    Intervention: Geriatric interdisciplinary home rehabilitation was individually designed and aimed at early discharge with the intention to prevent, detect, and treat complications after discharge.

    Main measures: Complications, readmissions, and days spent in hospital were registered from patients' digital records and interviews conducted during hospitalization and at 3- and 12-month follow-up visits.

    Results: No significant difference in outcomes was observed. Between discharge and the 12-month follow-up, among participants in the geriatric interdisciplinary home rehabilitation group (n = 106) and control group (n = 93), 57 (53.8%) and 44 (47.3%) had complications (P = 0.443), 46 (43.4%) and 38 (40.9%) fell (P = 0.828), and 38 (35.8%) and 27 (29.0%) were readmitted to hospital (P = 0.383); the median total days spent in hospital were 11.5 and 11.0 (P = 0.353), respectively.

    Conclusion: Geriatric interdisciplinary home rehabilitation for older individuals following hip fracture resulted in similar proportions of complications, readmissions, and total days spent in hospital after discharge compared with conventional geriatric care and rehabilitation.

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  • 27.
    Berggren, Monica
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Stenvall, Michael
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Englund, Undis
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Co-morbidities, complications and causes of death among people with femoral neck fracture: a three-year follow-up study2016In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 16, article id 120Article in journal (Refereed)
    Abstract [en]

    Background: The poor outcome after a hip fracture is not fully understood. The aim of the study was to describe the prevalence of co-morbidities, complications and causes of death and to investigate factors that are able to predict mortality in old people with femoral neck fracture. Methods: Data was obtained from a randomized, controlled trial with a 3-year follow-up at Umea University Hospital, Sweden, which included 199 consecutive patients with femoral neck fracture, aged >= 70 years. The participants were assessed during hospitalization and in their homes 4, 12 and 36 months after surgery. Medical records and death certificates were analysed. Results: Multivariate analysis revealed that cancer, dependence in P-ADL (Personal Activities of Daily Living), cardiovascular disease, dementia at baseline or pulmonary emboli or cardiac failure during hospitalization were all independent predictors of 3-year mortality. Seventy-nine out of 199 participants (40 %) died within 3 years. Cardiovascular events (24 %), dementia (23 %), hip-fracture (19 %) and cancer (13 %) were the most common primary causes of death. In total, 136 participants suffered at least one urinary tract infection; 114 suffered 542 falls and 37 sustained 56 new fractures, including 13 hip fractures, during follow-up. Conclusion: Old people with femoral neck fracture have multiple co-morbidities and suffer numerous complications. Thus randomized intervention studies should focus on prevention of complications that might be avoidable such as infections, heart diseases, falls and fractures.

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  • 28.
    Berggren, Monica
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Stenvall, Michael
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, Birgitta
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Evaluation of a fall-prevention program in older people after femoral neck fracture: a one-year follow-up2008In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 19, no 6, p. 801-809Article in journal (Refereed)
    Abstract [en]

    A randomized, controlled fall-prevention study including 199 patients operated on for femoral neck fracture reduced inpatient falls and injuries. No statistically significant effects of the intervention program could be detected after discharge. It seems that fall-prevention must be part of everyday life in fall-prone old people. Introduction This study evaluates whether a postoperative multidisciplinary, multifactorial fall-prevention program performed by a geriatric team that reduced inpatient falls and injuries had any continuing effect after discharge. The intervention consisted of staff education, systematic assessment and treatment of fall risk factors and vitamin D and calcium supplementation. Methods The randomized, controlled trial with a one-year follow-up at Umea University Hospital, Sweden, included 199 patients operated on for femoral neck fracture, aged >= 70 years. Results After one year 44 participants had fallen 138 times in the intervention group compared with 55 participants and 191 falls in the control group. The crude postoperative fall incidence was 4.16/1,000 days in the intervention group vs. 6.43/1,000 days in the control group. The incidence rate ratio was 0.64 (95% CI: 0.40-1.02, p = 0.063). Seven new fractures occurred in the intervention group and 11 in the control group. Conclusion A team applying comprehensive geriatric assessment and rehabilitation, including prevention and treatment of fall-risk factors, reduced inpatient falls and injuries, but no statistically significant effects of the program could be detected after discharge. It seems that fall-prevention must be part of everyday life in fall-prone elderly.

  • 29.
    Berginström, Nils
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Johansson, Jonas
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Nordström, Anna
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Attention in Older Adults: A Normative Study of the Integrated Visual and Auditory Continuous Performance Test for Persons Aged 70 Years2015In: Clinical Neuropsychologist (Neuropsychology, Development and Cognition: Section D), ISSN 1385-4046, E-ISSN 1744-4144, Vol. 29, no 5, p. 595-610Article in journal (Refereed)
    Abstract [en]

    Objective: Our objective was to present normative data from 70-year-olds on the Integrated Visual and Auditory Continuous Performance Test (IVA), a computerized measure of attention and response control. Method: 640 participants (330 men and 310 women), all aged 70years, completed the IVA, as well as the Mini-Mental State Examination and the Geriatric Depression Scale. Results: Data were stratified by education and gender. Education differences were found in 11 of 22 IVA scales. Minor gender differences were found in six scales for the high-education group, and two scales for the low-education group. Comparisons of healthy participants and participants with stroke, myocardial infarction, or diabetes showed only minor differences. Correlations among IVA scales were strong (all r > .34, p < .001), and those with the widely used Mini-Mental State Examination were weaker (all r < .21, p < .05). Skewed distributions of normative data from primary IVA scales measuring response inhibition (Prudence) and inattention (Vigilance) represent a weakness of this test. Conclusions: This study provides IVA norms for 70-year-olds stratified by education and gender, increasing the usability of this instrument when testing persons near this age. The data presented here show some major differences from original IVA norms, and explanations for these differences are discussed. Explanations include the broad age-range used in the original IVA norms (66-99years of age) and the passage of 15years since the original norms were collected.

  • 30.
    Bergman, Jonathan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Benefits and harms of Bisphosphonates: an observational study2022Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Bisphosphonates are first-line treatment for osteoporosis, but osteoporosis is considered an undertreated disease. The general aim of this dissertation was to further study the benefits and harms of bisphosphonates. There were four specific research questions: (1) Do bisphosphonates reduce the risk of new fractures in older adults who have a history of fracture? (2) Do bisphosphonates reduce the risk of fracture in people taking glucocorticoids? (3) Does confounding explain why bisphosphonates are associated with lower mortality in observational studies? (4) Do bisphosphonates increase the risk of non-jaw osteonecrosis?

    Methods: To answer these questions, we used Swedish register data on deaths, diagnoses, and prescription medications to conduct four matched cohort studies of bisphosphonate users and nonusers. The cohorts were selected from patients registered in the Hip Fracture Register and from all residents of Sweden who were aged 50 years or older on December 31, 2005.

    Results: (1) Bisphosphonate users had an initially increased risk of sustaining new fractures, which appeared to be due to an underlying high risk of fracture. This increased risk diminished over time, which is consistent with a gradual treatment effect, but it is also consistent with a bias known as depletion of susceptibles. (2) Bisphosphonate users had a lower risk of fracture during glucocorticoid therapy. (3) Bisphosphonate users had a lower mortality rate from day 2 of treatment. Although such an early treatment effect cannot be ruled out, this finding is consistent with confounding. (4) Bisphosphonate users had an increased risk of developing non-jaw osteonecrosis. 

    Conclusion: Most of the results were difficult to interpret as true benefits or harms of bisphosphonates because alternative explanations, arising from bias or confounding, were likely. The exception was the results of Study 2, where alternative explanations are more difficult to find. Therefore, Study 2 suggests that bisphosphonates reduce the risk of fractures in glucocorticoid-treated patients. Further research is needed to clarify the potential effects of bisphosphonates on mortality, non-jaw osteonecrosis, and new fractures after a previous fracture.

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  • 31.
    Bergman, Jonathan
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Nordström, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. School of Sport Sciences, UiT Arctic University of Norway, Postboks 1621, 9509, Alta, Norway.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Epidemiology of osteonecrosis among older adults in Sweden2019In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 30, no 5, p. 965-973Article in journal (Refereed)
    Abstract [en]

    Summary: This study estimated the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults. Osteonecrosis was approximately 10 times more common than in previous studies. The strongest risk factors were dialysis, hip fracture, osteomyelitis, and organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

    Introduction: The aim of this study was to estimate the incidence of osteonecrosis in a Swedish, nationwide cohort of older adults and in a large number of risk groups in that cohort.

    Methods: In this retrospective cohort study, we included everyone who was aged 50 years or older and who was living in Sweden on 31 December 2005. We used Swedish national databases to collect data about prescription medication use, diagnosed medical conditions, and performed medical and surgical procedures. The study outcome was diagnosis of primary or secondary osteonecrosis at any skeletal site. The strength of risk factors was assessed using age- and sex-standardized incidence ratios (SIRs).

    Results: The study cohort comprised 3,338,463 adults. The 10-year risk of osteonecrosis was 0.4% (n = 13,425), and the incidence rate was 4.7 cases/10000 person-years (95% confidence interval [CI], 4.6 to 4.7 cases). The strongest risk factors for osteonecrosis were hip fracture (SIR, 7.98; 95% CI, 7.69–8.27), solid organ transplantation (SIR, 7.14; 95% CI, 5.59–8.99), dialysis (SIR, 6.65; 95% CI, 5.62–7.81), and osteomyelitis (SIR, 6.43; 95% CI, 5.70–7.23). A history of hip fracture was present in 21.7% of cases of osteonecrosis, but osteomyelitis, dialysis, and solid organ transplantation were present in only 0.5 to 2% of cases.

    Conclusions: Osteonecrosis was approximately 10 times more common than a small number of previous population-based studies have suggested. The strongest risk factors for osteonecrosis were dialysis, hip fracture, osteomyelitis, and solid organ transplantation, but only hip fractures could have contributed substantially to the disease burden.

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  • 32.
    Bergström, Ulrica
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Jonsson, H
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Olofsson, B
    Pettersson, U
    Svensson, O
    Serial fractures - age and fracture site important predictors for a second fracture: results from 13-years population based dataManuscript (Other academic)
  • 33.
    Bixo, Marie
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Ovarian steroids in rat and human brain: effects of different endocrine states1987Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Ovarian steroid hormones are known to produce several different effects in the brain. In addition to their role in gonadotropin release, ovulation and sexual behaviour they also seem to affect mood and emotions, as shown in women with the premenstrual tension syndrome. Some steroids have the ability to affect brain excitability. Estradiol decreases the electroshock threshold while progesterone acts as an anti-convulsant and anaesthetic in both animals and humans. Several earlier studies have shown a specific uptake of several steroids in the animal brain but only a few recent studies have established the presence of steroids in the human brain.

    In the present studies, the dissections of rat and human brains were carried out macroscopically and areas that are considered to be related to steroid effects were chosen. Steroid concentrations were measured by radioimmunoassay after extraction and separation with celite chromatography. The accuracy and specificity of these methods were estimated.

    In the animal studies, immature female rats were treated with Pregnant Mare's Serum Gonadotropin (PMSG) to induce simultaneous ovulations. Concentrations of estradiol and progesterone were measured in seven brain areas pre- and postovulatory. The highest concentration of estradiol, pre- and postovulatory, was found in the hypothalamus and differences between the two cycle phases were detected in most brain areas. The preovulatory concentrations of progesterone were low and the highest postovulatory concentration was found in the cerebral cortex.

    In one study, the rats were injected with pharmacological doses of progesterone to induce "anaesthesia". High uptake of progesterone was found and a regional variation in the formation of 5<*-pregnane-3,20-dione in the brain with the highest ratio in the medulla oblongata.

    Concentrations of progesterone, 5a-pregnane-3*20-dione, estradiol and testosterone were determined in 17 brain areas of fertile compared to postmenopausal women. All steroids displayed regional differences in brain concentrations. Higher concentrations of estradiol and progesterone were found in the fertile compared to the postmenopausal women.

    In summary, these studies show that the concentrations of ovarian steroids in the brain are different at different endocrine states in both rats and humans and that there are regional differences in brain steroid distribution.

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  • 34.
    Björk, Sabine
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Juthberg, Christina
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Wimo, Anders
    Sandman, Per-Olof
    Umeå University, Faculty of Medicine, Department of Nursing. Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet; Department of Health Sciences, Luleå University of Technology.
    Winblad, Bengt
    Edvardsson, David
    Umeå University, Faculty of Medicine, Department of Nursing. School of Nursing and Midwifery, La Trobe University.
    Exploring the prevalence and variance of cognitive impairment, pain, neuropsychiatric symptoms and ADL dependency among persons living in nursing homes: a cross-sectional study2016In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 16, article id 154Article in journal (Refereed)
    Abstract [en]

    Background: Earlier studies in nursing homes show a high prevalence of cognitive impairment, dependency in activities of daily living (ADL), pain, and neuropsychiatric symptoms among residents. The aim of this study was to explore the prevalence of the above among residents in a nationally representative sample of Swedish nursing homes, and to investigate whether pain and neuropsychiatric symptoms differ in relation to gender, cognitive function, ADL-capacity, type of nursing-home unit and length of stay. Methods: Cross-sectional data from 188 randomly selected nursing homes were collected. A total of 4831 residents were assessed for cognitive and ADL function, pain and neuropsychiatric symptoms. Data were analysed using descriptive statistics and the chi-square test. Results: The results show the following: the prevalence of cognitive impairment was 67 %, 56 % of residents were ADL-dependent, 48 % exhibited pain and 92 % exhibited neuropsychiatric symptoms. The prevalence of pain did not differ significantly between male and female residents, but pain was more prevalent among cognitively impaired and ADL-dependent residents. Pain prevalence was not significantly different between residents in special care units for people with dementia (SCU) and general units, or between shorter-and longer-stay residents. Furthermore, the prevalence of neuropsychiatric symptoms did not differ significantly between male and female residents, between ADL capacities or in relation to length of stay. However, residents with cognitive impairment and residents in SCUs had a significantly higher prevalence of neuropsychiatric symptoms than residents without cognitive impairment and residents in general units. Conclusions: The prevalence rates ascertained in this study could contribute to a greater understanding of the needs of nursing-home residents, and may provide nursing home staff and managers with trustworthy assessment scales and benchmark values for further quality assessment purposes, clinical development work and initiating future nursing assessments.

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  • 35.
    Björk, Sabine
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lövheim, Hugo
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Wimo, Anders
    Edvardsson, David
    Umeå University, Faculty of Medicine, Department of Nursing. School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.
    Thriving in relation to cognitive impairment and neuropsychiatric symptoms in Swedish nursing home residents2018In: International Journal of Geriatric Psychiatry, ISSN 0885-6230, E-ISSN 1099-1166, Vol. 33, no 1, p. E49-E57Article in journal (Refereed)
    Abstract [en]

    Objectives: The purpose of this study was to explore relations among thriving, cognitive function, and neuropsychiatric symptoms (NPS) in nursing home residents.

    Methods: A national, cross-sectional, randomized study of Swedish nursing home residents (N = 4831) was conducted between November 2013 and September 2014. Activities of daily life functioning, cognitive functioning, NPS, and thriving were assessed with the Katz activities of daily living, Gottfries' Cognitive Scale, Nursing Home version of the Neuropsychiatric Inventory, and Thriving of Older People Scale, respectively. Individual NPS were explored in relation to cognitive function. Simple linear and multiple regression models were used to explore thriving in relation to resident characteristics.

    Results: Aggression and depressive symptoms were identified as negatively associated with thriving regardless of resident cognitive functioning. At higher levels of cognitive functioning, several factors showed associations with thriving; however, at lower levels of cognitive functioning, only the degree of cognitive impairment and the NPS was associated with thriving. Most of the individual NPS formed nonlinear relationships with cognitive functioning with higher symptom scores in the middle stages of cognitive functioning. Exceptions were elation/euphoria and apathy, which increased linearly with severity of cognitive impairment.

    Conclusions: The lower the cognitive functioning was, the fewer factors were associated with thriving. Aggression and depressive symptoms may indicate lower levels of thriving; thus, targeting these symptoms should be a priority in nursing homes.

  • 36. Blain, H.
    et al.
    Masud, T.
    Dargent-Molina, P.
    Martin, F. C.
    Rosendahl, Erik
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    van der Velde, N.
    Bousquet, J.
    Benetos, A.
    Cooper, C.
    Kanis, J. A.
    Reginster, J. Y.
    Rizzoli, R.
    Cortet, B.
    Barbagallo, M.
    Dreinhoefer, K. E.
    Vellas, B.
    Maggi, S.
    Strandberg, T.
    A comprehensive fracture prevention strategy in older adults: the European Union Geriatric Medicine Society (EUGMS) statement2016In: Aging Clinical and Experimental Research, ISSN 1594-0667, E-ISSN 1720-8319, Vol. 28, no 4, p. 797-803Article in journal (Refereed)
    Abstract [en]

    Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society, in collaboration with the International Association of Gerontology and Geriatrics for the European Region, the European Union of Medical Specialists, and the International Osteoporosis Foundation-European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

  • 37. Blain, H.
    et al.
    Masud, T.
    Dargent-Molina, P.
    Martin, F. C.
    Rosendahl, Erik
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    van der Velde, N.
    Bousquet, J.
    Benetos, A.
    Cooper, C.
    Kanis, J. A.
    Reginster, J. Y.
    Rizzoli, R.
    Cortet, B.
    Barbagallo, M.
    Dreinhofer, K. E.
    Vellas, B.
    Maggi, S.
    Strandberg, T.
    A comprehensive fracture prevention strategy in older adults: the European Union Geriatric Medicine Society (EUGMS) statement2016In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 20, no 6, p. 647-652Article in journal (Refereed)
    Abstract [en]

    Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society (EUGMS), in collaboration with the International Association of Gerontology and Geriatrics for the European Region (IAGG-ER), the European Union of Medical Specialists (EUMS), the International Osteoporosis Foundation - European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

  • 38. Blain, H.
    et al.
    Masud, T.
    Dargent-Molina, P.
    Martin, F. C.
    Rosendahl, Erik
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    van der Velde, N.
    Bousquet, J.
    Benetos, A.
    Cooper, C.
    Kanis, J. A.
    Reginster, J. Y.
    Rizzoli, R.
    Cortet, B.
    Barbagallo, M.
    Dreinhöfer, K.
    Vellas, B.
    Maggi, S.
    Strandberg, T.
    Alvarez, M. N.
    Annweiler, C.
    Bernard, P. -L
    Beswetherick, N.
    Bischoff-Ferrari, H. A.
    Bloch, F.
    Boddaert, J.
    Bonnefoy, M.
    Bousson, V.
    Bourdel-Marchasson, I.
    Capisizu, A.
    Che, H.
    Clara, J. G.
    Combe, B.
    Delignieres, D.
    Eklund, Patrik
    Umeå University, Faculty of Science and Technology, Department of Computing Science.
    Emmelot-Vonk, M.
    Freiberger, E.
    Gauvain, J. -B
    Goswami, N.
    Guldemond, N.
    Herrero, A. C.
    Joel, M. -E
    Jonsdottir, A. B.
    Kemoun, G.
    Kiss, I.
    Kolk, H.
    Kowalski, M. L.
    Krajcik, S.
    Kutsal, Y. G.
    Lauretani, F.
    Macijauskiene, J.
    Mellingsaeter, M.
    Morel, J.
    Mourey, F.
    Nourashemi, F.
    Nyakas, C.
    Puisieux, F.
    Rambourg, P.
    Ramirez, A. G.
    Rapp, K.
    Rolland, Y.
    Ryg, J.
    Sahota, O.
    Snoeijs, S.
    Stephan, Y.
    Thomas, E.
    Todd, C.
    Treml, J.
    Adachi, R.
    Agnusdei, D.
    Body, J. -J
    Breuil, V.
    Bruyere, O.
    Burckardt, P.
    Cannata-Andia, J. B.
    Carey, J.
    Chan, D. -C
    Chapuis, L.
    Chevalley, T.
    Cohen-Solal, M.
    Dawson-Hughes, B.
    Dennison, E. M.
    Devogelaer, J. -P
    Fardellone, P.
    Feron, J. -M
    Perez, A. D.
    Felsenberg, D.
    Glueer, C.
    Harvey, N.
    Hiligsman, M.
    Javaid, M. K.
    Jorgensen, N. R.
    Kendler, D.
    Kraenzlin, M.
    Laroche, M.
    Legrand, E.
    Leslie, W. D.
    Lespessailles, E.
    Lewiecki, E. M.
    Nakamura, T.
    Papaioannou, A.
    Roux, C.
    Silverman, S.
    Henriquez, M. S.
    Thomas, T.
    Vasikaran, S.
    Watts, N. B.
    Weryha, G.
    A comprehensive fracture prevention strategy in older adults: the European union geriatric medicine society (EUGMS) statement2016In: European Geriatric Medicine, ISSN 1878-7649, E-ISSN 1878-7657, Vol. 7, no 6, p. 519-525Article in journal (Refereed)
    Abstract [en]

    Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest group on falls and fracture prevention of the European union geriatric medicine society (EUGMS), in collaboration with the International association of gerontology and geriatrics for the European region (IAGG-ER), the European union of medical specialists (EUMS), the Fragility fracture network (FFN), the International osteoporosis foundation (IOF) - European society for clinical and economic aspects of osteoporosis and osteoarthritis (ECCEO), outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

  • 39. Boffetta, Paolo
    et al.
    Bobak, Martin
    Borsch-Supan, Axel
    Brenner, Hermann
    Eriksson, Sture
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Grodstein, Fran
    Jansen, Eugene
    Jenab, Mazda
    Juerges, Hendrik
    Kampman, Ellen
    Kee, Frank
    Kuulasmaa, Kari
    Park, Yikyung
    Tjonneland, Anne
    van Duijn, Cornelia
    Wilsgaard, Tom
    Wolk, Alicja
    Trichopoulos, Dimitrios
    Bamia, Christina
    Trichopoulou, Antonia
    The Consortium on Health and Ageing: Network of Cohorts in Europe and the United States (CHANCES) project-design, population and data harmonization of a large-scale, international study2014In: European Journal of Epidemiology, ISSN 0393-2990, E-ISSN 1573-7284, Vol. 29, no 12, p. 929-936Article in journal (Refereed)
    Abstract [en]

    There is a public health demand to prevent health conditions which lead to increased morbidity and mortality among the rapidly-increasing elderly population. Data for the incidence of such conditions exist in cohort studies worldwide, which, however, differ in various aspects. The Consortium on Health and Ageing: Network of Cohorts in Europe and the United States (CHANCES) project aims at harmonizing data from existing major longitudinal studies for the elderly whilst focussing on cardiovascular diseases, diabetes mellitus, cancer, fractures and cognitive impairment in order to estimate their prevalence, incidence and cause-specific mortality, and identify lifestyle, socioeconomic, and genetic determinants and biomarkers for the incidence of and mortality from these conditions. A survey instrument assessing ageing-related conditions of the elderly will be also developed. Fourteen cohort studies participate in CHANCES with 683,228 elderly (and 150,210 deaths), from 23 European and three non-European countries. So far, 287 variables on health conditions and a variety of exposures, including biomarkers and genetic data have been harmonized. Different research hypotheses are investigated with meta-analyses. The results which will be produced can help international organizations, governments and policy-makers to better understand the broader implications and consequences of ageing and thus make informed decisions.

  • 40.
    Boman, Erika
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Faculty of Nursing, Åland University of Applied Sciences, Mariehamn, Finland.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Häggblom, Anette
    Faculty of Nursing, Åland University of Applied Sciences, Mariehamn, Finland.
    Santamäki Fischer, Regina
    Umeå University, Faculty of Medicine, Department of Nursing. Faculty of Nursing, Åland University of Applied Sciences, Mariehamn, Finland.
    Nygren, Björn
    Umeå University, Faculty of Medicine, Department of Nursing.
    Inner strength: associated with reduced prevalence of depression among older women2015In: Aging & Mental Health, ISSN 1360-7863, E-ISSN 1364-6915, Vol. 19, no 12, p. 1078-1083Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim of this study was to explore if inner strength is independently associated with a reduced prevalence of depression after controlling for other known risk factors associated with depression.

    Methods: A population-based cross-sectional study was performed, where all women living in Åland, a Finnish self-govern island community in the Baltic Sea, aged 65 years or older were sent a questionnaire including the Geriatric Depression Scale and the Inner Strength Scale along with several other questions related to depression. Factors associated with depression were analyzed by means of multivariate logistic regression.

    Results: The results showed that 11.2% of the studied women (n = 1452) were depressed and that the prevalence increased with age and was as high as 20% in the oldest age group. Non-depressed women were more likely to never or seldom feel lonely, have a strong inner strength, take fewer prescription drugs, feeling needed, being able to engage in meaningful leisure activities, as well as cohabit.

    Conclusion: Our results showed an association between stronger inner strength and being non-depressed. This can be interpreted to mean that inner strength might have a protective effect against depression. These findings are interesting from a health-promotion perspective, yet to verify these results, further longitudinal studies are required.

  • 41.
    Boström, Gustaf
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Depression in older people with and without dementia: non-pharmacological interventions and associations between psychotropic drugs and mortality2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The aim of this thesis was to investigate associations between psychotropic drug use and death, associations between functional capacity, dependency in ADL and depression, and to evaluate a non-pharmacological intervention to reduce depressive symptoms, among older people with and without dementia.

    There is limited knowledge about the risk of death associated with psychotropic drug use among those aged ≥85 years, those with dementia, or those living in residential care facilities; groups that have a higher intake of psychotropic drugs and who are also more prone to adverse drug reactions. In a representative sample of people ≥85 years (n = 992), baseline antidepressant use was not associated with an increased 5-year mortality risk when adjusting for confounding factors. A significant interaction between gender and antidepressant use was found, with a higher mortality risk in women, than in men.  When analyzing men and women separately, no significant associations were found. In a sample of older people (i.e. ≥65 years) with dementia (n = 1037), there was a significant gender difference in 2-year mortality associated with the baseline use of antidepressant drugs, with a lower mortality risk in men, than in women. In men, the mortality risk was significantly reduced with antidepressant use, while there was no significant association in women. The association between baseline use of benzodiazepines and mortality had a tendency toward an increased risk during the first year of follow-up, although this became non-significant after adjustments. In this time period, the interaction term for sex was significant, with a higher mortality risk among men than women. When the sexes were analyzed separately, no significant associations were found. No significant associations were found between baseline use of antipsychotic drugs and mortality.

    Drug treatment for depression seems to have a limited effect in older people and may have no effect in people with dementia. In order to find alternative ways of treating or preventing depression in older age, it is important to increase our knowledge about factors associated with this condition. Functional capacity and dependency in activities of daily living (ADL) are associated with depression in community-dwelling older people. However, it is uncertain whether the same associations are to be found in very old people (i.e. ≥80 years), including those with severe cognitive or physical impairments. In a heterogeneous sample (n = 392) with a high mean age, a large range of cognitive and functional capacity, a wide spectrum of dependency in ADL, and a high prevalence of comorbidities, depressive symptoms were significantly associated with functional balance capacity, but not with overall dependency in ADL. Among individual ADL tasks, dependency in transfer and dressing were associated with depressive symptoms.

    Physical exercise has shown effect sizes similar to those of antidepressants in reducing depressive symptoms among older people without dementia, with moderate–high-intensity exercise being more effective than low-intensity exercise. However, these effects are unclear among older people with dementia. Care-facility residents with dementia (n = 186) were cluster-randomized to a high-intensity functional exercise program or a non-exercise control activity conducted for 45 minutes every other weekday for 4 months. No significant difference between the exercise and control activity was found in depressive symptoms at 4 or 7 months. Among participants with high levels of depressive symptoms, reductions were observed in both the exercise and control groups at 4 and 7 months.

    In conclusion, ongoing treatment at baseline with any of the three psychotropic drug classes antidepressants, antipsychotics and benzodiazepines did not increase the risk of mortality in older people with dementia.  Neither did antidepressant drugs in very old people. In both samples, gender differences were found in the mortality risk due to antidepressant use. In those with dementia, the mortality risk due to benzodiazepine use also differed by gender. The potential risk from initial treatment and gender differences regarding mortality risk require further investigation in randomized controlled trials or in large cohort studies properly controlled for confounding factors. In older people, living in community and residential care facilities, functional capacity seems to be independently associated with depressive symptoms whereas overall ADL performance may not be associated. Dependency in the individual ADL tasks of transfer and dressing appear to be independently associated with depressive symptoms and may be an important focus for future interdisciplinary multifactorial intervention studies. Among older people with dementia living in residential care facilities, a 4-month high-intensity functional exercise program has no superior effect on depressive symptoms than a control activity. Both exercise and non-exercise group activities may reduce high levels of depressive symptoms. However, this finding must be confirmed in three-armed randomized controlled trials including control groups receiving standard care.

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  • 42.
    Boström, Gustaf
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Conradsson, Mia
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Hörnsten, Carl
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Rosendahl, Erik
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Lindelöf, Nina
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Holmberg, Henrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Littbrand, Håkan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Effects of a high-intensity functional exercise program on depressive symptoms among people with dementia in residential care: a randomized controlled trial2016In: International Journal of Geriatric Psychiatry, ISSN 0885-6230, E-ISSN 1099-1166, Vol. 31, no 8, p. 868-878Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The aim of this study is to evaluate the effect of a high-intensity functional exercise program on depressive symptoms among older care facility residents with dementia.

    METHODS: Residents (n = 186) with a diagnosis of dementia, age ≥ 65 years, Mini-Mental State Examination score ≥ 10, and dependence in activities of daily living were included. Participants were randomized to a high-intensity functional exercise program or a non-exercise control activity conducted 45 min every other weekday for 4 months. The 15-item Geriatric Depression Scale (GDS) and the Montgomery-Åsberg Depression Rating Scale (MADRS) were administered by blinded assessors at baseline, 4, and 7 months.

    RESULTS: No difference between the exercise and control activity was found in GDS or MADRS score at 4 or 7 months. Among participants with GDS scores ≥ 5, reductions in GDS score were observed in the exercise and control groups at 4 months (-1.58, P = 0.001 and -1.54, P = 0.004) and 7 months (-1.25, P = 0.01 and -1.45, P = 0.007). Among participants with MADRS scores ≥ 7, a reduction in MADRS score was observed at 4 months in the control group (-2.80, P = 0.009) and at 7 months in the exercise and control groups (-3.17, P = 0.003 and -3.34, P = 0.002).

    CONCLUSIONS: A 4-month high-intensity functional exercise program has no superior effect on depressive symptoms relative to a control activity among older people with dementia living in residential care facilities. Exercise and non-exercise group activities may reduce high levels of depressive symptoms.

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  • 43.
    Boström, Gustaf
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Conradsson, Mia
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Rosendahl, Erik
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Littbrand, Håkan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Functional capacity and dependency in transfer and dressing are associated with depressive symptoms in older people2014In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 9, p. 249-257Article in journal (Refereed)
    Abstract [en]

    Background: This study examined associations between depressive symptoms and functional capacity, overall dependency in personal activities of daily living (ADLs), and dependency in individual ADL tasks, respectively, in people with a high mean age, large range of functional capacity, and wide spectrum of dependency in ADLs. Methods: Cross-sectional data from three studies were used. A total of 392 individuals living in community and residential care facilities were included. Mean age was 86.2 years, 72% were women, 75% were dependent in ADLs, 42% had depression, and 39% had dementia. Depressive symptoms were assessed with the 15-item Geriatric Depression Scale (GDS-15), functional capacity with the Berg Balance Scale (BBS), and ADLs with the Barthel ADL Index. Multiple linear regression analyses with comprehensive adjustments were performed between GDS-15 and BBS, GDS-15 and Barthel ADL Index, and GDS-15 and each individual ADL task, separately. Results: GDS-15 score was associated with BBS score (unstandardized b=-0.03, P=0.008), but not with Barthel ADL Index score (unstandardized b=-0.07, P=0.068). No significant interaction effects of sex, dementia, or living conditions were found in these associations. Among individual ADL tasks, dependency in transfer (unstandardized b=-1.03, P=0.007) and dressing (unstandardized b=-0.70, P=0.035) were associated with depressive symptoms. Conclusion: Functional capacity seems to be independently associated with depressive symptoms in older people living in community and residential care facilities, whereas overall ADL performance may not be associated. Dependency in the individual ADL tasks of transfer and dressing appear to be independently associated with depressive symptoms and may be an important focus of future interdisciplinary multifactorial intervention studies.

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  • 44.
    Boström, Gustaf
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Hörnsten, Carl
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Brännström, Jon
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Conradsson, Mia
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Allard, Per
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Littbrand, Håkan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Antidepressant use and mortality in very old people2016In: International psychogeriatrics, ISSN 1041-6102, E-ISSN 1741-203X, Vol. 28, no 7, p. 1201-1210Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Antidepressant treatment may increase the risk of death. The association between antidepressants and mortality has been evaluated in community-dwelling older people, but not in representative samples of very old people, among whom dementia, multimorbidity, and disability are common.

    METHODS: Umeå 85+/GERDA study participants (n = 992) aged 85, 90, and ≥95 years were followed for up to five years. Cox proportional hazard regression models were used to analyze mortality risk associated with baseline antidepressant treatment, adjusted for potential confounders.

    RESULTS: Mean age was 89 years; 27% of participants had dementia, 20% had stroke histories, 29% had heart failure, and 16% used antidepressants. In age- and sex-adjusted analyses, antidepressant use was associated with a 76% increased mortality risk (hazard ratio [HR] = 1.76; 95% confidence interval [CI], 1.41-2.19). Adding adjustment for Geriatric Depression Scale score, HR was 1.62 (95% CI, 1.29-2.03). The association was not significant when adjusting for additional confounding factors (HR = 1.08; 95% CI, 0.85-1.38). Interaction analyses in the fully adjusted model revealed a significant interaction between sex and antidepressant use (HR: 1.76; 95% CI, 1.05-2.94). Among male and female antidepressant users, the HRs for death were 0.76 (95% CI, 0.47-1.24) and 1.28 (95% CI, 0.97-1.70), respectively.

    CONCLUSION: Among very old people, baseline antidepressant treatment does not seem to be independently associated with increased mortality risk. However, the risk may be different in men and women. This difference and the potential risk of initial treatment require further investigation in future cohort studies of very old people.

  • 45. Bousquet, J.
    et al.
    Bewick, M.
    Cano, A.
    Eklund, Patrik
    Umeå University, Faculty of Science and Technology, Department of Computing Science. Four Computing Oy, Helsinki, Finland.
    Fico, G.
    Goswami, N.
    Guldemond, N. A.
    Henderson, D.
    Hinkema, M. J.
    Liotta, G.
    Mair, A.
    Molloy, W.
    Monaco, A.
    Monsonis-Paya, I.
    Nizinska, A.
    Papadopoulos, H.
    Pavlickova, A.
    Pecorelli, S.
    Prados-Torres, A.
    Roller-Wirnsberger, R. E.
    Somekh, D.
    Vera-Muñoz, C.
    Visser, F.
    Farrell, J.
    Malva, J.
    Andersen Ranberg, K.
    Camuzat, T.
    Carriazo, A. M.
    Crooks, G.
    Gutter, Z.
    Iaccarino, G.
    Manuel de Keenoy, E.
    Moda, G.
    Rodriguez-Mañas, L.
    Vontetsianos, T.
    Abreu, C.
    Alonso, J.
    Alonso-Bouzon, C.
    Ankri, J.
    Arredondo, M. T.
    Avolio, F.
    Bedbrook, A.
    Białoszewski, A. Z..
    Blain, H.
    Bourret, R.
    Cabrera-Umpierrez, M. F.
    Catala, A.
    O'Caoimh, R.
    Cesari, M.
    Chavannes, N. H.
    Correia-da-Sousa, J.
    Dedeu, T.
    Ferrando, M.
    Ferri, M.
    Fokkens, W. J.
    Garcia-Lizana, F.
    Guérin, O.
    Hellings, P. W.
    Haahtela, T.
    Illario, M.
    Inzerilli, M. C.
    Lodrup Carlsen, K. C.
    Kardas, P.
    Keil, T.
    Maggio, M.
    Mendez-Zorrilla, A.
    Menditto, E.
    Mercier, J.
    Michel, J. P.
    Murray, R.
    Nogues, M.
    O'Byrne-Maguire, I.
    Pappa, D.
    Parent, A. S.
    Pastorino, M.
    Robalo-Cordeiro, C.
    Samolinski, B.
    Siciliano, P.
    Teixeira, A. M.
    Tsartara, S. I.
    Valiulis, A.
    Vandenplas, O.
    Vasankari, T.
    Vellas, B.
    Vollenbroek-Hutten, M.
    Wickman, M.
    Yorgancioglu, A.
    Zuberbier, T.
    Barbagallo, M.
    Canonica, G. W.
    Klimek, L.
    Maggi, S.
    Aberer, W.
    Akdis, C.
    Adcock, I. M.
    Agache, I.
    Albera, C.
    Alonso-Trujillo, F.
    Angel Guarcia, M.
    Annesi-Maesano, I.
    Apostolo, J.
    Arshad, S. H.
    Attalin, V.
    Avignon, A.
    Bachert, C.
    Baroni, I.
    Bel, E.
    Benson, M.
    Bescos, C.
    Blasi, F.
    Barbara, C.
    Bergmann, K. C.
    Bernard, P. L.
    Bonini, S.
    Bousquet, P. J.
    Branchini, B.
    Brightling, C. E.
    Bruguière, V.
    Bunu, C.
    Bush, A.
    Caimmi, D. P.
    Calderon, M. A.
    Canovas, G.
    Cardona, V.
    Carlsen, K. H.
    Cesario, A.
    Chkhartishvili, E.
    Chiron, R.
    Chivato, T.
    Chung, K. F.
    d'Angelantonio, M.
    De Carlo, G.
    Cholley, D.
    Chorin, F.
    Combe, B.
    Compas, B.
    Costa, D. J.
    Costa, E.
    Coste, O.
    Coupet, A.-L.
    Crepaldi, G.
    Custovic, A.
    Dahl, R.
    Dahlen, S. E.
    Demoly, P.
    Devillier, P.
    Didier, A.
    Dinh-Xuan, A. T.
    Djukanovic, R.
    Dokic, D.
    Du Toit, G.
    Dubakiene, R.
    Dupeyron, A.
    Emuzyte, R.
    Fiocchi, A.
    Wagner, A.
    Fletcher, M.
    Fonseca, J.
    Fougère, B.
    Gamkrelidze, A.
    Garces, G.
    Garcia-Aymeric, J.
    Garcia-Zapirain, B.
    Gemicioğlu, B.
    Gouder, C.
    Hellquist-Dahl, B.
    Hermosilla-Gimeno, I.
    Héve, D.
    Holland, C.
    Humbert, M.
    Hyland, M.
    Johnston, S. L.
    Just, J.
    Jutel, M.
    Kaidashev, I. P.
    Khaitov, M.
    Kalayci, O.
    Kalyoncu, A. F.
    Keijser, W.
    Kerstjens, H.
    Knezović, J.
    Kowalski, M.
    Koppelman, G. H.
    Kotska, T.
    Kovac, M.
    Kull, I.
    Kuna, P.
    Kvedariene, V.
    Lepore, V.
    MacNee, W.
    Maggio, M.
    Magnan, A.
    Majer, I.
    Manning, P.
    Marcucci, M.
    Marti, T.
    Masoli, M.
    Melen, E.
    Miculinic, N.
    Mihaltan, F.
    Milenkovic, B.
    Millot-Keurinck, J.
    Mlinarić, H.
    Momas, I.
    Montefort, S.
    Morais-Almeida, M.
    Moreno-Casbas, T.
    Mösges, R.
    Mullol, J.
    Nadif, R.
    Nalin, M.
    Navarro-Pardo, E.
    Nekam, K.
    Ninot, G.
    Paccard, D.
    Pais, S.
    Palummeri, E.
    Panzner, P.
    Papadopoulos, N. K.
    Papanikolaou, C.
    Passalacqua, G.
    Pastor, E.
    Perrot, M.
    Plavec, D.
    Popov, T. A.
    Postma, D. S.
    Price, D.
    Raffort, N.
    Reuzeau, J. C.
    Robine, J. M.
    Rodenas, F.
    Robusto, F.
    Roche, N.
    Romano, A.
    Romano, V.
    Rosado-Pinto, J.
    Roubille, F.
    Ruiz, F.
    Ryan, D.
    Salcedo, T.
    Schmid-Grendelmeier, P.
    Schulz, H.
    Schunemann, H. J.
    Serrano, E.
    Sheikh, A.
    Shields, M.
    Siafakas, N.
    Scichilone, N.
    Siciliano, P.
    Skrindo, I.
    Smit, H. A.
    Sourdet, S.
    Sousa-Costa, E.
    Spranger, O.
    Sooronbaev, T.
    Sruk, V.
    Sterk, P. J.
    Todo-Bom, A.
    Touchon, J.
    Tramontano, D.
    Triggiani, M.
    Tsartara, S. I.
    Valero, A. L.
    Valovirta, E.
    van Ganse, E.
    van Hage, M.
    van den Berge, M.
    Vandenplas, O.
    Ventura, M. T.
    Vergara, I.
    Vezzani, G.
    Vidal, D.
    Viegi, G.
    Wagemann, M.
    Whalley, B.
    Wickman, M.
    Wilson, N.
    Yiallouros, P. K.
    Žagar, M.
    Zaidi, A.
    Zidarn, M.
    Hoogerwerf, E. J.
    Usero, J.
    Zuffada, R.
    Senn, A.
    de Oliveira-Alves, B.
    Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA2017In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 21, no 1, p. 92-104Article in journal (Refereed)
    Abstract [en]

    The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

  • 46.
    Brändström, Anders
    et al.
    Umeå University, Faculty of Arts, Department of historical, philosophical and religious studies.
    Meyer, Anna C.
    Modig, Karin
    Sandström, Glenn
    Umeå University, Faculty of Arts, Department of historical, philosophical and religious studies. Stockholm University Demography Unit (SUDA), Stockholm University.
    Determinants of home care utilization among the Swedish old: nationwide register-based study2022In: European Journal of Ageing, ISSN 1613-9372, E-ISSN 1613-9380, Vol. 19, p. 651-662Article in journal (Refereed)
    Abstract [en]

    Since the 1990s, Sweden has implemented aging-in-place policies increasing the share of older adults dependent on home care instead of residing in care homes. At the same time previous research has highlighted that individuals receive home care at a higher age than before. Consequently, services are provided for a shorter time before death, increasing reliance on family and kin as caregivers. Previous studies addressing how homecare is distributed rely primarily on small surveys and are often limited to specific regions. This study aims to ascertain how home care services are distributed regarding individual-level factors such as health status, living arrangements, availability of family, education, and socioeconomic position. To provide estimates that can be generalized to Sweden as a whole, we use register data for the entire Swedish population aged 65 + in 2016. The study's main findings are that home care recipients and the amount of care received are among the oldest old with severe co morbidities. Receiving home care is slightly more common among women, but only in the highest age groups. Childlessness and socioeconomic factors play a small role in who receives home care or not. Instead, the primary home care recipients are those older adults living alone who lack direct support from family members residing in the same household.

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  • 47.
    Brännström, Helene
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Bäckman, Margit
    Umeå University, Faculty of Medicine, Department of Nursing.
    Santamäki Fischer, Regina
    Umeå University, Faculty of Medicine, Department of Nursing.
    Walking on the edge: meanings of living in an ageing body and using a walker in everyday life - a phenomenological hermeneutic study2013In: International Journal of Older People Nursing, ISSN 1748-3735, E-ISSN 1748-3743, Vol. 8, no 2, p. 116-122Article in journal (Refereed)
    Abstract [en]

    Background.  In order to maintain one’s state of health whilst growing older, the ability to walk is essential.

    Aim and objective.  The aim of this study was to illuminate the meanings of the lived experience of living in an ageing body and using a walker in daily life.

    Methods.  Narrative interviews were performed with seven older persons aged 79–95 years. The transcribed text was analysed using a phenomenological hermeneutic method.

    Results.  The key finding of the study was that the lived experience of living in an ageing body and using a walker in daily life was interpreted as ‘walking on the edge’ based on the themes ‘Being vulnerable and dependent’ and ‘Being confident and independent’.

    Conclusions.  The results highlight the importance of reflecting on this phenomenon as a health care professional while meeting the care needs of older persons who use walkers.

    Implications for practice.  Nurses need to consider the walker as a personal and valued possession of the individual and handle the walker in agreement with the older person, placing the walker close at hand with the brakes locked to give secure support.

  • 48.
    Brännström, Jon
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Adverse effects of psychotropic drugs in old age2020Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: With increasing age, the body and mind transform. Many of our organs gradually lose capacity, making them more sensitive to the effects of several drugs. In parallel, many of us accumulate an increasing burden of disease and other conditions warranting the use of medications. Hence, the use of most classes of drugs increases with age, especially so in elderly women.At the same time, medical science is lagging behind due to the fact that the oldest people in society often are excluded from pharmacological studies, where young males are the most coveted subjects.In the absence of strong evidence, much of the knowledge about the clinical and adverse effects of several drugs in the elderly is derived from observational studies, prone to bias and confounding. The use of psychotropic drugs in elderly people is particularly controversial, and even more so in people suffering from major neurocognitive disorders (NCD). Psychotropics have been associated with several adverse effects as well as limited clinical effect. Still, they are frequently prescribed to elderly patients.

    AimsThis thesis aims to explore the associations between several types of psychotropic drugs and two of the most severe adversities attributed to their use, increased mortality and the risk of hip fracture. It aims to explore mortality in data from well-controlled studies. It also aims to employ novel statistical methods to investigate the associations between drug exposure and hip fracture, in an attempt to gain information on possible causality from observational data.

    Methods: This thesis uses quantitative, comparative and epidemiological methods, prospective as well as retrospective. Two of the four papers are based on data collections conducted by the Department of Community Medicine and Rehabilitation, Umeå University, and include 992 and 1,037 individuals, respectively. The other two papers are based on Swedish nationwide registers and include 408,144 and 255,274 subjects, respectively. In all four papers multivariable regression models were used to investigate the associations between the exposures and outcomes, adjusted for possible confounding variables.

    Results: In a population-based sample of very old people, and in old people with major NCD, ongoing use of psychotropic drugs was not independently associated with increased mortality. Analyses did show, however, a significant impact of sex on the mortality risk, with tendencies for antidepressant drug use to be protective in men, but not in women, and for benzodiazepines to increase the mortality risk in men, but not in women. 

    In two cohorts of old people, based on several nationwide registers, investigating the associations between psychotropic drug use and hip fracture revealed that users of antidepressants, as well as users of antipsychotics, had significantly increased risks of hip fracture, independent of a wide range of covariates. However, when studying how the risk changed over time, the strongest associations were found before the initiation of treatment with the respective drug, and no dose-response relationships were found.

    Discussion: The finding that psychotropic drug use was not independently associated with an elevated mortality risk was not in line with previous research, most of which have been based on data from large registers, and shown an increased risk of mortality. One reason for this difference is that the cohorts studied in this thesis were thoroughly investigated and characterised, making it possible to perform extensive adjusting for confounding variables. Hence, we expect a lesser amount of residual confounding, than in most other studies. Another explanation is that we studied ongoing drug use at baseline, rather than associations following initiation of treatment.  This might have introduced a selection bias in our studies, where the individuals most sensitive to adverse effects would have discontinued treatment or passed away. The finding of a significant impact of sex on the risk of mortality adds to the unexplored field of sex differences in drug responses in old age, and warrants further investigation.

    In our register studies of psychotropic drug use and the risk of hip fracture, novel methods were applied. We have tried to overcome the hurdles of several types of confounding through the investigation of associations before and after the initiation of antidepressants, and antipsychotics, respectively. Our finding that the associations between psychotropic drug use and hip fracture were not only present, but indeed strongest, before the initiation of treatment indicates a strong presence of residual confounding and confounding by indication, and points toward the absence of a causal relationship between psychotropic drug use and hip fracture.

    Conclusion: The evidence supporting causal relationships between psychotropic drug use and serious adverse events in old age is insufficient. Our results point towards bias and confounding having strong influences on the observed associations between psychotropic drug use and mortality, and hip fracture, respectively. 

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  • 49.
    Brännström, Jon
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Boström, Gustaf
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Rosendahl, Erik
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Littbrand, Håkan
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Lövheim, Hugo
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Psychotropic drug use and mortality in old people with dementia: investigating sex differences2017In: BMC Pharmacology & Toxicology, E-ISSN 2050-6511, Vol. 18, article id 36Article in journal (Refereed)
    Abstract [en]

    Background: Psychotropic drugs are common among old people with dementia, and have been associated with increased mortality. Previous studies have not investigated sex differences in this risk. This study was conducted to analyse associations between the use of antipsychotics, antidepressants, and benzodiazepines and 2-year mortality in old people with dementia, and to investigate sex differences therein.

    Methods: In total, 1037 participants (74% women; mean age, 89 years) with dementia were included from four cohort studies and followed for 2 years. Data were collected through home visits and medical records. Cox proportional hazard regression models were used to analyse associations between ongoing baseline drug use and mortality. Multiple possible confounders were evaluated and adjusted for.

    Results: In fully adjusted models including data from the whole population, no association between baseline psychotropic drug use and increased 2-year mortality was seen. Significant sex differences were found in mortality associated with antidepressant use, which was protective in men, but not in women (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.40–0.92 and HR 1.09, 95% CI 0.87–1.38, respectively). The interaction term for sex was significant in analyses of benzodiazepine use, with a higher mortality risk among men than among women.

    Conclusions: Among old people with dementia, ongoing psychotropic drug use at baseline was not associated with increased mortality in analyses adjusted for multiple confounders. Sex differences in mortality risk associated with antidepressant and benzodiazepine use were seen, highlighting the need for further investigation of the impact of sex.

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  • 50.
    Brännström, Jon
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Hamberg, Katarina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Molander, Lena
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Lövheim, Hugo
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Gustafson, Yngve
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Gender disparities in the pharmacological treatment of cardiovascular disease and diabetes mellitus in the very old: an epidemiological, cross-sectional survey2011In: Drugs & Aging, ISSN 1170-229X, E-ISSN 1179-1969, Vol. 28, no 12, p. 993-1005Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There are many reports of disparities in health and medical care both between women and men and between various age groups. In most cases, men receive better treatment than women and young and middle-aged people are privileged compared with the old and the very old. Cardiovascular morbidity and diabetes mellitus are common, increase with age and are often treated extensively with drugs, many of which are known to have significant adverse effects.

    OBJECTIVE: The aim of the study was to analyse gender differences in the pharmacological treatment of cardiovascular disease and diabetes among very old people.

    METHODS: The study took the form of an epidemiological, cross-sectional survey. A structured interview was administered during one or more home visits, and data were further retrieved from medical charts and interviews with relatives, healthcare staff and other carers. Home-dwelling people as well as people living in institutional care in six municipalities in the county of Västerbotten, Sweden, in 2005-7 were included in the study. Half of all people aged 85 years, all of those aged 90 years and all of those aged ≥95 years living in the selected municipalities were selected for inclusion in the study. In total, 467 people were included in the present analysis. The main study outcome measures were medical diagnoses and drug use.

    RESULTS: In total, women were prescribed a larger number of drugs than men (mean 7.2 vs 5.4, p < 0.001). Multiple logistic regression models adjusted for age and other background variables as well as relevant medical diagnoses (hypertension, heart failure) showed strong associations between female sex and prescriptions of thiazide diuretics (odds ratio [OR] 4.4; 95% CI 1.8, 10.8; p = 0.001), potassium-sparing diuretics (OR 3.5; 95% CI 1.4, 8.7; p = 0.006) and diuretics as a whole (OR 1.8; 95% CI 1.1, 2.9; p = 0.021). A similar model, adjusted for angina pectoris, showed that female sex was associated with prescription of short-acting nitroglycerin (OR 3.7; 95% CI 1.6, 8.9; p = 0.003). However, more men had been offered coronary artery surgery (p = 0.001). Of the participants diagnosed with diabetes, 55% of the women and 85% of the men used oral antihyperglycaemic drugs (p = 0.020), whereas no gender difference was seen in prescriptions of insulin.

    CONCLUSIONS: Significant gender disparities in the prescription of several drugs, such as diuretics, nitroglycerin and oral antihyperglycaemic drugs, were observed in this study of very old people. In most cases, women were prescribed more drugs than men. Men more often had undergone coronary artery surgery. These disparities could only in part be explained by differences in diagnoses and symptoms.

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