The overall aim was to investigate municipal guidelines for paid dependent care which were available online, i.e. documents regarding situations where a relative is hired to care for a next-to-kin. The overall aim has been built on the following three research questions regarding how municipalities describe: 1) which situations qualify for paid dependent care, 2) how the elderly person’s needs are met in case of paid dependent care and 3) how the dependent caregivers’ rights and well-being are ensured?

There is no legal basis for demanding cash-for-care setting, and the local self-government determines whether the municipality offers this form of care. Recently, paid dependent care has been restricted and banned in several Swedish municipalities, and according to some statistics paid dependent care is allowed in 55–65 % of the Swedish municipalities. It is mostly women of foreign origin who are dependent caregivers nowadays, and feminist care research and the media lift up cash-for-care settings as a trap for women and for migrant integration.

The study included guidelines from a total of 21 municipalities, which were analyzed using qualitative content analysis according to Elo & Kyngäs (2007). The guidelines analysed were found from the websites of Sweden's 121 medium and large municipalities (more than 20 000 inhabitants). The results were processed using feminist theory (Hirdman 2012).

The results show that overall there are few guidelines available in Sweden's municipalities and that the regulations differ in the different municipalities’ guidelines. The guidelines that are available often contain general or vague descriptions. One conclusion is therefore that many municipalities ensure their own discretion and prevail through vague and general rules in their guidelines. From a feminist perspective, these different municipal policies create unfair structures and differences in conditions and terms for the elderly and their family caregivers regarding cash-for-care settings. Finally, the result shows that the few detailed descriptions prioritize elder people's rights over their caregivers'. Ensuring the paid dependent caregivers’ rights is mainly described to be done by checking and controlling them. In other words, the paid dependent caregivers are often invisible in the guidelines, are often regarded as pseudo-employees and therefore fall between the cracks in terms of their need for support (Sand 2010).

Receipt of long-term care (LTC) is generally associated with worse psychological wellbeing for community-dwelling older adults. In addition to objective features of care use (e.g. formal vs. informal care), the subjective evaluation of care provision in terms of perceived sufficiency might be particularly predictive of one's wellbeing but is seldomly considered in the literature. Substantial changes in the availability of long-term care in past decades raise the question to what extent these effects, if present, are consistent over historic time. The present study, therefore, aims at better understanding the associations between types of LTC use and perceived care sufficiency on psychological wellbeing in a changing LTC context in the Netherlands. Data from the Longitudinal Aging Study Amsterdam (LASA) were used from three points in time: 1998 (N = 582), 2008 (N = 459) and 2018 (N = 415). At each wave, participants were between 75 and 85 years of age and living independently. The results show that after adjusting for age, gender, education and health, using formal LTC had a negative effect on depressive symptoms only in 2018, but that this effect was not significantly worse compared to previous cohorts. Perceived care sufficiency was consistently negatively associated with depressive symptoms in all three points in time. This suggests that despite a less generous Dutch LTC system, psychological wellbeing among LTC users remains stable. Perceiving care provision as sufficient, however, can help older adults maintain psychological wellbeing and should be considered by researchers and policymakers that aim to improve care recipients’ wellbeing. © 2022 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.

We used national surveys to study how older persons’ changing household patterns influence the gender balance of caregiving in two countries with distinct household structures and cultures, Spain and Sweden. In both countries, men and women provide care equally often for their partner in couple-only households. This has become the most common household type among older persons in Spain and prevails altogether in Sweden. This challenges the traditional dominance of young or middle-aged women as primary caregivers in Spain. In Sweden, many caregivers are old themselves. We focus attention to partners as caregivers and the consequences of changing household structures for caregiving, which may be on the way to gender equality in both countries, with implications for families and for the public services.

We used national surveys to study how older persons’ changing household patterns influence the gender balance of caregiving in two countries with distinct household structures and cultures, Spain and Sweden. In both countries, men and women provide care equally often for their partner in couple-only households. This has become the most common household type among older persons in Spain and prevails altogether in Sweden. This challenges the traditional dominance of young or middle-aged women as primary caregivers in Spain. In Sweden, many caregivers are old themselves. We focus attention to partners as caregivers and the consequences of changing household structures for caregiving, which may be on the way to gender equality in both countries, with implications for families and for the public services.

Usually it is women who take care of family members in the home, but with age, gender differences become less pronounced and, from 80 years onwards, there are more men caring for a family member – generally their partner – than women. Social and demographic changes are presenting new challenges for public services. In particular, in two-person households with elderly inhabitants, one of whom is dependent, it is necessary to tackle not only the needs of the dependent partner but also those of the carer partner. For this reason, carer support programmes are needed.

The housing situation of older people has been on the Swedish political agenda for some time. An increasing ageing population implies a demand for housing in correspodence to their needs. Assisted living facilities decreased with 30 000 places between 2002 and 2016, as a result, the majority of older people age in a dwelling in the ordinary housing market. In 2008 and 2015 respectively two government investigations on older people’s housing were presented. The investigations focused on the need for housing to bridge the gap between ordinary housing and assisted living facilities and issues of affordability and social community but also the lack of accessible housing in particular geographic areas. This paper aims to investigate the origins of the two investigations and relate them to changes in the housing market affecting older people, arguing that the strong emphasis on ageing in place has shifted the responsibility of having a good place to live from general welfare to older individuals themselves.

Background: Today's older people drink more alcohol than earlier cohorts of older people. Social integration has been identified as an important factor for older people's drinking, but the association is complex. This study investigates both high and low levels of social integration and their associations with longitudinal patterns of alcohol consumption among older women and men.

Methods: Longitudinal nationally representative data of older Swedish women and men aged over 65 - the Swedish Level of Living Survey (LNU) and Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD) - from 2010/2011 and 2014 (n = 1048). Associations between social contacts and social activities at baseline and longitudinal patterns of drinking frequency were examined with multinomial logistic regression analyses.

Results: Men reported drinking alcohol more often than women, but the most common drinking frequency among both women and men was to drink monthly or less. Drinking habits were generally stable over time. People with high levels of social activity at baseline were more likely to have a stable daily or weekly drinking frequency or increased drinking frequency over the four-year follow-up period, particularly women. People with low levels of social contacts and/or social activities were less likely to have a stable daily or weekly drinking frequency, compared to people in the low and stable drinking frequency group.

Conclusions: Alcohol consumption is embedded in a social context, older people drink in social situations and social integration predicts continued drinking patterns.

Objectives: To test whether older adults from high and low educational groups are differentially vulnerable to the impact of smoking and physical inactivity on the progression of mobility impairment during old age.

Methods: A nationally representative sample of older Swedish adults (n = 1,311), aged 57-76 years at baseline (1991), were followed for up to 23 years (2014). Multilevel regression was used to estimate individual trajectories of mobility impairment over the study period and to test for differences in the progression of mobility impairment on the basis of smoking status, physical activity status, and level of education.

Results: Compared to nonsmokers, heavy smokers had higher levels and steeper increases in mobility impairment with advancing age. However, there were only small and statistically nonsignificant differences in the impact of heavy smoking on mobility impairment in high versus low education groups. A similar pattern of results was found for physical inactivity.

Discussion: Differential vulnerability to unhealthy behaviors may vary across populations, age, time-periods, and health outcomes. In this study of older adults in Sweden, low and high education groups did not differ significantly in their associations between heavy smoking or physical inactivity, and the progression of mobility impairment.

Retirement is a major life transition that involves changes to everyday routines, roles, and habits. Previous studies suggest that retirement may influence drinking habits. Many natural inhibitors of alcohol consumption disappear with the removal of work constraints. The potential impact depends on both individual and contextual factors. Women in the cohorts undergoing retirement now have been more active on the labor market, including the occupation of higher status jobs, which indicates more financial resources as well as a larger role loss after retirement. Also, the current cohorts who retire have had more liberal drinking habits throughout their lives compared to previous cohorts. We therefore examined changes in alcohol consumption surrounding retirement in different education groups among women and men undergoing retirement using annual data from the Health, Aging and Retirement Transitions in Sweden (HEARTS) study, a longitudinal national study of 60- to 66-year-olds (n = 5,913), from 2015 to 2018. Latent growth curve models were used to estimate trajectories of alcohol consumption. Results showed that those who retired during the follow-up increased their usual weekly alcohol consumption while those who worked or were retired throughout the period had stable drinking habits. Those who were retired reported the highest alcohol consumption. The increase surrounding retirement was driven by people with higher education. Women with tertiary education and men with intermediate or tertiary education increased their weekly alcohol intake after retirement, while those with low education had unchanged drinking habits. Mechanisms and motivations that may fuel increased alcohol intake among people with higher education should be further investigated.

Background

Alcohol consumption in very old age is increasing; yet, little is known about the personal and health-related characteristics associated with different levels of alcohol consumption and the association between alcohol consumption and survival among the oldest old.

Methods

Nationally representative data from the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD, ages 76-101; n = 863) collected in 2010/2011 were used. Mortality was analyzed until 2014. Alcohol consumption was measured with questions about frequency and amount. Drinks per month were calculated and categorized as abstainer, light-to-moderate drinker (0.5–30 drinks/month) and heavy drinker (>30 drinks/month). Multinomial logistic regressions and Laplace regressions were performed.

Results

Compared to light-to-moderate drinkers, abstainers had lower levels of education and more functional health problems, while heavy drinkers were more often men, had higher levels of education, and no serious health or functional problems. In models adjusted only for age and sex, abstainers died earlier than drinkers. Among light-to-moderate drinkers, each additional drink/month was associated with longer survival, while among heavy drinkers, each additional drink/month was associated with shorter survival. However, after adjusting for personal and health-related factors, estimates were lower and no longer statistically significant.

Conclusions

The association between alcohol consumption and survival in very old age seems to have an inverse J-shape; abstention and heavy use is associated with shorter survival compared to light-to-moderate drinking. To a large extent, differences in survival are due to differences in baseline health and physical function.

Graphical abstract

Background: Alcohol consumption in very old age is increasing; yet, little is known about the personal and health-related characteristics associated with different levels of alcohol consumption and the association between alcohol consumption and survival among the oldest old. Methods: Nationally representative data from the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD, ages 76-101; n=863) collected in 2010/2011 were used. Mortality was analyzed unti12014. Alcohol consumption was measured with questions about frequency and amount. Drinks per month were calculated and categorized as abstainer, light-to-moderate drinker (0.5-30 drinks/month) and heavy drinker (>30 drinks/month). Multinomial logistic regressions and Laplace regressions were performed. Results: Compared to light-to-moderate drinkers, abstainers had lower levels of education and more functional health problems, while heavy drinkers were more often men, had higher levels of education, and no serious health or functional problems. In models adjusted only for age and sex, abstainers died earlier than drinkers. Among light-to-moderate drinkers, each additional drink/month was associated with longer survival, while among heavy drinkers, each additional drink/month was associated with shorter survival. However, after adjusting for personal and health-related factors, estimates were lower and no longer statistically significant. Conclusions: The association between alcohol consumption and survival in very old age seems to have an inverse J-shape; abstention and heavy use is associated with shorter survival compared to light-to moderate drinking. To a large extent, differences in survival are due to differences in baseline health and physical function.

Objectives: to examine the association between 34-year trajectories of social activity, from middle age to old age and late-life disability.                  

Methods: data from the Swedish Level of Living Survey (LNU) and the Swedish Panel Study of the Oldest Old (SWEOLD) were used. LNU data from 1968, 1981, 1991 and 2000 were merged with SWEOLD data from 1992, 2002 and 2004 to create a longitudinal data set  with five observation periods. Trajectories of social activities covered 1968–2002, and late-life disability was measured  in 2004. The sample consisted of 729 individuals aged 33–61 at baseline (1968), who participated in at least four observation periods and who were free from mobility limitations at baseline. Four trajectories of social activity were identified and used as predictors of late-life disability.                  

Results: reporting low/medium levels of social activity from mid-life to old age was the most common trajectory group. Persons reporting continuously low/medium or decreasing levels of social activity had higher odds ratios for late-life disability (OR = 2.33 and OR = 2.15, respectively) compared with those having continuously high levels of activity, even when adjusting for age, sex and mobility limitations, and excluding persons with baseline mobility limitations.                  

Conclusions: results suggest that the disability risk associated with social activities is related to recent levels of activity, but also that risk may accumulate over time, as indicated by the higher disability risk associated with the continuously low/medium level social activity trajectory.

OBJECTIVES: to examine the association between 34-year trajectories of social activity, from middle age to old age and late-life disability.

METHODS: data from the Swedish Level of Living Survey (LNU) and the Swedish Panel Study of the Oldest Old (SWEOLD) were used. LNU data from 1968, 1981, 1991 and 2000 were merged with SWEOLD data from 1992, 2002 and 2004 to create a longitudinal data set with five observation periods. Trajectories of social activities covered 1968-2002, and late-life disability was measured in 2004. The sample consisted of 729 individuals aged 33-61 at baseline (1968), who participated in at least four observation periods and who were free from mobility limitations at baseline. Four trajectories of social activity were identified and used as predictors of late-life disability.

RESULTS: reporting low/medium levels of social activity from mid-life to old age was the most common trajectory group. Persons reporting continuously low/medium or decreasing levels of social activity had higher odds ratios for late-life disability (OR = 2.33 and OR = 2.15, respectively) compared with those having continuously high levels of activity, even when adjusting for age, sex and mobility limitations, and excluding persons with baseline mobility limitations.

CONCLUSIONS: results suggest that the disability risk associated with social activities is related to recent levels of activity, but also that risk may accumulate over time, as indicated by the higher disability risk associated with the continuously low/medium level social activity trajectory.

Is activity participation in old age important for survival independent of one's earlier history of participation? A nationally representative sample of 457 older persons was followed for 25 years with data from the Level-of-Living Survey and the SWEOLD study. Cox regressions showed that regardless of earlier activities and health, late-life leisure engagement was associated with enhanced survival, especially among men. Among women, earlier activities (study groups) also seem important, perhaps by providing social networks. Results suggest that it is worthwhile to encourage elderly people to participate in leisure activities and to facilitate their participation in the community even at high ages.

Aim: To outline the organisation and responsibility for health and social care provided to older people in Denmark, Finland and Sweden.

Methods: Non-quantifiable data on the care systems were collated from the literature and expert consultations. The responsibilities for primary healthcare, specialised healthcare, prevention and health promotion, rehabilitation, and social care were presented in relation to policy guidance, funding and organisation.

Results: In all three countries, the state issues policy and to some extent co-funds the largely decentralised systems; in Denmark and Sweden the regions and municipalities organise the provision of care services – a system that is also about to be implemented in Finland to improve care coordination and make access more equal. Care for older citizens focuses to a large extent on enabling them to live independently in their own homes.

Conclusions: Decentralised care systems are challenged by considerable local variations, possibly jeopardising care equity. State-level decision and policy makers need to be aware of these challenges and monitor developments to prevent further health and social care disparities in the ageing population.

Older adults of today consume more alcohol, yet knowledge about the factors associated with different consumption levels is limited in this age group. Based on the data from a population-based sample (n = 1156, 539 men and 617 women) in The Gothenburg H70 Birth Cohort Study 2014–16, we examined sociodemographic, social, and health-related factors associated with alcohol consumption levels in 70-year-olds, using logistic regression. Total weekly alcohol intake was calculated based on the self-reported amount of alcohol consumed. Alcohol consumption was categorized as lifetime abstention, former drinking, moderate consumption (≤98 g/week), and at-risk consumption (>98 g/week). At-risk consumption was further categorized into lower at-risk (98–196 g/week), medium at-risk (196–350 g/week), and higher at-risk (≥350 g/week). We found that among the 1156 participants, 3% were lifetime abstainers, 3% were former drinkers, 64% were moderate drinkers, and 30% were at-risk drinkers (20% lower, 8% medium, 2% higher). Among several factors, former drinking was associated with worse general self-rated health (OR 1.65, 95% CI 1.08–2.51) and lower health-related quality of life (measured by physical component score) (OR 0.94, 95% CI 0.91–0.97), higher illness burden (OR 1.16, 95% CI 1.07–1.27), and weaker grip strength (OR 0.96, 95% CI 0.94–0.98). Higher at-risk drinkers more often had liver disease (OR 11.41, 95% CI 3.48–37.37) and minor depression (OR 4.57, 95% CI 1.40–14.95), but less contacts with health care (OR 0.32, 95% CI 0.11–0.92). Our findings demonstrate the importance of classifications beyond abstinence and at-risk consumption, with implications for both the prevention and clinical management of unhealthy consumption patterns in older adults.

‘Undernutrition state’ (UNS) is an ominous condition, in particular when associated with chronic obstructive pulmonary disease (COPD). In this review we discuss pathophysiological mechanisms and how UNS is defined and diagnosed. It seems unlikely that COPD-patients with established UNS have similar potential of reversibility (treatability) upon nutrition interventions as patients at a risk of developing such a condition, i.e. patients with low energy/nutrient intake, since pathophysiological, biochemical and metabolic conditions may differ substantially.

We summarize the results of 7 of 17 published randomized controlled trials of nutritional supplementation in COPD-patients with defined UNS in the latest Cochrane review (2012). We thus excluded 10 of 17 trials included in review (2012), mostly because those studies also included patients with ’risk of’ UNS.

The seven included trials exhibit extensive heterogeneity for all studied variables. Most studies did not show beneficial effects of nutritional supplementation, although some reported minor increase in body weight and physical function of unclear clinical relevance.

In contrast to the Cochrane review we conclude that it is difficult to draw firm conclusions regarding the effect of nutritional supplements in patients with COPD and UNS. Improved knowledge in this area is of utmost importance and some factors which should be considered in future studies are suggested.

The presence of multiple chronic conditions (i.e., multimorbidity) increases the risk of hospitalisation in older adults. We aimed to examine the association between different multimorbidity patterns and unplanned hospitalisations over 5 years. To that end, 2,250 community-dwelling individuals aged 60 years and older from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K) were studied. Participants were grouped into six multimorbidity patterns using a fuzzy c-means cluster analysis. The associations between patterns and outcomes were tested using Cox models and negative binomial models. After 5 years, 937 (41.6%) participants experienced at least one unplanned hospitalisation. Compared to participants in the unspecific multimorbidity pattern, those in the cardiovascular diseases, anaemia and dementia pattern, the psychiatric disorders pattern and the metabolic and sleep disorders pattern presented with a higher hazard of first unplanned hospitalisation (hazard ratio range: 1.49-2.05; p < 0.05 for all), number of unplanned hospitalisations (incidence rate ratio (IRR) range: 1.89-2.44; p < 0.05 for all), in-hospital days (IRR range: 1.91-3.61; p < 0.05 for all), and 30-day unplanned readmissions (IRR range: 2.94-3.65; p < 0.05 for all). Different multimorbidity patterns displayed a differential association with unplanned hospital care utilisation. These findings call for a careful primary care follow-up of older adults with complex multimorbidity patterns.

Neuropathological assessment was conducted on 1630 subjects, representing 5% of all the deceased that had been sent to the morgue of Uppsala University Hospital during a 15-year-long period. Among the 1630 subjects, 1610 were ≥ 41 years of age (range 41 to 102 years). Overall, hyperphosphorylated (HP) τ was observed in the brains of 98% of the 1610 subjects, and amyloid β-protein (Aβ) in the brains of 64%. The most common alteration observed was Alzheimer disease neuropathologic change (ADNC) (56%), followed by primary age-related tauopathy (PART) in 26% of the subjects. In 16% of the subjects, HPτ was limited to the locus coeruleus. In 14 subjects (<1%), no altered proteins were observed. In 3 subjects, only Aβ was observed, and in 17, HPτ was observed in a distribution other than that seen in ADNC/PART. The transactive DNA-binding protein 43 (TDP43) associated with limbic-predominant age-related TDP encephalopathy (LATE) was observed in 565 (35%) subjects and α-synuclein (αS) pathology, i.e., Lewy body disease (LBD) or multi system atrophy (MSA) was observed in the brains of 21% of the subjects. A total of 39% of subjects with ADNC, 59% of subjects with PART, and 81% of subjects with HPτ limited to the locus coeruleus lacked concomitant pathologies, i.e., LATE-NC or LBD-NC. Of the 293 (18% of the 1610 subjects) subjects with dementia, 81% exhibited a high or intermediate level of ADNC. In 84% of all individuals with dementia, various degrees of concomitant alterations were observed; i.e., MIXED-NC was a common cause of dementia. A high or intermediate level of PART was observed in 10 subjects with dementia (3%), i.e., tangle-predominant dementia. No subjects exhibited only vascular NC (VNC), but in 17 subjects, severe VNC might have contributed to cognitive decline. Age-related tau astrogliopathy (ARTAG) was observed in 37% of the 1610 subjects and in 53% of those with dementia.

Purpose:This study reports on how very old (VO) Finnish people without dementia perform in the Western Aphasia Battery (WAB) and two verbal fluency tasks and which demographic factors predict the performance.

Method:The study included fifty 80- to 100-year-old community-dwelling Finnish speakers with no dementing illnesses or speech-language disabilities, who completed the WAB and two verbal fluency tasks. Multifactorial statistical analyses with recursive partitioning were carried out to determine the significant predictors out of five predictor variables (age, gender, education, dentition, and Mini-Mental State Examination [MMSE]) for four response variables (WAB Aphasia Quotient [AQ], Language Quotient [LQ], semantic, and phonemic word fluencies).

Results:Overall, individual variation was notable in VO speakers. All predictor variables were statistically significantly associated with one or more of the language skills. Age was the most significant predictor; the critical age of 85–86 years was associated with a decline in WAB-AQ and semantic fluency. Poor dentition and the MMSE score both predicted a decline in WAB-LQ and phonemic fluency. A high level of education was positively associated with the skills of the best-performing individuals in WAB-AQ, WAB-LQ, and semantic fluency.

Conclusions:VO age is a significant factor contributing to language performance. However, a younger age, a good cognitive performance, intact teeth, and a higher educational level also seem to have a preservative power as regards language skills. Gender differences should be interpreted with caution. The results of this study provide culture- and language-specific normative data, which aids in differentiating typical aging from the signs of acute or degenerative neuropathology to ensure appropriate medical and therapeutic interventions.

Background: Polypharmacy, the use of multiple medications by one individual, may be associated with adverse health outcomes including poor cognition. However, it remains unclear whether a longitudinal relationship exists.

Objectives: To investigate the association between polypharmacy and 3-year cognitive ability in older adults.

Methods: A longitudinal cohort study of older adults 65 years and older, residing in the community, who participated in waves 12 (2012), 13 (2013) and 16 (2016) of the Household Income and Labour Dynamics (HILDA) Survey was conducted. Polypharmacy was defined as the regular use of 5 or more prescription medications. Cognitive ability was assessed using backwards digit span test (BDS), 25-item version of the National Adult Reading Test (NART-25) and symbol-digit modalities test (SDM). Linear regression was used to test the longitudinal association between polypharmacy and cognitive test scores at 3 years. All analyses were adjusted for age, sex, education, comorbidities, socioeconomic and lifestyle factors, and baseline cognitive test scores.

Results: A total of 2141 participants (mean age 72.9 years, 54.4% female) were included in the study sample. Polypharmacy was present in 27.3%. After adjusting for potential confounders, polypharmacy was negatively associated with cognitive ability at 3 years: BDS: −0.067 (95% CI = −0.353 to −0.051), NART-25: −0.071 (95% CI = −1.428 to −0.294), SDM: −0.073 (95% CI = −2.960 to −0.696).

Conclusion: Polypharmacy was associated with poorer cognitive ability at 3 years, even after adjusting for comorbidities and other confounders. Future research should consider the long-term impact of polypharmacy on cognitive ability, and identify strategies to optimise medication use and cognition in older adults.

Background: Socioeconomic inequalities in health and healthcare use in old age have been on the rise during the past two decades. So far, it is unknown whether these inequalities have permeated the nursing home setting. This study aimed to assess whether the socioeconomic position of newly admitted nursing home residents had an influence on their risk of unplanned hospitalization. Methods: We identified older persons (similar to 75 years) who were newly admitted to a nursing home between March 2013 and December 2014 using a set of linked routinely collected administrative and healthcare data in Sweden. The number of unplanned hospitalizations for any cause and the cumulative length of stay were defined as primary outcomes. Unplanned hospitalizations for potentially avoidable causes (i.e. fall-related injuries, urinary tract infections, pneumonia and decubitus ulcers) were considered as our secondary outcome. Results: Among 40 545 newly admitted nursing home residents (mean age 86.8 years), the incidence rate of unplanned hospitalization ranged from 53.9 per 100 person-years among residents with tertiary education up to 55.1 among those with primary education. After adjusting for relevant confounders, we observed no meaningful difference in the risk of unplanned hospitalization according to the education level of nursing home residents (IRR for tertiary vs. primary education: 0.96, 95% CI 0.92-1.00) or to their level of income (IRR for highest vs. lowest quartile of income: 0.98, 0.95-1.02). There were also no differences in the cumulative length of hospital stays or in the risk of experiencing unplanned hospitalizations for potentially avoidable causes. Conclusions: In sum, in this large cohort of newly admitted nursing home residents, we found no evidence of socioeconomic inequalities in the risk of unplanned hospitalization.

The overall aim of this thesis was to investigate the patients’ and their relatives’ perceived participation in discharge planning after stroke and the patients’ health-related quality of life, depressive symptoms, performance of personal daily activities and social activities in connection with discharge. Another aim was to evaluate the psychometric assumptions of the SF-36 for Swedish stroke patients.

Prospective, descriptive and cross-sectional designs were used to study all patients with stroke admitted to the stroke unit at a hospital in southern Sweden from October 1, 2003 to November 30, 2005 each with one close relative. The total sample consisted of 188 patients (mean age=74.0 years) and 152 relatives (mean age=60.1 years). Data were collected during interviews, 2-3 weeks after discharge.

The results showed that less depressive symptoms, more outdoor activities and performance of interests are important variables that related to higher HRQoL. SF-36 functions well as a measure of health related quality of life in Swedish stroke patients, but the two summary scales have shortcomings. Compared to a Swedish normal population, scores on all scales/components of the SF-36 were lower among stroke patients especially in the middle-aged group. Most of the patients perceived that they received information, but fewer perceived participation in the planning of medical treatment and needs of care/service/rehabilitation and goal setting. The relatives perceived that they need more information and they perceived low participation in goal setting and needs assessment. The professionals seem to lack effective practices for involving patients and their relatives to perceive participation in discharge planning. It is essential to develop and to implement methods for discharge planning, including sharing information, needs assessment with goal setting that facilitate patients’ and relatives’ perceived participation. The results suggest that ICF can be used in goal setting and needs assessment in discharge planning after acute stroke.

AIMS: This study examines different correlates to health-related quality (HRQoL) of life after discharge in patients with stroke.

BACKGROUND: HRQoL is an important aspect of life after suffering a stroke. Previous research has revealed several variables associated with poststroke quality of life, including age, gender, depression, fatigue, length of hospital stay, functional status and amount of social participation. However, the time span after stroke varies greatly in the different studies. Although the multiple factors that contribute to short-term postdischarge HRQoL have potential importance for discharge planning, to our knowledge, these factors have not been systematically investigated during the earlier days following discharge.

DESIGN: Cross-sectional study.

METHODS: The sample consisted of 188 consecutively included individuals (mean age 74 years, 56% men) from a stroke unit in southern Sweden. The interviews were performed two to three weeks after discharge and included use of the SF-36, the Center for Epidemiological Studies Depression Scale, the Barthel Index, the Frenchay Activities Index, performance of interests and survey of patients' perceived participation in discharge planning. Multiple linear regression analysis was conducted to identify variables associated with HRQoL.

RESULTS: Multiple regression analyses with the eight scales of SF-36 as dependent variables revealed eight models, one for each scale, which were statistically significant. Depressive symptoms were associated with lower HRQoL. Ability to perform personal and social activities, interests, younger age, education (elementary school) and shorter hospital stay were related to higher HRQoL. Patients' perceived participation in discharge planning was both positively and negatively associated with HRQoL.

CONCLUSIONS: Several variables were related to good HRQoL two to three weeks post-discharge, particularly fewer depressive symptoms, participation in social activities such as outdoor activities and performance of interests.

RELEVANCE TO CLINICAL PRACTICE: These results can be used to design needs assessment forms of discharge planning to promote adaptation and recovery after stroke.

Background: As the group of very old persons will form an increasing part of society, the study of how well-being is described and affected by specific factors will be of importance to meet the future needs of these persons. The aim of the study was to increase knowledge of well-being in very old persons by combining assessments and perceptions using the Philadelphia Geriatric Morale Scale (PGCMS).

Method: In a mixed method, convergent parallel design, 52 persons 80 years or older were assessed and interviewed using the PGCMS to combine assessment of morale and descriptions of perceptions of well-being using a mixed method approach.

Results: Quantitative and qualitative results converged in four areas: not feeling lonely and being included, rating and perceiving health as good, high physical function/ability and being physically active, living in own house and feeling at home. Areas perceived as important to well-being captured only in qualitative analysis were having freedom and engagement. An example of insights not achievable from the quantitative or qualitative analysis alone was that individuals with high morale expressed anxiety about losing their health due to potential ageing-related threats and that individuals with low morale struggled with acceptance. Acceptance was the key strategy for handling adverse consequences of ageing in all described areas.

Conclusion: When using standardized assessment scales in clinical practice, it could be useful to combine quantitative and qualitative data. Acceptance was key for well-being; however, acceptance could be resigned or reorienting in nature.

Introduction: Self-rated health (SRH) offers insights into the evolving health demographics of an ageing population.

Aim: To assess change in SRH from old age to very old age and their associations with health and well-being factors, and to investigate the association between SRH and survival.

Methods: All participants in the MONICA 1999 re-examination born before 1940 (n = 1595) were included in the Silver-MONICA baseline cohort. The Silver-MONICA follow-up started in 2016 included participants in the Silver-MONICA baseline cohort aged 80 years or older. Data on SRH was available for 1561 participants at baseline with 446 of them also participating in the follow-up. The follow-up examination included a wide variety of measurements and tests.

Findings: Most participants rated their health as "Quite good" (54.5 %) at baseline. Over the study period, 42.6 % had stable SRH, 40.6 % had declined, and 16.8 % had improved. Changes in SRH were at follow-up significantly associated with age, pain, nutrition, cognition, walking aid use, self-paced gait speed, lower extremity strength, independence in activities of daily living, weekly physical exercise, outdoor activity, participation in organized activities, visiting others, morale, and depressive symptoms. SRH at baseline was significantly associated with survival (p < 0.05).

Conclusion: This study demonstrates associations between changes in SRH and a multitude of health- and wellbeing-related factors, as well as a relation between survival and SRH, accentuating their relevance within the ageing population.

Background: Subjective memory is commonly considered to be a unidimensional measure. However, theories of performance-based memory suggest that subjective memory could be divided into more than one dimension. Objective: To divide subjective memory into theoretically related components of memory and explore the relationship to disease. Methods: In this study, various aspects of self-reported memory were studied with respect to demographics and diseases in the third wave of the HUNT epidemiological study in middle Norway. The study included all individuals 55 years of age or older, who responded to a nine-item questionnaire on subjective memory and questionnaires on health (n=18 633). Results: A principle component analysis of the memory items resulted in two memory components; the criterion used was an eigenvalue above 1, which accounted for 54% of the total variance. The components were interpreted as long-term memory (LTM; the first component; 43% of the total variance) and short-term memory (STM; the second component; 11% of the total variance). Memory impairment was significantly related to all diseases (except Bechterew's disease), most strongly to brain infarction, heart failure, diabetes, cancer, chronic obstructive pulmonary disease and whiplash. For most diseases, the STM component was more affected than the LTM component; however, in cancer, the opposite pattern was seen. Conclusions: Subjective memory impairment as measured in HUNT contained two components, which were differentially associated with diseases.

Practice effects (PEs) defined as an improvement of performance in cognition due to repeated assessments between sessions are well known in unimpaired individuals, while less is known about impaired cognition and particularly in latent brain disease as autosomal-dominant Alzheimer's disease. The purpose was to evaluate the general (across tests/domains) and domain-specific PE calculated as the annual rate of change (ARC) in relation to years to the estimated disease onset (YECO) and in four groups of AD: asymptomatic mutation carriers (aAD, n = 19), prodromal, i.e., symptomatic mutation carriers, criteria for AD diagnosis not fulfilled (pAD, n = 4) and mutation carriers diagnosed with AD (dAD, n = 6) as well as mutation non-carriers from the AD families serving as a healthy comparison group (HC, n = 35). Cognition was assessed at baseline and follow-up about 3 years later by 12 tests covering six domains. The aAD and HC groups were comparable at baseline in demographic characteristics (age, gender, and education), when they were in their early forties, while the pAD and dAD groups were older and cognitively impaired. The results on mean ARC for the four groups were significantly different, small, positive, and age-insensitive in the HC group, while ARC was negative and declined with time/disease advancement in AD. The differences between HC and aAD groups in mean ARC and domain-specific ARC were not significant, indicating a subtle PE in aAD in the early preclinical stage of AD. In the symptomatic stages of AD, there was no PE probably due to cognitive disease-related progression. PEs were the largest in the verbal domain in both the HC and aAD groups, indicating a relationship with cognitive vulnerability. The group-related difference in mean ARC was predominant in timekeeping tests. To conclude, the practice effect in over 3 years was suggested to be linked to procedural learning and memory.

To reveal new insights into statin cognitive effects, we performed an observational study on a population-based sample of 245,731 control and 55,114 statin-taking individuals from the UK Biobank. Cognitive performance in terms of reaction time, working memory and fluid intelligence was analysed at baseline and two follow-ups (within 5-10 years). Subjects were classified depending on age (up to 65 and over 65 years) and treatment duration (1-4 years, 5-10 years and over 10 years). Data were adjusted for health- and cognition-related covariates. Subjects generally improved in test performance with repeated assessment and middle-aged persons performed better than older persons. The effect of statin use differed considerably between the two age groups, with a beneficial effect on reaction time in older persons and fluid intelligence in both age groups, and a negative effect on working memory in younger subjects. Our analysis suggests a modulatory impact of age on the cognitive side effects of statins, revealing a possible reason for profoundly inconsistent findings on statin-related cognitive effects in the literature. The study highlights the importance of characterising modifiers of statin effects to improve knowledge and shape guidelines for clinicians when prescribing statins and evaluating their side effects in patients.

Background. We examined the association between extremely low-frequency magnetic fields (EMF) and the risk of dementia and Alzheimer’s disease using all 9,508 individuals from the Study of Dementia in Swedish Twins (HARMONY) with valid occupational and diagnostic data.

Methods. Dementia diagnoses were based on telephone screening followed by in-person clinical workup. Main lifetime occupation was coded according to an established EMF exposure matrix. Covariates were age, gender, education, vascular risk factors, and complexity of work. Based on previous research, data were also analyzed separately for cases with disease onset by age 75 years versus later, men versus women, and those with manual versus nonmanual main occupation. We used generalized estimating equations with the entire sample (to adjust for the inclusion of complete twin pairs) and conditional logistic regression with complete twin pairs only.

Results. Level of EMF exposure was not significantly associated with dementia or Alzheimer’s disease. However, in stratified analyses, medium and high levels of EMF exposure were associated with increased dementia risk compared with low level in cases with onset by age 75 years (odds ratio: 1.94, 95% confidence interval: 1.07–3.65 for medium, odds ratio: 2.01, 95% confidence interval: 1.10–3.65 for high) and in participants with manual occupations (odds ratio: 1.81, 95% confidence interval: 1.06–3.09 for medium, odds ratio: 1.75, 95% confidence interval: 1.00–3.05 for high). Results with 42 twin pairs discordant for dementia did not reach statistical significance.

Conclusions. Occupational EMF exposure appears relevant primarily to dementia with an earlier onset and among former manual workers.

Objectives. We used data from SWEOLD, a Swedish nationally representative study of individuals aged 77 years or older, to examine midlife indicators of job strain in relation to cognitive performance and impairment.

Methods. In all, 827 participants completed an abridged 11-point version of the Mini-Mental State Examination in-person in 1992 and/or 2002 and had self-reported and/or occupation-based scores for job control and demands from data collected in 1968. Seventeen percent scored below the cutoff for cognitive impairment.

Results. Controlling for age, sex, education, self-rated health, and year of cognitive screening, low self-reported and occupation-based job control at midlife was associated with poorer cognitive performance later (ps < .001). For the occupation-based measure, low job control was also associated with greater likelihood of impairment, whereas having an active job (high job control/high job demands) was associated with better cognitive performance and lower likelihood of impairment (ps < .01). Childhood environment, midlife depressive symptoms, and social activity had limited influence, whereas the influence of both adulthood socioeconomic position and work complexity on these results was more pronounced.

Discussion. Job control at midlife, by itself and in combination with job demands, may influence cognitive functioning later above and beyond demographic variables and other occupational characteristics.

OBJECTIVE: To examine whether occupational complexity of working with data or people, and cognitive or social leisure activity at midlife predicted cognition in advanced old age.

METHODS: We used 810 eligible participants from Longitudinal Study of Living Conditions of the Oldest Old, a Swedish nationally representative study of individuals aged 77+ with cognitive assessments (an abridged version of the Mini-Mental State Exam) administered in 1992 and 2002 and linked to information about their midlife occupation and leisure activities collected in 1968 and 1981. A bootstrapping technique was applied to examine the direct and interactive associations of occupational complexity and leisure activity with late-life cognition.

RESULTS: Controlling for demographic and health-related factors from childhood, midlife, and late life, we found that greater work complexity, both with people and with data, and greater participation in cognitive or social leisure activities independently related to better late-life cognitive scores. The complexity-cognition link was moderated by leisure activity such that the cognitive benefit related to the complexity of work-especially complexity of working with people-was rendered insignificant when participation in leisure activities-especially social activities-was above average.

DISCUSSION: Results are discussed in terms of using work complexity to compensate for lack of leisure activity as well as in terms of promoting leisure engagement to compensate for long-term cognitive disadvantage imposed by working in less challenging occupations.

OBJECTIVE:

To examine whether occupational complexity of working with data or people, and cognitive or social leisure activity at midlife predicted cognition in advanced old age.

METHODS:

We used 810 eligible participants from Longitudinal Study of Living Conditions of the Oldest Old, a Swedish nationally representative study of individuals aged 77+ with cognitive assessments (an abridged version of the Mini-Mental State Exam) administered in 1992 and 2002 and linked to information about their midlife occupation and leisure activities collected in 1968 and 1981. A bootstrapping technique was applied to examine the direct and interactive associations of occupational complexity and leisure activity with late-life cognition.

RESULTS:

Controlling for demographic and health-related factors from childhood, midlife, and late life, we found that greater work complexity, both with people and with data, and greater participation in cognitive or social leisure activities independently related to better late-life cognitive scores. The complexity-cognition link was moderated by leisure activity such that the cognitive benefit related to the complexity of work-especially complexity of working with people-was rendered insignificant when participation in leisure activities-especially social activities-was above average.

DISCUSSION:

Results are discussed in terms of using work complexity to compensate for lack of leisure activity as well as in terms of promoting leisure engagement to compensate for long-term cognitive disadvantage imposed by working in less challenging occupations.

BACKGROUND: Older people's use of the internet is increasingly coming into focus with the demographic changes of a growing older population. Research reports several benefits of older people's internet use and highlights problems such as various forms of inequality in use within the group. There is a need for consistent measurements to follow the development and use of the internet in this group and to be able to compare groups both within and between countries, as well as follow the changes over time.

OBJECTIVE: The aim of this study was to create an instrument to measure an older person's perception of the benefits of their online social participation, unconnected to specific applications and services. The instrument to measure internet social participation proposed in this paper builds on social participation factors and is a multidimensional construct incorporating both social relations and societal connectedness.

METHODS: A short instrument for measuring social participation over the internet was created. An exploratory factor analysis (EFA) was conducted in a random selection of persons aged 65 years or older (n=193) on 10 initial items. Further validation was made by confirmatory factor analysis (CFA) in the remaining group (n=193).

RESULTS: A 1-factor solution for the social internet score was decided upon after exploratory factor analysis (EFA; based on a random sample of half the data set). None of the questionnaire items were excluded based on the EFA, as they all had high loadings, the lowest being 0.61. The Cronbach α coefficient was .92. The 1-factor solution explained 55% of the variance. CFA was performed and included all 10 questionnaire items in a 1-factor solution. Indices of goodness of fit of the model showed room for improvement. Removal of 4 questions in a stepwise procedure resulted in a 6-item model (χ²₆=13.985; χ²/degrees of freedom=1.554; comparative fit index=0.992; root mean square error of approximation=0.054; standardized root mean square residual=0.025).

CONCLUSIONS: The proposed instrument can be used to measure digital social participation and coherence with society. The factor analysis is based on a sufficient sample of the general population of older adults in Sweden, and overall the instrument performed as expected.

The use of the internet has considerably increased over recent years, and the importance of internet use has also grown as services have gone online. Sweden is largely an information society like other countries with high reported use amongst European countries. In line with digitalization development, society is also changing, and many activities and services today take place on the internet. This development could potentially lead to those older persons who do not use the internet or do not follow the development of services on the internet finding it difficult to take part in information and activities that no longer occur in the physical world. This has led to a digital divide between groups, where the older generations (60+), in particular, have been affected. In a large study of Sweden’s adult population in 2019, 95 percent of the overall population was said to be internet users, and the corresponding number for users over 66 years of age was 84%. This study shows that the numbers reported about older peoples’ internet use, most likely, are vastly overestimated and that real use is significantly lower, especially among the oldest age groups. We report that 62.4% of the study subjects are internet users and that this number most likely also is an overestimation. When looking at nonresponders to the questionnaire, we find that they display characteristics generally attributed to non-use, such as lower education, lower household economy, and lower cognitive functioning.

Earlier research on residential mobility has demonstrated a tendency for the young old of the 55+ population to prefer peripheral locations, whereas older age groups choose central locations. Here, we present survey results indicating that such late-adulthood differences in preferences are supported by age-related shifts corresponding to differences in housing preferences expressed by individuals in peripheral as well as central locations in Sweden. A sample of 2,400 individuals aged 55 years and over was asked to select the seven most important characteristics of a dwelling from a list of 21 alternatives (Survey of Housing Intentions among the ELDerly in Sweden (SHIELD), 2013). The preferences expressed were used as dependent variables in logistic regressions to determine to what extent the housing preferences of older people are linked to age, gender, socio-economic status and type of geographical area. The results demonstrated a close link between neighbourhood characteristics and housing preferences. Owning the dwelling, having a garden and access to nature were stressed as important by individuals living in non-metropolitan middle-class areas and in suburban elite areas. The youngest cohort expressed similar preferences. Older age groups instead stressed the importance of an elevator, single-storey housing and a good design for independent living; preferences that have similarities to those expressed by individuals living in large cities and smaller urban centres where such housing is more readily available.

Age is a delicate matter, but the Swedish welfare state is ageing and has an increasingly larger propor-tion of elderly people, about 19 per cent (Sweden Statistics, 2014). Since the election campaign in 2006, the matter of appropriate housing and caregiving for older frail persons has been a reoccurring item on the political agenda. Governmental delegations and programmes have ventured out into the great unknown territory of architectural experiences and age-related problems. However, one existing residential care home, in the following RCH, pops up as an exemplary and universal model for architec-ture and the frail ageing process, the residential care home of Vigs Ängar.Initiated as a mutual initiative in the early 1990s, between a local anthroposophical interest group and the municipality of Ystad, Sweden, its creation and existence describe a troublesome tension between legal frameworks, managerial systems for eldercare, facility management and idealistic visions for fu-ture-oriented caregiving. Despite a 20 year existence, this exemplary model has resulted in few similar facilities, both architecture-wise and eldercare-wise. Instead, a large number of national and interna-tional study visits have turned the building along with caregiving into an open smorgasbord consisting of architectural elements or therapeutic approaches, subject to free sampling and tasting. To some extent, the anthroposophical label has clouded the resilient approach in architectural design and care-giving for the frail stages in life.The focus of this paper was to go behind semantics and unravel the generating images that constitute the fundamental reason for the exemplary status of the RCH in question. Critical analysis has been applied as a research method in order to scrutinize documents and drawings that originate from the design process. Random conversations and interviews with various informants associated with the RCH, among which the architect, have been executed over the period 2007-2013. This study suggests that the key factor in this successful realization of an RCH is the solid idea for a resilient architecture. This idea encompasses both ephemeral and tangible experiences of space that structure both the older person’s quality in life as well as the individual staff member’s satisfaction with the work envi-ronment. In that sense, the RCH of Vigs Ängar is more of a spatial sensation than an anthroposophical epiphany.