The STAIR OF KNOWLEDGE-a codesigned intervention to prevent pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes in Sweden: development of a complex intervention.

OBJECTIVES: To describe the development of a codesigned complex intervention intended to prevent the risks of pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes. DESIGN: A complex intervention development study. The development of the intervention was conducted in three phases. We established contact with stakeholders in the municipality, updated us of current status of the literature in this area and conducted studies in the local context (1). We codesigned the intervention in workshops together with end users (2). We codesigned the final outline of the intervention in an iterative process with stakeholders (3).Setting: Nursing homes in the municipality in southern Sweden. PARTICIPANTS: End users (n=16) in nursing homes (n=4) codesigned the intervention together with the research group in workshops (n=4) in March-April 2022. Additionally, stakeholders (n=17) who were considered to play an important role in developing the intervention participated throughout this process. Data were analysed using reflexive thematic analysis. RESULTS: Four workshops were conducted with end users (n=16) and 13 meetings with stakeholders (n=12) were held during the development process. The intervention aims to bridge the evidence-practice gap regarding the preventive care process of the risks of pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes. The intervention is aimed at end users, lasts for 3 weeks and is divided into two parts. First, end users obtain knowledge on their own by following written instructions. Second, they meet, interact and discuss the knowledge acquired during part 1. CONCLUSION: The intervention is robustly developed and thoroughly described. The study highlights the extensive process that is necessary for developing tailored complex interventions. The description of the entire development process may enhance the replicability of this intervention. The intervention needs to be tested and evaluated in an upcoming feasibility study. TRIAL REGISTRATION NUMBER: NCT05308862.

Prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls - a register study among older persons receiving municipal health care in southern Sweden.

BACKGROUND: Although pressure ulcers, malnutrition, poor oral health and falls are common among older persons, causing deteriorated health status, they have not been studied altogether among older persons receiving different types of municipal health care. The aim of this study was to determine the prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls among older persons aged ≥65 years receiving municipal health care in southern Sweden. METHODS: A retrospective cross-sectional study (n = 12,518 persons aged ≥65 years) using data from the national quality registry Senior Alert was conducted. The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was calculated based on categorical data from the instruments available in Senior Alert. T-tests, chi-square test, the Mantel- Haenszel test and logistic regression models were performed. RESULTS: The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was 27.9, 56.3, 34.2 and 74.5% respectively. Almost 90% of the older persons had at least one health risk. The prevalence of risk for pressure ulcers, poor oral health and falls was significantly higher in dementia care units compared to short term nursing care, home health care and nursing homes. The prevalence of risk for malnutrition was significantly higher among older persons staying in short term nursing care compared to other types of housing. The odds of having a risk for malnutrition were higher in short term nursing care compared to other types of housing. The oldest age group of 95-106 years had the highest odds of having a risk for falls. The presence of multiple health risks in one subject were more common in dementia homes compared to nursing homes and home health care but not compared to short term nursing care. CONCLUSION: The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was high, implying that these health risks are a great concern for older persons receiving municipal health care. A comprehensive supporting preventive process to prevent all the investigated health risks among older persons receiving municipal health care is recommended.

Co-afflicted but invisible: A qualitative study of perceptions among informal caregivers in cancer care.

This article explores the lived experience of informal caregivers in cancer care, focusing on the perceived burden and needs of individuals seeking support from an informal group for next of kin. A total of 28 individuals who were closely related to a patient with cancer participated in focus group interviews. Three themes were identified: setting aside one's own needs, assuming the role of project manager, and losing one's sense of identity. Together they form the framing theme: being co-afflicted. The characteristics of informal caregivers are shown to be similar to those of people with codependency, motivating development of targeted interventions from this perspective.

Prevention of pressure ulcers, malnutrition, poor oral health and falls in nursing homes: A focus group study with nurse aides, registered nurses and managers.

Background: Despite available knowledge how to prevent the risk of pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes, these risks still frequently occur and cause a major burden for older persons; furthermore, for the health care system, they are extremely costly. One way to combat these risks is to register the prevention process in quality registries. However, the increasing older population worldwide is going to put high demands on those working with this group of people. Objective: To explore how nurse aides, registered nurses and managers in nursing homes experience working with the prevention of pressure ulcers, malnutrition, poor oral health and falls in general and according to the quality register Senior Alert care process. Methods: A qualitative study was conducted in nursing homes in a municipality in southern Sweden. We purposively sampled nurse aides, registered nurses and managers (n = 21) working in nursing homes registered in the quality register Senior Alert, who then participated in one of five focus group semistructured digital interviews held between February and April 2020. The interviews were audio recorded. Data were analysed using reflexive thematic analysis. Results: Our findings explore how nurse aides, registered nurses and managers experience working with the prevention of pressure ulcers, malnutrition, poor oral health and falls in nursing homes both in general and according to Senior Alert. The following four themes were generated during the analysis: (1) is included in the everyday work, (2) requires team effort, (3) requires handling many challenges and (4) requires finding strategies. Conclusion: The prevention of pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes is complex. There is a commitment and responsibility among nurse aides, registered nurses and managers regarding preventive work and team effort, and finding useful strategies is necessary for the work to be successful. However, challenges, both at the individual and organizational levels, are involved, which implies that smoother organizational routines facilitating this preventive work are needed. Although nurse aides, registered nurses and managers are good at finding strategies that facilitate this work, one of the main challenges seems to lie in the variety of knowledge found among those working in nursing homes, particularly among nurse aides. This challenge was voiced by all the professionals, which suggests the need for a tailored educational intervention aimed at increasing the related knowledge among those working in nursing homes to enhance preventive work.

Evaluation of Automated Determination of Bilirubin and Oxyhemoglobin in Cerebrospinal Fluid Using the DrugLog© Instrument.

BACKGROUND: In a heterogenous group of patients with acute headache it is important to diagnose subarachnoid hemorrhage (SAH), a potentially lethal but treatable condition, with short turnaround time and high precision. Spectrophotometry of cerebrospinal fluid (CSF) is an essential part in the investigation of patients with suspected SAH but the analysis is slow and operator dependent. METHODS: We have evaluated a new instrument for ultraviolet and visible light (UV-VIS) spectroscopy (DrugLog©, Pharmacolog, Uppsala, Sweden) for automatic determination of oxyhemoglobin and bilirubin in CSF samples. The instrument incorporates software for calculating the absorbance values thus eliminating operator bias. Bilirubin and oxyhemoglobin in CSF was analyzed both with DrugLog© and traditional spectrophotometry at 415 and 476 nanometers (A415 and A476) using patient samples containing varying amounts of bilirubin and oxyhemoglobin. RESULTS: The DrugLog© method showed a strong correlation both for bilirubin (Pearson's r = 0.996) and oxyhemo-globin (Pearson's r = 0.993). The DrugLog© method had good linearity and precision, offering an automated determination of bilirubin and oxyhemoglobin, eliminating operator bias. CONCLUSIONS: The DrugLog© instrument has a short assay time and showed good agreement with traditional spectrophotometry.

The establishment of a shared care plan as it is experienced by elderly people and their next of kin: A qualitative study.

One strategy to achieve coordination of care for older people with complex care needs is the establishment of shared care plans. The aim of this study was to explore the process of establishing a shared care plan from the perspective of elderly people and their next of kin. Data were collected via 12 semi-structured interviews with 12 older persons targeted in joint care planning and 11 next of kin, either alone or together. The analysis was conducted using content analysis. The results reflect the process of establishing a shared care plan in the three categories; Preparation, Content and Results with belonging sub-categories. Preparation showed that the possibility to influence the preparation of the joint care plan meeting was sometimes limited and the purpose was not always clear. The Content category showed that the meeting was sometimes experienced as an unstructured, general conversation or focused on practical matters. And Results of the process were shown to be successful in terms of having positive effects or fulfilling needs, but also sometimes as being pointless. Thus, the results show that the process of establishing a shared care plan is somewhat unclear to the older person and their next of kin and that they are rarely involved in the decisions regarding when and if a shared care plan is needed. If joint care planning is expected to serve as a tool to accomplish a more person-centred care, then the person must be regarded as an equal partner all throughout the decision-making and planning process.

Exploring access to care among older people in the last phase of life using the behavioural model of health services use: a qualitative study from the perspective of the next of kin of older persons who had died in a nursing home.

BACKGROUND: There is little investigation into what care older people access during the last phase of their life and what factors enable access to care in this group. Illuminating this from the perspective of the next of kin may provide valuable insights into how the health and social care system operates with reference to providing care for this vulnerable group. The behavioural model of health services use has a wide field of application but has not been tested conceptually regarding access to care from the perspective of the next of kin. The aim of this study was to explore the care accessed by older people during the last phase of their life from the perspective of the next of kin and to conceptually test the behavioural model of health services use. METHODS: The data collection took place in 2011 by means of qualitative interviews with 14 next of kin of older people who had died in a nursing home. The interviews were analysed using directed content analysis. The behavioural model of health services use was used in deriving the initial coding scheme, including the categories: utilization of health services, consumer satisfaction and characteristics of the population at risk. RESULTS: Utilization of health services in the last phase of life was described in five subcategories named after the type of care accessed i.e. admission to a nursing home, primary healthcare, hospital care, dental care and informal care. The needs were illuminated in the subcategories: general deterioration, medical conditions and acute illness and deterioration when death approaches. Factors that enabled access to care were described in three subcategories: the organisation of care, next of kin and the older person. These factors could also constitute barriers to accessing care. Next of kin's satisfaction with care was illuminated in the subcategories: satisfaction, dissatisfaction and factors influencing satisfaction. One new category was constructed inductively: the situation of the next of kin. CONCLUSIONS: A bed in a nursing home was often accessed during what the next of kin regarded as the last phase of life. The needs among older people in the last phase of life can be regarded as complex and worsening over time. Most enabling factors lied within the organisation of care but the next of kin enabled access to care and contributed significantly to care quality. More research is needed regarding ageism and stigmatic attitudes among professionals and informal caregivers acting as a barrier to accessing care for older people in the last phase of their life. The behavioural model of health services use was extended with a new category showing that the situation of the next of kin must be taken into consideration when investigating access to care from their perspective. It may also be appropriate to include informal care as part of the concept of access when investigating access to care among older people in the last phase of their life. The results may not be transferable to older people who have not gained access to a bed in a nursing home or to countries where the healthcare system differs largely from the Swedish.

The collective voice: Legitimation strategies in focus group discussions with nurses in municipal palliative care for older people in Sweden.

This paper explores focus group discussions of registered nurses in municipal palliative care for older people, using data collected by researchers with an interest in health sciences. The linguistically based discourse analyis builds on a combination of Bakhtinian notions of dialogicity, the Other and addressivity, the use of quotations, and also van Leeuwen's framework for legitimation in discourse. The aim is to investigate strategies of addressing and legitimizing palliative care. Three types of narrative are discerned: the cautionary tale, fictionalization of professional experiences and the enactment of a fictive dialogue. The other professions involved (physicians, assistant nurses) are positioned as the Other as a means of legitimizing the perspectives of the registered nurses. As the patients and their next of kin are the objects of professional activities, the notion of the Third (connecting to the Other) is proposed. The objectification is a manifestation of commitment with routinized and professional distance to the patients.

In search of legitimacy--registered nurses' experience of providing palliative care in a municipal context.

BACKGROUND: The palliative care approach was originally developed for hospice care and for persons with cancer diseases, but has gradually expanded to embrace other contexts and people of all ages, with various life-threatening diseases. The palliative care concept thus also applies to older people and the context of municipal care, where Registered Nurses (RNs) hold key care provision positions. The municipal context is not, however, focused primarily on advanced nursing care, and it is important to highlight RNs' prerequisites for care provision. AIM: The study's aim was to describe RNs' experience of providing palliative care for older people in a municipal context. Data were collected through focus group discussions with 20 RNs from four different municipalities in southern Sweden and were analysed using conventional content analysis. FINDINGS: The results showed that the nurses experienced that it was they who cushioned the effects of unclear responsibilities between different organizations, but had limited legitimacy in the municipal context and in relation to other care providers. The results also showed that nurses lacked proper support and prerequisites for providing high-quality palliative care to older dying patients. CONCLUSION: The results pinpoint the importance of increased acknowledgement of nurses' knowledge and skills and a critical view on the effects of moving towards an organization composed of different consultants, which can lead to even more unclear responsibility for nursing care provision.

The experience of being next of kin to an older person in the last phase of life.

OBJECTIVE: The aim of the study was to investigate the experience of being next of kin to an older person in the last phase of life as narrated after the older person's death. METHOD: Qualitative interviews were performed with the next of kin (n = 17) to people aged 75 years and older who had recently died and had received help and/or care from the municipality in the last phase of life. Eleven women and six men participated, of whom seven were spouses, nine were children, and one was a grandchild. The interviews were analysed using qualitative content analysis. RESULTS: The experience of the next of kin could be understood as being a devoted companion during the transition toward the inevitable end, embracing the categories of living in the shadow of death; focusing on the needs of the dying person, making adjustments to everyday life; feeling the major responsibility; struggling with the health and social care system; and gaining strength from support. SIGNIFICANCE OF RESULTS: Being next of kin to an old person at the end of life means being a devoted companion during the transition toward the inevitable end, including the feeling of bearing the major responsibility and the need to be acknowledged by professionals. This study points to the importance of having access to professional care when it is needed, to complement and support the next of kin when his or her own resources and strength falter. This also includes support to enable the next of kin to remain involved in the care of his or her loved ones, thereby fulfilling their own wishes.

Old people receiving municipal care, their experiences of what constitutes a good life in the last phase of life: a qualitative study.

BACKGROUND: Old people's life situation when receiving municipal help and care in their last period of life is sparsely investigated from their own perspective. OBJECTIVE: The aim of this study was to investigate the experiences of aspects that bring about a good life in the last phase of life among people (75+ years) receiving municipal care. PARTICIPANTS: Older people living in a municipality in Southern Sweden being 75 years or older, receiving help and/or care from the municipality, and having a life-threatening disease and/or receiving palliative care were asked to participate. In all 17 people, 10 women and 7 men, aged 78-100 years were included. METHODS: Qualitative interviews, with the emphasis on their present life situation especially what brought about a good life, were performed. The interviews were analysed using qualitative content analysis. RESULTS: The experience was interpreted to be Turning inwards to come to peace with the past, the present and approaching death while being trapped by health complaints. Six categories embraced the experience of aspects that constitute a good life in the last phase of life: Maintaining dignity, Enjoying small things, Feelings of "being at home", Being in the hands of others, trying to adjust, Still being important for other people and Completing life while facing death. CONCLUSION: This study confirm theories suggesting that the last phase of life in old age meant focusing inwards, reflecting on the entire life as a way of completing it as well as enjoying small things and also viewing oneself in the perspective of contributing to the future. It also indicated that this phase of life meant being trapped by health complaints and functional limitations. The struggle to maintaining dignity as opposed to being in the hands of others implies that the concept of palliative care may be useful as a framework for providing nursing care to very old people, especially at the end of life.

Health care consumption and place of death among old people with public home care or in special accommodation in their last year of life.

BACKGROUND AND AIMS: Developing care for older people in the last phase of life requires knowledge about the type and extent of care and factors associated with the place of death. The aim of this study was to examine age, living conditions, dependency, care and service among old people during their last year of life, but also their place of death and factors predicting it. METHODS: The sample (n=1198) was drawn from the care and services part of the Swedish National Study on Ageing and Care (SNAC). Criteria for inclusion were being 75+ years, dying in 2001-2004, and having public care and services at home or in special accommodation. RESULTS: In the last year of life, 82% of persons living at home and 51% living in special accommodation were hospitalized; median stays were 10 and 6.7 days respectively. Those living at home were younger and less dependent in ADL than those living in special accommodation. Those living at home and those having several hospital stays more often died in hospital. In the total sample, more visits to physicians in outpatient care predicted dying in hospital, whereas living in special accommodation and PADL dependency predicted dying outside hospital. CONCLUSIONS: Old people in their last year of life consumed a considerable amount of both municipal care and outpatient and in-hospital medical care, especially those living at home, which in several cases ended with death in hospital.

The final period of life in elderly people in Sweden: factors associated with QOL.

Whether elderly people in the final period of life have a high quality of life (QOL) and what factors relate QOL in this context, is not well known. The aim of this study was to examine the final period in life in elderly people (75 years or older) in need of help with instrumental activities of daily living (ADL), with the focus on quality of life, sense of coherence (SOC), health complaints and self-reported diseases. Also to investigate factors associated with QOL and factors predicting mortality. The sample consisted of 411 people, fifty of the respondents (the study group) had died within 1 year of data collection. The results showed that the study group had lower QOL than the comparison group. More admissions to hospital as well as the number of health complaints present negatively affected QOL for all respondents. Factors that predicted mortality included older age and higher number of health complaints.

Application of a combined effect compartment and binding model for gastric acid inhibition of AR-HO47108: a potassium competitive acid blocker, and its active metabolite AR-HO47116 in the dog.

The effect of AR-HO47108, a potassium competitive acid blocker, and its active metabolite AR-HO47116 was studied in Heidenhain pouch dogs following administration of single oral and intravenous doses of the two compounds. The histamine-stimulated acid secretion was measured in different periods after dose up to 24h. All data obtained in the different studies was pooled and analyzed by non-linear mixed effects modelling. It was found that there is a delay between the plasma concentration-time peak and the maximum inhibitory effect and that the effect persisted longer than anticipated from the plasma concentration half-lives of the compounds. In addition, it was found that the peak effect was reached earlier at higher doses. The effect data was well described by a combined effect compartment and binding model and both distribution to the biophase i.e. the canaliculus of the parietal cell and a rate limiting binding interaction between drug and enzyme appear to contribute to the observed delay. In addition, a secretion rate dependent washout from the biophase may contribute. Furthermore, because the parent compound and metabolite bind to the same enzyme, the effect is determined by competition between the two for the same enzyme. The metabolite was found to be less potent than the parent compound, with Kd values of the combined model of 125 and 11.2 nM for the metabolite and parent compound, respectively. However, the metabolite is generated in high concentrations that rapidly exceed the concentration of parent compound after oral administration of parent compound, and this together with its longer plasma half-life will make its contribution to the overall effect increase with time and slightly prolong the duration of the effect.

Quality of life among older people in Sweden receiving help from informal and/or formal helpers at home or in special accommodation.

The present study describes and compares quality of life (QoL) and factors which predict QoL among people aged 75 years and over who receive help with activities of daily living (ADLs) from formal and/or informal helpers. The subjects were living at home or in special accommodation in Sweden. A postal questionnaire was sent to a randomly selected and age-stratified sample of 8500 people. The response rate was 52.8% (n = 4337), and 1247 people [mean age (+/- SD) = 86.4 +/- 5.9 years] received help and indicated who helped them with ADLs. The findings suggest that a greater age, being a woman, being a widow/widower, a higher number of health-related complaints, needing more help with ADLs and a lower QoL were found among those receiving help in special accommodation in comparison with those receiving help at home. The extent of help was highest among those receiving help in special accommodation. Having help with ADLs every day at home indicated having help from both informal and formal helpers, while respondents receiving help from only informal or only formal helpers received the smallest amount of help with ADLs. A need for greater help with ADLs, and a higher number of self-reported diseases and complaints determined low QoL, whilst a social network (contact with more than three people) and a greater age determined high QoL. However, who the helpers were did not have a significant influence on QoL; it was the extent of help with ADLs that influenced QoL negatively and the density of the social network that influenced QoL positively.