Formal support, mental disorders and personal characteristics: a 25-year follow-up study of a total cohort of older people.

The present study was designed to describe the pattern of long-term formal support received by people with mental disorders, and to investigate the relationship between the medical, psychological and social characteristics of the participants and types of formal support. This study is based on a cohort (n = 192) of people born in 1902 and 1903 in a community in Southern Sweden. The research participants were assessed using interviews, psychological tests and medical examinations. Information was collected about the use of primary healthcare and social services. The first assessment took place when the cohort was aged 67 years, and then on eight further occasions until they were 92. The participation rate ranged from 72% to 100%. During the observation period of 25 years, 53% of people with dementia eventually received both home help and institutional care compared to 34% of people with other psychiatric diagnoses and 12% of people with good mental health. The last group had all physical health problems and/or problems with activities of daily living. However, 35% of the dementia group, 46% with other psychiatric diagnoses and 52% of people with good mental health did not receive any formal support. Males and self-employed people were significantly less likely to use formal support. The institutionalised group reported loneliness significantly more often than the other two groups. In a logistic regression analysis, loneliness, low social class, high blood pressure and low problem-solving ability were predictors of formal support use. People with a mental disorder, including dementia, were significantly more likely to use formal support compared to people with good mental health. Social factors were the main factors predicting formal support.

The gender differences in growth hormone-binding protein and leptin persist in 80-year-old men and women and is not caused by sex hormones.

OBJECTIVE: Leptin and growth hormone-binding protein (GHBP) both show gender differences that might be explained by sex hormones. To study the potential relevance of oestradiol and testosterone, we have examined 80-year-old subjects in whom oestradiol is higher in men than in women. The interrelationships between leptin, insulin, GHBP and fat mass in this age group were also investigated. DESIGN AND SUBJECTS: Ninety-four subjects (55 females and 39 males), all 80 years old, were investigated in a community-based study. None of the investigated subjects was being treated for diabetes mellitus and none of the women had oestrogen replacement. METHODS: Levels of testosterone, oestradiol, SHBG, IGF-I, GHBP, glucose, insulin and leptin were analysed. Body composition was measured with bioimpedance analysis (BIA). RESULTS: As in younger age groups, serum leptin, the ratio leptin/kilogram fat mass and serum GHBP were higher in the women (all, P< or =0.007), although serum oestradiol was higher in the men (P<0.001). There were no significant associations between sex hormones and leptin or GHBP either in women or in men (all, r<0.13, P>0.1). Leptin correlated to kilogram fat mass in both women (r=0.55, P<0.001) and men (r=0.47, P=0.003), but in contrast, there were no significant correlations between GHBP and fat mass and GHBP and IGF-I, either in women or in men (all, r<0.24, P>0.2). Insulin and leptin were significantly associated with GHBP, both in women (r=0.48, P<0.001 and r=0.43, P=0.001, respectively) and in men (r=0.40, P=0.01 and r=0.34, P=0.03, respectively). CONCLUSIONS: Although the 80-year-old men had higher oestradiol levels than the women, the women had higher levels of leptin and GHBP. There were no correlations between sex hormones and leptin and GHBP, which indicates that the gender differences are not caused by sex hormones in old age. In contrast to studies in younger subjects, GHBP did not correlate to fat mass in the investigated 80-year-old men and women. In the older subjects investigated, as in younger subjects, GHBP was significantly correlated with leptin and insulin.

Insomnia and depressive symptoms in patients with Parkinson's disease. Relationship to health-related quality of life. An interview study of patients living at home.

The objectives of this study were to describe the prevalence of insomnia and depressive symptoms in patients with Parkinson's disease (PD) and to relate those symptoms to health-related quality of life. A total of 102 patients living at home, most of them moderately to severely disabled, were interviewed. Of them 43 patients were women with a mean age of 70 (range 58-79). The mean age for the men was 71 (range 56-80). Time since diagnosis was <2 years for 57%, 2-10 years for 31% and >10 years for 12%. The geriatric depression scale (GDS) and Livingston's insomnia scale were used. The results were related to quality of life as measured with the SF-36 health survey. The prevalence of insomnia was 80%. Moderate depressive symptoms were found in 47% and severe depressive symptoms in 5%. Patients with insomnia or with depressive symptoms had a significantly impaired quality of life on all eight scales of the SF-36. In a stepwise regression analysis the presence of pain and ache and depressive symptoms were significantly related to insomnia. The variables most related to depressive symptoms were Hoehn and Yahr group and insomnia. Hoehn and Yahr groups (more disability) were significantly related to insomnia and depressive symptoms. Thus, insomnia and depressive symptoms are prevalent in PD and influence quality of life and should, therefore, be considered when evaluating patients with PD.

Exploration of subjective well-being and dependence in daily activities at the beginning of the geriatric rehabilitation process: a challenge to traditional goal-setting and evaluation procedures?

The objectives of this study were to describe a population of elderly patients at the beginning of their rehabilitation period as regards subjective well-being and dependence in activities of daily living (ADL). In a Swedish rural county 244 patients aged 65+ who had begun rehabilitation within the last month were targeted. One part of the self-administered Göteborg Quality of Life Instrument and a revised version of the ADL Staircase were used. No correlation was found between subjective well-being and ADL dependence. However, significant correlations between ADL dependence and separate subjective well-being items were found in three out of 17, i.e. the items 'energy', 'leisure', and 'sense of significance and appreciation outside home'. Overall subjective well-being did not show any gender differences, but significant gender differences due to the distribution of scores was shown; females scored the items 'health', 'sleeping', and 'economy' as bad to a larger extent than males. Males were significantly more dependent than females in three out of nine ADL: 'going to the toilet', 'dressing', and 'cooking'. Additional knowledge of subjective well-being and ADL dependence at the beginning of the rehabilitation process challenges the traditional goal-setting and evaluation procedures of geriatric rehabilitation services.

Mini mental state examination in geriatric stroke patients. Validity, differences between subgroups of patients, and relationships to somatic and mental variables.

To study the validity of the Mini Mental State Examination (MMSE) in geriatric stroke patients, 116 patients were tested 2-8 weeks and 6 months post-stroke. A neuropsychological test battery consisting of five tests measuring memory, calculation and spatial ability was used for validation. Motor activity, depression, aphasia and activities of daily living were assessed. Confusion in the acute stage, Barthel Index, depression scores, level of motor activity, and most of the neuropsychological tests correlated to the MMSE. Logistic regression showed 4 independent variables which could predict the MMSE scores. A factor analysis showed 3 factors which could explain 53% of the variance. The sensitivity for detecting dementia was 56%, and increased to 68% if patients with isolated spatial dysfunction were excluded. The MMSE had acceptable validity in detecting cognitive dysfunction early poststroke in this old patient population.

Social relationships and health as predictors of life satisfaction in advanced old age: results from a Swedish longitudinal study.

This longitudinal study examines the relationship between family and friend social support, health, and life satisfaction for a single cohort of eighty-year-old persons living in Lund, Sweden. Results indicate that participants who remained in the study are healthier and score higher on life satisfaction when compared with those who either drop-out or die prior to age eighty-three. Even though well-integrated with family and friends, the number of friends decreases significantly from eighty to eighty-three years; those who reported no close friends nearly doubled from eighty to eighty-three years. However, for those with close friends, contact with friends increases with age. In contrast to previous research, a correlational analysis indicates that neither child nor friend support is related to life satisfaction at either eighty or eighty-three years. However, health measures and satisfaction with sibling contact are related to total life satisfaction at age eighty-three only. These findings indicate the multidimensionality of both social support and life satisfaction for the old-old.

Staff and administration perspectives in a one-year geriatric rehabilitation developmental process.

A health care reform for senior citizens took effect in 1992 in Sweden. Shortcomings as regards geriatric rehabilitation were identified and, in 1995, governmental grants were assigned to local developmental projects. The aim of this study was to report the staff and administration perspectives in a geriatric rehabilitation developmental process over a 1-year period. In all, 782 staff and 45 administration respondents took part. The investigation was based on questionnaires and series of interviews. Significant positive changes with respect to collaboration between the authorities involved were demonstrated at the administrative level, while the most positive results at staff level concerned competence development in the group of employees without college education. A positive process as regards geriatric rehabilitation has started in the study district, indicating that governmental grants assigned for the stimulation of developmental activities are beneficial. Official goals for geriatric rehabilitation, points of departure for the organization of rehabilitation services and the content of general and specialized rehabilitation programmes are pinpointed as some of the areas deserving further attention.

Concentrations of plasma methylmalonic acid in 80-year-olds show only weak relation to psychological performance.

Most studies of the relation between psychological performance in the elderly and deficiencies of cobalamin and folate have used methods that determine the blood concentrations of these vitamins, which might not reflect the vitamin status in the tissues. Recently, two new markers, plasma homocysteine and methylmalonic acid, have attracted growing interest since they are considered to reflect the status of cobalamins and folates in the tissues. In a previous study, we noted a strong association between five parameters of well-being and lower concentrations of plasma homocysteine. In the present study, we have extended these observations by determination of plasma methylmalonic acid in the same healthy elderly population. In the present study, 18 out of 100 subjects had increased plasma methylmalonic acid and in 7 of these subjects, the concentrations of serum cobalamin, blood folate, plasma homocysteine and serum creatinine were within normal limits. The relation between plasma methylmalonic acid concentrations and concentrations of serum cobalamin and blood folates and five parameters of well-being were investigated. Concentrations of plasma methylmalonic acid were only weakly associated with the concentrations of serum cobalamin and lower scores on the logical reasoning test. The present study clearly shows that the levels of plasma methylmalonic acid show a much lesser association with the parameters of well-being than did plasma homocysteine.

Insomnia in an 80-year-old population: relationship to medical, psychological and social factors.

In this study, insomnia in 80-year-olds was related to medical, psychological and social factors. The data were based on examinations every year in people aged between 80 and 89 years. Of 333 people living in the city of Lund and born in 1908, 67% participated. Increased severity of insomnia was significantly associated with use of diuretics, other cardiovascular drugs, hypnotics and laxatives, and with nervousness, difficulty relaxing, anorexia, nausea, constipation, backache, feeling cold, sweating, loss of weight, dizziness, depression, general fatigue, exhaustion, angina pectoris, cardiac insufficiency, worsened objective and subjective health, presence of negative T-waves on ECG, anxiety, total life satisfaction, neuroticism, disbelief in a just world, feeling lonely and lower survival rates. Thus insomnia has widespread associations with different aspects of life in 80-year-olds.

Plasma homocysteine in 80-year-olds: relationships to medical, psychological and social variables.

Plasma homocysteine concentrations in a group of 80-year-old persons were related to symptoms and signs. Plasma homocysteine concentrations higher than 15 micromol/l were associated with lower total life satisfaction (P<0.01), mood (P<0.05), zest for life (P<0.05), lower scores for reasoning (P<0.05), spatial ability (P<0.05), memory recognition (P<0.05), and subjective health (P<0.01). In an instrument comprising of 30 symptoms, plasma homocysteine concentrations higher than 15 micromol/l were associated with impaired concentration (P<0.05), restlessness (P<0.05), feeling cold (P<0.05), loss of weight (P<0.05), and feeling depressed (P<0.01). The above data indicate that plasma homocysteine values over 15 micromol/l could be relevant markers for clinical intervention.

Neglect in elderly stroke patients: a comparison of five tests.

Neglect is a disabling state in stroke patients. Five tests for visuo-spatial neglect, star cancellation, line crossing, line bisection, draw a clock and copy a cross, were compared in 57 elderly patients. Sensitivity and intercorrelations between the tests were determined. Patients with neglect were studied as regards their activities of daily living, motor activity and cognition. Left-hemisphere neglect in patients with right-hemisphere lesions was more severe than right-sided neglect in patients with left-sided lesions in the star cancellation test. Sensitivity of the tests was moderate for star cancellation, line bisection and draw a clock, and low for line crossing and copy a cross. Significant correlations existed between the tests and cognitive and functional ability. Intercorrelations between the tests were moderate. Neglect patients showed a slower recovery after 6 and 12 months. Draw a clock and a cross displayed no sensitivity for neglect in patients with hemianopia, which may be due to the fact that these tests also evaluate constructional apraxia. The cancellation tests were influenced by hemianopia and there is evidence that hemianopia exacerbates neglect. This study shows that a battery of neglect tests is required to diagnose the neglect syndrome.

Blood pressure in relation to medical, psychological and social variables in a population of 80-year-olds. Survival during 6 years.

OBJECTIVES: To relate elevated blood pressure in 80-year-olds to symptoms, life satisfaction and survival. DESIGN: Examinations of medical, psychological and social factors every year between 80 and 86 years of age. SETTING: Primary health care in the city of Lund in southern Sweden. SUBJECTS: Three-hundred and thirty-three persons living in the city of Lund and born in 1908. Participation rate was 67%. INTERVENTION: Abnormal findings were further examined and treated. MAIN OUTCOME MEASURES: Symptoms, blood pressure, laboratory values, psychological factors, cognition, living conditions, and survival. RESULTS: Hypertension according to the definition used was found in 70%. Women were over-represented (P < 0.05). Amongst persons with alleged hypertension, diuretics (P < 0.001) and 'other cardiovascular drugs' (P < 0.001) were more often used. Analgesics were more often used amongst assessed hypertensives (P < 0.05). Those with assessed hypertension scored better in testing of cognition compared to nonhypertensives (P < 0.05), and less often lived in institutions (P < 0.001). Assessed hypertensives had a better survival than alleged hypertensives during the following 7 years (P < 0.01). CONCLUSIONS: Eighty-year-olds with assessed hypertension in the consulting room showed fewer symptoms and had a better cognition and survival than alleged hypertensives (those with a history of hypertension).

A comparison of zopiclone and propiomazine as hypnotics in outpatients: a multicentre, double-blind, randomized, parallel-group comparison of zopiclone and propiomazine in insomniacs.

In a double-blind, parallel-group study of 135 patients with a mean age of 60 years, zopiclone 5 mg was compared with propiomazine 25 mg. The patients rated their sleep in a diary. There were statistically significant differences in favour of zopiclone for nine out of 13 variables measuring subjective sleep quality and quantity. Concerning side-effects, bad taste was reported more frequently in the zopiclone group and restless legs in the propiomazine group.

Laboratory values, symptoms and survival in an 80-year-old population.

Medical, psychological and sociological factors were related to laboratory values in an 80-year-old population encompassing 211 persons. 21% of the men and 17% of the women had elevated ESR. 36% had elevated blood glucose (7% had diabetes). 13% of the men and 7% of the women had anaemia. Persons with anaemia generally had a lower quality of life compared with non-anaemic persons. Low haemoglobin, elevated ESR and low serum iron were all associated with impaired subjective and objective health. There were no significant correlations between the laboratory data and psychological and social parameters. The survival over 5 years was significantly decreased for those with anaemia, elevated ESR, high white blood count, high blood glucose, low serum iron or deviating serum potassium.

Double-blind comparison of zopiclone and flunitrazepam in elderly insomniacs with special focus on residual effects.

In a double-blind study of 102 patients with a mean age of 79 years, zopiclone was compared to flunitrazepam. The patients rated their sleep in a diary. There was no statistically significant difference between the relatively low dose of 5 mg zopiclone and 1 mg flunitrazepam for eleven out of the twelve variables measuring subjective sleep quality and quantity. There was no differences between the drugs as regards patients' feelings of being rested or alertness.

Urinary incontinence in primary health care. 1. Perceived knowledge and training among various categories of nursing personnel and care units.

OBJECTIVES: To investigate perceived knowledge, skills and education of urinary incontinence (UI), focusing on UI facts, product assessment, and quality of care. DESIGN: A quantitative-qualitative questionnaire study. SETTING: Three different care units; a health care centre, a nursing home, and a geriatric clinic in Sweden. SUBJECTS: 254 nurses, nursing assistants, and auxiliary nurses. MAIN OUTCOME MEASURES: Responses to questionnaire. RESULTS: The study shows fragmentary knowledge about UI facts, aid products, and costs, and a lack of holistic view. The differences in knowledge between the groups were small but registered nurses generally showed better results, probably due to their longer vocational training. The health care centre had the best total knowledge as regards facts about UI. CONCLUSION: All categories of nursing personnel wanted more knowledge about UI care and aids, which indicates that improvements in quality of care could be achieved by increasing product awareness.

Urinary incontinence in primary health care. 2. Care routines and consequences--perception of various categories of nursing personnel and care units.

OBJECTIVE: To find out whether the nursing personnel's perceptions of urine incontinence (UI) care routines and patient observations were in agreement with quality of care, and to analyse differences between nursing personnel categories and care units. DESIGN: A quantitative-qualitative questionnaire study. SETTING: Three different care units; a health care centre, a nursing home, and a geriatric clinic in a county in Sweden. SUBJECTS: 254 nurses, nursing assistants, and auxiliary nurses. MAIN OUTCOME MEASURES: Responses to questionnaire. RESULTS: Faulty perception of UI, diagnosis and treatment possibilities. Care routines about hygiene and integrity, and knowledge about volume frequency chart, selection and changing of pads seemed to be indulgent. Registered nurses showed slightly better results than the other groups, even if the differences were small. There were no significant differences between the care units, but the health care centre had the best total result as regards patient observations. CONCLUSION: The study confirmed that the nurses used faulty procedures to achieve quality of care. The study especially highlighted the role of nurses in primary health care, but since UI is a multidisciplinary symptom it demands interest and UI qualification of all personnel groups in the primary health care team.