Accepting the inevitable: A mixed method approach with assessment and perceptions of well-being in very old persons within the northern Sweden Silver-MONICA study.

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.

Alcohol intake in relation to non-fatal and fatal coronary heart disease and stroke: EPIC-CVD case-cohort study.

OBJECTIVE: To investigate the association between alcohol consumption (at baseline and over lifetime) and non-fatal and fatal coronary heart disease (CHD) and stroke. DESIGN: Multicentre case-cohort study. SETTING: A study of cardiovascular disease (CVD) determinants within the European Prospective Investigation into Cancer and nutrition cohort (EPIC-CVD) from eight European countries. PARTICIPANTS: 32 549 participants without baseline CVD, comprised of incident CVD cases and a subcohort for comparison. MAIN OUTCOME MEASURES: Non-fatal and fatal CHD and stroke (including ischaemic and haemorrhagic stroke). RESULTS: There were 9307 non-fatal CHD events, 1699 fatal CHD, 5855 non-fatal stroke, and 733 fatal stroke. Baseline alcohol intake was inversely associated with non-fatal CHD, with a hazard ratio of 0.94 (95% confidence interval 0.92 to 0.96) per 12 g/day higher intake. There was a J shaped association between baseline alcohol intake and risk of fatal CHD. The hazard ratios were 0.83 (0.70 to 0.98), 0.65 (0.53 to 0.81), and 0.82 (0.65 to 1.03) for categories 5.0-14.9 g/day, 15.0-29.9 g/day, and 30.0-59.9 g/day of total alcohol intake, respectively, compared with 0.1-4.9 g/day. In contrast, hazard ratios for non-fatal and fatal stroke risk were 1.04 (1.02 to 1.07), and 1.05 (0.98 to 1.13) per 12 g/day increase in baseline alcohol intake, respectively, including broadly similar findings for ischaemic and haemorrhagic stroke. Associations with cardiovascular outcomes were broadly similar with average lifetime alcohol consumption as for baseline alcohol intake, and across the eight countries studied. There was no strong evidence for interactions of alcohol consumption with smoking status on the risk of CVD events. CONCLUSIONS: Alcohol intake was inversely associated with non-fatal CHD risk but positively associated with the risk of different stroke subtypes. This highlights the opposing associations of alcohol intake with different CVD types and strengthens the evidence for policies to reduce alcohol consumption.

Temporal variation in out-of-hospital cardiac arrest with validated cardiac cause.

OBJECTIVE: Temporal variations in the occurrence of out-of-hospital cardiac arrest (OHCA) have been shown. Most previous studies have in common that they include individuals whom have received cardiopulmonary resuscitation (CPR) and thus excluding a great number of all the actual cases of OHCA when conducting a study. Therefore the aim of this study was to describe temporal variations of OHCA, regardless of whether CPR was performed or not. DESIGN: All individuals aged 25-74 years in northern Sweden, 1989-2009, who suffered an out-of-hospital cardiac arrest with validated myocardial infarction aetiology (OHCA-V), regardless of whether CPR was performed or not, were included in this study, which resulted in 3357 individuals. RESULTS: Regarding the diurnal variation, a daytime excess of OHCA-V was seen, with most occurring between 12:00-17:59 (29%) closely followed by the 06:00-11:59 time block (27%). In terms of the weekly variation, most OHCA-V was seen on Saturdays (17%), while January (11%), followed by December (9%), saw the highest incidence of the months. CONCLUSION: A temporal variation in OHCA-V is seen even when including cases where no CPR is attempted. However, this variation differs in some aspects to what some previous studies have shown, in that no clear morning or Monday peaks were seen. In order to explore potential triggers and underlying factors that influence OHCA, more studies like these are needed, preferably following standardized inclusion criteria and definitions of OHCA to better be able to compare results, all in order to develop the best possible preventive strategies.

A second chance at life: people's lived experiences of surviving out-of-hospital cardiac arrest.

BACKGROUND: There is more to illuminate about people's experiences of surviving out-of-hospital cardiac arrest (OHCA) and how such an event affects people's lives over time. AIMS: This study aimed to elucidate meanings of people's lived experiences and changes in everyday life during their first year after surviving OHCA. METHODS: A qualitative, longitudinal design was used. Eleven people surviving OHCA from northern Sweden agreed to participate and were interviewed 6 and 12 months after the event. A phenomenological hermeneutic interpretation was used to analyse the transcribed texts. FINDINGS: The structural analysis resulted in two themes: (i) striving to regain one's usual self and (ii) a second chance at life, and subthemes (ia) testing the body, (ib) pursuing the ordinary life, (ic) gratitude for help to survival, (iia) regaining a sense of security with one's body, (iib) getting to know a new self, and (iic) seeking meaning and establishing a future. CONCLUSION: To conclude, we suggest that people experienced meanings of surviving OHCA over time as striving to regain their usual self and getting a second chance at life. The event affected them in many ways and resulted in a lot of emotions and many things to think about. Participants experienced back-and-forth emotions, when comparing their present lives to both their lives before cardiac arrest and those lives they planned for the future. During their first year, participants' daily lives were still influenced by 'being dead' and returning to life. As time passed, they wanted to resume their ordinary lives and hoped for continued lives filled with meaning and joyous activities.

Prodromal symptoms and health care consumption prior to out-of-hospital cardiac arrest in patients without previously known ischaemic heart disease.

AIMS: To describe prodromal symptoms and health care consumption prior to an out-of-hospital cardiac arrest (OHCA) in patients without previously known ischaemic heart disease (IHD). BACKGROUND: The most common lethal event of cardiovascular disease is sudden cardiac death, and the majority occur outside hospital. Little is known about prodromal symptoms and health care consumption associated with OHCAs. DESIGN: Case-crossover study. METHODS: Medical records of 403 OHCA cases without previously known IHD, age 25-74 years in the MONICA myocardial registry in Norrbotten County 2000-2008, were reviewed. Presenting symptoms and emergency visits at public primary care facilities and internal medicine clinics in Norrbotten County were analyzed from the week prior to the OHCA and from the same week one year previously, which served as a control week. Unlike most studies we included unwitnessed arrests and those where no cardiopulmonary resuscitation (CPR) was attempted. RESULTS: Emergency visits were more common during the week prior to the OHCA than during the control week, both for visits to primary care (29 vs. 6, p<0.001) and to internal medicine clinics (16 vs. 0, p<0.001). Symptoms were more prevalent during the week prior to the OHCA (36.7 vs. 6.7%, p<0.001). The most prevalent symptoms were chest pain (14.6 vs. 0%, p<0.001), gastrointestinal symptoms (7.7 vs. 1.2%, p<0.001) and dyspnoea/peripheral oedema (6.9 vs. 0.2%, p<0.001). CONCLUSIONS: Patients who suffer an OHCA seek health care and present prodromal symptoms significantly more often the week prior to the event than the same week one year earlier.

Meanings of people's lived experiences of surviving an out-of-hospital cardiac arrest, 1 month after the event.

BACKGROUND: The out-of-hospital cardiac arrest (OHCA) survival rate has been poor and stable for a long time, but more recent studies describe its increase. However, there are few studies in which people narrate their experiences from surviving. OBJECTIVE: The aim of this study was to elucidate meanings of people's lived experiences of surviving an OHCA with validated myocardial infarction (MI) etiology, 1 month after the event. METHODS: A purposive sample of 2 women and 9 men was interviewed between February 2011 and May 2012. A phenomenological hermeneutical method was used for analysis, which involved 3 steps: naive reading and understanding, structural analysis, and comprehensive understanding. RESULTS: There were 2 themes, (1) returning to life and (2) revaluing life, and five subthemes, (1a) waking up and missing the whole picture, (1b) realizing it was not time to die, (2a) wondering why and seeking explanations, (2b) feeling ambiguous in relations, and (2c) wondering whether life will be the same. All were constructed from the analysis. CONCLUSIONS: Surviving an OHCA with validated MI etiology meant waking up and realizing that one had experienced a cardiac arrest and had been resuscitated. These survivors had memory loss and a need to know what had happened during the time they were dead/unconscious. They searched for a reason why they experienced an MI and cardiac arrest and had gone from being "heart-healthy" to having a lifelong illness. They all had the experience of passing from life to death and back to life again. For the participants, these differences led to a revaluation of what is important in life.

Risk factors among people surviving out-of-hospital cardiac arrest and their thoughts about what lifestyle means to them: a mixed methods study.

BACKGROUND: The known risk factors for coronary heart disease among people prior suffering an out-of-hospital cardiac arrest with validated myocardial infarction aetiology and their thoughts about what lifestyle means to them after surviving have rarely been described. Therefore the aim of the study was to describe risk factors and lifestyle among survivors. METHODS: An explanatory mixed methods design was used. All people registered in the Northern Sweden MONICA myocardial registry between the year 1989 to 2007 who survived out-of-hospital cardiac arrest with validated myocardial infarction aetiology and were alive at the 28th day after the onset of symptoms (n = 71) were included in the quantitative analysis. Thirteen of them participated in interviews conducted in 2011 and analysed via a qualitative manifest content analysis. RESULTS: About 60% of the people had no history of ischemic heart disease before the out-of-hospital cardiac arrest, but 20% had three cardiovascular risk factors (i.e., hypertension, diabetes mellitus, total cholesterol of more or equal 5 mmol/l or taking lipid lowering medication, and current smoker). Three categories (i.e., significance of lifestyle, modifying the lifestyle to the new life situation and a changed view on life) and seven sub-categories emerged from the qualitative analysis. CONCLUSIONS: For many people out-of-hospital cardiac arrest was the first symptom of coronary heart disease. Interview participants were well informed about their cardiovascular risk factors and the benefits of risk factor treatment. In spite of that, some chose to ignore this knowledge to some extent and preferred to live a "good life", where risk factor treatment played a minor part. The importance of the support of family members in terms of feeling happy and having fun was highlighted by the interview participants and expressed as being the meaning of lifestyle. Perhaps the person with illness together with health care workers should focus more on the meaningful and joyful things in life and try to adopt healthy behaviours linked to these things.

Trends in incidence and outcome of out-of-hospital cardiac arrest among people with validated myocardial infarction.

AIMS: To describe trends in incidence, outcome, and background characteristics among people who suffered an out-of-hospital cardiac arrest with validated myocardial infarction aetiology (OHCA-V). METHODS AND RESULTS: People from the northern Sweden MONICA myocardial registry (1989-2007) with OHCA-V (n = 2977) were divided in two age groups (25-64 and 65-74 years). Both those who were resuscitated outside hospital and those who died before resuscitation was started were included in the study. The younger age group was studied during 1989-2007 and the older group during 2000-2007. The incidence of OHCA-V decreased in both the younger group (men p < 0.0001, women p = 0.04) and the older group (men p < 0.0001, women p < 0.0007, respectively). The proportion with a history of ischaemic heart disease prior to the event decreased (p < 0.0001). The proportion of previous myocardial infarction decreased (p < 0.0001), diabetes mellitus increased (p = 0.001), coronary interventions increased (p < 0.0001), and survival after OHCA-V increased (p < 0.0001) in the younger group but not in the older group. Long-term survival after OHCA-V was better in the younger than in the older group (p = 0.026). CONCLUSION: The incidence of OHCA-V decreased in both sexes. The proportion surviving after OHCA-V was small but increased, and long-term survival (≥ 28 days) was better in the younger age group. Primary preventive measures may explain most of the improvements. However, the effects of secondary preventive measures cannot be excluded.

Sudden cardiac death among people with diabetes: preventive measures documented in their medical records.

AIMS: The purpose of this study was to examine how prevention of complications for people with diabetes mellitus had been conducted, as described in their medical records, focusing particularly on sudden cardiac death. A further aim was to compare the documentation with guidelines for diabetes care. BACKGROUND: Diabetes mellitus is associated with an increased risk of cardiovascular disease, death and sudden cardiac death. About half of those affected by sudden cardiac death are assumed to have had one or more risk factors for cardiovascular disease that could have been treated effectively resulting in a reduced risk of sudden death. DESIGN: Survey. METHOD: Fifty-six people diagnosed with diabetes mellitus, who had died of a sudden cardiac arrest between the years 2003-2005, from the Northern Sweden MONICA myocardial registry were included. These people's medical records were examined with regard to documentation of the care given during the year prior to the person's sudden cardiac death. RESULTS: The qualitative content analysis resulted in four categories: individualised goals for diabetes care; prevention of complications; self-care; and factors which may affect ability to adhere to treatment. The quantitative analysis showed that few people with diabetes mellitus achieved goals for metabolic control, compared with those set in guidelines for diabetes mellitus care. CONCLUSION: To prevent complications for people with diabetes mellitus, it is a challenge for nurses and physicians to involve people with diabetes mellitus in their own care to improve the prognosis. RELEVANCE TO CLINICAL PRACTICE: Examination of medical records of people with diabetes mellitus showed that documentation could be more informative and systematic. It is important to achieve better adherence to treatment and to increase people's understanding of their illness.