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  • 201.
    Rizzuto, Debora
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Melis, Rene J. F.
    Angleman, Sara
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Qiu, Chengxuan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Marengoni, Alessandra
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). University of Brescia, Italy.
    Effect of Chronic Diseases and Multimorbidity on Survival and Functioning in Elderly Adults2017In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 65, no 5, p. 1056-1060Article in journal (Refereed)
    Abstract [en]

    ObjectivesTo determine the effect of chronic disorders and their co-occurrence on survival and functioning in community-dwelling older adults. DesignPopulation-based cohort study. SettingKungsholmen, Stockholm, Sweden. ParticipantsIndividuals aged 78 and older examined by physicians four times over 11 years (N = 1,099). MeasurementsChronic diseases (grouped according to 10 organ systems according to the International Classification of Diseases, Tenth Revision, code) and multimorbidity (2 coexisting chronic diseases) were evaluated in terms of mortality, population attributable risk of death, median years of life lost, and median survival time with and without disability (need of assistance in 1 activities of daily living). ResultsApproximately one in four deaths were attributable to cardiovascular and one in six to neuropsychiatric diseases. Malignancy was the condition with the shortest survival time (2.5 years). Malignancies and cardiovascular disorders each accounted for approximately 5 years of life lost. In contrast, neurosensorial and neuropsychiatric conditions had the longest median survival time (>6 years), and affected people were disabled for more than half of this time. The most-prevalent and -burdensome condition was multimorbidity, affecting 70.4% of the population, accounting for 69.3% of total deaths, and causing 7.5 years of life lost. Finally, people with multimorbidity lived 81% of their remaining years of life with disability (median 5.2 years). ConclusionSurvival in older adults differs in length and quality depending on specific conditions. The greatest negative effect at the individual (shorter life, greater dependence) and societal (number of attributable deaths, years spent with disability) level was from multimorbidity, which has made multimorbidity a clinical and public health priority.

  • 202.
    Rizzuto, Debora
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Orsini, Nicola
    Qiu, Chengxuan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Wang, Hui-Xin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Lifestyle, social factors, and survival after age 75: population based study2012In: BMJ. British Medical Journal, E-ISSN 1756-1833, Vol. 345, p. e5568-Article in journal (Refereed)
    Abstract [en]

    Objective To identify modifiable factors associated with longevity among adults aged 75 and older.

    Design Population based cohort study.

    Setting Kungsholmen, Stockholm, Sweden.

    Participants 1810 adults aged 75 or more participating in the Kungsholmen Project, with follow-up for 18 years.

    Main outcome measure Median age at death. Vital status from 1987 to 2005.

    Results During follow-up 1661 (91.8%) participants died. Half of the participants lived longer than 90 years. Half of the current smokers died 1.0 year (95% confidence interval 0.0 to 1.9 years) earlier than non-smokers. Of the leisure activities, physical activity was most strongly associated with survival; the median age at death of participants who regularly swam, walked, or did gymnastics was 2.0 years (0.7 to 3.3 years) greater than those who did not. The median survival of people with a low risk profile (healthy lifestyle behaviours, participation in at least one leisure activity, and a rich or moderate social network) was 5.4 years longer than those with a high risk profile (unhealthy lifestyle behaviours, no participation in leisure activities, and a limited or poor social network). Even among the oldest old (85 years or older) and people with chronic conditions, the median age at death was four years higher for those with a low risk profile compared with those with a high risk profile.

    Conclusion Even after age 75 lifestyle behaviours such as not smoking and physical activity are associated with longer survival. A low risk profile can add five years to women's lives and six years to men's. These associations, although attenuated, were also present among the oldest old (≥ 85 years) and in people with chronic conditions.

  • 203. Robine, Jean-Marie
    et al.
    Cheung, Siu Lan Karen
    Saito, Yasuhiko
    Jeune, Bernard
    Parker, Marti G
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Herrmann, François R
    Centenarians Today: new Insights on Selection from the 5-COOP Study2010In: Current Gerontology and Geriatrics Research, ISSN 1687-7063, E-ISSN 1687-7071, Vol. 2010, article id 120354Article in journal (Refereed)
    Abstract [en]

    The number of oldest old grew tremendously over the past few decades. However, recent studies have disclosed that the pace of increase strongly varies among countries. The present study aims to specify the level of mortality selection among the nonagenarians and centenarians living currently in five low mortality countries, Denmark, France, Japan, Switzerland, and Sweden, part of the 5-Country Oldest Old Project (5-COOP). All data come from the Human Mortality Database, except for the number of centenarians living in Japan. We disclosed three levels of mortality selection, a milder level in Japan, a stronger level in Denmark and Sweden and an intermediary level in France and Switzerland. These divergences offer an opportunity to study the existence of a trade-off between the level of mortality selection and the functional health status of the oldest old survivors which will be seized by the 5-COOP project.

  • 204. Rusanen, Minna
    et al.
    Kivipelto, Miia
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Quesenberry, Charles P
    Zhou, Jufen
    Whitmer, Rachel A
    Heavy smoking in midlife and long-term risk of Alzheimer disease and vascular dementia2011In: Archives of Internal Medicine, ISSN 0003-9926, E-ISSN 1538-3679, Vol. 171, no 4, p. 333-339Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Smoking is a risk factor for several life-threatening diseases, but its long-term association with dementia is controversial and somewhat understudied. Our objective was to investigate the long-term association of amount of smoking in middle age on the risk of dementia, Alzheimer disease (AD), and vascular dementia (VaD) several decades later in a large, diverse population.

    METHODS: We analyzed prospective data from a multiethnic population-based cohort of 21,123 members of a health care system who participated in a survey between 1978 and 1985. Diagnoses of dementia, AD, and VaD made in internal medicine, neurology, and neuropsychology were collected from January 1, 1994, to July 31, 2008. Multivariate Cox proportional hazards models were used to investigate the association between midlife smoking and risk of dementia, AD, and VaD.

    RESULTS: A total of 5367 people (25.4%) were diagnosed as having dementia (including 1136 cases of AD and 416 cases of VaD) during a mean follow-up period of 23 years. Results were adjusted for age, sex, education, race, marital status, hypertension, hyperlipidemia, body mass index, diabetes, heart disease, stroke, and alcohol use. Compared with nonsmokers, those smoking more than 2 packs a day had an elevated risk of dementia (adjusted hazard ratio [HR], 2.14; 95% CI, 1.65-2.78), AD (adjusted HR, 2.57; 95% CI, 1.63-4.03), and VaD (adjusted HR, 2.72; 95% CI, 1.20-6.18).

    CONCLUSIONS: In this large cohort, heavy smoking in midlife was associated with a greater than 100% increase in risk of dementia, AD, and VaD more than 2 decades later. These results suggest that the brain is not immune to long-term consequences of heavy smoking.

  • 205.
    Rydwik, Elisabeth
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Äldres hälsa: ett sjukgymnastiskt perspektiv2012Collection (editor) (Other academic)
    Abstract [sv]

    Rehabilitering anpassad för äldre var under många år ett eftersatt ­kunskapsområde, men de senaste decennierna har forskningen ­bidragit till att utveckla metoder för att både förebygga och återvinna funktions- och aktivitetsbegränsningar. Med den demo­grafiska utvecklingen som kommer att eskalera under de närmsta 30–40 åren med allt fler äldre över 80 år, så ser man ett allt större behov av att äldre personer bibehåller sin förmåga att vara självständiga i dagliga aktiviteter. Detta för att samhället ska klara vården och omsorgen om de mest sjuka äldre. Kunskap om ­rehabilitering anpassad för äldre kan här spela en viktig roll.

    Det finns många orsaker till i vilken takt vi åldras i, och varia­tionen är stor. Heterogeniteten i åldrandet ställer därmed krav på en bred kunskap hos de sjukgymnaster som möter äldre personer i sitt ­kliniska arbete. Äldres hälsa – ett sjukgymnastik perspektiv ­spänner därför över ett brett område av olika insatser och metoder för att möta den äldre personens individuella behov, alltifrån hälso­promotion för den friska äldre personen till rehabilitering inom kommunal äldreomsorg och palliativ vård. Andra aspekter som motivation, anhörigstöd, psykisk ohälsa, läkemedel, ­nutrition och mobil informations- och kommunikationsteknik berörs också.

    Grundläggande i all sjukgymnastisk rehabilitering anpassad till äldre är att stimulera till rörelse, fysisk aktivitet, oberoende i dag­liga aktiviteter och välbefinnande. Att utgå ifrån det biologiska istället för det krono­logiska åldrandet är en väsentlig del och förutsätter kunskaper i gerontologi (det normala åldrandet) samt på vilket sätt och till vilken grad äldre personer drabbas av sjukdomar och aktivitetsbegränsningar och vilka insatser och metoder som står till buds för att bemöta dessa.

  • 206.
    Rydwik, Elisabeth
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm City Council .
    Welmer, Anna-Karin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Kåreholt, Ingemar
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Jönköping University.
    Angleman, Sara
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Wang, Hui-Xin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Adherence to physical exercise recommendations in people over 65 - The SNAC-Kungsholmen study2013In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 23, no 5, p. 799-804Article in journal (Refereed)
    Abstract [en]

    Background: There is limited knowledge regarding to what extent the older population meet the recommendations of physical exercise, especially fitness-enhancing exercise. This study assessed participation in health- and fitness-enhancing exercises in people aged >65, and explored to what extent the possible differences in meeting current recommendations differs by age, gender and education. Methods: The study population was derived from the Swedish National study on Aging and Care, and consisted of a random sample of 2593 subjects, aged 65+ years. Participation in health- and fitness-enhancing exercise according to the WHO and the American College of Sports Medicine's recommendations in relation to age, gender and education was evaluated using multinomial logistic regression adjusted for health indicators and physical performance. Results: According to the recommendations, 46% of the participants fulfilled the criteria for health-enhancing and 16% for fitness-enhancing exercises. Independent of health indicators and physical performance, women <80 years of age were less likely than men to participate in fitness-enhancing exercise, but they participated more in health-enhancing exercise. In the advanced age group (80+ years), women were less likely to participate both in fitness- and health-enhancing exercise. Advanced age and low education were negatively related to participation in both health- and fitness-enhancing exercise independent of health indicators, but the association was not observed among people with fast walking speed. Conclusion: Promoting physical exercise and encouraging participation among older adults with lower education, especially among those with initial functional decline, may help to reduce adverse health outcomes.

  • 207. Rönnlund, Michael
    et al.
    Sundström, Anna
    Adolfsson, Rolf
    Nilsson, Lars-Göran
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Umeå University, Sweden.
    Subjective memory impairment in older adults predicts future dementia independent of baseline memory performance: Evidence from the Betula prospective cohort study2015In: Alzheimer's & Dementia, ISSN 1552-5260, E-ISSN 1552-5279, Vol. 11, no 11, p. 1385-1392Article in journal (Refereed)
    Abstract [en]

    Introduction: The objective was to examine whether subjective memory impairment (SMI) predicts all-cause dementia or Alzheimer's disease (AD) in a population-based study with long-term followup (median = 10 years).

    Methods: A total of 2043 initially dementia-free participants (>= 60 years) made three memory ratings (compared with others, compared with five years ago, and complaints from family/friends) at baseline. During follow-up, 372 participants developed dementia (208 with AD).

    Results: Cox regression revealed that subjective memory impairment ratings predicted all-cause dementia in models adjusting for age and sex (hazard ratio or HR from 2.04 to 3.94), with even higher values for AD (HR from 2.29 to 5.74). The result persisted in models including other covariates, including baseline episodic memory performance, and in analyses restricted to participants with long time to dementia diagnosis (>= 5 years).

    Discussion: The findings underscore the usefulness of subjective memory assessment in combination with other factors in identifying individuals at risk for developing dementia.

  • 208.
    Salami, Alireza
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Umeå University, Sweden.
    Avelar-Pereira, Barbara
    Stockholm Univ, Stockholm, Sweden.
    Garzon, Benjamin
    Stockholm Univ, Stockholm, Sweden.
    Sitnikov, Rouslan
    Kalpouzos, Grégoria
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Functional coherence of striatal resting-state networks is modulated by striatal iron content2018In: NeuroImage, ISSN 1053-8119, E-ISSN 1095-9572, Vol. 183, p. 495-503Article in journal (Refereed)
    Abstract [en]

    Resting-state spontaneous fluctuations have revealed individual differences in the functional architecture of brain networks. Previous research indicates that the striatal network shows alterations in neurological conditions but also in normal aging. However, the neurobiological mechanisms underlying individual differences in striatal resting-state networks (RSNs) have been less explored. One candidate that may account for individual differences in striatal spontaneous activity is the level of local iron accumulation. Excessive iron in the striatum has been linked to a loss of structural integrity and reduced brain activity during task performance in aging. Using independent component analysis in a sample of 42 younger and older adults, we examined whether higher striatal iron content, quantified using relaxometry, underlies individual differences in spontaneous fluctuations of RSNs in general, and of the striatum in particular. Higher striatal iron content was linked to lower spontaneous coherence within both caudate and putamen RSNs regardless of age. No such links were observed for other RSNs. Moreover, the number of connections between the putamen and other RSNs was negatively associated with iron content, suggesting that iron modulated the degree of cross-talk between the striatum and cerebral cortex. Importantly, these associations were primarily driven by the older group. Finally, a positive association was found between coherence in the putamen and motor performance, suggesting that this spontaneous activity is behaviorally meaningful. A follow-up mediation analysis also indicated that functional connectivity may mediate the link between striatal iron and motor performance. Our preliminary findings suggest that striatal iron potentially accounts for individual differences in spontaneous striatal fluctuations, and might be used as a locus of intervention.

  • 209.
    Samrani, George
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Bäckman, Lars
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Persson, Jonas
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Age-Differences in the Temporal Properties of Proactive Interference in Working Memory2017In: Psychology and Aging, ISSN 0882-7974, E-ISSN 1939-1498, Vol. 32, no 8, p. 722-731Article in journal (Refereed)
    Abstract [en]

    The inability to suppress irrelevant information has been suggested as a primary cause of proactive interference (PI), and this deficit may be enhanced in aging. The current study examines age differences and temporal boundaries of PI, by manipulating lure distances in a verbal 2-back working memory task. Both younger and older adults showed effects of interference for proximal 3-and 4-back lures, and this effect was greater for older adults. Whereas younger adults showed less interference during 4-back compared to 3-back lures, in both reaction times and accuracy, older adults improved only in accuracy. For distant lures, when the time between the 1st presentation of an item to its reappearance as a lure item was longer (e.g., 5-to 10-back lures), younger adults were no longer affected by PI. However, older adults were affected by PI throughout all distant lures, up to the most distant lure (9-/10-back). The results suggest that older adults were less successful in resolving interference from both proximal and distant familiar lures. Further, younger adults were able to overcome the effects of PI completely after a specific lure distance. The age differences in temporal properties of PI may therefore highlight a unique component linked to impaired interference control and aging.

  • 210.
    Sandberg, Linn
    Stockholm University, Faculty of Humanities, Department of Ethnology, History of Religions and Gender Studies, Gender Studies.
    Sex, sexuality and later life2015In: Routledge Handbook of Cultural Gerontology / [ed] Julia Twigg, Wendy Martin, Abingdon: Routledge, 2015, p. 218-225Chapter in book (Refereed)
  • 211.
    Santoni, Giola
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Marengoni, Alessandra
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). University of Brescia, Italy.
    Calderon-Larranaga, Amaia
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Aragon Health Sciences Institute, Sweden.
    Angleman, Sara
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Rizzuto, Debora
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Welmer, Anna-Karin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Mangialasche, Francesca
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Orsini, Nicola
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Defining Health Trajectories in Older Adults With Five Clinical Indicators2017In: The journals of gerontology. Series A, Biological sciences and medical sciences, ISSN 1079-5006, E-ISSN 1758-535X, Vol. 72, no 8, p. 1123-1129Article in journal (Refereed)
    Abstract [en]

    Background: People age differently, challenging the identification of those more at risk of rapid health deterioration. This study aimed to explore the heterogeneity in the health of older adults by using five clinical indicators to detect age-related variation and individual health trajectories over time. Methods: Health of 3,363 people aged 60+ from the Swedish National study on Aging and Care-Kungsholmen (SNAC-K) assessed at baseline and at 3-and 6-year follow-ups. Number of chronic diseases, physical and cognitive performance, personal and instrumental activities of daily living were integrated in a health assessment tool (HAT). Interindividual health differences at baseline and follow-ups were assessed with logistic quantile regression. Intraindividual health trajectories were traced with quantile mixed-effect models. Results: The HAT score ranges from 0 (poor health) to 10 (good health); each score corresponds to a specific clinical profile. HAT was reliable over time and accurately predicted adverse health outcomes (receiver-operating characteristic areas hospitalization = 0.78; 95% confidence interval = 0.74-0.81; mortality = 0.85; 95% confidence interval = 0.83-0.87; similar areas obtained for gait speed). Before age 85, at least 90% of participants were free of severe disability, and at least 50% were functionally independent despite chronic disorders. Age-and sex-related variation and high heterogeneity in health were detected at baseline and confirmed by intraindividual health trajectories. Conclusions: This study provides a positive picture of the health status of people 60+. Despite the complexity and heterogeneity of health in this age group, we could identify age-and sex-specific health trajectories using an integrated HAT. HAT is potentially useful in clinical practice and public health interventions.

  • 212. Santoni, Giola
    et al.
    Meinow, Bettina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Wimo, Anders
    Marengoni, Alessandra
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Calderon-Larranaga, Amaia
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Using an Integrated Clinical and Functional Assessment Tool to Describe the Use of Social and Medical Care in an Urban Community-Dwelling Swedish Older Population2019In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 20, no 8, p. 988-+Article in journal (Refereed)
    Abstract [en]

    Objectives: To describe the use of social and medical care services in a community-dwelling older population from Stockholm, Sweden, using an integrated clinical and functional assessment tool. Design: Study based on data from the longitudinal community-based Swedish National Study on Aging and Care in Kungsholmen. Setting and Participants: Random sample of people >65 years of age living in the community in central Stockholm between March 2001 and June 2004 (N = 2368). Measures: Health status was measured with a health assessment tool (HAT), which combines 5 indicators (gait speed, cognitive function, chronic multimorbidity, mild disability, severe disability) collected during Swedish National Study on Aging and Care in Kungsholmen clinical examinations. The amount of formal and informal social care was self-reported in hours per month and recorded by trained nurses at baseline and the 3-year follow-up for those >= 78 years of age at baseline. Data on hospital admissions, 30-day readmissions, days spent in the hospital, primary care visits, and specialist visits were obtained from Stockholm County Council registers (2001-2007). Results: At baseline, 10% of the sample received formal social care and 11% received informal care. Annually between baseline and the 3-year follow-up, 15% were admitted to the hospital, 5% were readmitted, 78% visited a specialist, and 89% visited primary care. Those with the best HAT scores received 0.02 hours/month of formal care; those with the worst, 34 h/mo. The corresponding numbers for other variables were 0.02 vs 73 h/mo of informal care, 2 vs 11 hospital admissions per 10 persons/year, 44 vs 226 hospital days per 10 persons/y, 0.4 vs 2 30-day readmissions per 10 persons/y, 37 vs 78 specialist visits per 10 persons/y, and 50 vs 327 primary care visits per 10 persons/y. Conclusions/Implications: Because of its high discriminative power, the easy-to-use HAT index could help decision makers to plan medical and social care services. (C) 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

  • 213.
    Schön, Pär
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Hagman, Lisbeth
    Wånell, Sven-Erik
    Tio Hundraprojektets effekter på vård och omsorg för målgruppen de mest sjuka äldre2012Report (Other academic)
  • 214.
    Seubert, Janina
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet, Sweden.
    Laukka, Erika J.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Rizzuto, Debora
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Hummel, Thomas
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Bäckman, Lars
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Larsson, Maria
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Perception and psychophysics.
    Prevalence and Correlates of Olfactory Dysfunction in Old Age: A Population-Based Study2017In: The journals of gerontology. Series A, Biological sciences and medical sciences, ISSN 1079-5006, E-ISSN 1758-535X, Vol. 72, no 8, p. 1072-1079Article in journal (Refereed)
    Abstract [en]

    Background: Olfactory dysfunction (OD) in old age is associated with poor health outcomes. Interrelationships among different correlates of OD can offer insights into the underlying mechanisms, but to date remain understudied. Methods: Odor identification performance and self-reported olfactory functioning were studied in 2,234 people aged 60-90 years, who were free of neurodegenerative disease and enrolled in the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K) study, Stockholm, Sweden. OD was defined as the inability to identify more than 10 out of 16 odors (free or cued identification) in a standardized odor identification task. OD prevalence was estimated, and associations with demographic, genetic, vascular, clinical, and behavioral factors, as well as their interactions were examined using multiple logistic regression analyses. Results: Overall prevalence of OD was 24.8% (CI: 23.1; 26.6). Self-reports were characterized by low sensitivity (35%), but high specificity (87%). Advancing age (OR = 15.50, CI = 9.40; 26.10 between the first and last age group), and history of coronary heart disease (OR = 1.35, 95% CI = 1.04; 1.75) were the principal factors associated with an increased probability of OD, whereas female gender (OR = 0.53, 95% CI = 0.43; 0.66) and more years of education (OR = 0.97, CI 0.94; 0.99) were linked to a lower probability. Exploratory interaction analyses indicated that prevalence of OD was particularly elevated among Apolipropotein E (APOE) epsilon 4 allele carriers who were also obese, and that being physically active counteracted the negative impact of cerebrovascular disease on OD. Conclusion: Demographic and genetic factors, but also prior and current health insults, are linked to OD in old age. Modulatory effects of behavioral factors highlight their value as possible prevention targets.

  • 215.
    Shakersain, Behnaz
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Rizzuto, Debora
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Wang, Hui-Xin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Faxén-Irving, Gerd
    Prinelli, Federica
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Institute of Biomedical Technologies - National Research Council, Italy.
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Xu, Weili
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Tianjin Medical University, China.
    An Active Lifestyle Reinforces the Effect of a Healthy Diet on Cognitive Function: A Population-Based Longitudinal Study2018In: Nutrients, ISSN 2072-6643, E-ISSN 2072-6643, Vol. 10, no 9, article id 1297Article in journal (Refereed)
    Abstract [en]

    The joint effect of diet and leisure activity on cognitive function remains unknown. We aimed to verify the hypothesis that an active lifestyle reinforces the effect of the Nordic Prudent Dietary Pattern (NPDP) on cognitive function. A total of 2223 dementia-free Swedish adults aged 60 with Mini-Mental State Examination (MMSE) scores 27 were followed for an average of 6 years. MMSE was tested during follow-ups. Diet was assessed by food frequency questionnaire. The NPDP index was calculated and tertiled (low, moderate, and high adherence). Participation in physical, mental and social activities was trichotomised (low, moderate, and intense). An active lifestyle was defined based on the participation in each activity. Data were analyzed using mixed-effects models. Moderate-to-high adherence to NPDP was associated with a reduced decline in the MMSE score (: 0.19, 95% Confidence Interval (CI): 0.14-0.24). This association became stronger when combined with moderate-to-intense physical (: 0.34, 95% CI: 0.2-0.45), mental (: 0.29, 95% CI: 0.21-0.37), or social (: 0.27, 95% CI: 0.19-0.34) activities. An active lifestyle strengthened the effect of NPDP on cognitive function by two times, and further lowered risk of MMSE decline by 30%. Thus, an active lifestyle reinforces the effect of a healthy diet on preserved cognitive function, and further decreases the risk of cognitive decline.

  • 216. Shaw, Benjamin A.
    et al.
    Fors, Stefan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Fritzell, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Lennartsson, Carin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Agahi, Neda
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Who Lives Alone During Old Age? Trends in the Social and Functional Disadvantages of Sweden's Solitary Living Older Adults2018In: Research on Aging, ISSN 0164-0275, E-ISSN 1552-7573, Vol. 40, no 9, p. 815-838Article in journal (Refereed)
    Abstract [en]

    This study identifies specific social and functional disadvantages associated with living alone during old age in Sweden and assesses whether these associations have changed during recent decades. Data came from repeated cross-sectional surveys of Swedish adults aged 77+ during 1992-2014. Findings indicate that several types of disadvantage are consistently associated with the probability of living alone including financial insecurity and having never married for women and having never married and mobility impairment for men. Also for older men, low education has become an increasing strong determinant of living alone. These findings suggest that older adults who live alone are a subgroup that is particularly, and in some cases increasingly, vulnerable with respect to social and functional status. This has important policy implications related to addressing the needs of this growing subgroup as well as methodological implications for studies on the health effects of living alone.

  • 217. Silverstein, Merril
    et al.
    Heap, Josephine
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Sense of coherence changes with aging over the second half of life2015In: Advances in Life Course Research, ISSN 1569-4909, E-ISSN 1879-6974, Vol. 23, p. 98-107Article in journal (Refereed)
    Abstract [en]

    Sense of coherence (SOC), a concept reflecting meaningfulness, comprehensibility, and manageability of life, has been demonstrated to have strong connections to positive outcomes such as good health. However, less is known about how SOC changes over the second half of life as age-related deficits accumulate. We used longitudinal samples of mature adults that included the oldest-old to track change in SOC from age 55 to 101. Growth curves using an accelerated longitudinal design were estimated for 1809 individuals who contributed 4072 observations from five national Swedish surveys between 1991 and 2010/11. Results indicated that deficits in health and social resources were largely responsible for the precipitous decline in SOC after age 70. When controlling for these deficits, SOC increased continuously into advanced old age. We conclude that the capacity to comprehend, manage, and find meaning in life the component elements of SOC strengthens over the last years of life, suggesting a positive ontogenic development that runs parallel but opposite to the negative impact of health and social decline.

  • 218.
    Sindi, Shireen
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet Center for Alzheimer Research, Sweden.
    Hagman, Göran
    Håkansson, Krister
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet Center for Alzheimer Research, Sweden.
    Kulmala, Jenni
    Nilsen, Charlotta
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Kåreholt, Ingemar
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet Center for Alzheimer Research, Sweden; Jönköping University, Sweden.
    Soininen, Hilkka
    Solomon, Alina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet Center for Alzheimer Research, Sweden; University of Eastern Finland, Finland.
    Kivipelto, Miia
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet Center for Alzheimer Research, Sweden; National Institute for Health and Welfare, Finland; University of Eastern Finland, Finland.
    Midlife Work-Related Stress Increases Dementia Risk in Later Life: The CAIDE 30-Year Study2017In: The journals of gerontology. Series B, Psychological sciences and social sciences, ISSN 1079-5014, E-ISSN 1758-5368, Vol. 72, no 6, p. 1044-1053Article in journal (Refereed)
    Abstract [en]

    To investigate the associations between midlife work-related stress and mild cognitive impairment (MCI), dementia, and Alzheimer's disease later in life, in a large representative population. Cardiovascular Risk Factors, Aging and Dementia (CAIDE) study participants were randomly selected from independent population-based surveys (mean age 50 years). A random sample of 2,000 individuals was invited for two reexaminations including cognitive tests (at mean age 71 and mean age 78), and 1,511 subjects participated in at least one reexamination (mean follow-up 28.5 years). Work-related stress was measured using two questions on work demands that were administered in midlife. Analyses adjusted for important confounders. Higher levels of midlife work-related stress were associated with higher risk of MCI (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.08-1.76), dementia (OR, 1.53; CI, 1.13-2.07), and Alzheimer's disease (OR, 1.55; CI, 1.19-2.36) at the first follow-up among the CAIDE participants. Results remained significant after adjusting for several possible confounders. Work-related stress was not associated with MCI and dementia during the extended follow-up. Midlife work-related stress increases the risk for MCI, dementia, and Alzheimer's disease in later life. The association was not seen after the extended follow-up possibly reflecting selective survival/participation, heterogeneity in dementia among the oldest old, and a critical time window for the effects of midlife stress.

  • 219.
    Sindi, Shireen
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet, Sweden; Imperial College London, United Kingdom.
    Johansson, Lena
    Skoog, Johan
    Mattsson, Alexander Darin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Sjöberg, Linnea
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet, Sweden.
    Wang, Hui-Xin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm University, Faculty of Social Sciences, Stress Research Institute. Karolinska Institutet, Sweden.
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet, Sweden; Stockholm Gerontology Research Center, Sweden.
    Kulmala, Jenni
    Soininen, Hilkka
    Solomon, Alina
    Johansson, Boo
    Skoog, Ingmar
    Kivipelto, Miia
    Kåreholt, Ingemar
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Jönköping University, Sweden.
    Sleep disturbances and later cognitive status: a multi-centre study2018In: Sleep Medicine, ISSN 1389-9457, E-ISSN 1878-5506, Vol. 52, p. 26-33Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate the associations between sleep disturbances in mid-life and late-life and late-life cognitive status. Methods: In four population-based studies (three Swedish studies: H70 study, Kungsholmen Project (KP) and The Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD); and one Finnish study: Cardiovascular Risk Factors, Aging and Dementia (CAIDE)), participants provided self-reports on insomnia, nightmares and general sleep problems. Late-life cognitive status was measured by the Mini Mental State Exam (MMSE). The associations between late-life sleep disturbances and cognition 3-11 years later were investigated across all studies (n = 3210). Mean baseline ages were 70 (CAIDE, H70 and SWEOLD), and 84 years (KP). Additional analyses examined the association between midlife sleep and late-life cognition using CAIDE (21 and 31 years follow-up, n = 1306, mean age 50 years), and SWEOLD (20-24 years follow-up, n = 2068, mean age 58 years). Ordered logistic regressions, adjusted for potential baseline confounders, were used in the analyses. Results: Late-life sleep disturbances were associated with poorer cognition after 3-11 years (fully adjusted beta = -0.12, 95% CI = -0.24 to -0.01). Midlife nightmares and insomnia were also associated with lower MMSE scores (fully adjusted beta = -0.28, 95% CI = -0.49 to -0.07 and beta = -0.20, 95% CI = -0.39 to -0.01), although the latter association was attenuated after adjusting for lifestyle/health-related confounders. Midlife general sleep problems were not associated with late-life MMSE performance. Conclusions: Sleep disturbances and midlife nightmares were associated with lower MMSE scores, which suggests that sleep disturbances in earlier life stages can be associated with worse late-life cognition.

  • 220. Sindi, Shireen
    et al.
    Kåreholt, Ingemar
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Jönköping University, Sweden.
    Eskelinen, Marjo
    Hooshmand, Babak
    Lehtisalo, Jenni
    Soininen, Hilkka
    Ngandu, Tiia
    Kivipelto, Miia
    Healthy Dietary Changes in Midlife Are Associated with Reduced Dementia Risk Later in Life2018In: Nutrients, ISSN 2072-6643, E-ISSN 2072-6643, Vol. 10, no 11, article id 1649Article in journal (Refereed)
    Abstract [en]

    Diet is an important modifiable lifestyle factor related to dementia risk. Yet, the role of midlife dietary changes is unclear. The goal is to investigate whether midlife healthy dietary changes are associated with late-life dementia risk. Data were collected within the Cardiovascular Risk Factors, Aging, and Dementia (CAIDE) population-based cohort study (n = 2000) (mean baseline age = 56 years). Participants returned for two late-life re-examinations (mean age = 70 and 78 years). Self-reported midlife diet was measured in a sub-sample (n = 341) (mean total follow-up = 16.8 years). Changes in specific dietary components (fats, vegetables, sugar, salt) were measured in midlife. Dementia diagnoses were ascertained with detailed examinations. Analyses adjusted for potential confounders. Total midlife healthy dietary changes (improving quality of fats, increasing vegetables, decreasing sugar and salt) were associated with a reduced risk of dementia (fully adjusted odds ratio (OR) 0.41, 95% confidence interval (CI) = 0.20-0.85). In contrast, when each factor was assessed individually, associations were not significant. This study is the first to show that beneficial midlife dietary changes are associated with a reduced dementia risk later in life. The results highlight the importance of targeting dietary patterns, where various food items may have synergistic effects.

  • 221.
    Sjölund, Britt-Marie
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Nordberg, Gunilla
    Wimo, Anders
    von Strauss, Eva
    Morbidity and physical functioning in old age: differences according to living area2010In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 58, no 10, p. 1855-62Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To describe differences in morbidity and functional status according to living area.

    DESIGN: Community-based survey.

    SETTING: A community-based prospective cohort, the Kungsholmen-Nordanstig Project.

    PARTICIPANTS: Adults aged 75 and older living in an urban area of central Stockholm (n=1,222) and in the rural community of Nordanstig in northern Sweden (n=919).

    MEASUREMENTS: Physicians clinically examined all participants using the same standardized protocols in both living areas; trained nurses directly assessed disability.

    RESULTS: Cardiovascular disease was the most common disorder in both living areas (39.9% in the urban area and 45.2% in the rural area). There were great area differences in the prevalence of stroke (7.4% and 14.0%), diabetes mellitus 6.3% and 16.1%), and Parkinson's disease (1.0% and 3.7%). It was more common to have two or more diseases than no diseases in the rural area than in the urban area (odds ratio=1.9, 95% confidence interval=1.4-2.4). Significant living area differences (urban vs rural) in population attributable risk (PAR) was found for disability due to stroke (5.6 vs 32.2), diabetes mellitus (1.2 vs 6.1), fractures (1.4 vs 10.7), and hearing impairment (8.7 vs 22.0).

    CONCLUSION: Differences were found in disability, morbidity, and disease patterns according to living area. The rural elderly population was more disabled and had more diseases than the urban elderly population, despite being slightly younger than the urban cohort. There were significant area differences in the PAR of how specific chronic conditions influenced the risk of disability.

  • 222.
    Sjölund, Britt-Marie
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Wimo, Anders
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Qiu, Chengxuan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Engström, Maria
    von Strauss, Eva
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Time trends in prevalence of activities of daily living (ADL) disability and survival: Comparing two populations (aged 78+years) living in a rural area in Sweden2014In: Archives of gerontology and geriatrics (Print), ISSN 0167-4943, E-ISSN 1872-6976, Vol. 58, no 3, p. 370-375Article in journal (Refereed)
    Abstract [en]

    The aim was to study time trends in prevalence of disability in ADL and survival among men and women 78 years and older comparing two cohorts. The study was a time trend study based on two population-based community cohorts, the Nordanstig Project (NP), collected 1995-1998 and the Swedish National Study on Aging and Care in Nordanstig (SNAC-N), collected 2001-2003. The participants were people aged 78 years and older from the NP cohort (N = 303) and from the SNAC-N cohort (N = 406). All were clinically examined by physicians and nurses using standardized protocols. Disability was defined as a need for assistance in one or more ADL activities. The prevalence of disability and survival were compared using logistic and Cox models. The prevalence of ADL disability was stable for men, while women became more disabled in ADL during the time period, OR 2.36 (1.12-4.94). There was no significant difference in survival time between the cohorts in either ADL disabled persons or nondisabled persons. There was a tendency for increased survival for non-disabled persons in SNAC-N compared with NP, although not significant; this was particularly true for women. In general, women survived longer than men did regardless of whether they were ADL disabled or not. The time trends for ADL disability found in the study show that ADL disability had increased in women but not in men. More studies are needed to identify risk factors for ADL disability with a view to preventing it in time.

  • 223.
    Sjölund, Sara
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Perception and psychophysics.
    Larsson, Maria
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Perception and psychophysics.
    Olofsson, Jonas K.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Perception and psychophysics.
    Seubert, Janina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet, Sweden.
    Laukka, Erika J.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Phantom Smells: Prevalence and Correlates in a Population-Based Sample of Older Adults2017In: Chemical Senses, ISSN 0379-864X, E-ISSN 1464-3553, Vol. 42, no 4, p. 309-318Article in journal (Refereed)
    Abstract [en]

    Loss of olfactory function is common in old age, but evidence regarding qualitative olfactory dysfunction in the general older population is scarce. The current study investigates the prevalence and correlates of phantom smell experiences (phantosmia) in a population-based study (Swedish National Study on Aging and Care in Kungsholmen [SNAC-K]) of Swedish adults (n = 2569) aged between 60 and 90 years. Phantosmia was assessed through a standardized interview and defined as reporting having experienced an odor percept in the absence of any stimuli in the surrounding environment that could emit the odor. The relationships between phantosmia and demographic, genetic, health-related, and behavioral variables were analyzed with hierarchical logistic regression analyses. The overall prevalence of phantom smells was 4.9%, and was associated with female gender, carrying the met allele of the BDNF gene, higher vascular risk burden, and reporting distorted smell sensations (parosmia). Olfactory dysfunction was, however, not related to phantosmia. The most frequently reported phantom smell was smoky/burnt. A novel finding was that some individuals reported phantom smells with an autobiographical connotation. The results from this study indicate that the prevalence of phantosmia in the general older population is not negligible and that some factors that are beneficial for preserved olfactory function, such as female gender and the BDNF met allele, are also associated with the occurrence of phantom smells.

  • 224.
    Sköldunger, Anders
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Fastbom, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Wimo, Anders
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Johnell, Kristina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden.
    Impact of Inappropriate Drug Use on Hospitalizations, Mortality, and Costs in Older Persons and Persons with Dementia: Findings from the SNAC Study2015In: Drugs & Aging, ISSN 1170-229X, E-ISSN 1179-1969, Vol. 32, no 8, p. 671-678Article in journal (Refereed)
    Abstract [en]

    Background: Inappropriate drug use (IDU) is an important risk factor for adverse outcomes in older persons. We aimed to investigate IDU and the risk of hospitalizations and mortality in older persons and in persons with dementia and to estimate the costs of IDU-related hospitalizations.

    Methods: We analyzed 4108 individuals aged a parts per thousand yen60 years from the Swedish National Study on Aging and Care (SNAC) data from Kungsholmen and Nordanstig (2001-2004). IDU was assessed by indicators developed by the Swedish National Board of Health and Welfare. Hospitalizations and mortality data were collected from Swedish registers. Regression models were used to investigate associations between IDU, hospitalizations, and mortality in the whole population and in the subpopulation of persons with dementia (n = 319), after adjustment for sociodemographics, physical functioning, and co-morbidity. Costs for hospitalizations were derived from the Nord-Diagnose Related Group cost database. Results IDU was associated with a higher risk of hospitalization [adjusted odds ratio (OR) = 1.46; 95 % confidence interval (CI) 1.18-1.81] and mortality [adjusted hazard ratio (HR) = 1.15; 95 % CI 1.01-1.31] within 1 year in the whole study population and with hospitalization (adjusted OR = 1.88; 95 % CI 1.03-3.43) in the subpopulation of persons with dementia, after adjustment for confounding factors. There was also a tendency for higher costs for hospitalizations with IDU than without IDU, although this was not statistically significant.

    Conclusions: Our findings suggest that IDU is associated with an increased risk of hospitalization in older persons and in persons with dementia. IDU is also associated with mortality among older persons. These findings highlight the need for cautious prescribing of long-acting benzodiazepines, anticholinergic drugs, concurrent use of three or more psychotropic drugs and drug combinations that may lead to serious drug-drug interactions to older patients. Further studies are needed to investigate the association between IDU and costs for hospitalizations.

  • 225.
    Sköldunger, Anders
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Johnell, Kristina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Winblad, Bengt
    Wimo, Anders
    Mortality and treatment costs have a great impact on the cost-effectiveness of disease modifying drugs in Alzheimer's disease - a simulation study2013In: Current Alzheimer Research, ISSN 1567-2050, E-ISSN 1875-5828, Vol. 10, no 2, p. 207-216Article in journal (Refereed)
    Abstract [en]

    Background: The societal costs of Alzheimer's Disease (AD) are enormous and pose a great challenge for the health and social care in any society. It is of vital importance to develop and identify cost effective treatment. The aim of the study was to present a hypothetical economic model of Disease Modifying Treatment (DMT) in AD. Methods: A 20 year Markov cohort model of DMT was constructed, based on Swedish care conditions. States and progression were defined according to the Mini Mental State Examination (MMSE). Epidemiological studies of incidence of dementia, prevalence and costs of Mild Cognitive Impairment (MCI) and AD as well as conversion studies of MCI and demographic statistics were used as inputs in the model. Results: Total costs were 113,797 million SEK for patients treated with DMT vs 88,562 million SEK for untreated patients. The corresponding gained QALYs were 529,945 and 450,307 respectively, giving an incremental cost effectiveness ratio of 293,002 SEK/QALY in the base option. Survival in the model was 8.72 years with DMT and 7.77 years for untreated. With an assumed Willingness to pay (WTP) of 600,000 SEK (about 86,200 US$ and 62,000 €) per gained QALY, the model indicated cost effectiveness with DMT. The sensitivity analysis implied no cost savings with DMT, but most options indicated cost effectiveness vs. the chosen WTP. Conclusion: The main reasons for the higher costs with DMT were the costs of DMT itself and the prolonged survival with DMT. Even if costs increase with DMT, the model indicates cost effectiveness.

  • 226.
    Sköldunger, Anders
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Wimo, Anders
    Johnell, Kristina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Net costs of dementia in Sweden - an incidence based 10 year simulation study2012In: International Journal of Geriatric Psychiatry, ISSN 0885-6230, E-ISSN 1099-1166, Vol. 27, no 11, p. 1112-1117Article in journal (Refereed)
    Abstract [en]

    Background

    Aging of the population results in increasing number people suffering from dementia, and this will have a great impact on costs for the society. Because of the long duration of dementia disorders, it is difficult to collect empirical data for the whole survival period of incident cases. Therefore, modeling approaches are frequently used. The purpose of this study was to describe the costs of an incident dementia cohort with progression modeling.

    Methods

    Epidemiological data indicated that the incidence of dementia in Sweden was 24,000 people in 2005. Thus, incident cases were run in a Markov model for 10 cycles of 1 year each. Severity state specific costs were used and defined by Clinical Dementia Rating scale.

    Results

    Total cost for the cohort was 27.24 billion Swedish Krona (SEK). The mean cost per person and year was 269,558 SEK. Total cost for long-term institutional care was 21 billion SEK during the modeled period.

    Conclusion

    Cost of long-term institutional care is the major cost driver, even in mild dementia.

  • 227.
    Solomon, A
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Sippola, R
    Soininen, H
    Wolozin, B
    Tuomilehto, J
    Laatikainen, T
    Kivipelto, M
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Lipid-lowering treatment is related to decreased risk of dementia: a population-based study (FINRISK)2010In: Neurodegenerative diseases, ISSN 1660-2862, Vol. 7, no 1-3, p. 180-182Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Several lines of evidence have linked cholesterol to dementia.

    OBJECTIVE: To investigate lipid-lowering drug use and dementia development in a Finnish population.

    METHODS: FINRISK is a large population-based survey of cardiovascular risk factors carried out since 1972 every 5 years using independent, random and representative population samples from different parts of Finland. Several cohorts were part of the WHO-MONICA study. Data from cohorts 1972-2002 were linked to the Hospital Discharge Registry and Drug Reimbursement Registry (1995-2007) to ascertain dementia diagnoses and lipid-lowering treatment. Selection criteria for the study were: (1) alive and without dementia in 1995; (2) age > or = 60 years (in 1995 for earlier cohorts and in 1997 or 2002 for later cohorts; (3) treatment prescribed at least 1 year before dementia diagnosis.

    RESULTS: 17,597 persons were included in the study. Lipid-lowering treatment was related to decreased dementia risk. In Cox proportional hazards model, hazard ratio (95% CI) was 0.42 (0.37-0.49; controlled for age, sex, education, survey region, survey year, baseline cholesterol, body mass index and systolic blood pressure).

    CONCLUSION: Preliminary results from the FINRISK study indicate that lipid-lowering drugs may have a beneficial effect in dementia prevention. Further data linkage is ongoing in order to investigate the roles of different types of lipid-lowering drugs.

  • 228.
    Solomon, Alina
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Dobranici, Letitia
    Kåreholt, Ingemar
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Tudose, Cătălina
    Lăzărescu, Mircea
    Comorbidity and the rate of cognitive decline in patients with Alzheimer dementia2011In: International Journal of Geriatric Psychiatry, ISSN 0885-6230, E-ISSN 1099-1166, Vol. 26, no 12, p. 1244-1251Article in journal (Refereed)
    Abstract [en]

    Methods: One hundred and two AD outpatients examined at the Psychiatry Department of the CF2 Polyclinic in Bucharest, Romania and re-evaluated after 2 years. Comorbidity was rated using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Results: Baseline mean age (SD) was 75.4 (8.2) years, median CDR (range) was 2 (1-3), and mean MMSE (SD) 14.2 (4.9). MMSE declined to 11.2 (4.8) during follow-up. Baseline mean total CIRS-G score (SD) was 13.8 (5.4), median number of endorsed categories (range) was 8 (1-14), and mean severity index (SD) 1.9 (0.4). Main comorbidity areas were cardiovascular, ear, nose and throat, genitourinary, musculoskeletal/integument, and neurological. Severity of comorbidity increased with dementia severity (p < 0.001). Baseline comorbidity was related to increased rate of cognitive decline; truncated regression coefficients (p-values) were 0.01 (0.02) for CIRS-G total score, and 0.15 (0.006) for severity index (controlled for age, sex, education, and AD treatment). Faster cognitive decline was associated with faster functional decline: OR (95% CI) was 5.2 (1.9-13.6) for increased rate of ADL change and 3.8 (1.0-14.1) for increased rate of IADL change (controlled for age, sex, education, AD medication, and comorbidity). Comorbidity tended to increase functional decline; however, the associations were not statistically significant. Conclusions: In this group of patients with AD, comorbidity increased the rate of cognitive decline. Considering comorbidity instead of focusing on separate conditions may be more helpful in managing AD.

  • 229.
    Stenholm, Sari
    et al.
    Stockholm University, Faculty of Social Sciences, Stress Research Institute. University of Turku, Finland; Turku University Hospital, Finland; University of Tampere, Finland.
    Head, Jenny
    Kivimaki, Mika
    Hanson, Linda L. Magnusson
    Pentti, Jaana
    Rod, Naja H.
    Clark, Alice J.
    Oksanen, Tuula
    Westerlund, Hugo
    Vahtera, Jussi
    Sleep Duration and Sleep Disturbances as Predictors of Healthy and Chronic Disease-Free Life Expectancy Between Ages 50 and 75: A Pooled Analysis of Three Cohorts2019In: The journals of gerontology. Series A, Biological sciences and medical sciences, ISSN 1079-5006, E-ISSN 1758-535X, Vol. 74, no 2, p. 204-210Article in journal (Refereed)
    Abstract [en]

    Background The aim of this study was to examine the associations of sleep duration and sleep disturbances with healthy and chronic disease-free life expectancy (LE) between ages 50 and 75. Methods Data were drawn from repeated waves of three occupational cohort studies in England, Finland, and Sweden (n = 55,494) and the follow-up ranged from 6 to 18 years. Self-reported sleep duration was categorized into <7, 7-8.5, and 9 hours and sleep disturbances into no, moderate, and severe. Health expectancy was estimated with two health indicators: healthy LE based on years in good self-rated health and chronic disease-free LE based on years without chronic diseases. Multistate life table models were used to estimate healthy and chronic disease-free LE from age 50 to 75 years for each category of sleep measures in each cohort. Fixed-effects meta-analysis was used to pool the cohort-specific results into summary estimates. Results Persons who slept 7-8.5 hours could expect to live 19.1 (95% CI 19.0-19.3) years in good health and 13.5 (95% CI 13.2-13.7) years without chronic diseases between ages 50 and 75. Healthy and disease-free years were 1-3 years shorter for those who slept less than 7 hours or slept 9 hours or more. Persons who did not have sleep disturbances could expect to live 20.4 (95% CI 20.3-20.6) years in good health and 14.3 (95% CI 14.1-14.5) years without chronic diseases between ages 50 and 75. Healthy and disease-free years were 6-3 years shorter for those who reported severe sleep disturbances. Conclusions Sleeping 7-8.5 hours and having no sleep disturbances between ages 50 to 75 are associated with longer healthy and chronic disease-free LE.

  • 230. Stenholm, Sari
    et al.
    Head, Jenny
    Kivimäki, Mika
    Kawachi, Ichiro
    Aalto, Ville
    Zins, Marie
    Goldberg, Marcel
    Zaninotto, Paola
    Magnusson Hanson, Linda
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Westerlund, Hugo
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Vahtera, Jussi
    Smoking, physical inactivity and obesity as predictors of healthy and disease-free life expectancy between ages 50 and 75: a multicohort study2016In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 45, no 4, p. 1260-1270Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Smoking, physical inactivity and obesity are modifiable risk factors for morbidity and mortality. The aim of this study was to examine the extent to which the co-occurrence of these behaviour-related risk factors predict healthy life expectancy and chronic disease-free life expectancy in four European cohort studies.

    METHODS: Data were drawn from repeated waves of four cohort studies in England, Finland, France and Sweden. Smoking status, physical inactivity and obesity (body mass index ≥30 kg/m(2)) were examined separately and in combination. Health expectancy was estimated by using two health indicators: suboptimal self-rated health and having a chronic disease (cardiovascular disease, cancer, respiratory disease and diabetes). Multistate life table models were used to estimate sex-specific healthy life expectancy and chronic disease-free life expectancy from ages 50 to 75 years.

    RESULTS: Compared with men and women with at least two behaviour-related risk factors, those with no behaviour-related risk factors could expect to live on average8 years longer in good health and 6 years longer free of chronic diseases between ages 50 and 75. Having any single risk factor was also associated with reduction in healthy years. No consistent differences between cohorts were observed.

    CONCLUSIONS: Data from four European countries show that persons with individual and co-occurring behaviour-related risk factors have shorter healthy life expectancy and shorter chronic disease-free life expectancy. Population level reductions in smoking, physical inactivity and obesity could increase life-years lived in good health.

  • 231. Stenholm, Sari
    et al.
    Westerlund, Hugo
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Head, Jenny
    Hyde, Martin
    Stockholm University, Faculty of Social Sciences, Stress Research Institute.
    Kawachi, Ichiro
    Pentti, Jaana
    Kivimäki, Mika
    Vahtera, Jussi
    Comorbidity and Functional Trajectories From Midlife to Old Age: the Health and Retirement Study2015In: The journals of gerontology. Series A, Biological sciences and medical sciences, ISSN 1079-5006, E-ISSN 1758-535X, Vol. 70, no 3, p. 332-338Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The number of diseases and physical functioning difficulties tend to increase with age. The aim of this study was to examine the trajectories of physical functioning across age groups and whether the trajectories differ according to disease status in different population subgroups.

    METHODS: Repeat data from a nationally representative population sample, the Health and Retirement Study, was used. Participants were 10,709 men and 13,477 women aged 60-107 years at baseline with biennial surveys from 1992 to 2010. Average length of follow-up was 10.3 years ranging from 0 to 18 years. Disease status and physical functioning was asked about at all study phases and 10 items were summed to obtain a physical functioning score (0-10).

    RESULTS: Age modified the relationship between number of chronic diseases and physical functioning with older participants having more physical functioning difficulties with increasing number of diseases. An average 70-year-old participant with no diseases had 0.89 (95% CI: 0.85-0.93) physical functioning difficulties, with one disease 1.72 (95% CI: 1.69-1.76) difficulties, with two diseases 2.57 (95% CI: 2.52-2.62) difficulties, and with three or more diseases 3.82 (95% CI: 3.76-3.88) difficulties. Of the individual diseases memory-related diseases, stroke, pulmonary diseases, and arthritis were associated with significantly higher physical functioning difficulties compared with other diseases.

    CONCLUSIONS: Comorbidity is associated with greater burden of physical functioning difficulties. Of the studied diseases, memory-related diseases, stroke, pulmonary diseases, and arthritis alone or in combination limit most physical functioning.

  • 232. Stomby, Andreas
    et al.
    Boraxbekk, Carl-Johan
    Lundquist, Anders
    Nordin, Annelie
    Nilsson, Lars-Göran
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Cognitive psychology. Umeå University, Sweden.
    Adolfsson, Rolf
    Nyberg, Lars
    Olsson, Tommy
    Higher diurnal salivary cortisol levels are related to smaller prefrontal cortex surface area in elderly men and women2016In: European Journal of Endocrinology, ISSN 0804-4643, E-ISSN 1479-683X, Vol. 175, no 2, p. 117-126Article in journal (Refereed)
    Abstract [en]

    Objective: Elevated cortisol levels with aging have been associated with atrophy of the hippocampus and prefrontal cortex (PFC), as well as with impaired cognitive functions in men. However, coexisting diseases have confounded many studies examining these relationships. Studies in women are lacking. Our objective was to test whether salivary cortisol levels were related to morphology of the hippocampus and the PFC, and to cognitive performance.

    Design: A cross-sectional study including 200 elderly (55-80 years old) men and women.

    Method: We used magnetic resonance imaging, tests of episodic-, semantic-, and working memory, visuospatial ability, and cortisol levels in four saliva samples collected during 1 day.

    Results: Area under the curve (AUC) for cortisol levels was negatively related to cortical surface area of the left anterior cingulate gyrus (caudal P < 0.001; rostral P = 0.006), right lateral orbitofrontal cortex (P = 0.004), and right rostral middle frontal gyrus (P = 0.003). In women, there was also a negative relationship with cortical surface area in the left rostral middle frontal gyrus (P = 0.006). No relationship was found between cortisol levels and hippocampal volume.

    Conclusion: This study suggests that the structure of the medial PFC is related to cortisol levels in both elderly women and men.

  • 233. Sundvall, Helena
    et al.
    Fastbom, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Wallerstedt, Susanna M.
    Vitols, Sigurd
    Use of statins in the elderly according to age and indication—a cross-sectional population-based register study2019In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 75, no 7, p. 959-967Article in journal (Refereed)
    Abstract [en]

    Purpose

    To investigate statin use in the elderly by age (≥ 80 vs. 65–79 years) in relation to established indications.

    Methods

    A population-based cohort, including data from four registers, encompassing inhabitants in Region Västra Götaland, Sweden, was used. Statin users were defined as those filling statin prescriptions ≥ 75% of the year 2010. Primary care and hospital diagnoses in 2005–2010 regarding ischemic heart disease, stroke, transient ischemic attacks, and diabetes were considered established indications.

    Results

    A total of 278,205 individuals were analyzed. In individuals aged ≥ 80 and 65–79 years (n = 81,885 and n = 196,320, respectively), 17% (95% confidence interval 17%; 18%) and 23% (23%; 23%) respectively, were statin users. Among the statin users, 74% (73%; 74%) of those aged ≥ 80 and 60% (59%; 60%) of those aged 65–79 years had ≥ 1 established indication. Conversely, of those with ≥ 1 established indication, 30% (30%; 31%) and 53% (52%; 53%) were on statins in the respective age groups. Logistic regression revealed that age, nursing home residence, and multi-dose drug dispensing were the most prominent negative predictors for statin use; adjusted odds ratios (95% confidence interval): 0.45 (0.44; 0.46), 0.39 (0.36; 0.42), and 0.47 (0.44; 0.49), respectively.

    Conclusions

    In the oldest old (≥ 80 years), statin users were fewer and had more often an established indication, suggesting that physicians extrapolate scientific evidence for beneficial effects in younger age groups to the oldest, but require a more solid ground for treatment. As the oldest old, nursing home residents, and those with multi-dose drug-dispensing were statin users to a lesser extent, physicians may often refrain from treatment in those with lower life expectancy, either due to age or to severely reduced health status. In both age groups, our results however also indicate some over- as well as undertreatment.

  • 234. Sörman, Daniel Eriksson
    et al.
    Rönnlund, Michael
    Sundström, Anna
    Adolfsson, Rolf
    Nilsson, Lars-Göran
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Umeå University, Sweden.
    Social relationships and risk of dementia: a population-based study2015In: International psychogeriatrics, ISSN 1041-6102, E-ISSN 1741-203X, Vol. 27, no 8, p. 1391-1399Article in journal (Refereed)
    Abstract [en]

    Background: The objective was to examine whether aspects of social relationships in old age are associated with all-cause dementia and Alzheimer's disease (AD).

    Methods: We studied 1,715 older adults (>= 65 years) who were dementia-free at baseline over a period of up to 16 years. Data on living status, contact/visit frequency, satisfaction with contact frequency, and having/not having a close friend were analyzed using Cox proportional hazards regressions with all-cause dementia or AD as the dependent variable. To control for reverse causality and to identify potential long-term effects, we additionally performed analyses with delayed entry.

    Results: We identified 373 incident cases of dementia (207 with AD) during follow-up. The variable visiting/visits from friends was associated with reduced risk of all-cause dementia. Further, a higher value on the relationships index (sum of all variables) was associated with reduced risk of all-cause dementia and AD. However, in analyses with delayed entry, restricted to participants with a survival time of three years or more, none of the social relationship variables was associated with all-cause dementia or AD.

    Conclusions: The results indicate that certain aspects of social relationships are associated with incident dementia or AD, but also that these associations may reflect reverse causality. Future studies aimed at identifying other factors of a person's social life that may have the potential to postpone dementia should consider the effects of reverse causality.

  • 235.
    Tan, Edwin C. K.
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Monash University, Australia.
    Qiu, Chengxuan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Liang, Yajun
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Karolinska Institutet, Sweden.
    Wang, Rui
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Bell, J. Simon
    Fastbom, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Johnell, Kristina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Antihypertensive Medication Regimen Intensity and Incident Dementia in an Older Population2018In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 19, no 7, p. 577-583Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate the association between antihypertensive medication regimen intensity and risk of incident dementia in an older population. Design: Prospective, longitudinal cohort study. Participants/Setting: A total of 1208 participants aged >= 78 years, free of dementia, and residing in central Stockholm at baseline (2001-2004). Measurements: Participants were examined at 3- and 6-year follow-up to detect incident dementia. Data were collected through face-to-face interviews, clinical examinations, and laboratory tests. Data on antihypertensive use were obtained by a physician through patient self-report, visual inspection, or medical records. Cox proportional hazards models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between time-varying antihypertensive regimen intensity and incident dementia after adjusting for potential confounders. Results: During the follow-up period, 125 participants were diagnosed with dementia. Participants who developed dementia were more likely to have vascular disease at baseline (66.4% vs 55.3%, P=.02). In fully adjusted analyses, the number of antihypertensive classes (HR 0.68, 95% CI 0.55-0.84) and total prescribed daily dose (HR 0.70, 95% CI 0.57-0.86) were significantly associated with reduced dementia risk. After considering all-cause mortality as a competing risk, the number (HR 0.75, 95% CI 0.62-0.91) and doses (HR 0.71, 95% CI 0.59-0.86) of antihypertensive classes, and the independent use of diuretics (HR 0.66, 95% CI 0.44-0.99), were significantly associated with lower dementia risk. Conclusions: Greater intensity of antihypertensive drug use among older people may be associated with reduced incidence of dementia.

  • 236.
    Tan, Edwin C. K.
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Monash University, Australia.
    Sluggett, Janet K.
    Johnell, Kristina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Onder, Graziano
    Elseviers, Monique
    Morin, Lucas
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Vetrano, Davide L.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Università Cattolica del Sacro Cuore, Italy.
    Wastesson, Jonas W.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Fastbom, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Taipale, Heidi
    Tanskanen, Antti
    Bell, J. Simon
    Research Priorities for Optimizing Geriatric Pharmacotherapy: An International Consensus2018In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 19, no 3, p. 193-199Article in journal (Refereed)
    Abstract [en]

    Medication management is becoming increasingly challenging for older people, and there is limited evidence to guide medication prescribing and administration for people with multimorbidity, frailty, or at the end of life. Currently, there is a lack of clear research priorities in the field of geriatric pharmacotherapy. To address this issue, international experts from 5 research groups in geriatric pharmacotherapy and pharmacoepidemiology research were invited to attend the inaugural Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network workshop. A modified nominal group technique was used to explore and consolidate the priorities for conducting research in this field. Eight research priorities were elucidated: quality of medication use; vulnerable patient groups; polypharmacy and multimorbidity; person-centered practice and research; deprescribing; methodological development; variability in medication use; and national and international comparative research. The research priorities are discussed in detail in this article with examples of current gaps and future actions presented. These priorities highlight areas for future research in geriatric pharmacotherapy to improve medication outcomes in older people.

  • 237. Tannenbaum, Cara
    et al.
    Johnell, Kristina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Managing Therapeutic Competition in Patients with Heart Failure, Lower Urinary Tract Symptoms and Incontinence2014In: Drugs & Aging, ISSN 1170-229X, E-ISSN 1179-1969, Vol. 31, no 2, p. 93-101Article in journal (Refereed)
    Abstract [en]

    Up to 50 % of heart failure patients suffer from lower urinary tract symptoms. Urinary incontinence has been associated with worse functional status in patients with heart failure, occurring three times more frequently in patients with New York Heart Association Class III and IV symptoms compared with those with milder disease. The association between heart failure and urinary symptoms may be directly attributable to worsening heart failure pathophysiology; however, medications used to treat heart failure may also indirectly provoke or exacerbate urinary symptoms. This type of drug-disease interaction, in which the treatment for heart failure precipitates incontinence, and removal of medications to relieve incontinence worsens heart failure, can be termed therapeutic competition. The mechanisms by which heart failure medication such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers aggravate lower urinary tract symptoms are discussed. Initiation of a prescribing cascade, whereby antimuscarinic agents or beta 3-agonists are added to treat symptoms of urinary urgency and incontinence, is best avoided. Recommendations and practical tips are provided that outline more judicious management of heart failure patients with lower urinary tract symptoms. Compelling strategies to improve urinary outcomes include titrating diuretics, switching ACE inhibitors, treating lower urinary tract infections, appropriate fluid management, daily weighing, and uptake of pelvic floor muscle exercises.

  • 238.
    Thorslund, Mats
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Hälsa och ohälsa bland äldre2012In: Jämlik ålderdom?: i samtiden och framtiden / [ed] Lars Andersson, Peter Öberg, Malmö: Liber, 2012, p. 137-163Chapter in book (Other academic)
  • 239.
    Thorslund, Mats
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Wastesson, Jonas W.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Agahi, Neda
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Lagergren, Mårten
    Parker, Marti G.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    The rise and fall of women's advantage: a comparison of national trends in life expectancy at age 65 years2013In: European Journal of Ageing, ISSN 1613-9372, E-ISSN 1613-9380, Vol. 10, no 4, p. 271-277Article in journal (Refereed)
    Abstract [en]

    The female advantage in life expectancy (LE) is found worldwide, despite differences in living conditions, the status of women and other factors. However, this advantage has decreased in recent years in low-mortality countries. Few researchers have looked at the gender gap in LE in old age (age 65) in a longer historical perspective. Have women always had an advantage in LE at old age and do different countries share the same trends? Life expectancy data for 17 countries were assessed from Human Mortality Database from 1751 to 2007. Since most of the changes in LE taking place today are driven by reductions of old age mortality the gender difference in LE was calculated at age 65. Most low-mortality countries show the same historical trend, a rise and fall of women's advantage in LE at age 65. Three phases that all but two countries passed through were discerned. After a long phase with a female advantage in LE at 65 of <1 year, the gender gap increased significantly during the twentieth century. The increase occurred in all countries but at different time points. Some countries such as England and France had an early rise in female advantage (1900-1919), while it occurred 50 years later in Sweden, Norway and in the Netherlands. The rise was followed by a more simultaneous fall in female advantage in the studied countries towards the end of the century, with exceptions of Japan and Spain. The different timing regarding the increase of women's advantage indicates that country-specific factors may have driven the rise in female advantage, while factors shared by all countries may underlie the simultaneous fall. More comprehensive, multi-disciplinary study of the evolution of the gender gap in old age could provide new hypotheses concerning the determinants of gendered differences in mortality.

  • 240. Thorvaldsson, Valgeir
    et al.
    Macdonald, Stuart W. S.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Winblad, Bengt
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Kivipelto, Miia
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Laukka Jonsson, Erika
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Skoog, Ingmar
    Sacuiu, Simona
    Guo, Xinxin
    Östling, Svante
    Börjesson-Hanson, Anne
    Gustafson, Deborah
    Johansson, Boo
    Bäckman, Lars
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Onset and rate of cognitive change before dementia diagnosis: findings from two Swedish population-based longitudinal studies2011In: Journal of the International Neuropsychological Society, ISSN 1355-6177, E-ISSN 1469-7661, Vol. 17, no 1, p. 154-162Article in journal (Refereed)
    Abstract [en]

    We used data from two population-based longitudinal studies to estimate time of onset and rate of accelerated decline across cognitive domains before dementia diagnosis. The H70 includes an age-homogeneous sample (127 cases and 255 non-cases) initially assessed at age 70 with 12 follow-ups over 30 years. The Kungsholmen Project (KP) includes an age-heterogeneous sample (279 cases and 562 non-cases), with an average age of 82 years at initial assessment, and 4 follow-ups spanning 13 years. We fit mixed linear models to the data and determined placement of change points by a profile likelihood method. Results demonstrated onset of accelerated decline for fluid (speed, memory) versus crystallized (verbal, clock reading) abilities occurring approximately 10 and 5 years before diagnosis, respectively. Although decline before change points was greater for fluid abilities, acceleration was more pronounced for crystallized abilities after the change points. This suggests that onset and rate of acceleration vary systematically along the fluid-crystallized ability continuum. There is early onset in fluid abilities, but these changes are difficult to detect due to substantial age-related decline. Onset occurred later and acceleration was greater in crystallized abilities, suggesting that those markers may provide more valid identification of cases in later stages of the prodromal phase.

  • 241. Tolppanen, Anna-Maija
    et al.
    Lavikainen, Piia
    Solomon, Alina
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Institute of Clinical Medicine-Neurology, University of Eastern Finland, Kuopio, Finland.
    Kivipelto, Miia
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Soininen, Hilkka
    Hartikainen, Sirpa
    Incidence of stroke in people with Alzheimer disease: a national register-based approach2013In: Neurology, ISSN 0028-3878, E-ISSN 1526-632X, Vol. 80, no 4, p. 353-358Article in journal (Refereed)
    Abstract [en]

    Objective: Stroke increases the risk of dementias, including Alzheimer disease (AD), but it is unknown whether persons with AD have a higher risk of strokes. We investigated whether noninstitutionalized persons with AD were more likely to experience incident stroke than persons without AD and whether there are differences in the incidence of ischemic or hemorrhagic strokes.

    Methods: We performed a register-based matched cohort study including all community-dwelling persons with verified clinical diagnosis of AD, residing in Finland on December 31, 2005, and a single age-, sex-, and region of residence–matched comparison person without AD for each individual with AD (n = 56,186, mean age 79.6 [SD 6.9] years). Persons with previous strokes and their matched participants were excluded, leaving 50,808 individuals with 2,947 incident strokes occurring between January 1, 2006, and December 31, 2009. Diagnosis of AD was based on prescription reimbursement register and diagnosis of stroke on hospital discharge register of Finland.

    Results: AD dementia was not associated with risk of all strokes or ischemic strokes, but the risk of hemorrhagic strokes was higher among persons with AD (adjusted hazard ratio [95% confidence interval] 1.34 [1.12–1.61]). When the associations were analyzed according to age groups, AD was associated with higher risk of all strokes, regardless of etiology, in the 2 youngest age groups, but not in the older groups. Similar associations were observed when the results were categorized according to age at diagnosis.

    Conclusions: Our findings suggest that persons with AD dementia, especially younger patients, have higher risk of hemorrhagic strokes.

  • 242.
    Torssander, Jenny
    et al.
    Stockholm University, Faculty of Social Sciences, The Swedish Institute for Social Research (SOFI).
    Ahlbom, Anders
    Modig, Karin
    Four Decades of Educational Inequalities in Hospitalization and Mortality among Older Swedes2016In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 3, article id e0152369Article in journal (Refereed)
    Abstract [en]

    Background The inverse association between education and mortality has grown stronger the last decades in many countries. During the same period, gains in life expectancy have been concentrated to older ages; still, old-age mortality is seldom the focus of attention when analyzing trends in the education-mortality gradient. It is further unknown if increased educational inequalities in mortality are preceded by increased inequalities in morbidity of which hospitalization may be a proxy. Methods Using administrative population registers from 1971 and onwards, education-specific annual changes in the risk of death and hospital admission were estimated with complimentary log-log models. These risk changes were supplemented by estimations of the ages at which 25, 50, and 75% of the population had been hospitalized or died (after age 60). Results The mortality decline among older people increasingly benefitted the well-educated over the less well-educated. This inequality increase was larger for the younger old, and among men. Educational inequalities in the age of a first hospital admission generally followed the development of growing gaps, but at a slower pace than mortality and inequalities did not increase among the oldest individuals. Conclusions Education continues to be a significant predictor of health and longevity into old age. That the increase in educational inequalities is greater for mortality than for hospital admissions (our proxy of overall morbidity) may reflect that well-educated individuals gradually have obtained more possibilities or resources to survive a disease than less well-educated individuals have the last four decades.

  • 243. Tukiainen, T.
    et al.
    Jylänki, P.
    Mäkinen, V. -P.
    Gröhn, O.
    Hallikainen, M.
    Soininen, H.
    Kivipelto, Miia
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). University of Kuopio and Kuopio University Hospital, Finland.
    Kaski, K.
    Groop, P. H.
    Savolainen, M. J.
    Pirttilä, T.
    Soininen, P.
    Ala-Korpela, M.
    Mild cognitive impairment associates with concurrent decreases in serum cholesterol and cholesterol-related lipoprotein subclasses2012In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 16, no 7, p. 631-635Article in journal (Refereed)
    Abstract [en]

    Background and objective: Accumulating evidence suggests that serum lipids are associated with cognitive decline and dementias. However, majority of the existing information concerns only serum total cholesterol (TC) and data at the level of lipoprotein fractions and subclasses is limited. The aim of this study was to explore the levels and trends of main cholesterol and triglyceride measures and eight lipoprotein subclasses during normal aging and the development of mild cognitive impairment by following a group of elderly for six years. Design: Longitudinal. Setting: City of Kuopio, Finland. Participants: 45 elderly individuals of which 20 developed mild cognitive impairment (MCI) during the follow-up. Measurement: On each visit participants underwent an extensive neuropsychological and clinical assessment. Lipoprotein levels were measured via 1H NMR from native serum samples. Results: Serum cholesterol and many primarily cholesterol-associated lipoprotein measures clearly decreased in MCI while the trends were increasing for those elderly people who maintained normal cognition. Conclusion: These findings suggest that a decreasing trend in serum cholesterol measures in elderly individuals may suffice as an indication for more detailed inspection for potential signs of cognitive decline.

  • 244. Ulfvarson, Johanna
    et al.
    Rahmner, Pia Bastholm
    Fastbom, Johan
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Sjöviker, Susanne
    Karlsson, Eva Andersén
    Medication reviews with computerised expert support: evaluation of a method to improve the quality of drug utilisation in the elderly2010In: International Journal of Health Care Quality Assurance, ISSN 0952-6862, E-ISSN 1758-6542, Vol. 23, no 6, p. 571-82Article in journal (Refereed)
    Abstract [en]

    PURPOSE: This paper aims to examine whether a computerised system for medication reviews can support physicians' decisions and improve the quality of drug treatment in the elderly.

    DESIGN/METHODOLOGY/APPROACH: This is a descriptive intervention study. The study included 275 patients living in community settings and nursing homes in Stockholm, Sweden. Patient data were analysed using computer software and scrutinised by a clinical pharmacologist. Pharmaco-therapeutic advice was sent to the physician responsible for each patient. The main outcome measures were initiation and discontinuation of drugs, changes of doses and rates of identified drug-related problems.

    FINDINGS: Expert opinions were given by the clinical pharmacologist, for 275 patients, mean age 85 years; 70 per cent female. An average of 3.3 remarks was given concerning unsuitable drugs, unclear indication, dosing when the kidney function was decreased, drug-drug interactions and quality indicators. On average 1.5 drug-related problems (DRP) per patient were attended to by the responsible physician at each unit. The most common action taken was withdrawal of a drug (n = 208). On average the drug use decreased from 10.4 to 9.5 drugs per patient, and several quality indicators were met. The drug costs decreased, and resulted in a more cost-effective drug therapy.

    ORIGINALITY/VALUE: The paper develops and tests a method for intervention in the care of elderly patients. The method is based on a computerised expert support system for medication reviews at a distance and on education of the staff. A safer drug therapy with improved quality and cost-effectiveness is thus provided.

  • 245.
    Unevik, Erik
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.
    The influence of educational attainment and immigration status on outcomes of a national self-management program for hip and knee osteoarthritis – results on 22 741 patients from the BOA register2018Independent thesis Advanced level (degree of Master (Two Years)), 80 credits / 120 HE creditsStudent thesis
    Abstract [en]

    Background: Supervised exercise and delivered education are first step treatment for knee, hip and hand osteoarthritis (OA) according to international guidelines. It is uncertain whether OA outcomes from participation in the Swedish self-management program “Better management of Osteoarthritis (BOA)” differs for participants with different sociodemographic background. The aim of this master thesis was thus to assess to what extent there were differences by level of education and immigration status among participants in the self-management program in terms of Health, Health-related quality of life, Mobility, Health-related behaviours and Adherence to the self-management program, measured at baseline, three and 12 months. Methods: Analysis of covariance (ANCOVA), logistic and multinomial regression was used to analyse outcomes for 22 741 participants. Results: For most adjusted outcomes, there were sociodemographic inequalities at all measurement points. However, there were no educational differences in mobility and attitude to physical activity at baseline, but at the follow-ups such inequalities emerged. Conversely, the willingness to undergo joint surgery differed by immigration status at baseline, but not at the follow-ups, and immigrants were more adherent towards the self-management program than domestic born participants. Conclusion: These results are pioneer findings showing that it exists sociodemographic differences related to OA treatment.

  • 246. Vaskivuo, Laura
    et al.
    Hokkanen, Laura
    Hanninen, Tuomo
    Antikainen, Riitta
    Bäckman, Lars
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI).
    Laatikainen, Tiina
    Paajanen, Teemu
    Stigsdotter-Neely, Anna
    Strandberg, Timo
    Tuomilehto, Jaakko
    Soininen, Hilkka
    Kivipelto, Miia
    Ngandu, Tiia
    Associations between Prospective and Retrospective Subjective Memory Complaints and Neuropsychological Performance in Older Adults: The Finger Study2018In: Journal of the International Neuropsychological Society, ISSN 1355-6177, E-ISSN 1469-7661, Vol. 24, no 10, p. 1099-1109Article in journal (Refereed)
    Abstract [en]

    Objectives: Subjective memory complaints (SMCs) are among the key concerns in the elderly, but their role in detecting objective cognitive problems is unclear. The aim of this study was to clarify the association between SMCs (both prospective and retrospective memory complaints) and neuropsychological test performance in older adults at risk of cognitive decline. Methods: This investigation is part of the FINGER project, a multicenter randomized controlled trial aiming at preventing cognitive decline in high-risk individuals. The cognitive assessment of participants was conducted at baseline using a modified neuropsychological test battery (NTB). SMCs were evaluated with the Prospective and Retrospective Memory Questionnaire (PRMQ) in a sub-sample of 560 participants (mean age, 69.9 years). Results: Having more prospective SMCs was associated with slower processing speed, but not with other NTB domains. Retrospective SMCs were linked to poorer function on NTB total score, processing speed, and memory. Executive function domain was not associated with any PRMQ ratings. Depressive symptoms and poor quality of life diluted the observed associations for NTB total score and memory. However, the association between PRMQ and processing speed remained even after full adjustments. Conclusions: Our results indicate that self-reported memory problems, measured with PRMQ, are associated with objectively measured cognitive performance. Such complaints in healthy elderly people also seem to reflect reduced mental tempo, rather than memory deficits. Slowing of processing speed may thus be negatively related to memory self-efficacy. It is also important to consider affective factors among those who report memory problems.

  • 247. Verrel, Julius
    et al.
    Lövdén, Martin
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Lund University, Sweden; Center for Lifespan Psychology, Germany.
    Lindenberger, Ulman
    Older Adults Show Preserved Equilibrium but Impaired Step Length Control in Motor-Equivalent Stabilization of Gait2012In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 7, no 12, article id e52024Article in journal (Refereed)
    Abstract [en]

    Stable walking depends on the coordination of multiple biomechanical degrees of freedom to ensure the dynamic maintenance of whole-body equilibrium as well as continuous forward progression. We investigated adult age-related differences in whole-body coordination underlying stabilization of center of mass (CoM) position and step pattern during locomotion. Sixteen younger (20-30 years) and 16 healthy older men (65-80 years) walked on a motorized treadmill at 80%, 100% and 120% of their self-selected preferred speed. Preferred speeds did not differ between the age groups. Motor-equivalent stabilization of step parameters (step length and width) and CoM position relative to the support (back and front foot) was examined using a generalized covariation analysis. Across age groups, covariation indices were highest for CoM position relative to the front foot, the measure most directly related to body equilibrium. Compared to younger adults, older adults showed lower covariation indices with respect to step length, extending previous findings of age-related differences in motor-equivalent coordination. In contrast, no reliable age differences were found regarding stabilization of step width or any of the CoM parameters. The observed pattern of results may reflect robust prioritization of balance over step pattern regularity, which may be adaptive in the face of age-associated sensorimotor losses and decline of coordinative capacities.

  • 248.
    Vetrano, Davide L.
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Catholic University of Rome, Italy.
    Bianchini, Elisa
    Onder, Graziano
    Cricelli, Iacopo
    Cricelli, Claudio
    Bernabei, Roberto
    Bettoncelli, Germano
    Lapi, Francesco
    Poor adherence to chronic obstructive pulmonary disease medications in primary care: Role of age, disease burden and polypharmacy2017In: Geriatrics & Gerontology International, ISSN 1444-1586, E-ISSN 1447-0594, Vol. 17, no 12, p. 2500-2506Article in journal (Refereed)
    Abstract [en]

    Aim

    The aim of the present study was to assess the occurrence and determinants of poor adherence to pharmacological treatment in a cohort of primary care patients with chronic obstructive pulmonary disease (COPD), paying special attention to the role of age, comorbidity and polypharmacy.

    Methods

    We identified a cohort of COPD patients using the primary care Italian Health Search – IMS Longitudinal Patient Database. We assessed 1-year adherence to COPD maintenance pharmacotherapy (encompassing inhaled corticosteroids, long-acting beta agonists and long-acting anticholinergics). Poor adherence was defined as <80% of proportion of days covered by pharmacological treatment over a 1-year period.

    Results

    Of 22 505 patients (mean age 67.3 ± 13.2; 41.3% women) entering the study, 17 486 (77.7%) were poorly adherent. According to multivariate analysis, poor adherence is less likely in older adults (OR 0.51, 95% CI 0.40–0.66), in non-smokers (OR 0.77, 95% CI 0.69–0.86) and in those with a history of alcohol abuse (OR 0.74, 95% CI 0.58–0.94). Higher comorbidity (OR 1.43, 95% CI 1.13–1.80) was positively associated with poor adherence. Polypharmacy was associated with poor adherence only in patients aged ≥65 years (OR 1.34, 95% CI 1.13–1.59). Finally, COPD severity was associated with a reduced likelihood of poor adherence (OR 0.20, 95% CI 0.07–0.61 for stage IV).

    Conclusions

    The present findings show that poor medication adherence is common in patients with COPD receiving long-term treatment. The interaction between age and polypharmacy, and the role of comorbidity suggest a pivotal role of biological age as a steering determinant of poor adherence. Geriatr Gerontol Int 2017; 17: 2500–2506.

  • 249.
    Vetrano, Davide L.
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Catholic University of Rome, Italy.
    Calderón-Larrañaga, Amaia
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Aragon Health Sciences Institute (IACS), Spain.
    Marengoni, Alessandra
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). University of Brescia, Italy.
    Onder, Graziano
    Bauer, Juergen M.
    Cesari, Matteo
    Ferrucci, Luigi
    Fratiglioni, Laura
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Stockholm Gerontology Research Center, Sweden .
    An International Perspective on Chronic Multimorbidity: Approaching the Elephant in the Room2018In: The journals of gerontology. Series A, Biological sciences and medical sciences, ISSN 1079-5006, E-ISSN 1758-535X, Vol. 73, no 10, p. 1350-1356Article in journal (Refereed)
    Abstract [en]

    Multimorbidity is a common and burdensome condition that may affect quality of life, increase medical needs, and make people live more years of life with disability. Negative outcomes related to multimorbidity occur beyond what we would expect from the summed effect of single conditions, as chronic diseases interact with each other, mutually enhancing their negative effects, and eventually leading to new clinical phenotypes. Moreover, multimorbidity mirrors an accelerated global susceptibility and a loss of resilience, which are both hallmarks of aging. Due to the complexity of its assessment and definition, and the lack of clear evidence steering its management, multimorbidity represents one of the main current challenges for clinicians, researchers, and policymakers. The authors of this article recently reflected on these issues during two twin international symposia at the 2016 European Union Geriatric Medicine Society (EUGMS) meeting in Lisbon, Portugal, and the 2016 Gerontological Society of America (GSA) meeting in New Orleans, USA. The present work summarizes the most relevant aspects related to multimorbidity, with the ultimate goal to identify knowledge gaps and suggest future directions to approach this condition.

  • 250.
    Vetrano, Davide L.
    et al.
    Stockholm University, Faculty of Social Sciences, Aging Research Center (ARC), (together with KI). Catholic University of Rome, Italy.
    Collamati, Agnese
    Magnavita, Nicola
    Sowa, Agnieszka
    Topinkova, Eva
    Finne-Soveri, Harriet
    van der Roest, Henriette G.
    Tobiasz-Adamczyk, Beata
    Giovannini, Silvia
    Ricciardi, Walter
    Bernabei, Roberto
    Onder, Graziano
    Poscia, Andrea
    Health determinants and survival in nursing home residents in Europe: Results from the SHELTER study2018In: Maturitas, ISSN 0378-5122, E-ISSN 1873-4111, Vol. 107, p. 19-25Article in journal (Refereed)
    Abstract [en]

    Objective: The care processes directed towards institutionalized older people needs to be tailored on goals and priorities that are relevant for this specific population. The aim of the present study was (a) to describe the distribution of selected health determinants in a sample of institutionalized older adults, and (b) to investigate the impact on survival of such measures. Design: Multicentre longitudinal cohort-study. Setting: 57 nursing homes (NH) in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non-EU country (Israel). Participants: 3036 NH residents participating in the Services and Health for Elderly in Long TERm care (SHELTER) study. Measurements: We described the distribution of 8 health determinants (smoking habit, alcohol use, body mass index [BMI], physical activity, social participation, family visits, vaccination, and preventive visits) and their impact on 1-year mortality. Results: During the one-year follow up, 611 (20%) participants died. Overweight (HR 0.79; 95% C.I. 0.64-0.97) and obesity (HR 0.64; 95% C.I. 0.48-0.87) resulted associated with lower mortality then normal weight. Similarly, physical activity (HR 0.67; 95% C.I. 0.54-0.83), social activities (HR 0.63; 95% C.I. 0.51-0.78), influenza vaccination (HR 0.66; 95% C.I. 0.55-0.80) and pneumococcal vaccination (HR 0.76 95% C.I. 0.63-0.93) were associated with lower mortality. Conversely, underweight (HR 1.28; 95% C.I. 1.03-1.60) and frequent family visits (HR 1.75; 95% C.I. 1.27-2.42) were associated with higher mortality. Conclusions: Health determinants in older NH residents depart from those usually accounted for in younger and fitter populations. Ad hoc studies are warranted in order to describe other relevant aspects of health in frail older adults, with special attention on those institutionalized, with the ultimate goal of improving the quality of care and life.

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