Risk of death associated with use of PPIs in three cohorts of institutionalized older people in Finland

OBJECTIVES

To (1) explore clinical and demographic characteristics of users and nonusers of PPIs in 3 cohorts of institutionalized older people in Finland, and (2) compare the risk of death associated with use of PPIs in each setting.

DESIGN

Cross-sectional assessment of 3 institutionalized cohorts with 1-year follow-up of all-cause mortality.

SETTING AND PARTICIPANTS

A total of 1389 residents of 69 assisted living facilities (first cohort), 1004 residents of long term care hospitals (second cohort), and 425 residents in acute geriatric wards or in nursing homes (third cohort).

MEASUREMENTS

Demographic, drug use, and diagnostic data were collected during structured assessments conducted by trained nurses or geriatricians. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between use of PPIs and mortality.

RESULTS

In the assisted living facility, the mortality was 20.2% (n = 74) and 20.4% (n = 208) among users and nonusers of PPIs, respectively (P = 0.94). PPIs were not associated with mortality in unadjusted or adjusted analyses. In the long term care hospitals, use of PPIs was associated with increased mortality (HR, 1.36; 95% CI 1.04-1.77) when adjusted for age, sex, comorbidity, use of SSRIs, and malnutrition. In the acute geriatric wards and nursing homes, use of PPIs was associated with increased mortality (HR, 1.90; 95% CI 1.23-2.94) when adjusted for age, sex, comorbidity, delirium, and use of aspirin and SSRIs.

CONCLUSION

PPIs were not associated with mortality among residents in assisted living facilities, but were associated with increased mortality in settings where residents experienced higher levels of disability and possible susceptibility to adverse drug events.

Older adults' own reasoning for their alcohol consumption

OBJECTIVE

The aim of the study was to investigate what the older adults themselves consider to be the reasons for their alcohol consumption.

METHODS

The data were collected with a postal questionnaire from a random sample of 2100 elderly people (≥65 years) living in the medium-sized city of Espoo, Finland. The response rate was 71.6% from the community-dwelling sample. Altogether 868 persons responded that they use alcohol. Of them, 831 gave reasons for their drinking. We defined "at-risk users" as consuming >7 drinks per week, or ≥5 drinks on a typical drinking day, or using ≥3 drinks several times per week.

RESULTS

Main reasons given for alcohol consumption were "having fun or celebration" (58.7%), "for social reasons" (54.2%), "using alcohol for medicinal purposes" (20.1%), and "with meals" (13.8%). Younger age groups reported more often than the older age groups that they use alcohol for "having fun or celebration" and "for social reasons." The older age groups used more often "alcohol for medicinal purposes". Men used alcohol more often than women "as pastime" or "as sauna drink". Those defined as "at-risk users" reported using alcohol because of "meaningless life," for "relieving depression," "relieving anxiety," and "relieving loneliness."

CONCLUSIONS

Older adults have diverse alcohol consumption habits like people in other age groups. The oldest olds reported that they use alcohol for medicinal purposes. The "at-risk users" admit they use alcohol because of meaningless life, and relieving depression, anxiety, and loneliness.

Effect of cholesterol on mortality and quality of life up to a 46-year follow-up

The effect of cholesterol level on the health of older people is a matter of debate, probably because of the bidirectional association. We investigated this paradox in a long-term study. The baseline assessments of the Helsinki Businessmen Study (a cohort of mainly business executives, born 1919 to 1934) included the total cholesterol value and other cardiovascular risk factors from 1964 to 1973. These men were followed up for ≤46 years (through January 2010). During the follow-up period, the cholesterol value was assessed by self-report in 2000 (n = 1,292). Mortality was ascertained from the national registers, symptoms, and health-related quality of life with RAND-36 from questionnaires in 2000. A total of 3,277 healthy men without chronic diseases at baseline were included in the analyses. The median total cholesterol concentration at baseline was 6.5 mmol/L (251 mg/dl) (interquartile range 5.8 to 7.3 mmol/L, 224 to 282 mg/dl) and, in 2000, was 5.2 mmol/L (201 mg/dl) (interquartile range 4.6 to 5.9 mmol/L, 178 to 228 mg/dl). During the follow-up period, 1,773 men (54%) died. A strong and graded relation was found between the cholesterol level and total mortality, with the men with a cholesterol level ≤4 mmol/L (154 mg/dl) having the lowest mortality. In all, the men with the lowest cholesterol gained the most life years. However, no association was found with the cholesterol level in 2000 (when 16% were using statins) and subsequent mortality. The lowest (≤4 mmol/L) cholesterol value in midlife also predicted a higher score in the physical functioning scale of RAND-36 in old age. In conclusion, a low total cholesterol value in midlife predicts both better survival and better physical functioning in old age.

Alzheimer's patients' spouses critiques of the support services

Introduction. Caregiving families of patients with dementia are often reluctant to use support services. The aim of this study was to describe their subjective critiques of these services. Material and Methods. A cross-sectional questionnaire was sent to a random sample (N = 1943) of Alzheimer's patients' spouses in Finland with an open-ended question: “What kind of problems have you faced with the services?” Their responses were analyzed with thematic content analysis. Results. Of the responders identifying themselves as caregivers (N = 1386), 728 (mean age 77.8, 65.1% females) responded. Opinions could be divided into two categories: (1) problems with the service application process (N = 296); (2) critiques of the services offered (N = 270) including either problems with community care support services or institutional care. 74 indicated that they had no need for services, and 15 praised the services they had received. Conclusions. From the caregiver's perspective, the service system is complicated, bureaucratic and works organization centredly.

Concomitant use of SSRIs, NSAIDs/aspirin and gastroprotective drugs among residents of long-term care facilities: a medical record review

BACKGROUND AND OBJECTIVES

Concomitant use of selective serotonin reuptake inhibitors (SSRIs) and nonsteroidal anti-inflammatory drugs (NSAIDs) [including aspirin (acetylsalicylic acid)] may potentiate the likelihood of upper gastrointestinal haemorrhage (UGIH). The objectives of this study were to determine the prevalence and factors associated with concomitant SSRI/NSAID use among residents of long-term care facilities, and to investigate the use of gastroprotective drugs among concomitant SSRI/NSAID users.

METHODS

The study sample comprised 1087 out of 1444 residents of all 53 long-term care wards in Helsinki, Finland, in September 2003. Data were extracted from residents' medication charts and medical records by trained nurses. Medication, diagnostic and mortality data were available for 1004 residents.

RESULTS

Among the 1004 residents (mean ± SD age 81.3 ± 10.9 years), 28% used an SSRI, 38% used an NSAID and 24% used a gastroprotective drug. Thirteen percent of residents were concomitant users of SSRIs/NSAIDs. Concomitant use was associated with diabetes mellitus (p < 0.001), previous stroke (p < 0.001) and a higher degree of co-morbidity (p < 0.001). Gastroprotective drugs were used by 27% of concomitant users of SSRIs/NSAIDs compared with 37%, 20% and 22% of SSRI users, NSAID users and non-users of SSRIs/NSAIDs, respectively. One-year all-cause mortality was similar among all groups.

CONCLUSION

The long-term facility residents in this study sample were frequently exposed to drug-drug interactions that potentiate the risk of UGIH. Only about one-quarter of concomitant users of SSRIs/NSAIDs were prescribed a gastroprotective drug. Further initiatives are needed to optimize the use of SSRIs, NSAIDs and gastroprotective drugs.

Use of Anticholinergic Drugs and Cholinesterase Inhibitors and Their Association with Psychological Well-Being Among Frail Older Adults in Residential Care Facilities

Background

Drugs with anticholinergic properties have harmful effects among frail older people and they may antagonize the effects of cholinesterase inhibitors (ChEIs). However, their association with psychological well-being has not been studied.

Objective:

To determine (1) the prevalence of the use of anticholinergic drugs, ChEIs, or their combination among older adults in residential care facilities and their association with psychological well-being, and (2) the association of anticholinergic drugs with an individual's psychological well-being.

Methods:

In 2007, all older adults (N = 1475) living in residential care facilities in the cities of Helsinki and Espoo, Finland, were assessed in a cross-sectional study. A trained nurse retrieved data on demographic factors, regularly administered medications, and diagnoses from medical charts. Psychological well-being was assessed using 6 questions concerning life satisfaction, zest for life, plans for the future, feeling needed, and feeling depressed or lonely, and a psychological well-being score was created (range 0-1).

Results:

Residents taking anticholinergic drugs (n = 613) were significantly younger, used more drugs, and were more often on ChEIs compared with nonusers (n = 862). There was no significant difference in Charlson comorbidity index, stage of cognition, or dependence on activities of daily living between the users or nonusers of anticholinergic drugs. The anticholinergic drug users had significantly lower psychological well-being scores compared with the nonusers. Of the participants, 10.7% used ChEIs and anticholinergic drugs concomitantly. In logistic regression analysis where age, sex, comorbidities, and use of ChEIs were used as covariates, lower psychological well-being was associated with the use of anticholinergic drugs (OR 1.40; 95% CI 1.00 to 1.94; p = 0.048).

Conclusions:

Concomitant use of anticholinergic drugs and ChEIs is common among older adults. The use of anticholinergic drugs is associated with poor psychological well-being.

Suffering from loneliness indicates significant mortality risk of older people

Background. The harmful associates of suffering from loneliness are still in dispute. Objective. To examine the association of feelings of loneliness with all-cause mortality in a general aged population. Methods. A postal questionnaire was sent to randomly selected community-dwelling of elderly people (>74 years) from the Finnish National Population Register. The questionnaire included demographic characteristics, living conditions, functioning, health, and need for help. Suffering from loneliness was assessed with one question and participants were categorized as lonely or not lonely. Total mortality was retrieved from the National Population Information System. Results. Of 3687 respondents, 39% suffered from loneliness. Lonely people were more likely to be deceased during the 57-month follow-up (31%) than subjects not feeling lonely (23%, P < .001). Excess mortality (HR = 1.38, 95% CI = 1.21-1.57) of lonely people increased over time. After controlling for age and gender, the mortality risk of the lonely individuals was 1.33 (95% CI = 1.17-1.51) and after further controlling for subjective health 1.17 (CI = 1.02-1.33). The excess mortality was consistent in all major subgroups. Conclusion. Suffering from loneliness is common and indicates significant mortality risk in old age.

Anticholinergic drugs and their effects on delirium and mortality in the elderly

Aim

To investigate the use of drugs with anticholinergic properties (DAPs) and their associations with delirium and mortality among elderly patients with comorbidities.

Methods

425 patients (≥70 years of age) in geriatric wards and nursing homes were assessed. The use of DAPs was retrieved from their medical records. Delirium was diagnosed according to the DSM-IV criteria.

Results

Of the 341 patients (80.2%) treated with multiple DAPs (≥2), 92 patients (27.0%) suffered from delirium, whereas 14 of 84 patients (16.7%) without DAP treatment had delirium (p = 0.050). In a logistic regression analysis with age, gender, and Charlson Comorbidity Index as covariates, DAP treatment did not predict delirium (odds ratio 1.67, 95% confidence interval 0.87–3.21). The 2-year mortality was 49.3% (n = 168) in DAP users and 35.7% (n = 30) in non-users, respectively (p = 0.026). In the Cox proportional hazard model adjusted for age, gender, and comorbidity, DAPs did not predict mortality (hazard ratio 1.12, 95% confidence interval 0.75–1.68).

Conclusion

The use of DAPs is very frequent among frail inpatients with comorbidities, but their use has no independent prognostic significance.

Anticholinergic drug use and mortality among residents of long-term care facilities: a prospective cohort study

Few studies have investigated the possible association between use of anticholinergic drugs and mortality. The objectives of this study were to investigate the prevalence and determinants of anticholinergic drug use and the possible association between anticholinergic drug use and mortality. Data were obtained from 53 long-term care wards in Helsinki, Finland, in 2003. Medication, diagnostic, and mortality data were available for 1004 residents. Each resident's anticholinergic load was calculated using the Anticholinergic Risk Scale (ARS). Cox proportional hazards models were used to investigate the risk of death among users with a mild anticholinergic load (ARS score 1-2) and high load (ARS score ≥3) compared with nonusers of anticholinergic drugs. Age, sex, and nutritional status were used as covariates. Among the 1004 residents, 455 (45%) were nonusers of anticholinergic drugs, 363 (36%) had a mild anticholinergic load, and 186 (19%) had a high anticholinergic load. One-year all-cause mortality rates were 28%, 29%, and 27%, respectively. Higher ARS scores were not associated with mortality (ARS score 1-2: hazard ratio 1.08; 95% confidence interval, 0.84-1.41; ARS score ≥3: hazard ratio 1.05; 95% confidence interval, 0.75-1.46). Anticholinergic drug use was common; however, high ARS scores were not associated with mortality. Further research is needed using alternative models and among different resident populations.

Sedative load among long-term care facility residents with and without dementia: a cross-sectional study

BACKGROUND AND OBJECTIVE

People with cognitive impairment are particularly susceptible to adverse drug events linked to sedative and psychotropic drugs. A model to calculate sedative load has been developed to quantify the cumulative effect of taking multiple drugs with sedative properties. The objective of this study was to describe the sedative load and use of sedative and psychotropic drugs among long-term care facility residents with and without dementia.

METHODS

Cross-sectional data were collected from all 53 long-term care wards in Helsinki, Finland, in September 2003. Of the 1444 eligible residents, consent to participate was obtained for 1087 (75%) residents. Medication and diagnostic data were available for 1052 residents. All drugs were classified using the Anatomical Therapeutic Chemical (ATC) classification system. Sedative load was calculated for each resident using a previously published four-group model.

RESULTS

Of the 1052 residents, 781 (74.2%) were determined to have dementia. Residents with and without dementia had a similar sedative load (mean 3.0 vs 2.7, p = 0.267), but residents with dementia were taking fewer drugs than residents without dementia (mean 6.7 vs 7.4, p = 0.011). Residents with dementia were more frequent users of antipsychotics (42.8% vs 32.8%, p = 0.004), but less frequent users of antidepressants (35.6% vs 46.1%, p = 0.002) and sedative-hypnotics (22.8% vs 27.7%, p = 0.003) than residents without dementia. The most frequently used primary sedatives among people with dementia were temazepam (n = 122, 15.6%), oxazepam (n = 98, 12.5%) and lorazepam (n = 95, 12.2%). The most frequently used drugs with sedation as a prominent adverse effect or preparations with a sedating component among people with dementia were citalopram (n = 183, 23.4%), risperidone (n = 155, 19.8%) and olanzapine (n = 73, 9.3%).

CONCLUSIONS

Residents with dementia were less frequent users of sedative-hypnotic drugs than residents without dementia. However, residents with and without dementia had a similar sedative load. Clinicians should be aware of the extent to which all individual drugs, not only those prescribed for intentional sedation, contribute to a resident's sedative load. The very high rates of sedative and psychotropic use observed in long-term care facility residents highlight the need for new strategies to optimize drug use.

The association of the dopamine transporter gene and the dopamine receptor 2 gene with delirium, a meta-analysis

Delirium is the most common neuropsychiatric syndrome in elderly ill patients. Previously, associations between delirium and the dopamine transporter gene (solute carrier family 6, member 3 (SLC6A3)) and dopamine receptor 2 gene (DRD2) were found. The aim of this study was to validate whether markers of the SLC6A3 and DRD2 genes are were associated with delirium in independent populations. Six European populations collected DNA of older delirious patients. Associations were determined per population and results were combined in a meta-analysis. In total 820 medical inpatients, 185 cardiac surgery patients, 134 non-cardiac surgery patients and 502 population-based elderly subjects were included. Mean age was 82 years (SD 7.5 years), 598 (36%) were male, 665 (41%) had pre-existing cognitive impairment, and 558 (34%) experienced delirium. The SLC6A3 rs393795 homozygous AA genotype was more frequent in patients without delirium in all populations. The meta-analysis showed an Odds Ratio (OR) for delirium of 0.4 (95% confidence interval (C.I.) 0.2-0.6, P = 0.0003) for subjects with AA genotype compared to the AG and GG genotypes. SLC6A3 marker rs1042098 showed no association with delirium. In meta-analysis the DRD2 rs6276 homozygous GG genotype showed an OR of 0.8 for delirium (95% C.I. 0.6-1.1, P = 0.24). When subjects were stratified for cognitive status the rs6276 GG genotype showed ORs of 0.6 (95% C.I. 0.4-1.0, P = 0.06) and 0.8 (95% C.I. 0.5-1.5, P = 0.51) for delirium in patients with and without cognitive impairment, respectively. In independent cohorts, a variation in the SLC6A3 gene and possibly the DRD2 gene were found to protect for delirium.

Family care as collaboration: effectiveness of a multicomponent support program for elderly couples with dementia. Randomized controlled intervention study

OBJECTIVES

To determine whether community care of people with dementia can be prolonged with a 2-year multicomponent intervention program and to analyze effects of the intervention on total usage and expenses of social and healthcare services.

DESIGN

Randomized controlled trial.

SETTING

Community-dwelling couples with one spouse caring for the other spouse with dementia.

PARTICIPANTS

Couples with dementia (N=125) were allocated at random to the intervention (n=63) or control group (n=62).

INTERVENTION

Intervention couples were provided with a multicomponent intervention program with a family care coordinator, a geriatrician, support groups for caregivers, and individualized services.

MEASUREMENTS

Time from enrollment to institutionalization of spouses with dementia and use of services and service expenditure of couples.

RESULTS

At 1.6 years, a larger proportion in the control group than in the intervention group was in long-term institutional care (25.8% vs 11.1%, P=.03). At 2 years, the difference was no longer statistically significant. The 2-year adjusted hazard ratio for the intervention group was 0.53 (95% confidence interval (CI)=0.23-1.19, P=.12). Intervention led to reduction in use of community services and expenditures. The difference for the benefit of intervention group was -7,985 Euro (95% CI=-16,081 to -1,499, P=.03). When the intervention costs were included, the differences between the groups were not significant.

CONCLUSION

Although the intervention did not result in a significant difference in the need for institutional care after 2 years, individualizing services in collaboration with families may lead to reduction in use of and expenditures on municipal services.

Sedative load and mortality among residents of long-term care facilities: a prospective cohort study

BACKGROUND

Older people are often prescribed multiple drugs with sedative properties. Most research has focused on specific classes of sedative and psychotropic drugs. The cumulative effect of taking multiple drugs with sedative properties has been termed 'sedative load'. Few previous studies have investigated the sedative load among residents of long-term care facilities. No previous studies have assessed the possible association between sedative load and mortality.

OBJECTIVE

The objective of this study was to describe the sedative load among residents of long-term care facilities, and to investigate a possible association between sedative load and mortality.

METHODS

This was a prospective cohort study. The study population comprised all 1444 residents of 53 long-term care wards in seven hospitals in Helsinki during September 2003. Of the eligible residents, 1087 residents or their proxies provided written informed consent to participate. Medical, medication and follow-up mortality data were available for 1004 residents. The main outcome measures were sedative load and all-cause mortality.

RESULTS

The mean age of the residents was 81.3 (SD 10.9) years, and the mean number of regularly used drugs per resident was 7.1 (SD 3.4). Fifteen percent of residents were categorized as non-users of sedative drugs, 32% as users of some drugs with sedative properties and 53% as residents with a high sedative load. There was a bivariate association between having a higher sedative load and younger age (p < 0.001), male sex (p = 0.006), not being widowed (p = 0.001), diagnosis of depression (p < 0.001), diagnosis of psychiatric illness other than depression (p < 0.001), not being diagnosed with dementia (p = 0.009) and a shorter duration of institutional care (p = 0.02). Unadjusted analysis revealed that having a higher sedative load was associated with increased survival (p = 0.04, log rank test). However, in the adjusted Cox proportional hazard model, only poor nutritional status (hazard ratio [HR] 1.55; 95% CI 1.32, 1.82), male sex (HR 1.37; 95% CI 1.12, 1.69), increasing age (HR 1.04; 95% CI 1.03, 1.05) and co-morbidity (HR 1.07; 95% CI 1.02, 1.13) were significantly associated with risk of death.

CONCLUSIONS

There is a very high rate of sedative and psychotropic drug use among residents of long-term care facilities in Helsinki. However, having a high sedative load was not associated with an increased risk of death. Further research is needed to investigate the possible association between sedative load and mortality using alternative models and methods, and in different resident populations.

Explaining the obesity paradox: cardiovascular risk, weight change, and mortality during long-term follow-up in men

AIMS

To examine life-long weight trajectories behind the 'obesity paradox', and whether cardiovascular disease (CVD) risk contributes.

METHODS AND RESULTS

Cardiovascular disease risk and body mass index (BMI) at mean ages of 25, 47 (year 1974), and 73 years (year 2000) were available of a socioeconomically homogenous sample of 1114 men, without chronic diseases and diabetes in 1974. Overweight was defined as BMI > 25 kg/m(2), and 7-year mortality (2000-06) from the mean age of 73 years determined (188 deaths). Between 1974 and 2000, 44.3% (n = 494) were constantly overweight, 31.0% (n = 345) constantly normal weight, 12.2% (n = 136) moved from normal to overweight, and 12.5% (n = 139) moved from overweight to normal. The last group had highest CVD risk in midlife, and in late life more co-morbidities and greatest total mortality (P < 0.001). Adjusted mortality hazard ratio was 2.0 (95% confidence interval, CI 1.3-3.0; constantly normal weight group as referent). The hazard ratio remained similar (1.9, 95% CI 1.2-3.0) after adjustment for prevalent diseases in 2000.

CONCLUSION

In old age, both normal weight and overweight men are a mixture of individuals with different weight trajectories during their life course. Overweight and high-CVD risk in midlife with subsequent weight decrease predict the worst prognosis in late life.

The use of legal guardians and financial powers of attorney among home-dwellers with Alzheimer's disease living with their spousal caregivers

We conducted a cross-sectional survey of a random sample of 1943 spouses of home-dwellers with Alzheimer's disease (AD) to examine the prevalence of court-appointed guardians or financial powers of attorney for persons with AD, related factors and the need for information about these issues among caregiving families. The questionnaire consisted questions on variables of demographic characteristics, disability, symptoms and care needs of the person with dementia, the strain of caregiving, the use of court-appointed legal guardians or powers of attorney, as well as discussions about these issues -- and the need for them -- with a doctor. The response rate was 77% and the mean ages of those with AD and caregivers were 80.2 and 78.2 years, respectively. The use of legal guardians was rare (4.3%), while the use of financial powers of attorney was more common (37.8%). Only 9.9% of the couples had discussed these issues with their doctor, whereas 47.9% expressed a need for it. The factors associated with the use of these legal arrangements were related to the severity of dementia, including experiencing dementia symptoms for more than 3 years, poor functioning, incontinence and behavioural symptoms. There is a clear need for information on medico-legal issues related to dementia among caregivers of AD patients. If held soon after the diagnosis, such discussions could support the autonomy of these persons in spite of AD and enable them to plan for the future as they wish.

A qualitative analysis of student Balint groups in medical education: contexts and triggers of case presentations and discussion themes

OBJECTIVE

No previous rigorous qualitative studies exist on student Balint groups. The aim of this study was to explore the contexts and triggers of cases presented in student Balint groups and to clarify the themes in the group discussions.

METHODS

Fifteen student Balint sessions in two groups were organised. Nine female students participated. A grounded theory-based approach with thematic content analysis of the field notes was used.

RESULTS

We identified five triggers for case narrations (witnessing injustice, value conflict, difficult human relationships, incurable patient, role confusion) that originated from three distinct contexts (patient encounters, confusing experiences in medical education, tension between privacy and profession). Four main discussion themes could be identified (feelings related to patients, building professional identity, negative role models, cooperation with other medical professionals).

CONCLUSION

The concept of case in student Balint groups was wider than in traditional Balint groups. Feelings related to patients and to one's own role as a doctor were openly discussed in groups. The discussions often touched on professional growth and future professional identity as doctors.

PRACTICE IMPLICATIONS

The Balint groups may support medical students' professional growth process. This topic warrants further study in more heterogeneous student groups.

How do elderly spouse care givers of people with Alzheimer disease experience the disclosure of dementia diagnosis and subsequent care?

OBJECTIVES

To examine the experiences of spousal care givers of Alzheimer patients to disclosure of dementia diagnosis and subsequent care.

METHODS

A random sample of 1943 spousal care givers of people receiving medication for Alzheimer disease (AD) was sent a cross-sectional postal survey about their opinions on the disclosure of dementia and follow-up care. A smaller qualitative study (n = 63) included open-ended questions concerning their experiences of the same topics.

RESULTS

The response rate for the survey was 77%. Of the respondents, 1214 of 1434 acknowledged themselves as their spouse's care giver. The mean age of the care givers was 78.2 years, and that of demented spouses, 80.5 years. Of the care givers, 63% were women. The couples had long-lasting marriages (mean 52 years). Of the care givers, 93% reported that dementia had been disclosed openly to their spouse; 97% also preferred that physicians openly inform the patients of the dementia diagnosis, although 55% of their spouses with AD had developed depressive symptoms after the disclosure. Of the care givers, 71% felt they had received sufficient information about dementia. However, only 50% estimated that their spouses' follow-up care had been well organised. The responses in the qualitative study indicated that many care givers felt grief and anxiety. They also expressed feelings of loneliness and uncertainty about how to deal with follow-up care for dementia.

CONCLUSIONS

Elderly spousal care givers were quite satisfied with the information given them about dementia. However, the support with regard to the follow-up care of care-giving families failed to meet their needs adequately.

Managing delirium in hospitalized elderly patients

This review highlights the key elements of guidelines developed for the management of delirium. Experts and expert panels in several countries have presented their own guidelines, which have similarities but also differences in their emphases. The essential elements in the management of delirium are appropriate detection and diagnosis, assessment and treatment of underlying conditions, symptom management, environmental and supportive interventions, post-delirium care and follow-up, and paying attention to risk factors and prevention. The level of evidence behind each recommendation of the guidelines is discussed, as well as some of the typical pitfalls in the care of patients with delirium. Although rigorous randomized intervention trials on full-blown delirium are still scarce, we have some trials suggesting how to manage each dimension of the care of delirium.

Use of laxatives among older nursing home residents in Helsinki, Finland

BACKGROUND AND OBJECTIVE

Constipation and, as a consequence, the use of laxatives are common among frail older people. The causes of and factors associated with laxative use, however, have undergone surprisingly little study. The objectives of our study were to (i) assess the prevalence of regularly administered laxatives, (ii) identify factors associated with regular use of laxatives, and (iii) determine which drug classes or medications are associated with regular laxative use in an older nursing home population in Helsinki.

METHODS

This study was a cross-sectional assessment of all long-term nursing home residents aged >/=65 years in Helsinki, Finland. In February 2003, the health status of these residents was assessed and data on their demographic characteristics, health and medication use were collected from medical charts.

RESULTS

Of all nursing home residents in Helsinki, 82% (n = 1987, mean age 83.7 years) participated in the study. Of all residents, 55.3% received laxatives regularly. Factors associated with regular laxative use in univariate analysis included age >80 years, stroke, Parkinson's disease, inability to move independently, poor Mini Nutritional Assessment (MNA) score (<17), fluid intake less than five glasses per day, and chewing problems. Drugs associated with laxative use included opioids, antacids, diuretics, tricyclic antidepressants, lipid-lowering drugs other than HMG-CoA reductase inhibitors (statins), histamine H(2) receptor antagonists, nonselective NSAIDs, anticholinergic drugs for urine incontinence, and calcium channel antagonists other than verapamil and nifedipine. In logistic regression analysis, age >80 years (odds ratio [OR] 1.29; 95% CI 1.03, 1.60), inability to move independently (OR 1.80; 95% CI 1.42, 2.28), poor MNA score (<17) [OR 1.51; 95% CI 1.19, 1.93], chewing problems (OR 1.27; CI 95% 1.00, 1.61), Parkinson's disease (OR 1.63; 95% CI 1.01, 2.64), and concomitant use of a high number (>7) of drugs other than laxatives and constipation-inducing drugs found in univariate analysis (OR 1.06; 95% CI 1.03, 1.09) were associated with use of laxatives. Having snacks between meals (OR 0.74; 95% CI 0.60, 0.90) was associated with lower risk of laxative use.

CONCLUSIONS

Regular laxative use in older nursing home residents in Helsinki is very common. Offering snacks between meals and regular evaluation of medication use may influence laxative use.

Neither atypical nor conventional antipsychotics increase mortality or hospital admissions among elderly patients with dementia: a two-year prospective study

BACKGROUND

Antipsychotics are widely used to manage behavioral disorders in patients with dementia. Recently, serious concerns have been raised about the stroke and mortality risk of atypical antipsychotics when administered to patients with dementia.

AIM

The aim of this study was to examine the impact of atypical and conventional antipsychotics on mortality and hospital admissions among Finnish elderly institutionalized patients with dementia in a two-year follow up and to compare their prognosis with that of nonusers.

PATIENTS AND METHODS

The authors examined 254 very frail patients with dementia, mean age 86 years, from seven Finnish nursing homes and two hospitals in 1999-2000. Medical records provided information on the use of daily antipsychotic medication; central registers confirmed mortality for up to two years.

RESULTS

Nearly one-half (48.4%) of the patients used antipsychotic medication: 37.4% received conventional neuroleptics (N = 95) and 11.0% received atypical antipsychotics (N = 28). The mean number of hospital admissions was higher among the nonusers than among the users of conventional or atypical antipsychotics. Of the users of atypical antipsychotics (risperidone, olanzapine), 32.1% died within 2 years. The respective figures for users of conventional neuroleptics were 45.3%, and for the nonusers, 49.6%. In the Cox proportional hazard model, a high number of medications and the use of physical restraint predicted higher mortality at two years. The use of atypical antipsychotics showed lower risk of mortality, if any. The respective test for conventional antipsychotics was nonsignificant.

CONCLUSION

Among these frail and very old patients with dementia, neither the use of atypical antipsychotics nor the use of conventional neuroleptics increased mortality or hospital admissions. The use of restraints, however, doubled the risk of mortality.

Cardiovascular Risk in Midlife and Psychological Well-being Among Older Men

BACKGROUND

Negative and positive affects influence the prognosis in the elderly, but underlying mechanisms are obscure. We investigated whether cardiovascular disease risk in midlife is related to psychological well-being in older men (aged 69-84 years old).

METHODS

A socioeconomically homogeneous volunteer sample of men, born from 1919 through 1934, was followed up for 29 years. At baseline in 1974, they were healthy but considered to be at low (n = 593) or high (n = 610) risk of cardiovascular diseases (repeatedly 1 or more of classic cardiovascular risk factors). From November 1, 2002, through March 31, 2003, a mailed questionnaire was used to assess psychological well-being in older survivors. Mortality up to December 31, 2002, was retrieved from national registers.

RESULTS

During the entire follow-up, 303 men died, 127 (21.4%) and 176 (28.9%) in the low- and high-risk groups, respectively (hazard ratio, 1.54; 95% confidence interval, 1.19-2.00; P = .001). From 2002 through 2003, the response rates were 73.7% (336/456) and 71.4% (297/416) in the low- and high-risk groups, respectively (P = .45), and the mean age was 76 years. The variables related to psychological well-being were consistently better in the low-risk than in the high-risk group as they became older. The differences were observed especially in life satisfaction (P = .02), feeling of happiness (P = .001), positive life orientation as a whole (P = .04), and the Zung depression score (P = .007). The difference in the feeling of happiness between the groups prevailed (P = .01) after adjustments, including the feeling of depression.

CONCLUSION

Low cardiovascular risk in midlife was associated not only with better survival but also with better psychological well-being in the elderly.

Social contacts and their relationship to loneliness among aged people - a population-based study

BACKGROUND

Emotional loneliness and social isolation are major problems in old age. These concepts are interrelated and often used interchangeably, but few studies have investigated them simultaneously thus trying to clarify their relationship.

OBJECTIVES

To describe the prevalence of loneliness among aged Finns and to study the relationship of loneliness with the frequency of social contacts, with older people's expectations and satisfaction of their human relationships. Especially, we wanted to clarify whether emotional loneliness is a separate concept from social isolation.

METHODS

The data were collected with a postal questionnaire. Background information, feelings of loneliness, number of friends, frequency of contacts with children, grandchildren and friends, the expectations of frequency of contacts as well as satisfaction of the contacts were inquired. The questionnaire was sent to a random sample of 6,786 aged people (>74 years) in various urban and rural areas in Finland. We report here the results of community-dwelling respondents (n = 4,113).

MAIN RESULTS

More than one third of the respondents (39.4%) suffered from loneliness. Feeling of loneliness was not associated with the frequency of contacts with children and friends but rather with expectations and satisfaction of these contacts. The most powerful predictors of loneliness were living alone, depression, experienced poor understanding by the nearest, and unfulfilled expectations of contacts with friends.

CONCLUSION

Our findings support the view that emotional loneliness is a separate concept from social isolation. This has implications for practice. Interventions aiming at relieving loneliness should be focused on enabling an individual to reflect her own expectations and inner feelings of loneliness.

Multicomponent geriatric intervention for elderly inpatients with delirium: a randomized, controlled trial

BACKGROUND

Delirium is a common syndrome with poor prognosis affecting elderly inpatients. Treatment is mainly based on common sense with wide variations in practice. We investigated whether intensified, multicomponent geriatric treatment could improve the prognosis of delirious patients.

METHODS

We performed a randomized, controlled trial of 174 patients with delirium in six general medicine units from an acute hospital in Helsinki, Finland. The intervention group received individually tailored geriatric treatment. The primary endpoint was the sum of those deceased individuals and the patients permanently institutionalized. Secondary endpoints included the number of days in hospitals and other institutions, delirium intensity, and cognition.

RESULTS

The mean age of patients was 83 years, and 31% had previous dementia. The intervention group (N = 87) received significantly more acetylcholinesterase inhibitors (58.6% vs 9.2%), atypical antipsychotics (69.8% vs 30.2%), specialist consultations (49.4% vs 28.7%), hip protectors (88.5% vs 3.4%), physiotherapy (87.4% vs 47.1%), and fewer conventional neuroleptics (8.0% vs 23.0%) than did the control group (N = 87). During the 1-year follow-up, 60.9% of the intervention group and 64.4% of controls were either deceased or permanently institutionalized (p =.638). The intervention group spent a mean of 126 days in institutions, and the control group 140 days (p =.688). Delirium was, however, alleviated more rapidly during hospitalization, and cognition improved significantly at 6 months in the intervention group.

CONCLUSIONS

Faster alleviation of delirium and improved cognition justify good, comprehensive geriatric care for these patients although treatment produced no significant improvements in hard endpoints of prognosis.

Predictors and subjective causes of loneliness in an aged population

The aim of the study was to examine the prevalence and self-reported causes of loneliness among Finnish older population. The data were collected with a postal questionnaire from a random sample of 6,786 elderly people (>or=75 years of age). The response rate was 71.8% from community-dwelling sample. Of the respondents, 39% suffered from loneliness, 5% often or always. Loneliness was more common among rural elderly people than those living in cities. It was associated with advancing age, living alone or in a residential home, widowhood, low level of education and poor income. In addition, poor health status, poor functional status, poor vision and loss of hearing increased the prevalence of loneliness. The most common subjective causes for loneliness were illnesses, death of a spouse and lack of friends. Loneliness seems to derive from societal life changes as well as from natural life events and hardships originating from aging.

Use of Inappropriate Medications and Their Prognostic Significance Among In-Hospital and Nursing Home Patients with and without Dementia in Finland

BACKGROUND

Although the Beers criteria have been frequently utilised to describe the use of inappropriate medications in various elderly populations, less is known about the use of such medications among patients with dementia, and nor have many studies dealt with their impact on mortality or use of healthcare services. This study examines the use of inappropriate drugs and their impact on mortality and use of health services among Finnish elderly nursing home and hospital patients. Patients with dementia were studied as a special subgroup.

METHODS

A total of 425 patients consecutively admitted to seven Finnish nursing homes and two hospitals in 1999-2000 were examined. Details of all medications prescribed and administered were retrieved from medical records and coded according to the Beers 1997 criteria. Mortality data as well as days in acute hospital were obtained from central registers and all area hospitals during 2 years of follow-up.

RESULTS

The entire population was old and frail (mean age 86 years, 82% females), 60% had dementia and 36.2% received at least one potentially inappropriate drug (PID). No differences existed in the proportion of users of PIDs among those 60% of patients with dementia compared with those without. The most common PID was temazepam, with 14% of all patients on high doses. Other commonly used PIDs were oxybutynin and dipyridamole. Amitriptyline was more commonly used among patients without dementia (4.7%) compared with those with dementia (0.8%). Nevertheless, in this very old and frail study population, use of inappropriate drugs did not predict mortality or use of health services.

CONCLUSION

Use of PIDs is common in nursing homes and hospitals in Finland but has no impact on mortality or hospital admissions. Use of high-dose temazepam as a hypnotic accounted for most of the high use of PIDs.

Feelings related to first patient experiences in medical school. A qualitative study on students' personal portfolios

Feelings and thoughts of medical students related to first patient experiences during the first clinical year were examined. Twenty-two volunteer third and fourth year medical students (15 women and 7 men) of the University of Helsinki participated in a portfolio course for 1 year. Their reflective learning diaries and writings on specific themes were analyzed by qualitative content analysis. First patient encounters were strong emotional experiences for medical students. The first patient examination was often described as an anxiety-provoking and confusing incident. Other emotionally significant encounters included helplessness when faced with serious illness and death, and role confusion when examining patients of one's own age but opposite sex. Students felt guilty for using patients for their own learning purposes. Portfolios as learning tools may help in recognizing key experiences and support professional development of medical students.