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Objectives: To investigate the prevalence of malnutrition and the association between Body Mass Index (BMI), Mini Nutritional Assessment (MNA) and five-year mortality in a representative population of very old (>85 years) people. Design: A prospective cohort study. Setting: A population-based study of very old people in northern Sweden and western Finland, living in institutional care or in the community. Participants: Out of 1195 potential participants, 832 were included (mean age 90.2±4.6 years). Measurements: Nutritional status was assessed using BMI and MNA and the association of those two variables with five-year mortality was analyzed. Results: The mean BMI value for the whole population was 25.1±4.5 kg/m2, with no difference between genders (P=0.938). The mean MNA score was 22.5±4.6 for the whole sample, and it was lower for women than for men (PA<0.001). Thirteen percent were malnourished (MNA<17) and 40.3% at risk of malnutrition (MNA 17-23.5) according to MNA. Also, 34.8% of those with a MNA score A<17 still had a BMI value ≥22.2 kg/m2. A BMI value A<22.2 kg/m2 and a MNA scoreA<17 were associated with lower survival. The association with mortality seemed to be J-shaped for BMI, and linear for MNA. Conclusions: Malnutrition according to MNA was common, but a substantial portion of those with a low MNA score still had a high BMI value, and vice versa. The association with mortality appeared to be J-shaped for BMI, and linear for MNA. The MNA seems to be a good measurement of malnutrition in very old people, and BMI might be misleading and could underestimate the prevalence of malnutrition, especially in women. [ABSTRACT FROM AUTHOR]

Objective: To study the association between structural and cognitive aspects of social capital and depression among older adults in two Nordic regions. Method: Data were retrieved from a postal survey targeting older adults aged 65, 70, 75 and 80 years (N = 6 838, response rate = 64%) residing in the Västerbotten region (Sweden), and the Österbotten region (Finland) in 2010. The associations between structural (measured by frequency of social contact with friends and neighbours) and cognitive (measured by experienced trust in friends and neighbours) aspects of social capital and depression (measured by Geriatric Depression Scale, GDS-4) were tested by logistic regression analyses. Results: Both low structural and cognitive social capital as defined in the study showed statistically significant associations with depression in older adults. Only experienced trust in neighbours failed to show significant association with depression. In addition, being single and being 80 years of age indicated a higher risk of depression as defined by GDS-4. Conclusion: The findings underline the connection between adequate levels of both structural and cognitive individual social capital and mental health in later life. They also suggest that the connection differs depending on various network types; the cognitive aspect of relationships between friends was connected to depression, while the connection was not found for neighbours. Further, the oldest age group in the sample (80 years of age) is pointed out as a population especially vulnerable for depression that should not be overlooked in mental health promotion and depression prevention. [ABSTRACT FROM PUBLISHER]

This study aimed to investigate the prevalence of having plans for the future among very old people and the factors associated with having such plans. A longitudinal population-based study with home visits for 85-, 90-, and ≥95-year-old participants in Sweden and Finland was used. Multivariate logistic regression and Cox proportional-hazards regression models with a maximum 5-year follow-up period were used. The prevalence of having plans for the future was 18.6% (174/936). More men than women and more people living in Sweden than in Finland had plans for the future. In multivariate models, having plans for the future was associated with speaking Swedish, being dentate, and living in the community in the total sample; speaking Swedish and being dentate among women; and speaking Swedish, having a lower Geriatric Depression Scale score, and urban residence among men. Having plans for the future was associated univariately, but not multivariately, with increased survival.

Background: high morale is defined as future-oriented optimism. Previous research suggests that a high morale independently predicts increased survival among old people, though very old people have not been specifically studied., Objective: to investigate whether high morale is associated with increased survival among very old people., Subjects: the Umeå 85+/GErontological Regional DAtabase-study (GERDA) recruited participants aged 85 years and older in northern Sweden and western Finland during 2000-02 and 2005-07, of whom 646 were included in this study., Methods: demographic, functional- and health-related data were collected in this population-based study through structured interviews and assessments carried out during home visits and from reviews of medical records. The 17-item Philadelphia Geriatric Center Morale Scale (PGCMS) was used to assess morale., Results: the 5-year survival rate was 31.9% for participants with low morale, 39.4% for moderate and 55.6% for those with high morale. In an unadjusted Cox model, the relative risk (RR) of mortality was higher among participants with low morale (RR = 1.86, P < 0.001) and moderate morale (RR = 1.59, P < 0.001) compared with participants with high morale. Similar results were found after adjustment for age and gender. In a Cox model adjusted for several demographic, health- and function-related confounders, including age and gender, mortality was higher among participants with low morale (RR = 1.36, P = 0.032) than those with high morale. There was a similar but non-significant pattern towards increased mortality in participants with moderate morale (RR = 1.21, P value = 0.136)., Conclusion: high morale is independently associated with increased survival among very old people., (© The Author 2015. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: The aim of this study was to explore if inner strength is independently associated with a reduced prevalence of depression after controlling for other known risk factors associated with depression., Methods: A population-based cross-sectional study was performed, where all women living in Åland, a Finnish self-govern island community in the Baltic Sea, aged 65 years or older were sent a questionnaire including the Geriatric Depression Scale and the Inner Strength Scale along with several other questions related to depression. Factors associated with depression were analyzed by means of multivariate logistic regression., Results: The results showed that 11.2% of the studied women (n = 1452) were depressed and that the prevalence increased with age and was as high as 20% in the oldest age group. Non-depressed women were more likely to never or seldom feel lonely, have a strong inner strength, take fewer prescription drugs, feeling needed, being able to engage in meaningful leisure activities, as well as cohabit., Conclusion: Our results showed an association between stronger inner strength and being non-depressed. This can be interpreted to mean that inner strength might have a protective effect against depression. These findings are interesting from a health-promotion perspective, yet to verify these results, further longitudinal studies are required.

Delirium has mainly been studied in various patient samples and in people living in institutions. The present study investigates the 30-day prevalence of delirium in a population-based sample of very old people in northern Sweden and Finland. Seven hundred and eight persons aged 85 years and older from the GErontological Regional DAtabase (GERDA) were assessed. Information was also collected from relatives, carers and medical records. Assessments performed were among others the Organic Brain Syndrome (OBS) scale, the Mini Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15). Delirium, depression and dementia diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. The prevalence of delirium was 17% among 85 year-olds, 21% among 90 year-olds and 39% among participants aged 95 years and older (p<0.001). Delirium prevalence among individuals without dementia was lower than among those with dementia (5% vs. 52%, p<0.001). Factors independently associated with delirium superimposed on dementia in a multivariate logistic regression model were depression (Odds Ratio (OR)=2.0, 95% Confidence Interval (CI)=1.2-3.3), heart failure (OR=2.1, 95% CI=1.2-3.7), institutional living (OR 4.4, 95% CI=2.4-8.2) and prescribed antipsychotics (OR=3.0, 95% CI=1.5-6.0). Delirium is highly prevalent among very old people with dementia. Depression, heart failure, institutional living and prescribed antipsychotic medication seem to be associated with delirium., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: The aim of this study was to investigate the association between aspects of social capital and loneliness among the very old living at home and in institutional settings., Method: Half of those aged 85 years, and all 90- and 95-year-olds and older in urban and rural municipalities in northern Sweden and western Finland were invited to participate in a cross-sectional population-based study in 2005-2007. A sample of 483 participants who completed the study was included in the analyses., Results: Loneliness was experienced by 55% percent of those living in institutional settings often or sometimes and 45% of those living in their own homes. Loneliness was closely related to living alone, to depression, and to region (northern Sweden)., Discussion: Social capital and loneliness are context dependent (i.e., geographical or living environment). Among the very old, the link between social capital resources and loneliness is also highly influenced by health status.

Background and Purpose: Depression after stroke has been associated with increased mortality, but little is known about this association among very old people., Methods: A population-based study among people ≥85 years of age was conducted in northern Sweden and Finland, comprising cross-sectional assessments and subsequent survival data. The 452 individuals who had completed the Geriatric Depression Scale-15 assessment were selected. Depression was defined as a score of ≥5 on the geriatric depression scale., Results: Of those with a history of stroke, 38 of 88 (43.2%) people were depressed, and 11 of the 38 (28.9%) were treated with antidepressants, compared with 91 of 364 (25.0%) depressed (P=0.001) and 17 of 91 (18.7%) treated with antidepressants among those without stroke. Having a history of stroke and ongoing depression was associated with increased 5-year mortality compared with having only stroke (hazard ratio, 1.90; confidence interval, 1.15-3.13), having only depression (hazard ratio, 1.59; confidence interval, 1.03-2.45), and compared with having neither stroke nor depression (hazard ratio, 2.50; confidence interval, 1.69-3.69). Having only stroke without depression did not increase mortality compared with having neither stroke nor depression., Conclusions: A history of stroke was associated with increased mortality among very old people but only among those who were also depressed. Depression seemed to be underdiagnosed and undertreated.

Objectives: In older people, usual gait speed has been shown to independently predict mortality; however, less is known about whether usual gait speed is as informative in very old populations, in which prevalence of multimorbidity and disability is high. The aim of this study was to investigate if usual gait speed can independently predict all-cause mortality in very old people, and whether the prediction is influenced by dementia disorder, dependency in activities of daily living (ADL), or use of walking aids in the gait speed test., Design: Prospective cohort study., Setting: Population-based study in northern Sweden and Finland (the Umeå 85+/GERDA Study)., Participants: A total of 772 participants with a mean age of 89.6 years, 70% women, 33% with dementia disorders, 54% with ADL dependency, and 39% living in residential care facilities., Measurements: Usual gait speed assessed over 2.4 meters and mortality followed-up for 5 years., Results: The mean ± SD gait speed was 0.52 ± 0.21 m/s for the 620 (80%) participants able to complete the gait speed test. Cox proportional hazard regression analyses adjusted for potential confounders were performed. Compared with the fastest gait speed group (≥ 0.64 m/s), the hazard ratio for mortality was for the following groups: unable = 2.27 (P < .001), ≤ 0.36 m/s = 1.97 (P = .001), 0.37 to 0.49 m/s = 1.99 (P < .001), 0.50 to 0.63 m/s = 1.11 (P = .604). No interaction effects were found between gait speed and age, sex, dementia disorder, dependency in ADLs, or use of walking aids., Conclusion: Among people aged 85 or older, including people dependent in ADLs and with dementia disorders, usual gait speed was an independent predictor of 5-year all-cause mortality. Inability to complete the gait test or gait speeds slower than 0.5 m/s appears to be associated with higher mortality risk. Gait speed might be a useful clinical indicator of health status among very old people., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this population-based study was to investigate the usefulness of the Geriatric Depression Scale 15-item version (GDS-15) to assess depressive symptoms among very old people with differing levels of cognitive function., Methods: The 834 participants were aged 85 and over. Feasibility of GDS-15 was evaluated as the proportion of people who completed the scale. Concurrent criterion validity was evaluated by calculating correlations between GDS-15 and Philadelphia Geriatric Center Morale Scale (PGCMS). PGCMS measures psychological wellbeing which is closely related with depressive symptoms. Correlations were calculated within groups according to cognitive function assessed with Mini-Mental State Examination (MMSE); 0-4, 5-9, 10-14, 15-19, 20-24, 25-27, and 28-30, using Pearson's two-sided correlation and compared using Fisher r-to-z transformation. Internal consistency of the GDS-15 was evaluated by calculating Cronbach's α in each group., Results: In total, 651 (78%) of the 834 participants completed the GDS-15. For the two MMSE-groups with scores of <10, the proportion who completed GDS-15 were 1% and 42%, respectively, compared to 65-95% in the MMSE-groups with scores of ≥10. Cronbach's α in each MMSE-group ranged from 0.636 (MMSE 28-30) to 0.821 (MMSE 5-9). The level of correlation between GDS-15 and PGCMS did not significantly differ between MMSE-groups with scores of 5-27 compared to the MMSE-group with scores of 28-30., Conclusions: The GDS-15 seems to have an overall usefulness to assess depressive symptoms among very old people with an MMSE score of 10 or more. More studies are needed to strengthen the validity of GDS-15 among older people with MMSE scores of 10-14. For older people with MMSE scores lower than 10, there is a need to develop and validate other measurements.

There are few studies comparing those who have had and have not had a stroke among those aged 80 years and over, the very old. The aim of this paper was to investigate the prevalence of stroke and the association between stroke and depression in a very old population. This paper is based on cross-sectional data from a population-based study performed between 2005 and 2007. Half of those aged 85 years, all 90-, and 95-year-olds and older in eight urban and rural municipalities in northern Sweden and Finland were invited to participate. A sample of 601 individuals who participated fully in the study was selected. Data were collected through assessments, structured interviews and investigation of medical charts. A specialist in geriatric medicine determined disease status for depression based on medical records and results from the Geriatric Depression Scale (GDS)-15, the Montgomery Åsberg Depression Rating Scale (MADRS) and the Organic Brain Syndrome (OBS) scale, and for stroke based on medical records and reported disease. The prevalence of stroke was 21.5%. The prevalence of depression was 50.4% among those with stroke compared to 34.3% among those without stroke (OR 1.944, p<0.001). In a logistic regression model adjusted for several demographic variables, diseases and functional level, stroke was independently associated with depression (OR 1.644, p=0.038). A large proportion of those with depression, both with and without stroke, were not receiving antidepressant medication. In conclusion, the stroke prevalence was high and stroke showed a strong association with depression among very old people., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Aim: This paper is a report of a study exploring possible external and inner sources of the sense of security felt by older people aged 65 and 75. Background.  The concept of 'security' has been parsimoniously defined and explored, especially as pertains to older people, and previous research has primarily focused on risks in relation to individuals' declining health and functional ability., Methods: In 2005, population-based cross-sectional surveys were carried out in 15 municipalities in Västerbotten, Sweden and 18 municipalities in Ostrobothnia, Finland. A 15-page questionnaire (84 questions) was distributed, with the final total response rate reaching 68· % (n = 3370): 1825 Swedish-speaking Swedes, 926 Swedish-speaking Finns and 621 Finnish-speaking Finns. The statistical analysis was three-stage, including nominal stepwise regressions., Results: Older people who indicate that they are 'very secure' are more likely to consider life meaningful and are able to master various life crises. Moreover, they possess confidence in economic institutions and are more likely to feel economically secure. Weak trust in family and friends or neighbours and decreased functional ability seem to indicate a subjective feeling of 'insecurity'., Conclusion: Caregivers in health care should focus more on supporting older persons' meaningfulness in life and how their feelings of security can be strengthened by trusting relationships and activities. In nursing, there should be more focus on developing knowledge of inner health resources, including positive life orientation and meaningfulness in life., (© 2011 Blackwell Publishing Ltd.)

Purpose: Old people in general, and particularly those with dementia, are more sensitive to adverse drug effects than younger people. Despite this, the use of central nervous system (CNS) drugs among old people is common. The aim of the present study was to compare the use of central nervous system drugs and analgesics among people aged 85 years or older, with and without dementia., Methods: One half of all people aged 85 years old and all those aged 90, 95 and above in Umeå, Sweden and Vaasa and Mustasaari, Finland, were asked to participate in this part of the GERDA/Umeå 85+ study. Both those living in their own homes and those in institutions were included. Trained investigators performed structured interviews and assessments. Medication data were obtained from the participants and medical records. Dementia disorders were diagnosed according to DSM-IV., Results: Dementia was diagnosed in 247/546 participants (45.2%). A higher proportion of the participants with dementia used paracetamol (50.6% compared to 21.4%, p < 0.001), antipsychotics (22.3% and 2.7%, p < 0.001), antidepressants (33.6% and 11.4%, p < 0.001) and anxiolytics (19.0% and 8.0%, p < 0.001). There were no differences in the use of opioid analgesics, anticonvulsants and hypnotics., Conclusions: The use of CNS drugs and analgesics was common among this population of very old people. Furthermore, the prescription of CNS drugs was more common among people with dementia. The use of antipsychotics in people with dementia should arouse particular concern, because of the high risk of severe adverse events and the limited evidence of positive effects.

Objectives: First, to outline the theoretical and practical framework for geriatric rehabilitation in the Nordic countries and second, to survey the scientific medical publications for evidence-based geriatric rehabilitation., Methods: Brainstorming on geriatric rehabilitation in a working group of Nordic teachers in geriatric medicine. Papers on scientific programmes for geriatric rehabilitation from Internet sources were collected and analyzed. All articles describing randomized studies in geriatric rehabilitation were selected for meta-analyses. The papers were divided into four groups according to diseases, infirmity and resource settings: stroke, hip-fractures, acute admissions and programmes conducted in nursing homes, day hospitals and home services., Results: The literature survey included 30 scientific studies (9496 patients) in randomized trials with valid endpoints. Geriatric rehabilitation programmes for stroke patients in geriatric settings (six papers, 1138 patients) reduced mortality and the need for nursing home placement, but the outcome for ADL function was not significantly changed. Function and length of stay varied between the studies. The outcome of geriatric rehabilitation was even more decisive in the randomized hip-fracture studies (seven articles, 2414 patients): the readmission rate and cost were significantly better. Ten studies were found, comparing the outcome of acute admissions of frail elderly patients (4683) with either geriatric (GEMU, GRU) or general medical wards. The effect of rehabilitation regarding mortality rate at one year, placement in a nursing home, physical function, contentment with services, readmission rate and cost was significant improvement in the geriatric settings. Internal comparisons of geriatric programmes in nursing homes, day hospitals and in-home services (seven studies, 1261 patient) revealed some differences in outcomes regarding function, contentment and costs., Conclusion: Specialized geriatric rehabilitation is complicated but effective when properly performed. Interdisciplinary teamwork, targeting of patients, comprehensive assessment and intensive and patient-targeted rehabilitation seem to characterize the most effective programmes. Rehabilitation of frail elderly people poses a major future challenge and has to be developed further for the sake of elderly people's quality of life as well as economic reasons.

A group established by the Nordic professors of geriatrics has developed a position document presenting a shared and updated review of geriatric work-up as a way of comprehensive geriatric assessment in the Nordic countries. The main intention is that the document will serve as support and help for the clinician concerned with hospital based geriatric medicine. It may also be useful for quality control and teaching. Not least, it may be useful for health professionals other than geriatricians. To some extent, the position of geriatric medicine in the Nordic countries varies between the countries. However, the background for developing a Nordic version of geriatric work-up is shared attitudes and principally the same organization of the health care system, and collaboration within geriatrics for many years. Several trials on comprehensive geriatric assessment and management performed in different settings have shown favourable outcomes. Results from controlled Nordic trials are compiled and summaries of meta-analyses are presented. The concept of Nordic geriatric work-up is based on a model defining health and disease in old age as dimensions of pathology, impairments, functional limitations, and disability, all being modified by extra- and intraindividual factors. Handicap is defined as the disability gap. Different health professionals have varying responsibilities in the geriatric team-work, but all should be dedicated to establish common goals. The geriatric work-up is presented with success factors and barriers, stating important differences between multidisciplinary and interdisciplinary processes. Checklists and assessment scales may be very useful when performing a geriatric work-up, but they should be used with caution. Specific scales covering different functional areas of the geriatric patient are recommended for clinical practice. Such scales must be valid, reliable, acceptable to the patient, responsive to change, and should be in an appropriate format, as well as easy to administer. Prior to the use among geriatric teams in the Nordic countries the scales should be translated into all the Nordic languages, and the translated versions should ideally have been subjected to validity and reliability testing. However, so far no scale meets these demands regarding all the five Nordic languages.