Helena Salminen

Nutritional status, as determined by the Mini-Nutritional Assessment, and osteoporosis: a cross-sectional study of an elderly female population

Objective:To investigate the relationship between osteoporosis and nutritional status as determined by the Mini-Nutritional Assessment (MNA).Design:A cross-sectional study.Setting:Stockholm, Sweden.Subjects:A total of 351 elderly free-living women (mean age 73±2.3 years).Methods:MNA (range 0–30 points; <17 indicates malnutrition, 17.5–23.5 risk of malnutrition and ⩾24 well nourished), measurements of bone mineral density of the left hip and lumbar spine using Hologic QDR 4500, and of the heel using Calscan DEXA-T.Results:The median MNA score was 27 (range 12.5–30). One woman was classified as malnourished and 7.4% were at risk of malnutrition. Osteoporosis of the femoral neck was observed in 22% and a fracture after the age of 50 was reported by 31% of the participants. The following items in the MNA questionnaire exhibited an increased risk of having osteoporosis in the femoral neck and/or total hip: an MNA score of <27 (odds ratio (OR)=2.09; CI=1.14–3.83); a mid-arm circumference of less than 28 cm (OR=2.97; CI=1.29–6.81); and regular use of more than 3 drugs each day (OR=2.12; CI=1.00–4.50). A body weight of more than 70 kg exhibited a decreased risk of having osteoporosis (OR=0.31; CI=0.14–0.70).Conclusions:In general, the nutritional status was good in this population of free-living elderly women. Nevertheless, half of the women who displayed an MNA score <27 points had a twofold increased risk of having osteoporosis.Sponsorship:Karolinska Institutet, Stockholm County Council.

Mini nutritional assessment and 10-year mortality in free-living elderly women: a prospective cohort study with 10-year follow-up

Background/Objectives:Mini nutritional assessment (MNA) is the most frequently used screening test for malnutrition in elderly populations in continental Europe and Asia. Most studies on MNA’s ability to predict mortality have only included persons admitted to hospital, living in nursing homes or at home with professional help with activities of daily living. The aim of this cohort study was to examine if MNA can predict 10-year mortality in the general elderly female population.Subjects/Methods:Of the 584 free-living elderly women invited, 351 agreed to participate and were tested with MNA between 1999 and 2000. A 10-year follow-up was conducted in 2010 with dates of death obtained from the Swedish death register.Results:Participants whose MNA score was ⩽23.5 points at inclusion had a significantly higher age-adjusted 10-year mortality risk than participants with a MNA score of >23.5 points. The hazard ratio was 2.36 (95% confidence interval 1.25–4.46), P <0.01.Conclusions:Participants with a MNA score, indicating an increased risk for malnutrition, were more than twice as likely to die during the 10-year follow-up as participants whose MNA score indicated normal nutritional status. Hence, MNA can predict mortality in a general, free-living, elderly female population.

Adaptation and validation of the instrument Clinical Learning Environment and Supervision for medical students in primary health care

BackgroundClinical learning takes place in complex socio-cultural environments that are workplaces for the staff and learning places for the students. In the clinical context, the students learn by active participation and in interaction with the rest of the community at the workplace. Clinical learning occurs outside the university, therefore is it important for both the university and the student that the student is given opportunities to evaluate the clinical placements with an instrument that allows evaluation from many perspectives. The instrument Clinical Learning Environment and Supervision (CLES) was originally developed for evaluation of nursing students’ clinical learning environment.The aim of this study was to adapt and validate the CLES instrument to measure medical students’ perceptions of their learning environment in primary health care.MethodsIn the adaptation process the face validity was tested by an expert panel of primary care physicians, who were also active clinical supervisors. The adapted CLES instrument with 25 items and six background questions was sent electronically to 1,256 medical students from one university. Answers from 394 students were eligible for inclusion. Exploratory factor analysis based on principal component methods followed by oblique rotation was used to confirm the adequate number of factors in the data.Construct validity was assessed by factor analysis. Confirmatory factor analysis was used to confirm the dimensions of CLES instrument.ResultsThe construct validity showed a clearly indicated four-factor model.The cumulative variance explanation was 0.65, and the overall Cronbach’s alpha was 0.95. All items loaded similarly with the dimensions in the non-adapted CLES except for one item that loaded to another dimension. The CLES instrument in its adapted form had high construct validity and high reliability and internal consistency.ConclusionCLES, in its adapted form, appears to be a valid instrument to evaluate medical students’ perceptions of their clinical learning environment in primary health care.

District nurses’ perceptions of osteoporosis management: a qualitative study

SummaryUnderdiagnosis of osteoporosis is common. This study investigated Swedish district nurses’ perceptions of osteoporosis management. They perceived the condition as having low priority, and the consequences of this perception were insufficient awareness of the condition and perceptions of bone-specific medication as unsafe. They perceived, though, competency when working with fall prevention.IntroductionUndertreatment of patients with osteoporosis is common. Sweden’s medical care strategy dictates prioritisation of various conditions; while guidelines exist, osteoporosis is not prioritised. The aim of this study was to investigate district nurses’ perceptions of osteoporosis management within Sweden’s primary health care system.MethodsFour semi-structured focus group interviews were conducted with 13 female district nurses. The interviews were analysed using thematic analysis.ResultsThe overall theme was perceiving osteoporosis management as ambiguous. The themes were perceiving barriers and perceiving opportunities. These subthemes were linked to perceiving barriers: (i) insufficient procedures, lack of time and not aware of the condition; (ii) insufficient knowledge about diagnosis and about fracture risk assessment tools; (iii) low priority condition and unclear responsibility for osteoporosis management; and (iv) bone-specific medication was sometimes perceived to be unsafe. These subthemes were linked to perceiving opportunities: (i) professional competency when discussing fall prevention in home visit programs, (ii) willingness to learn more about osteoporosis management, (iii) collaboration with other professionals and (iv) willingness to identify individuals at high risk of fracture.ConclusionsOsteoporosis was reported, by the district nurses, to be a low-priority condition with consequences being unawareness of the condition, insufficient knowledge about bone-specific medications, fracture risk assessment tools and procedures. These may be some of the explanations for the undertreatment of osteoporosis. At the same time, the district nurses described competency performing the home visits, which emerged as an optimal opportunity to discuss fall prevention and to introduce FRAX with the aim to identify individuals at high risk of fracture.

IGFBP-1 predicts all-cause mortality in elderly women independently of IGF-I

OBJECTIVE Previous studies on the insulin-like growth factor (IGF) system and mortality have shown ambiguous results. We investigated the association between IGF-I and insulin- like growth factor binding protein-1 (IGFBP-1) with all-cause mortality in an elderly female Swedish population. DESIGN AND METHODS A prospective cohort study of elderly women (n=338) aged between 68 and 79 years (mean age 72 years) with a mean follow-up time of 9.9 years. Baseline data in the PRIMOS (Primary Health Care and Osteoporosis) study were collected between 1999 and 2001. Data of risk factors for cardiovascular disease were collected. Death rates were registered from the Swedish Cause of Death register for the period 1999-2009. Cox regression models were used to calculate hazard ratios. IGF-I and IGFBP-1 levels were separately divided into 3 groups (high, medium and low), with cut offs at the 30th and the 70th percentiles. RESULTS In a fully adjusted Cox proportional hazard model, increased risk of mortality was shown for women with high serum levels of IGFBP-1, HR 3.03 (95% CI 1.64-5.63) and also with low serum levels of IGFBP-1, HR 1.98 (95% CI 1.03-3.81), compared to women with moderate levels. No significant association between IGF-I and mortality was observed. CONCLUSIONS High and low serum insulin-like IGFBP-1 levels were associated with an increased risk of all-cause mortality in elderly women, compared to moderate levels.

Laser-Supported Dual Energy X-Ray Absorptiometry (DXL) Compared to Conventional Absorptiometry (DXA) and to FRAX as Tools for Fracture Risk Assessments

Dual X-ray and Laser (DXL) adds a measure of the external thickness of the heel, measured by laser, to a conventional measurement of bone mineral density (BMD) of the calcaneus, using Dual energy X-ray Absorptiometry (DXA). The addition of heel thickness aims at a better separation of fatty tissue from bone than the standard method of DXA, which may mistake fatty tissue for bone and vice versa. The primary aim of this study was to evaluate whether DXL of the calcaneus can be used to assess the 10-year risk of fractures. Secondary aims were to compare the predictive ability of DXL with the two most established methods, Dual energy X-ray Absorptiometry (DXA) of the hip and spine and the WHO fracture risk assessment tool, FRAX. In 1999 a cohort of 388 elderly Swedish women (mean age 73.2 years) was examined with all three methods. Prospective fracture data was collected in 2010 from health care registers. One SD decrease in BMD of the heel resulted in an age-adjusted Hazard Ratio (HR) of 1.47 for a hip fracture (95% CI 1.09–1.98). Harrell’s C is the Cox regression counterpart of the Area Under Curve (AUC) of the Receiver Operating Characteristic (ROC) as a measure of predictive accuracy. Harrell’s C for BMD of the calcaneus was 0.65 for prediction of hip fractures. These results were not significantly different from those for BMD of the femoral neck or for FRAX. The HR for a hip fracture, for one SD decrease in BMD at the femoral neck, was 1.72 (95% CI 1.21–2.44. Harrell’s C was 0.67 for BMD at the femoral neck and 0.59 for FRAX. We conclude that DXL of the calcaneus could be a useful tool for fracture risk assessments.

Circling the undefined—A grounded theory study of intercultural consultations in Swedish primary care

Well-functioning physician-patient communication is central to primary care consultations. An increasing demand on primary care in many countries to manage a culturally diverse population has highlighted the need for improved communication skills in intercultural consultations. In previous studies, intercultural consultations in primary care have often been described as complex for various reasons, but studies exploring physician-patient interactions contributing to the understanding of why they are complex are lacking. Therefore, the aim of this study was to explore intercultural physician-patient communication in primary care consultations, generating a conceptual model of the interpersonal interactions as described by both the patients and the physicians. Using grounded theory methodology, 15 residents in family medicine and 30 foreign-born patients, the latter with Arabic and Somali as native languages, were interviewed. The analysis generated a conceptual model named circling the undefined, where a silent agreement on issues fundamental to the core of the consultation was inadequately presumed and the communicative behaviors used did not contribute to clarity. This could be a possible contributory cause of the perceived complexity of intercultural consultations. Identifying what takes place on an interpersonal level in intercultural consultations might be a first step towards building a common ground for increased mutual understanding, thereby bringing us one step closer to sharing, rather than circling the undefined.

Conditions for interprofessional education for students in primary healthcare: a qualitative study

BackgroundPrimary healthcare in Sweden and worldwide has a diverse structure with many kinds of healthcare units involved. This is a challenge for collaboration between different professions in primary healthcare, as the different healthcare professions often work in silos. Interprofessional education (IPE) in the context of primary healthcare is less studied than IPE at hospitals and most of the studies in primary healthcare have focused on collaboration between general practitioners and nurses. The aim of this study was to describe how healthcare students perceived conditions for IPE in primary healthcare.MethodsQualitative group interviews were used and a total of 26 students, recruited on a voluntary basis participated in four group interviews with students mixed from study programmes in nursing, physiotherapy, occupational therapy and medicine. Students from the study programme in medicine were in their second to eleventh semesters of 11 semesters in total, whilst students from the occupational therapist, physiotherapist and nursing programmes were in their fourth to sixth of six semesters in total.ResultsOur findings indicated one theme: Students perceived a need for support and awareness of IPE from both study programmes and clinical placements. Five categories were found to belong to the theme. Students’ tunnel-vision focus on their own profession may have affected their ability to collaborate with students from other professions. The nature of the patients’ healthcare problems decided if they were perceived as suitable for IPE. Clinical supervisors’ support for and attitude towards IPE were important. The hierarchy between different professions was perceived as a hindrance for seeking help from the other professions. The students asked for more collaboration between different study programmes, in order to gain knowledge about the roles and responsibilities of the other professions.ConclusionsIn conclusion, students in this study considered it essential for different study programmes and clinical placements to be more aware of the opportunities for and importance of IPE. The study identified conditions that were required for IPE in primary healthcare that may be helpful for healthcare teachers and clinical supervisors to better understand how students perceive IPE in primary healthcare, thus facilitating the planning of IPE.

Long-term effects of a ten-year osteoporosis intervention program in a Swedish population—A cross-sectional study

The aim of the study was to explore long-term effects seven years after the completion of a ten-year community-based osteoporosis intervention program in Vadstena, Sweden. The association between calcaneal bone mineral density and several life style factors, and the impact of risk factors for sustaining a fracture after the age of 50 were also studied. Previous participants in the intervention group, and matched subjects were invited to calcaneal bone mass measurement by a portable device including the dual X-ray and laser (DXL) technology by Calscan, and to complete a questionnaire in 2006. A total of 417 persons (63% of those invited) in the intervention (I) group, and 120 persons (47% of those invited) in the control (C) group participated. Mean age was 63 years (37–94 years). There was somewhat more knowledge of osteoporosis in the I-group (M = 18) than in the C-group (M = 17) (p < 0.05), and more use of shoe/cane spikes in elderly women in the I-group (67%) than in the C-group (40.5%). The fully adjusted model of logistic regression showed that participants with an osteoporotic DXL T-score (≤− 2.5) had a 3-fold increased risk (95%CI 1.48–6.89) of having a history of a self-reported fracture after the age of fifty compared to women with a calcaneal T-score >− 2.5. The long-term effects of a ten-year, community-based, osteoporosis intervention program on knowledge and behavior were modest seven years after its completion.

The association between spinal curvature and balance in elderly women at high risk of osteoporotic fractures in primary health care

Abstract The main aim was to study the relationship between spinal curvature and balance in elderly women at high risk of osteoporotic fractures. Ninety-four women were included in this cross-sectional study. Static timed standing and dynamic balance tests were performed; spinal curvature was measured by using the Flexicurve ruler; and radiological data on vertebral fractures were gathered. The women in the hyperkyphosis subgroup had a 5.6 s longer tandem standing time eyes open (p < 0.05), tandem gait forwards (p < 0.05) and tandem gait backwards (p < 0.01) than those without hyperkyphosis. Logistic regression with the ability to tandem walk as a dichotomous outcome (cut-off ≥4 steps) showed that women with a hyperkyphosis had an age-adjusted Odds ratio of 4.5 (95% CI 1.7–12.1) to perform ≥4 tandem steps backwards and their Odds ratio to perform ≥4 tandem steps forwards was also significantly higher with an age-adjusted Odds ratio of 2.8 (95% CI 1.1–7.4). Lordotic Index was positively correlated to one-leg standing with eyes open (p < 0.05). The present study suggests an association between hyperkyphosis and a better tandem standing and tandem gait forwards and backwards.