Lennarth Johansson

Nutritional Status According to Mini Nutritional Assessment in an Institutionalized Elderly Population in Sweden

Background: In 1992, local municipalities in Sweden took over full responsibility for the long-term care of elderly. This has led to an increased care burden for the various assisted accommodation services run by the municipalities. Objective: Since ageing and chronic diseases are risk factors for protein-energy malnutrition, we evaluated the nutritional status of all individuals in assisted accommodation, i.e., service flats (SF), old people’s homes (OPH), group living for the demented (GLD), and nursing homes (NH), in three Swedish municipalities. Methods: Of 994 eligible subjects, 872 were examined; the average age was 84.5 ± 8 years, and 69% were female. The Mini Nutritional Assessment (MNA) scale (0–30 points) was used, consisting of 18 point-weighted questions in four categories, i.e., anthropometry, global and dietary issues, and self-assessment. Results: MNA <17, i.e., malnutrition, was noted in 36% of the study population. Divided according to accommodation type, the MNA scores were <17 in 21% of individuals in SF, 33% of those in OPH, 38% of those in GLD, and 71% of those in NH. The corresponding values for MNA scores 17–23.5 (risk for malnutrition) were 49, 51, 57, and 29%, respectively. Average body mass index (BMI) values were 24.2 ± 5 (SF), 23.6 ± 5 (OPH), 23.9 ± 4 (GLD), and 22.3 ± 4 (NH). BMI values ≤20 were found in 18% of those in SF, in 25% of those in OPH, in 19% of those in GLD, and in 33% of those in NH. Both MNA and BMI correlated with upper arm and calf circumference, with r values ranging from 0.4 to 0.7 (p < 0.001). MNA and BMI correlated significantly (r = 0.52, p < 0.001). Age correlated with MNA and BMI with r values of 0.1 (p < 0.01) and 0.14 (p < 0.001), respectively. Subjects with signficant help requirements during meals ate fewer whole meals per day than those who could feed themselves. Conclusions: Based on the MNA, one third of the study subjects living in assisted accommodation, and more than half of those living in NH, appeared to be malnourished. Further studies are necessary to assess to what extent these nutritional disturbances are reversible.

Time spent on informal and formal care giving for persons with dementia in Sweden

The purpose of this paper was to explore the time spent on caring by families of persons with dementia in Sweden. As part of a European Commission project, interviews were carried out on a sample of 92 carers, caring for persons with dementia. The interviews focused on time spent on caring, IADL, ADL and surveillance, as well as formal support received and used. Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night). Formal care input and informal support, in terms of ADL increased with dementia severity. A regression analysis showed that dementia severity, behavioural disturbances and coping were associated with the amount of informal care. This study gives some new perspectives on informal care giving for persons with dementia and support strategies in general. Some carers do carry a very heavy 24 h responsibility. This aspect of caring must be addressed by the development of well-targeted respite and relief support programmes.

State provision down, offspring's up : the reverse substitution of old-age care in Sweden

Substitution among the providers of old-age care has usually meant a process whereby the state ‘takes over’ what families used to do, but during the 1980s and 1990s, both home help and institutional care were cut back substantially in Sweden as elsewhere. Comparable, nationally representative surveys in Sweden of the provision of care for older people living in the community enable analysis of the effects of these cutbacks on the sources and patterns of care. It emerges that increased inputs from families match the decline of public services, that is, a ‘reverse’ substitution has recently been taking place. Local studies, of older people who have been followed over time as the provision of home help has changed, support these conclusions. Of the increased informal care, most has been provided by daughters, but sons have also contributed. A problematic aspect of these shifting patterns of care is that an increasing number of family carers with increasingly heavy care commitments are now without formal or informal support, whereas in the recent past many could expect their responsibilities to be shared with the state. The evidence from this study also calls into question common metaphors and assumptions about the assumed interdependence between informal care and public services for older people, and challenges the so-called substitution thesis.

Balancing family and state care: neither, either or both? The case of Sweden

Old-age care has frequently been conceptualised as being either family-based or publicly-provided. This article analyses the overlap in provision from the two sources and their relationship in the Swedish welfare state. Many older people and their carers rely on both sources of help rather than on just one, and prefer to do so. The empirical evidence on patterns of care in Sweden supports a joint family-state conceptualisation of care. Its realisation may depend on general coverage rates of public services and the efficient targeting of frail elderly people who live alone. Most older people in need of care rely on help only from their family, but many are helped by both the family and the state, particularly those with the greatest needs. Dynamic concepts like ‘substitution’ and ‘complementarity’ are hard to apply in cross-sectional studies: there may be complementarity in individual cases but long-term substitution or its reversal in successive cohorts. Yet again, both sources of care may increase simultaneously in individual cases. The need for care varies considerably among Swedish municipalities, with implications for the levels of both public services and family support. High coverage rates of the public services may facilitate and support family care.

Informal Caregiving for Elders in Sweden : An Analysis of Current Policy Developments

In Sweden, care of elderly people is a public responsibility. There are comprehensive public policies and programs providing health care, social services, pensions, and other forms of social insurance. Even so, families are still the major providers of care for older people. In the 1990s, the family was “rediscovered” regarding eldercare in Sweden. New policies and legislative changes were promoted to support family caregivers. The development of services and support for caregivers at the municipal level has been stimulated through the use of national grants. As a result, family caregivers have received more recognition and are now more visible. However, the “Swedish model” of publicly financed services and universal care has difficulty addressing caregivers. Reductions in institutional care and cutbacks in public services have had negative repercussions for caregivers and may explain why research shows that family caregiving is expanding. At the same time, a growing “caregivers movement” is lobbying local and national governments to provide more easily accessible, flexible, and tailored support. In 2009, the Swedish Parliament passed a new law that states: “Municipalities are obliged to offer support to persons caring for people with chronic illnesses, elderly people, or people with functional disabilities.” The question is whether the new legislation represents a paradigm shift from a welfare system focused on the individual to a more family-oriented system. If so, what are the driving forces, motives, and consequences of this development for the different stakeholders? This will be the starting point for a policy analysis of current developments in family caregiving of elderly people in Sweden.

Unequal but equitable: an analysis of variations in old-age care in Sweden

This study aimed to investigate whether contraction in services has led to inequitable service levels or simply large local variations. Previous attempts to explain service variations with aggregate, municipal level data have failed. We link representative Swedish data from 3,267 individuals aged 65 and older in 2002–2003 with coverage rates of public Home Help services in the 288 municipalities in which they reside. What past attempts have masked is that needs also vary substantially between municipalities; needs being defined as old people who live alone and need help with their activities of daily living (ADL). Once these local individual level variations are incorporated, municipal differences in public Home Help coverage largely vanish. Multivariate analyses confirm that advanced age, inability to perform ADL and solitary living are the major determinants of Home Help use. Variations in local supply have no association with individual use of public Home Help. These services are unequal but hence yet deemed to be reasonably equitable.

Decentralisation from acute to home care settings in Sweden.

Sweden has a regionally based, publicly operated and financed, national health care system. Implementation of policy and the provision of health care has been the responsibility of the county council. In 1992, the major responsibility and resources for care of the elderly was transferred to the municipalities. The start of this reform, unintentionally, coincided with an economic recession which caused additional difficulties for the financing of the present level of public services generally. This development, in combination with innovations in health care technology, resulted in a rapid decentralisation of certain elderly care services from acute care settings.

Chapter 5. Elderly People's Health - 65 and After

1Centre for Epidemiology, National Board of Health and Welfare, SE-106 30 Stockholm, Sweden. Tel: + 46 8 5555 3013, Fax: + 46 8 5555 3327. E-mail: gudrun.persson@sos.se, 2Centre for Epidemiology, National Board of Health and Welfare, SE-106 30 Stockholm, Sweden. Tel: + 46 8 5555 3258, Fax: + 46 8 5555 3327, 3University of Göteborg, Department of Social Medicine, Vasa hospital, SE. 411 33 Göteborg, Sweden. Tel: + 46 31 617 963, 4Stockholm Gerontology Research Center, Box 6401, S-113 82 Stockholm, Sweden. Tel: + 46 8 690 5807, 5Institute of Gerontology, University College of Health Sciences, Box 1038, SE-551 11 Jönköping, Sweden. Tel: + 46 36 324 900, 6National Board of Health and Welfare, SE-106 30 Stockholm, Sweden. Tel: + 46 8 5555 3261, 7National Institute of Public Health, SE-103 52 Stockholm, Sweden. Tel: + 46 8 5661 3500.

Personal Assistance in Sweden

Abstract This article provides an overview of the Swedish personal assistance program for persons with severe impairments, introduced in 1994. The personal assistance program makes it financially possible for people with severe disabilities to appoint a personal assistant, by themselves or through a provider, to create support adapted to the individual and to optimize the persons influence over how the support is arranged. The article describes how the reform has increased the opportunity for people with severe disabilities to choose their own way of living. Overall, the personal assistance has enhanced the quality of life for people with severe disabilities and their families.

The changing balance of government and family in care for the elderly in Sweden and other European countries

Patterns of care for the elderly have changed dramatically in Sweden over the post‐war years, and new trends have emerged in the last decade. Relatively fewer elderly are institutionalised or use public Home Help and more are helped by family members. The family structure of the elderly in Sweden is more favourable today than before for providing help: more elders are married (or cohabit) and stay married longer and more of them have children and other kin than previously. Although old parents and their offspring very seldom live together, they often do not live far apart. Social services increasingly target elders who are short on kin, very frail and live alone, a pattern that is common in European countries. Both carers and cared‐for elderly persons want shared responsibility, that state and family together provide for frail elders. Paradoxically, more elders are cared for longer and more by their families, but eventually also a larger proportion of elders than before use public services; in particular, more elderly persons now use institutional care for some period before the end of their life than previously. This paper draws on evidence across 50 years of shifting patterns in Swedish old age care and makes comparisons with living arrangements and patterns of care in several western European countries.