Sölve Elmståhl

Design and feasibility

Abstract. The Malmö Diet and Cancer study is a 10‐year prospective case‐control study in 45–64‐year‐old men and women (n = 53.000) living in a city with 230000 inhabitants. One objective is to clarify whether a western diet is associated with certain forms of cancer whilst taking other life‐style factors into account. Another broad question is whether oxidative stress and the activity in DNA‐repairing systems influence the impact of diet on the development of all or certain forms of cancer. The study is also to act as a resource available for testing new hypotheses emanating from other studies.

The Malmö Diet and Cancer Study: representativity, cancer incidence and mortality in participants and non-participants

In order to investigate potential selection bias in population‐based cohort studies, participants (n  = 28 098) and non‐participants (n  = 40 807) in the Malmö Diet and Cancer Study (MDCS) were compared with regard to cancer incidence and mortality. MDCS participants were also compared with participants in a mailed health survey with regard to subjective health, socio‐demographic characteristics and lifestyle. Cancer incidence prior to recruitment was lower in non‐participants, Cox proportional hazards analysis yielded a relative risk (RR) with a 95% confidence interval of 0.95 (0.90–1.00), compared with participants. During recruitment, cancer incidence was higher in non‐participants, RR: 1.08 (1.01–1.17). Mortality was higher in non‐participants both during, 3.55 (3.13–4.03), and following the recruitment period, 2.21 (2.03–2.41). The proportion reporting good health was higher in the MDCS than in the mailed health survey (where 74.6% participated), but the socio‐demographic structure was similar. We conclude that mortality is higher in non‐participants than in participants during recruitment and follow‐up. It is also suggested that non‐participants may have a lower cancer incidence prior to recruitment but a higher incidence during the recruitment period.

A longitudinal study integrating population, care and social services data. The Swedish National study on Aging and Care (SNAC)

Background and aims: A large, national, long-term, longitudinal, multi-purpose study has been launched in Sweden — the Swedish National study on Aging and Care (SNAC). The study involves four research centers collecting data in four different areas of Sweden. Methods: The study consists of two parts: the population part and the care and services part. In the population part, a large, representative panel of elders in different age cohorts is followed over time to record and describe the aging process from different aspects. In the care and services part, a systematic, longitudinal, individually-based collection of data is performed concerning provision of care and services together with functional ability, specific health care problems, and living conditions of the recipients living in the area. Results: The data collection in the population part of the SNAC is not yet completed. In the present article, some preliminary results are reported from the care and services part. These pertain to comparisons between the participating areas with respect to the prevalence of disability among those receiving care and social services in their ordinary homes and those receiving care in special accommodation. A comparison is also presented with regard to the amount of home help provided to subjects with a given disability. Conclusions: This project has several advantages. It is expected to generate a rich data base relevant for future research on aging and care and to have a direct impact on the future Swedish system of care and services for the elderly.

Caregiver's Burden of Patients 3 Years After Stroke Assessed by a Novel Caregiver Burden Scale

OBJECTIVE To assess burden of caregivers to stroke patients three year after primary stroke and to test validity and reliability of a novel caregiver burden scale (CB scale). DESIGN A longitudinal community-based 3-year follow-up study of 35 consecutive primary stoke patients initially admitted to an Acute Medical Unit (mean age 82 yr). The validity of the CB scale was studied in 150 patients (mean age 77 yr): 83 demented outpatients with stroke from a general geriatric day-care unit. Reliability was studied in another 23 outpatients (mean age 72 yr) with stroke from the same unit. METHODS A 22-item CB scale for different types of caregiver burden and scales for neuroticism and extroversion (Eysenck Personality Inventory) and quality of life (11-item scale). Activities of daily life were assessed by a 6-item, scale, initially and 3 years later. OUTCOME MEASURE Reliability and validity of the CB scale. Improvements of activities of daily life of stroke patients. RESULTS Factor analyses of the CB scale gave five indices--general strain, isolation, disappointment, emotional involvement, and environment--having good kappa values, .89 to 1.00 and Cronbachs alpha, .70 to .87, except for environment. A higher burden was related to a closer relationship but not to the living situation. The highest caregiver burden was found among patients showing the greatest improvements of ADL, when divided into tertiles. The patients degree of extroversion and quality of life were negatively correlated to caregiver burden, -.46(p < .05) and .59(p < .01). CONCLUSIONS The CB scale proved to be a valid and reliable instrument to assess caregiver burden. To improve the caregiver situation, individual patient personality characteristics, like extroversion, feeling of quality of life, and progression of the disease, must be considered.

The relationship between caregiver burden, caregivers’ perceived health and their sense of coherence in caring for elders with dementia

AIM The aim of this study is to examine associations between caregiver burden, perceived health and sense of coherence in family caregivers to persons with dementia living at home. BACKGROUND Most of the studies on family caregivers have focused on burden and morbidity. However, the caregivers sense of coherence and perceived health have not been studied earlier in relation to caregiver burden. DESIGN A cross-sectional investigation design was used. METHODS Older persons, 2238 subjects, with any form of social services, were invited to an assessment of cognitive capacity. Those who had cognitive decline (255) were invited for a medical examination and 130 persons were diagnosed as having dementia. The family caregivers to persons with dementia answered a questionnaire including a caregiver burden scale, the Nottingham health profile scale, sense of coherence scale and the Euroqol instrument. RESULTS The family caregivers experienced moderate burden, and strong associations were noted between burden, especially isolation, disappointment and emotional involvement with perceived health and sense of coherence, adjusted for age and relationship. Caregivers with lower burden reported significantly better perceived health and higher mean score of sense of coherence than caregivers with higher burden. CONCLUSIONS Assessment of status of family caregivers of persons with dementia living at home seems to be gaining considerable importance. The caregiver burden scale and the sense of coherence scale seem to be highly useful for identifying carers at risk of stress, pattern of burden and coping strategies. RELEVANCE TO CLINICAL PRACTICE Nurses can help family caregivers to identify their negative experiences about caregiving and can help them reflect upon their coping strategies to find balance in their situation. Risk groups of caregivers may be identified, especially those with low perceived health and sense of coherence, for early interventions to reduce burden.

Treatment of dysphagia improves nutritional conditions in stroke patients

Abstract. Dysphagia is a common symptom in stroke patients, and malnutrition is prevalent among these patients. Thus far, nutritional effects of dysphagic treatment have not been evaluated. The aim of the present report was to study the effects of swallowing techniques on nutritional and anthropometric variables. A survey with follow-up was performed at the Departments of Geriatric Medicine and Neurology, Malmö University Hospital, Sweden. Thirty-eight stroke patients, 53–89 years of age, with subjective complaints of dysphagia and oral/pharyngeal dysfunction according to videofluoroscopic barium swallowing examination (VSBE), were given swallowing treatment. The treatment included oral motor exercise, different swallowing techniques, positioning, and diet modification. Plasma protein levels, body composition, VSBE, and a viso-analogical scale for subjective complaints were repeated before and after treatment. At baseline, 94% of cases had signs of penetration and 50–72% had plasma protein levels below recommended levels. Treatment reduced the degree of oral dysfunction, (dissociation) and pharyngeal dysfunction (penetration and constrictor paresis). Sixty percent of cases showed an improved overall VSBE score, and improved levels of albumin and total iron-binding capacity were restricted to this group. In cases with unchanged or decreased VSBE score, body weight was reduced and a negative correlation to total iron-binding capacity was noted (r=−0.60, p < 0.05). Changes of subjective complaints did not correlate with swallowing function or nutritional improvements. Swallowing treatment improves swallowing function, and improved swallowing function is associated with improvements in nutritional parameters. Subjective complaints is not sufficient to evaluate the clinical course, and nutritional parameters should be monitored in patients with oral or pharyngeal dysfunction.

Consumption of Oat Milk for 5 Weeks Lowers Serum Cholesterol and LDL Cholesterol in Free-Living Men with Moderate Hypercholesterolemia

The aim of this study was to investigate whether consumption of a newly developed oat milk deprived of insoluble fiber would result in lower serum cholesterol and low-density lipoprotein (LDL) cholesterol levels in men with moderate hypercholesterolemia. The study had a randomized, controlled double-blind design, and oat milk was compared with an identically flavored control drink. Sixty-six men were recruited from a screening program and were randomly assigned to two groups. Each group took either oat milk or a control drink (rice milk) for 5 weeks (0.75 liters/day) and then switched to the other drink regimen for another 5-week period with a 5-week washout period between the test periods. The oat milk contained more dietary fiber, especially β-glucan (0.5 g/100 g), than the control drink (<0.02 g/100 g). Both drinks were well appreciated and got similar sensory evaluation, indicating that the double-blind design had been attained. In the final analysis 52 subjects remained. Compared with the control drink, intake of oat milk resulted in significantly lower serum total cholesterol (6%, p = 0.005) and LDL cholesterol (6%, p = 0.036) levels. The decrease in LDL cholesterol was more pronounced if the starting value was higher (r = –0.55, p < 0.001). The concentration of high-density lipoprotein cholesterol was not significantly different after consumption of the two drinks. Serum triglycerides did not change significantly after intake of oat milk, but a significant increase was observed after intake of the control drink (p = 0.003). It is concluded that also oat milk deprived of insoluble fiber has cholesterol-reducing properties.

Reliability and validity assessments of measures of social networks, social support and control — results from the Malmö Shoulder and Neck Study

The reliability and validity of methods to assess social networks, social support and control were investigated in a population of 12,009 females and males born between 1926 and 1945 (the “Malmö Shoulder and Neck Study”). This study demonstrated an overall reliability with kappa coefficients between 0.70 and 0.47, but the reliability was more varying among females and lower in the youngest age group. The analysis of the construct validity indicated that the different indices measure different aspects of the psychosocial environment, but both theoretical and methodological problems were identified, when the validity of multidimensional concepts are to be determined. The validity of such indices can best be judged by combining quantitative and qualitative methods. Potential validity problems must be kept in mind when these indices are used in epidemiological research. The results from the reliability analysis call for repeated assessments and the sample size must be adjusted vis-à-vis the reliability.

Postural Hypotension and EEG Variables Predict Cognitive Decline: Results from a 5-Year Follow-Up of Healthy Elderly Women

Quantified electroencephalographic activity (EEG) has been used to study normal ageing and dementia. Few studies have described longitudinal changes in the very old. A cognitive decline has been described in subjects with white-matter lesions and hypertension but the association with hypotension is unclear. Our aim was to study the predictive value of quantified EEG for the development of cognitive decline and associations with postural hypotension. Participants. Thirty-three healthy women aged 75-95 years, with no signs of cerebrovascular disease, dementia or acute illness at baseline examination took part in a longitudinal 5-year follow-up study. The women were recruited from a random selection using the Municipal Registry. Quantified EEG was assessed twice and recorded on a Siemens-Elema connected to a Biological Banker. The medical and neuropsychological examination was conducted twice. Dementia was classified according to DSM criteria. The assessment included Mini-Mental Scale Examination (MMSE), spatial and vocabulary tests. Blood pressure was measured in supine position and an orthostatic test was performed with continuous ECG recording. Seven women (cases) developed cognitive decline at the 5-year follow-up, defined as newly developed MMSE < 27 and dementia symptoms. Low beta activity at baseline predicted development of cognitive decline. The women who remained healthy at follow-up showed an increase of alpha and theta activity. The cases had a higher orthostatic blood pressure fall during tilting at baseline (16 mm Hg) than the controls (1 mm Hg, p < 0.01). The orthostatic reaction was correlated with increased levels of theta and alpha activity at follow-up (r = -0.47 to -0.52; p < 0.01). Low beta activity predicts for cognitive decline in the elderly and an orthostatic blood pressure reaction is a risk factor for cognitive decline.

Invitation to a population-based cohort study: differences between subjects recruited using various strategies.

AIM The present study compares subjects recruited to a population-based prospective cohort study by community versus personal invitation, and subjects responding late versus early to personal invitation. Subjects were compared with respect to sociodemographic characteristics, selected lifestyle factors, cancer incidence and mortality. METHODS The Malmö Diet and Cancer Study recruited a total of 28,098 subjects between 1991 and 1996. Entire birth-year cohorts, born 1923-50, were recruited using community directed (passive) invitation, and a personal letter of invitation (active recruitment). Information on sociodemography and lifestyle was obtained using a self-administered questionnaire. Anthropometric measurements were assessed at a physical examination. Cancer incidence and cause of death were retrieved using record linkage with national registries. RESULTS Subjects responding to community directed invitation were older, and more often females, than participants recruited using personal invitation. Furthermore, participants recruited through passive invitation had a comparably more favourable situation with regard to sociodemographic and lifestyle factors. They also had a lower frequency of prevalent disease, lower incidence of cancer and lower mortality. Contrary to this, men were more likely to respond late to a personal letter of invitation and late responders were also older, as compared with subjects responding early to personal invitation. Furthermore, those who responded late had a comparatively unfavourable socioeconomic situation and were characterized by a high prevalence of current smoking, obesity, weight change, and prevalent disease. CONCLUSIONS Subjects who are recruited using different strategies in population-based cohort studies may have different sociodemographic and lifestyle characteristics, and may vary with regard to prevalent disease, cancer incidence and subsequent mortality.