University of Groningen Geriatric syndromes; prevalence, associated factors and outcomes Rausch, Christian

Geriatric syndromes; prevalence, associated factors and outcomes

Rausch, Christian

DOI:

10.33612/diss.145064339

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Rausch, C. (2020). Geriatric syndromes; prevalence, associated factors and outcomes. University of Groningen. https://doi.org/10.33612/diss.145064339

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Chapter 1

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Aging Populations

Changes in global population demographics are reflected in the increasing proportion of the older population segment [1]. The proportion of people aged at least 65 years within the total global population is projected to increase from 9% in 2019 to 16% in 2050, with one in every four individuals in North America and Western Europe estimated to be 65 years and older [1].

Advances in science and medicine have contributed to increased longevity and delayed mortality [2]. In addition, international migration and declining fertility rates in specific regions and countries have contributed to aging populations [1,3]. In Western European countries, such as Sweden and the Netherlands, delayed mortality and low fertility rates, in particular, have led to aging populations [1,3]. Life expectancies in Sweden (82.5 years) and the Netherlands (81.8 years) are among the highest for Organization for Economic Co-operation and Development (OECD) member countries [4].

An aging population poses challenges for the healthcare systems of these countries. Healthcare demands increase as individuals live longer with their morbidities, possibly requiring institutionalization and frequent hospitalization [5,6]. The provision of appropriate care for the older population segment may therefore also result in increasing healthcare expenditure [5,6].

As older individuals continue to age, their morbidities persist, and they may be concomitantly burdened by multiple and increasingly complex health conditions [6]. The coexistence of multiple health conditions further increases the healthcare needs of older individuals. Current health care provision is primarily geared toward the management of one specific health condition or organ system, such as cardiovascular disease [7,8]. Older people multiple or complex health conditions require more comprehensive assessment and management.

Within the literature too, the focus is predominantly on specific, and often chronic, health conditions among older people, such as diabetes [6]. Studies aimed at contributing to the prevention, delay, and management of these conditions have focused on their associations with sociodemographic attributes, health behaviors, and health-related factors [9–13]. Their findings have contributed to interventions

that include improved physical activity to address chronic health conditions among older people [13–16].

With aging and its related impairments in various organs, older people do not only present with one specific chronic health conditions but they also present other aging-related health conditions, for example, frailty, hearing impairments, and vision problems [17]. The evidence and literature on these aging-related conditions and their clinical management, as well as public health interventions targeting them are limited [17,18]. Further studies on these syndromes are needed to develop a better understanding of their role in older people’s health, assess their health conditions adequately, and provide appropriate care and management.

Geriatric syndromes

Geriatric syndromes are prevalent presentations and conditions that include urinary incontinence, vision and hearing impairments, depressive symptoms, sleep problems, frailty, cognitive impairment, falls, and polypharmacy (see Fig. 1) [19]. Although lists of syndromes vary within the literature, geriatric syndromes are defined as follows:

1. Health or health-related conditions [17,19]

2. Presentations of underlying and accumulated impairments in various organs that stem from aging-related processes [17,18,20,21] 3. Indicators of vulnerability and increased care needs [21,22]

These syndromes are inter-related, sharing risk factors and underlying mechanisms [23]. However, unlike diseases or specific chronic conditions, geriatric syndromes can stem from changes in various organs and do not always present in the organ system that is most affected [17,24–26].

An important factor associated with all geriatric syndromes as well as with other age-dependent health conditions is the aging process itself [21,27]. Aging is associated with time (biological age) as well as individuals’ genetic predispositions and environments [17,21,27]. The rate of aging may differ among individuals of comparable chronological ages depending on their genetic predispositions as

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well as external and environmental factors [28–31]. Successful and healthy aging

occurs when diseases are absent or at least manageable, high levels of physical and cognitive functioning are maintained, and capabilities for engaging in social and physical activities are sustained [32]. However, aging can also transition toward “unhealthy” or “pathological” states that occur as a result of continual changes at the molecular and cellular levels within various organs, notably cellular senescence or mitochondrial dysfunction [21,27]. Over time, the accumulated eff ects of these changes may lead to irreversible dysregulations and the presentation of geriatric syndromes [17,33]. Th us, geriatric syndromes may be viewed as atypical presentations of pathologies and the progression of underlying dysfunctions. Studies have shown that the presentation of geriatric syndromes is linked with increased risks for adverse health outcomes, notably hospitalization (see Fig. 1) [34]. Th erefore, the focus in this thesis is on the pathway outlined in Fig. 1.

Health outcomes Aging / underlying dysfunctions Mortality Hospitalization Geriatric syndromes

Incontinence Vision and hearing

impairments Depressive

symptoms Sleep problems

Frailty _impairmentCognitive

Falls Polypharmacy

Fig. 1. Aging, geriatric syndromes, and health outcomes

Geriatric syndromes considered separately and in combination

Most geriatric syndromes have been studied separately in terms of their outcomes and associated factors [17,34]. However, geriatric syndromes tend to be concurrent [19,33,35,36]. Furthermore, the presence of a geriatric syndrome is not always associated with impairments in one organ system; rather, it may occur as an initial phenotype of impairments in multiple organ systems [17]. Therefore, rather than focusing on isolated geriatric syndromes, these syndromes should be considered as a combined entity. The presentation of one geriatric syndrome can be followed by others, with an increasing number of geriatric syndromes possibly indicating the advanced progression of aging and its associated impairments [28]. However, the relationship between the number and course of geriatric syndromes and the level of impairment and dysfunction remains to be elucidated. The number and course of geriatric syndromes may be correlated with the level of dysfunction among older people, but it may also depend on the presence of co-morbidities, such as chronic health conditions, and their severity [22,35]. The presentation of any geriatric syndrome requires a comprehensive assessment, as various factors and organs can be involved. The following geriatric syndromes were considered in this thesis in light of the definition of geriatric syndromes presented earlier and the findings reported in the existing literature.

Sleeping problems

Sleeping problems (or insomnia) among older individuals are associated with the interaction of multiple factors, including cognitive, psychological, and physical morbidities. With increasing age, the sleep architecture, which includes the release of melatonin, changes, leading to different types of sleep problems, such as waking up early, the inability to sleep through the night, or difficulty falling asleep [37]. Consequently, older people are more likely to develop chronic conditions, such as hypertension, cardiovascular diseases, and other geriatric syndromes [37,38]. Sleeping problems may also be related to other health conditions prevalent among older people, such as depression [39].

Incontinence

Incontinence is another prevalent geriatric syndrome. Urinary incontinence is a result of multiple factors in which aging-related processes play a role. Decreased activity of muscles, such as the detrusor muscle, neurological changes, and factors such as immobility and cognitive impairment can contribute to urinary

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incontinence [40,41]. Despite its increasing prevalence with age, particularly

among women, urinary incontinence is often overlooked [42,43]. The assessment and management of urinary incontinence in older people is important, as urinary incontinence is an indicator of increased care requirements and is associated with the occurrence of other geriatric syndromes, such as falls, depressive symptoms, and polypharmacy [43,44]. Furthermore, urinary incontinence is associated with increased risks of hospitalization, long-term care, and mortality [44].

Hearing and vision impairments

While specific diseases, such as diabetes, can interfere with vision or hearing, aging-related cellular and vascular changes are known to impair hearing and vision in older individuals [45,46]. Decreases in neurotransmitters, atrophy of the vestibular membrane, or cognitive decline are some of the aging-related factors that contribute to hearing impairments [47]. Examples of vision impairments associated with aging are atherosclerosis, a reduction in pupil size, the thickening of the lens, and a reduction in the number of rods in the macula, which can cause spatial acuity and night vision problems [48]. Both impairments have a strong societal impact on individuals through social deprivation and loneliness [49,50]. In addition, they contribute to an increased risk of other geriatric syndromes, such as falls and depressive symptoms, as well as adverse health outcomes, for instance, disability, immobility, and mortality [46,50].

Frailty

Frailty refers to limited physical and/or mental reserves that are not fully replenished after exposure to stressors, such as diseases or external events, notably injuries [17,33]. Frailty has been the subject of various studies in the field of geriatrics and gerontology, including those offering various definitions and assessment models [28,51,52]. While the most commonly applied criteria were formulated by Fried et al., Rockwood et al. developed more clinically focused criteria [51,52]. Fried et al. described a phenotype model of frailty, that is, the presentation of diminishing homeostatic reserves [33,51], whereas Rockwood et al. described frailty in terms of a cumulative model relating to the accumulation of various deficits in different organs [33,52]. In most assessments, considerations of frailty have focused primarily on functional impairment or decline and relate to the inability to walk for a short distance, rise out of a chair, a loss of strength, and a potential reduction in weight [20,51–53]. Some studies and assessments

have focused directly on functional impairment [20,51–53]. The presence of other health conditions and geriatric syndromes as well as factors such as weight loss, poor nutrition, and lack of physical activity can contribute to the occurrence and progression of frailty.

Polypharmacy

Polypharmacy, or the use of multiple medications, is a prevalent problem among older people and is therefore considered a geriatric syndrome [19,22]. Polypharmacy relates to the use of five to nine medications, with excessive polypharmacy entailing the concurrent use of ten or more medications [54–56]. Polypharmacy may also refer to the use of more medications than are clinically required or safe, for example, a large number of inappropriate medications [56]. Inappropriate medications are those that are not recommended for older people because of potential drug–drug interactions. Polypharmacy is particularly challenging in a context of age-related metabolic changes [54,56–58].

Compared with other geriatric syndromes, polypharmacy is extrinsic and may be associated with multimorbidity, that is, multiple health conditions or diseases. Despite its overlap with multimorbidity, polypharmacy fulfills the definition of a geriatric syndrome definition, as it is an outcome of multiple impairments that can be related to the aging processes [47,56].

Falls

Falls are among the more prevalent geriatric syndromes [19]. Studies have estimated that one- third of community-dwellers aged 65 years and above fall at least once a year, while nearly half of older people living in nursing or long-term homes are prone to fall once a year [59–63]. Most falls do not lead to death, but they can be associated with injuries, such as hip fractures and head trauma, as well as severe outcomes, for example, progressive disability and hospitalization [64]. There are various known risk factors for falls, including not only extrinsic environmental factors or hazardous activities but also intrinsic risk factors, such as the presence of neurosensory deficits [64,65]. Aging can be linked to a variety of processes, including the presence of other geriatric syndromes associated with falling [22,61,66]. Some examples of aging-related changes are muscle loss and weakness, declining eyesight, or vestibular and balance-related changes [67,68].

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Cognitive impairment

Cognitive impairment, as a geriatric syndrome, relates to impairments in various cognition-related domains. Loss or decline in one or more of the cognitive domains, such as executive functioning, visual-spatial judgments, memory, learning, attention span, and language are considered hallmarks of cognitive impairment [46]. With aging, the cortical neuronal synapsis, which is essential for information exchange between neurons, decreases, which in specific brain regions can lead to a decline in cognitive domains [69]. Vascular changes as well as dehydration, electrolyte imbalances, or adverse life events, for example, the loss of a spouse can contribute to cognitive impairment [19,70,71]. The definition of this geriatric syndrome can overlap with or include specific conditions, such as mild cognitive impairment, delirium, dementia, and other dementia-related conditions [26]. Moreover, other conditions, such as stroke, can constrain cognitive abilities. Thus, disentangling the effects of aging processes and other pathologies related to cognitive impairment is challenging.

Depressive symptoms

Up to 12% of older people experience depressive symptoms that include a lack of energy or pleasure but that do not always signal a major depressive episode [19]. Aging-related neural changes as well as a lack of social interaction can contribute to depressive symptoms among older people [45,50,72]. It is therefore important to consider the underlying factors associated with this geriatric syndrome, as depressive symptoms can increase the risk of morbidity and mortality [73,74].

Individual factors associated with geriatric syndromes

Many factors, such as sociodemographics and health behaviors, are associated with aging (see Fig. 2). However, unlike chronic health conditions among older people, which have been widely researched, the associations among geriatric syndromes and sociodemographic attributes, health-behaviors, health status, and health outcomes are not well-known.

Health behaviors Health outcomes Health status Aging / underlying dysfunctions Mortality Hospitalization Geriatric syndromes

Incontinence Vision and hearing

impairments Depressive

symptoms Sleep problems

Frailty _impairmentCognitive

Falls Polypharmacy

Socio-demographic attributes

Fig. 2. Aging, geriatric syndromes and individual factors

Fig. 2. Aging, geriatric syndromes and individual factors

Sociodemographic attributes

Older people tend to have more geriatric syndromes with increasing chronological age [19]. However, chronological age may not always correlate with the progression

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of aging-related processes. For example, an 80-year-old individual may undergo

a healthy aging process without any presentation of geriatric syndromes or other health conditions, while someone aged 60 years may have frequent falls and experience urinary incontinence.

Several studies have pointed to sex differences in health among older people. Women have lower mortality rates as well as lower rates of chronic diseases, such as specific cardiovascular diseases [75–77]. However, aging women are more likely than aging men to suffer from severe functional limitations, such as the inability to engage in a variety of daily living activities, and these limitations may affect them earlier than they affect men [78]. Biological differences between the sexes may also affect older individuals’ health. For example, certain conditions, notably osteoporosis, are more common among women, whose risks for outcomes such as injurious falls and subsequent hospitalization are consequently higher than they are for men [79,80]. Moreover, studies have shown that women are more likely to have geriatric syndromes than men, the only exception being syndromes relating to sensory deficits, such as hearing impairments [19].

Not only age and sex, but also factors related to social position like education and income, may be associated with aging and the presentation of geriatric syndromes [18].

Social position

Social position refers to an individual’s position within a hierarchical societal order, which affects his or her access to material and social resources [81–84]. Common measures of social position include the highest level of education achieved, occupation, or income [81,85]. Various other proxies of social position exist, including wealth, financial stress, current housing, and income [85–88]. Education levels are associated with different health outcomes, such as cognitive impairment, in later life [89,90]. The association between a low education level and poor health among older people can entail multiple linked pathways and include other factors, for example, health behaviors [88].

Income and related indicators, including financial stress or housing (e.g. renting or owning a property) may reflect the current circumstances of older people [88,91,92]. Low income has been shown to be associated with chronic health

conditions as well as specific geriatric syndromes, for example, frailty and cognitive impairment [92–94].

Health risk behaviors

Tobacco use, alcohol misuse, poor diet, and physical inactivity account for an estimated one-third of the global chronic disease burden and have considerable impacts on the health of older people [95–97].

Smoking is a known risk factor for various conditions, including cardiovascular diseases and poor health in general [97]. Smoking over an extended period of time leads to accumulated damage in various organs, which is linked to molecular and cellular aging as well as geriatric syndromes [97–99]. Smoking is a modifiable risk behavior and cessation, even in old age, can be beneficial for an individual’s health [98].

Excessive use of alcohol and alcoholism have long been known to have detrimental health effects [100]. Among older people the relationship between alcohol use and cognitive impairments, such as Alzheimer’s disease and dementia, has been frequently emphasized [101–103]. Alcohol use among older people is a known risk factor for various health conditions and is associated with falls, depressive symptoms, and other geriatric syndromes [103].

Nutrition in the sense of an optimal diet is another factor linked to the health status of older people. Although energy needs decrease with age, the physiological requirement of proper nutrition remains [104]. Other factors related to older age, such as loneliness, immobility, and general dependence on others, can further increase the risk of malnutrition or a poor diet [105], with poor nutrition also found to be associated with geriatric syndromes [106].

Physical activity is another health behavioral factor associated with health and aging. Increasing or maintaining physical activity has health benefits in old age, for example, offering protection against cardiovascular diseases [107–109]. However, with increasing age and aging-related changes like muscle loss or neuro-sensory changes physical activity levels change over time [109]. Various other factors, such as the health status of older individuals also impact on their physical activities, and geriatric syndromes may affect their levels of physical activity over time [107,108,110].

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Health status

The aging process generally relates to changes at the molecular and cellular levels across different organ systems [17,27]. These changes overlap with disease-related pathophysiology, which makes it difficult to disentangle the effects of aging from the development of diseases and chronic health conditions. Studies have shown that certain chronic health conditions, for example, diabetes and chronic obstructive pulmonary disease (COPD) co-occur [35]. Aging-related processes and the presence of geriatric syndromes are known to increase susceptibility to pathophysiological processes, thereby also potentially contributing to the development of new chronic health conditions, for example, cardiovascular diseases [17,18].

Knowledge gaps in research on geriatric syndromes

The knowledge base on geriatric syndromes is still limited [17]. To manage and prevent geriatric syndromes and to maintain good health in old age requires a better understanding of the prevalence of these syndromes and their associations with social position, health-related behaviors, other health conditions, and health outcomes.

Part I. Geriatric syndromes, prevalence and associated factors

The findings of studies on the prevalence of geriatric syndromes vary. Moreover, few studies have examined geriatric syndromes together with their associations with social position, physical activity, and chronic health conditions.

Geriatric syndromes, prevalence and social position

Previous studies have determined the prevalence of geriatric syndromes separately and combined with other factors [19,66,111]. Findings on the prevalence of geriatric syndromes vary widely, ranging between 49.9% and 80.5% [19,22,111]. These variations in findings on the prevalence of geriatric syndromes may be attributed to the inclusion of a wide range of syndromes, such as social isolation [19]. One study only reported results for women [22], while another focused on those aged 75 years and older [19]. In addition, whether or not the prevalence of geriatric syndromes changes over time remains unclear. Thus, more information is

needed on the prevalence of geriatric syndromes and changes over time to acquire a better understanding of them.

Studies have shown that the effects of social position differ depending on the particular outcome studied, with education having differential effects on the presence of specific geriatric syndromes [96,104,105]. The association between social position and combined geriatric syndromes is still not clear. Thus, studies focusing on this association are necessary to identify categories of older individuals who are most vulnerable to geriatric syndromes.

Geriatric syndromes and physical activity

Studies have shown that physical activity benefits health, including geriatric syndromes, in old age [108]. Older individuals demonstrate different trajectories of physical activity [107,108]. While some decrease their physical activity over time, others manage to maintain and even increase their physical activity [107]. Various factors, such as age and health status, have been found to impact on trajectories of decreasing or increasing physical activity over time [107,110]. However, the association between geriatric syndromes and trajectories of physical activity among older people has not been assessed. Thus, an examination of the effect of geriatric syndromes on patterns of physical activity could facilitate the identification of older people at risk for declining physical activity.

Geriatric syndromes and chronic health conditions

Geriatric syndromes can present as underlying dysfunctions in various organ systems. Aging-related impairments that contribute to these dysfunctions are associated not only with geriatric syndromes but also with the development of chronic health conditions [18]. Geriatric syndromes may thus be initial presentations that subsequently develop into chronic health conditions such as cardiovascular diseases. While cross-sectional studies have revealed an association between geriatric syndromes and chronic health conditions, studies using longitudinal data are limited [35,112].

Part II. Polypharmacy, falls, and health outcomes

Geriatric syndromes represent underlying dysfunctions, but they may also directly contribute to susceptibility of new dysfunctions through injuries brought on by falls or drug interactions caused by taking numerous medications.

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Polypharmacy, hospitalization, and mortality

The consumption of a large number of medications implies accumulated impairments and dysfunctions. Aging-related changes in metabolism or drug clearance increase the risk for adverse outcomes such as mortality among older people receiving multiple medications [55,56]. In particular, prescriptions comprising five or more medications (i.e., polypharmacy) have been shown to increase the risk of hospitalization and mortality [113]. In addition, specific medications, namely those interacting with other medications or diseases are deemed inappropriate for older people [114,115]. However, little is known about the association between an increasing number of prescribed medications and hospitalization and mortality when medications known to be inappropriate for use with older patients are taken into consideration.

Associations between falls and hospitalization and mortality

Among older people, falls can be linked to gait problems, vertigo, and even the fear of falling [64,65]. Apart from being an indicator of underlying impairments, a fall may also directly increase the risk for health outcomes such as hospitalization or mortality [34,71,116,117]. In relation to medication use, a fall may be an atypical presentation of an adverse reaction to medication resulting from metabolic changes in drug clearance associated with aging [55,71,118]. Failing to recognize a fall as a geriatric syndrome may increase the risk of medication-related health outcomes, for example, hospitalization or mortality due to unintentional poisoning [119– 121]. While falls are associated with a variety of health outcomes, little is known about their association with hospitalization or mortality relating to unintentional poisoning. Assessing this association may be important for identifying older people who are at risk for severe health outcomes.

Thesis aims and research questions

The overall aim of this thesis was to advance knowledge on the role of geriatric syndromes in older people’s health by determining their associations with sociodemographic attributes, health behaviors, and health status as well as their effects on health-related outcomes, notably hospitalizations and mortality.

The first objective was to determine the prevalence of geriatric syndromes and their association with sociodemographic attributes, health behaviors, and health status among older-community-dwellers.

The second objective was to determine the association between specific geriatric syndromes and health outcomes, such as hospitalization and mortality resulting from unintentional poisoning.

The thesis comprises population-based studies conducted among older people in Sweden and the Netherlands.

Part I: Geriatric syndromes, prevalence, and associated

factors

Research questions 1a and 1b examined in chapter 2

1a. What is the prevalence of geriatric syndromes among older community-dwellers?

1b. Are measures of social position associated with the presence of geriatric syndromes among older community-dwellers?

Research questions 2a and 2b examined in chapter 3

2a. What is the trend of prevalence of geriatric syndromes among older community-dwellers?

2b. What factors are associated with prevalence trends relating to geriatric syndromes?

Research question 3 examined in chapter 4

3. Are geriatric syndromes associated with distinct trajectories of physical activity among older community-dwellers?

Research question 4 examined in chapter 5

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Part II: Falls, polypharmacy, and the risks of

hospitalization and mortality

Research question 5 examined in chapter 6

5. Taking inappropriate drug use among older individuals into consideration, are increasing numbers of prescribed medications associated with hospitalization and mortality due to adverse drug events by unintentional poisoning?

Research question 6 examined in chapter 7

6. Taking existing clinical conditions among older individuals into consideration, are injurious falls associated with subsequent hospitalization and mortality due to adverse drug events by unintentional poisoning?

Thesis components and the geriatric syndrome concept

Par t I : Ger iatr ic s yn dr om es, th ei r p re valen ce , an d ass ociate d f ac to rs am on g old er co m m un ity -d weller sin Swed en an d t he Neth er lan ds Cha pte rs 2 a nd 3 : Th e p re valen ce of g er iatr ic sy nd ro m es an d so cial p os itio n am ong old er co m m un ity -d weller sin Swed en Cha pte r 4 : Ger iatr ic sy nd ro m es a nd tr aje cto ries o f ph ys ical ac tiv ity in ol de r co m m un ity -dweller sin th e Neth er lan ds Cha pte r 5 : Ger iatr ic sy nd ro m es a nd su bs eq uen t ch ro nic hea lth co nd itio ns am on g ol der co m m un ity -d weller sin th e Ne th er lan ds He al th ou tcom es He al th statu s He al th b eh av io rs Ph ys ica la ct iv ity Ch ro nic h ea lth c ondi tio ns Agi ng / unde rly in g d ys func tio ns M or ta lity Ho sp ita liz at io n Ge riatr ic synd ro m es Inc ont ine nc e Vi sio n and h ea ring imp ai rme nt s Dep res siv e sy mp to ms Sle ep p ro ble m s Fr ailt y Co gn iti ve imp ai rme nt Fa lls Po lyp ha rm ac y II II So cio -d emo gr ap hi c attr ibut es So cia l p os itio n I I I Pa rt II: Po ly ph ar m ac y, falls ,an d th e ris k o f ho sp italizatio n an d m or tality Cha pte r 6 : Po ly ph ar m ac y, h os pitalizatio n, an d m or tality due to un in ten tio nal poi soni ng Cha pte r 7 : In ju rio us falls , h os pitalizatio n, an d m or tality due to un in ten tio nal poi soni ng Fig . 3 .Th esi s c om po ne nts an d th e g er iatr ic sy nd ro me co nc ep t Par t I: G er ia tr ic sy ndr om es, t heir p re va len ce , a nd a ss oci at ed fac to rs a m on g older co mm uni ty-d w el ler s in S w eden a nd t he N et her la nd s Chapt ers 2 and 3: Th e p re va len ce o f g er ia tr ic sy ndr om es a nd s oci al p osi tio n a m on g older co mm uni ty-d w el ler s in S w eden Chapt er 4: G er ia tr ic sy ndr om es an d tra je ct or ies of ph ysic al ac tiv ity in older co mm uni ty-d w el ler s in t he N et her la nd s Chapt er 5: G er ia tr ic sy ndr om es a nd s ubs eq uen t c hr onic h ea lth co ndi tio ns am on g o lder co mm uni ty-d w el ler s in t he N et her la nd s Par t II: Po lyp ha rm ac y, fa lls, a nd t he r isk o f h os pi ta liza tio n a nd m or ta lit y Chapt er 6: Po lyp ha rm ac y, h os pi ta liza tio n, a nd m or ta lit y d ue t o unin ten tio na l p oi son in g Chapt er 7: In jur io us fa lls, h os pi ta liza tio n, a nd m or ta lit y d ue t o unin ten tio na l p oi so nin g F ig . 3. Th esi s co m po nen ts a nd t he g er ia tr ic sy ndr om e co ncep t

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Data sources and measures

Data sourced from the Stockholm County Council Public Health Surveys, the Swedish administrative registers, and the Dutch Lifelines Cohort Study were used to answer the research questions posed in this thesis. Table 1 presents an overview of the data sources, study designs, numbers of participants, and the main determinants and outcomes of each of the studies described in respective chapters of this thesis.

Stockholm County Council Public Health Surveys

Cross-sectional data from waves of the Stockholm County Council Public Health Surveys were used for the research. The surveys were conducted for the purposes of health and risk factor surveillance and policy planning [122]. So far, four waves have been implemented in 2002, 2006, 2010, and 2014. Because of adaptations made for successive waves, only the data from the 2006 survey could be used to assess geriatric syndromes.

The population samples covered in the Stockholm County Council Public Health Surveys and used for the cross-sectional analyses were derived from the Swedish Total Population Register. The samples were obtained using area-stratified random sampling. The populations covered in the Stockholm County Council Public Health Surveys comprised adults aged 18–84 years in 2006 and adults aged ≥18 years in 2010 and 2014. Approximately 50,000 individuals were invited to participate in each wave, with around 1,300 individuals sampled in each of the 39 municipalities and urban districts in Stockholm County. For the purpose of the studies presented in this thesis, the analyses were limited to adults aged 65–84 years (n = 18,592). The response rates for the respective years were 6,713 (74.5%) in 2006, 7,153 (74.1%) in 2010, and 4,726 (60.1%) in 2014.

Ethical approval was obtained from the regional ethical review board in Stockholm (case numbers: 2011/344–31/5, 2013/466–32, 2016/984–32, and 2016/1932– 31/5). By completing and returning the questionnaire, respondents provided their informed consent.

Dutch Lifelines Cohort Study

The Dutch study sample was derived from the Lifelines Cohort Study [123]. Lifelines was a multidisciplinary prospective population-based cohort study that

applied a unique three-generational design to assess the health and health-related behaviors of 167,729 persons living in the northern part of the Netherlands. It employed a broad range of investigative procedures for assessing the biomedical, sociodemographic, behavioral, physical, and psychological factors contributing to health and disease within the general population, with a special focus on multi-morbidity and complex genetics. Lifelines population samples were deemed broadly representative for this region [124]. The participants were recruited from November 2006 to December 2013 via three routes: their general practitioners, participating family members, or self-registration. At baseline, the participants were invited to come to a physical location for physical assessments and to answer questionnaires. They subsequently received follow-up questionnaires every 1.5 years and were invited for further physical assessments and to complete questionnaires after approximately five years. At the time of the data assessment, information was available for 152,737 of the enrolled participants, of whom 152,144 (99.6 %) responded to the first questionnaire distributed for the baseline assessment. A total of 125,286 (82.0%) participants responded to the first follow-up questionnaire and 96,135 (62.9%) participants responded to the second follow-up questionnaire. The third follow-up entailed physical assessments and questionnaire completion, with 90,980 participants (59.6 %) responding to the questionnaire. Further information on the recruitment and data collection processes has been published [123]. The Lifelines Cohort Study was conducted according to the guidelines set forth in the Declaration of Helsinki, and all of the procedures involving human subjects were approved by the Medical Ethics Committee of the University Medical Center Groningen. Written informed consent was obtained from all of the participants during their visits to the research center [123,125].

Cohort based on Swedish administrative registers

Individuals born before 1959 and living in Sweden from 1973 onward were identified within the Swedish Total Population Register. The Swedish National Patient Register and Swedish Cause of Death Register were used to identify cases of unintentional poisoning among older adults (50 years and above) that occurred between January 1, 2006 and December 31, 2009. Information on prescribed medications was extracted from the Swedish Prescribed Drug Register, which is a computerized system of pharmaceutical services that stores records of all dispensations of prescribed drugs at all pharmacies in Sweden using the

five-1

level anatomical therapeutic and chemical classification system (ATC). The data

are linked through the unique personal identification numbers assigned to all Swedish residents. The cohort was created using the linked registers for a project that focused on injuries among the elderly relating to their health conditions. In accordance with Swedish regulations, namely the Personal Data Act (Personuppgiftslagen) paragraph 10 [126], the ethical application submitted by the researchers specified why informed consent was not necessary or feasible given the nature of the study, which was a large register-based one. The study was approved by the Regional Ethical Review Board in Stockholm, Sweden (2010/865– 31/2 and 2011/15–32).

Thesis outline

The thesis comprises eight chapters, of which chapters 2 to 7 represent the included research papers.

Chapter 1 introduces the thesis, presenting a discussion of the relation between aging and geriatric syndromes and identifying current gaps in the literature. Part I focuses on geriatric syndromes, their prevalence, and their associations with social position, physical activity, and chronic health conditions. Chapter 2 determines the prevalence and associations between social position, measured by education level, type of accommodation, and financial stress, and the presence of geriatric syndromes. Chapter 3 determines the prevalence of geriatric syndromes and assesses trends in their occurrence using data obtained from the Stockholm Public Health Cohort, Moreover, factors contributing to changes in the prevalence of geriatric syndromes during the period 2006–2014 among older Stockholm residents are identified and discussed. Chapter 4 determines the association of geriatric syndromes and physical activity trajectories using longitudinal data from three provinces in the northern part of the Netherlands derived from the Lifelines Cohort Study. Chapter 5 determines the associations between geriatric syndromes and subsequent health conditions experienced by older community-dwellers in the northern part of the Netherlands using data extracted from the Lifelines Cohort Study.

Part II focuses on polypharmacy and injurious falls as specific examples of geriatric syndromes and their associations with hospitalization and mortality attributed to unintentional poisoning. The Swedish Total Population, National Patient, Cause of Death, and Prescribed Drug Registers were used for these studies. Chapter 6 determines the associations between numbers and types of medications and hospitalization and mortality attributed to unintentional poisoning. The chapter also includes an assessment of the association between numbers of medications and hospitalization and mortality in which medications known to be inappropriate were excluded. Chapter 7 examines associations between injurious falls and hospitalization and death resulting from unintentional poisoning, considering the occurrence of different clinical conditions among older people.

Chapter 8 presents a discussion of the research findings in a broader context, pointing to methodological strengths and limitations of the studies and their implications for ongoing research as well as for policy and practice. The final section presents a summary of the findings of the thesis.

1

Table 1. D at a s our ces, s tud y desig ns, n um ber s o f p ar tici pa nts, m ain det er min an ts a nd o ut co m es f or s tudies p res en te d in c ha pt er s 2–7 o f t he t hesi s Ch ap te r D ata s our ce St udy d es ig n N M ain d et ermina nt(s) M ain o ut co me(s) 2. S oci al p osi tio n a nd g er ia tr ic sy ndr om es a m on g Sw edi sh o lder p eo ple: a p op ul at io n-b as ed s tud y St oc kh olm Pu blic H ea lth C oh or t Cr os s-s ec tio na l 17,612 Edu ca tion H ou sin g Fin an ci al s tres s G er ia tr ic sy ndr om es 3. P re va len ce , t ren d a nd co nt rib ut in g fac to rs o f ger ia tr ic sy ndr om es a m on g o lder S w edes: r es ul ts fro m t he S to ck ho lm C oun ty C oun ci l Pu blic H ea lth Sur ve ys St oc kh olm Pu blic H ea lth C oh or t Cr os s-s ec tio na l 17,560 So cio dem og ra phics Ci vi l s ta tu s Edu ca tion H ou sin g Fin an ci al s tres s H ea lth b eh av ior s Chr onic di se as es G er ia tr ic sy ndr om es 4. G er ia tr ic sy ndr om es a nd t ra je ct or ies o f p hysic al ac tivi ty Lif elin es C oh or t St ud y C oh or t 16,024 G er ia tr ic sy ndr om es Tra je ct or ies o f p hysic al ac tivi ty 5. G er ia tr ic sy ndr om es a nd in ciden t c hr onic h ea lth co ndi tio ns Lif elin es C oh or t St ud y C oh or t 9,094 G er ia tr ic sy ndr om es Chr onic h ea lth co ndi tio ns 6. N um ber o f m edic at io ns a nd ad ver se dr ug e ven ts by unin ten tio na l p oi so nin g a m on g o lder ad ul ts in co nsidera tio n o f in ap pr op ria te dr ug u se: a S w edi sh po pu la tio n-b as ed m at ch ed c as e-co nt ro l s tud y Sw edi sh admini stra tiv e re gi ste rs Ca se-co nt ro l 5,336 c as es 21,344 co nt ro ls N um ber o f m edic at io ns H os pi ta liza tio n o r de at h due t o ad ver se dr ug e ven ts 7. I nj ur io us fa lls a nd s ubs eq uen t ad ver se dr ug ev en ts a m on g e lder ly - a S w edi sh p op ul at io n b as ed m at ch ed c as e-co nt ro l s tud y Sw edi sh admini stra tiv e re gi ste rs Ca se-co nt ro l 4,418 c as es 17,672 co nt ro ls In jur io us fa lls H os pi ta liza tio n o r de at h due t o ad ver se dr ug e ven ts

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