Introduction: Self-rated health (SRH) offers insights into the evolving health demographics of an ageing population.

Aim: To assess change in SRH from old age to very old age and their associations with health and well-being factors, and to investigate the association between SRH and survival.

Methods: All participants in the MONICA 1999 re-examination born before 1940 (n = 1595) were included in the Silver-MONICA baseline cohort. The Silver-MONICA follow-up started in 2016 included participants in the Silver-MONICA baseline cohort aged 80 years or older. Data on SRH was available for 1561 participants at baseline with 446 of them also participating in the follow-up. The follow-up examination included a wide variety of measurements and tests.

Findings: Most participants rated their health as "Quite good" (54.5 %) at baseline. Over the study period, 42.6 % had stable SRH, 40.6 % had declined, and 16.8 % had improved. Changes in SRH were at follow-up significantly associated with age, pain, nutrition, cognition, walking aid use, self-paced gait speed, lower extremity strength, independence in activities of daily living, weekly physical exercise, outdoor activity, participation in organized activities, visiting others, morale, and depressive symptoms. SRH at baseline was significantly associated with survival (p < 0.05).

Conclusion: This study demonstrates associations between changes in SRH and a multitude of health- and wellbeing-related factors, as well as a relation between survival and SRH, accentuating their relevance within the ageing population.

In the decades to come, Sweden will be facing an unprecedented increase in the proportion of inhabitants aged 80 years or older. This age group is characterised by large heterogeneity; however ageing also poses challenges for health and well-being. These challenges apply not only to the individual, but also to the health care systems. Care of this older age group employs much of the nursing resources, affecting society as a whole. Healthy ageing can and should, therefore, be promoted in the decades prior to reaching old age, and once having reached old age, well-being should be a continued focus of health care and society. In this way older adults can continue perceiving good health and well-being. The overall aim of this thesis was to explore and describe areas of importance to healthy ageing and well-being in old age. 

Predictors of healthy ageing were prospectively studied as part of the northern Sweden Silver-MONICA project, from baseline in 1999 (n=1595) to follow-up 20 years later (n=541). For the healthy ageing outcome, a composite outcome comprised of measures of cognition (MMSE), 2.4 metre walking speed, personal independence in everyday life (Katz P-ADL) and depression (GDS15) was constructed. To study perceptions of general well-being in old age, a subsample (n=52) age > 80 was analysed as a cross-section using mixed method with open-ended interviews and the PGCMS well-being measure. A similar approach was used (n=50) to investigate specific aspects of well-being in relation to home. To study the relationship between well-being and objectively measure everyday physical activity, an accelerometer was worn 24 hours per day for at least 5 consecutive days (n=77) and analysed for associations with the PGCMS and its subscales.  

The five top ranking predictors determined by the healthy ageing index, comprising the total baseline cohort including those who passed away before possible follow-up were smoking status, NT-proBNP, waist circumference, leisure time physical activity level and HbA1c. For those who participated in the Silver-MONICA follow-up, the top five ranking predictors as determined by the healthy ageing index were leisure time physical activity, HbA1c, BMI, waist circumference and high sensitivity Troponin I. In interviews of general well-being, six areas were described that related to social context, health, physical activity, home, engagement and freedom. In regression analysis independence in activities of everyday living along with age were significantly associated with well-being. Acceptance was key for handling consequences of ageing that impacted well-being. Home was perceived as a central aspect of well-being; however, participants described being in the margins of home. Morale was higher among persons living in single-dwelling housing compared to those living in apartments. In activity measures, well-being was associated with the number of steps, time spent stepping and time spent stepping at >75 steps/minute.

In conclusion, the combination of qualitative, quantitative and mixed methodology utilised in this thesis to study healthy ageing allowed for the possibility to nuance conclusions and to describe the subject from different points of view. Based on the findings, this thesis suggests that physical ability in old age is the basis for being able to engage in and experience the important factors of well-being described above. However, support from others, often family, can compensate for the lack of physical ability. The support is positive to well-being as long as it does not create feelings of being a burden. As consequences of ageing affect the areas most crucial to well-being, it seems that the extent and way these changed conditions are accepted has an important role in the maintaining of well-being in old age.

The present study aims to describe accelerometer-assessed physical activity (PA) patterns and fulfillment of PA recommendations in a large sample of middle-aged men and women, and to study differences between subgroups of socio-demographic, socio-economic, and lifestyle-related variables. A total of 27 890 (92.5% of total participants, 52% women, aged 50–64 years) middle-aged men and women with at least four days of valid hip-worn accelerometer data (Actigraph GT3X+, wGT3X+ and wGT3X-BT) from the Swedish CArdioPulmonary bioImage Study, SCAPIS, were included. In total, 54.5% of daily wear time was spent sedentary, 39.1% in low, 5.4% in moderate, and only 0.1% in vigorous PA. Male sex, higher education, low financial strain, born in Sweden, and sedentary/light working situation were related to higher sedentary time, but also higher levels of vigorous PA. High BMI and having multiple chronic diseases associated strongly with higher sedentary time and less time in all three PA intensities. All-year physically active commuters had an overall more active PA pattern. The proportion fulfilling current PA recommendations varied substantially (1.4% to 92.2%) depending on data handling procedures and definition used. Twenty-eight percent was defined as having an “at-risk” behavior, which included both high sedentary time and low vigorous PA. In this large population-based sample, a majority of time was spent sedentary and only a fraction in vigorous PA, with clinically important variations between subgroups. This study provides important reference material and emphasizes the importance of a comprehensive assessment of all aspects of the individual PA pattern in future research and clinical practice.

Studies that objectively investigate patterns of everyday physical activity in relation to well-being and that use measures specific to older adults are scarce. This study aimed to explore objectively measured everyday physical activity and sedentary behavior in relation to a morale measure specifically constructed for older adults. A total of 77 persons (42 women, 35 men) aged 80 years or older (84.3 ± 3.8) wore an accelerometer device for at least 5 days. Morale was measured with the Philadelphia Geriatric Center Morale Scale (PGCMS). PGCMS scores were significantly positively associated with number of steps, time spent stepping, and time spent stepping at >75 steps per minute. Sedentary behavior did not associate with PGCMS. Promoting PA in the form of walking at any intensity–or even spending time in an upright position—and in any quantity may be important for morale, or vice versa, or the influence may be bidirectional.

Background

Physical activity and sedentary behavior vary across the life span, and in very old people activity behavior can vary considerably over 24 hours. A physical activity questionnaire adapted for this age group is lacking. This study was conducted to validate such a newly developed questionnaire suitable for use in very old people.

Research question

Is the International Physical Activity Questionnaire adapted for adults aged ≥ 80 years (IPAQ-E 80+) a valid measure of physical activity in very old people?

Methods

Seventy-six participants (55.3% women) with a mean age of 84.4 ± 3.8 years wore accelerometers for ≥5 consecutive days, and completed the IPAQ-E 80+. Spearman’s rho and Bland-Altman plots were used to analyze the validity of IPAQ-E 80+ against accelerometer measures. Analyses were conducted for the separate items sitting, laying down at daytime and nighttime, walking, moderate to vigorous (MV) walking, and moderate to vigorous physical activity (MVPA), and the summary measures: total inactive time, sedentary time (i.e. lying down at daytime + sitting), total active time, and total MVPA + MV walking.

Results

The IPAQ-E 80+ correlated with the accelerometer measures of total inactive- (r=0.55, p<0.001), sedentary- (r=0.28, p=0.015), walking- (r=0.54 p<0.001) and total active- (r=0.60, p<0.001) times, but not with measures of intensity of walking or physical activity; MV walking (r=0.06, p=0.58), MVPA (r=0.17, p=0.13).

Significance

In this study the IPAQ-E 80+ showed fair to substantial correlations with accelerometers, and it therefore seems able to rank very old people according to levels of PA (total inactive-, sedentary-, and total active time, and walking time). The IPAQ-E 80+ seems promising for use in studies investigating associations between activity behavior and health in this population. Further investigation is needed to determine whether the IPAQ-E 80+ can accurately measure PA intensity.

Aims To (1) describe experiences of home from a well-being perspective, (2) describe participant characteristics and well-being measures in relation to housing type (3) and how the aforementioned aspects may affect well-being in very old persons. Design Cross-sectional, convergent parallel-results mixed method design with semi-structured interviews analysed by qualitative content analysis, in relation to descriptive statistics and specific well-being outcome measures related to home. Methods A total of 50 persons 80 years or older living in ordinary housing were interviewed (July 2017 to November 2018) about home in relation to well-being, along with collection of participant characteristics and well-being measures related to home. Results Participants described how home had become increasingly important as it provided autonomy and acted as a social and occupational hub. However, autonomy was not unconditional, and home could also be perceived as a place of inactive solitude. Results were interpreted as relating to being in the margins of home and had a major impact on well-being. Housing type seemed of importance with higher measures of well-being for participants in single-living housing compared with those living in apartment. Conclusion Home is increasingly central to well-being in old age; however, very old persons also have to relate to being physically and mentally in the margins of being able to remain in the home. These aspects of home potentially have a major impact on well-being. Impact As very old persons living in ordinary housing will constitute a larger segment of society in coming years, aspects of home can potentially have a considerable impact on well-being for this age-group. This study describes aspects of home that contribute to, or has adverse impact on well-being. These aspects need thorough consideration in policy-making and planning of health care that can affect experiences of home.

Background

As the group of very old persons will form an increasing part of society, the study of how well-being is described and affected by specific factors will be of importance to meet the future needs of these persons. The aim of the study was to increase knowledge of well-being in very old persons by combining assessments and perceptions using the Philadelphia Geriatric Morale Scale (PGCMS).

Method

In a mixed method, convergent parallel design, 52 persons 80 years or older were assessed and interviewed using the PGCMS to combine assessment of morale and descriptions of perceptions of well-being using a mixed method approach.

Results

Quantitative and qualitative results converged in four areas: not feeling lonely and being included, rating and perceiving health as good, high physical function/ability and being physically active, living in own house and feeling at home. Areas perceived as important to well-being captured only in qualitative analysis were having freedom and engagement. An example of insights not achievable from the quantitative or qualitative analysis alone was that individuals with high morale expressed anxiety about losing their health due to potential ageing-related threats and that individuals with low morale struggled with acceptance. Acceptance was the key strategy for handling adverse consequences of ageing in all described areas.

Conclusion

When using standardized assessment scales in clinical practice, it could be useful to combine quantitative and qualitative data. Acceptance was key for well-being; however, acceptance could be resigned or reorienting in nature.