To Örebro University

AIMS: Research shows that the older population increases worldwide, which will likely lead to a rise in the number of people living with age-related disabilities (i.e. hearing and vision difficulties, physical mobility or cognitive ability). However, studies from the Nordic countries have indicated that the likelihood of having disabilities has decreased over time among older adults. This doctoral thesis is based on four studies, which collectively aim to analyze how older adults (aged 75 and above) perceive what constitutes successful aging, estimate the prevalence of hearing and vision impairments in different segments of the older population, examine the importance of cognitive abilities and hearing and vision in the observed declines in disabilities over time among older adults in Sweden and Denmark, and, finally, investigate the longitudinal interplay between sensory function and cognitive abilities among older adults.. METHODS: For Study I, a systematic review was conducted, while for Study II the prevalence of sensory difficulties was estimated. For Study III, the Karlson Holm Breen method was used to estimate the contribution of the cognitive and sensory functions on disability, whereas Study IV applied a cross-lagged panel model to explore the bidirectional relationship between sensory and cognitive functions. For study II, III and IV, data from the Survey of Health, Ageing and Retirement in Europe was used. RESULTS: The findings show that older adults’ own perceptions of successful aging include themes such as life, death, and environmental/systemic influences (Study I). Study II showed that the prevalence of hearing and vision impairments varied among different groups of older adults. Study III found that the decline in the prevalence of disabilities among older adults in Sweden and Denmark could be explained by improved cognition, education, and vision and hearing. Finally, the results from Study IV indicate that no reciprocal effects could be established between sensory functions and cognitive abilities in the short term. DISCUSSION: This thesis highlights the complex relationship between aging and disabilities in Sweden and Denmark and shows various perspectives on what successful aging means for older adults. The findings also reveal significant differences in the prevalence of hearing and vision difficulties among different groups of older adults and show that the prevalence of disabilities has decreased over time in the older population due to improvements in cognition, education, vision, and hearing. These results emphasize the importance of further research on how these factors, along with the use of assistive devices, have contributed to the observed trend. Further research, based on various types of studies and assumptions, is also needed to clarify whether there are any longitudinal associations between cognitive and sensory functions among older adults and, if so, to what extent they can be considered causal.

BACKGROUND: The objective of this study is to estimate the prevalence of self-reported hearing difficulties, vision difficulties and combined vision and hearing difficulties in a Swedish adult population that varies according to migration status, sex, age, disability measured by ADL and IADL and educational attainment level.

METHODS: The study utilised data from the Survey of Health, Ageing and Retirement in Europe, which consisted of 2257 individuals aged 60 and above that were interviewed in Sweden in the 2019/2020, SHARE wave 8. To determine the prevalence of sensory difficulties (hearing, vision and dual-sensory difficulties) among various subgroups of the population, a multinomial logistic regression was used. The results of these analyses are presented in terms of predicted probabilities.

RESULTS: The study findings indicate that foreign-born older adults experience a lower prevalence of visual difficulties (6.2% [3.3-11.5] in comparison to their Swedish-born counterparts. Moreover, older adults with higher levels of education tend to report a lower prevalence of sensory difficulties overall. Furthermore, sex differences are apparent, with males reporting a higher prevalence of hearing difficulties (18.9% [15.5-22.8] vs. 12.8% [10.7-15.3]) and females reporting a higher prevalence of vision difficulties (12.7% [10.7-15.1] vs. 8.5%[6.8-10.5]).

CONCLUSION: The findings highlight disparities in the prevalence and type of perceived sensory difficulties experienced by older adults, by factors such as age, sex, education and migration status. It is important to consider these demographic factors in healthcare planning and interventions aimed at mitigating sensory difficulties in the older population.

INTRODUCTION: There is high evidence that chronic exercise benefits overall depression severity in older adults. However, late-life depression is characterized by considerable heterogeneity in clinical manifestation emphasizing the need for more individualized exercise intervention programs. Therefore, the objective of the proposed review is to investigate the effects of chronic exercise on overall depression severity and on different symptoms of depression in randomized controlled trials (RCTs) including older adults with a mean age of at least 60 years, and by considering the moderating effects of intervention characteristics and individual characteristics.

METHODS: This protocol is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). We will use the Population-Intervention-Comparator-Outcomes-Study design (PICOS) criteria for study inclusion and will search the following database sources for relevant RCTs: Web of Science, Academic Search Complete, CINAHL, APA Psycinfo, SPORTDiscuss, Cochrane. Two independent reviewers will conduct the study selection, data extraction, and quality assessment. Disagreement will be solved by a third reviewer. Primary outcome will be changes in overall depression severity and secondary outcomes will encompass changes in symptoms of depression as defined by the DSM-5, such as sleep quality, fatigue, anxiety, mood, apathy, changes in weight, information processing speed, and executive functions, from baseline until the end of the intervention and to any available intermediary measurement or follow up. Meta-analysis will be undertaken to synthesize the effects of chronic exercise on primary and secondary outcomes. Subgroup analysis will investigate the moderating effects of intervention characteristics (frequency, intensity, duration, type of exercise, cognitive demand, social interactions, exercise supervision, behavioral change techniques, compliance, study design, dropout-rate, type of control group) and individual characteristics (age, sex, education, functional capacity, global cognition, population) on primary and secondary outcomes. Additionally, we plan to assess quality of evidence and publication bias, and to carry out sensitivity analysis.

CONCLUSION: The results of the proposed review are anticipated to have a substantial impact on research and clinical practice. On the one hand, the review's conclusions could form the foundation for developing evidence-based recommendations for individualized exercise programs that alleviate depression in older adults. On the other hand, by revealing research gaps, the review results could encourage the formulation of research questions for further RCTs.

PROTOCOL REGISTRATION NUMBER: This protocol has been published in the Prospero repository (PROSPERO 2022 CRD42022361418, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022361418).

BACKGROUND: Executive functions (EFs) and episodic memory are fundamental components of cognition that deteriorate with age and are crucial for independent living. While numerous reviews have explored the effect of exercise on these components in old age, these reviews screened and analyzed selected older adult populations, or specific exercise modes, thus providing only limited answers to the fundamental question on the effect of exercise on cognition in old age. This article describes the protocol for a systematic review and multilevel meta-analytic study aiming at evaluating the effectiveness of different types of chronic exercise in improving and/or maintaining EFs and long-term episodic memory in older adults.

METHODS AND ANALYSIS: The study protocol was written in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Several databases will be searched. Randomized controlled trials (RCTs) conducted in older adults aged ≥ 60 years providing any kind of planned, structured, and repetitive exercise interventions, and EFs and/or episodic memory measures as outcomes, published in English in peer-reviewed journals and doctoral dissertations will be included. Two independent reviewers will screen the selected articles, while a third reviewer will resolve possible conflicts. The Cochrane risk-of-bias tool will be used to assess the quality of the studies. Finally, data will be extracted from the selected articles, and the formal method of combining individual data from the selected studies will be applied using a random effect multilevel meta-analysis. The data analysis will be conducted with the metafor package in R.

DISCUSSION AND CONCLUSION: This review will synthesize the existing evidence and pinpoint gaps existing in the literature on the effects of exercise on EFs and episodic memory in healthy and unhealthy older adults. Findings from this meta-analysis will help to design effective exercise interventions for older adults to improve and/or maintain EFs and episodic memory. Its results will be useful for many researchers and professionals working with older adults and their families.

SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022367111.

How we think and feel about death and dying affects how we live our lives and our opportunities for healthy aging. This scoping review, using the PRISMA guidelines and drawing on the World Health Organizations public health framework for healthy aging, examined the personal, health and environmental factors associated with attitudes toward death and dying in persons 50 years and older. Most of the 74 eligible studies focused only on negative attitudes to death and few studies investigated the comprehensive range of factors that influence attitudes to death and dying. In the context of population aging and the United Nations Decade of healthy aging (2021-2030) attention to death attitudes and the factors that influence them are imperative to enable current and future generations to age and die well.

BACKGROUND: The objective of this study is to explore the bidirectional, longitudinal associations between self-reported sensory functions (hearing/vision) and cognitive functioning among older adults in Sweden and Denmark during the period 2004-2017.

METHODS: The study is based on data from The Survey of Health, Ageing and Retirement in Europe and consists of 3164 persons aged 60 to 93 years. Within-person associations between sensory and cognitive functions were estimated using random intercept cross-lagged panel models.

RESULTS: The results indicated that cognitive and sensory functions were associated within their respective domains over time. The results on the bidirectional associations between sensory functions and cognition over time showed weak and statistically non-significant estimates.

CONCLUSION: Our study showed no clear evidence for cross-lagged effects between sensory functions and cognitive functioning. Important to note, however, is that using longitudinal data to estimate change within persons is a demanding statistical test and various factors may have contributed to the absence of conclusive evidence in our study. We discuss several of these factors.

Background: Health inequalities have been linked to reduced life expectations. This study aimed to investigate regional variations in all-cause years of life lost (YLLs) in European Economic Area (EEA) countries prior to the COVID-19 pandemic.

Methods: Demographic data were extracted from Eurostat for 1390s mall regions 32 EEA countries. Age-standardised sex specific YLL rates per 100,000 population in 2019 were estimated for EEA regions (Eurostat NUTS level 3) using methodologies derived from the Global Burden of Disease study. Relative spatial disparities were evaluated using the Gini coefficient (GC) and absolute spatial disparities assessed using the slope index of inequality (SII).

Results: Between EEA countries, relative geographical inequality in age-standardized YLL rates was higher than within them, slightly more so for males (GC ¼ 16.96% [95% CI ¼ 16.26-17.65]) than females (14.22% [13.62-14.82]). Among females, the UK (11.21% [95% CI 10.11-12.30]), Greece, and Croatia had the highest relative spatial inequality, while Ireland (3.37% [2.26-4.48]), Slovakia, and the Netherlands had the lowest. For males, Belgium (10.76% [9.34-12.17]), the UK, and Croatia exhibited the highest relative spatialin equality, while Ireland (1.99% [1.18-2.81]), Lithuania, and Slovakia had the lowest. Germany had the largest absolute geographical inequality in YLLs among females (SII¼16.86% [16.28 to 17.44]), followed by Estonia and the UK. Among males, Estonia had the largest absolute spatial inequality (36.60% [-10.88 to 84.07]), followed by Latvia and Hungary. Ireland had the lowest absolute spatial inequality for both females and males.

Conclusions: Relative and absolute disparities in premature mortality rates are evident across regions of the EEA, both within countries and across the entire region. These findings offer insights for national and local stakeholders, aiding them in customising public health interventions to target spatial health disparities.

BACKGROUND: Health inequalities have been associated with shorter lifespans. We aimed to investigate subnational geographical inequalities in all-cause years of life lost (YLLs) and the association between YLLs and socioeconomic factors, such as household income, risk of poverty, and educational attainment, in countries within the European Economic Area (EEA) before the COVID-19 pandemic.

METHODS: In this ecological study, we extracted demographic and socioeconomic data from Eurostat for 1390 small regions and 285 basic regions for 32 countries in the EEA, which was complemented by a time-trend analysis of subnational regions within the EEA. Age-standardised YLL rates per 100 000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease study. Geographical inequalities were assessed using the Gini coefficient and slope index of inequality. Socioeconomic inequalities were assessed by investigating the association between socioeconomic factors (educational attainment, household income, and risk of poverty) and YLLs in 2019 using negative binomial mixed models.

FINDINGS: Between Jan 1, 2009, and Dec 31, 2019, YLLs lowered in almost all subnational regions. The Gini coefficient of YLLs across all EEA regions was 14·2% (95% CI 13·6-14·8) for females and 17·0% (16·3 to 17·7) for males. Relative geographical inequalities in YLLs among women were highest in the UK (Gini coefficient 11·2% [95% CI 10·1-12·3]) and among men were highest in Belgium (10·8% [9·3-12·2]). The highest YLLs were observed in subnational regions with the lowest levels of educational attainment (incident rate ratio [IRR] 1·19 [1·13-1·26] for females; 1·22 [1·16-1·28] for males), household income (1·35 [95% CI 1·19-1·53]), and the highest poverty risk (1·25 [1·18-1·34]).

INTERPRETATION: Differences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA.

Background: The COVID-19 pandemic has underscored older adults' vulnerability to severe illness or death. Increased public awareness of mortality, with daily reminders of preventive measures, spurred interest in understanding the impact on death-related thoughts. This systematic review analyses existing literature on death attitudes among individuals aged 50 and older during the COVID-19 pandemic and focuses on associated factors.

Methods: A systematic literature search was conducted using the WHO COVID database without any language limit, up until April 2023. The review protocol was registered in PROSPERO and PRISMA guidelines were followed. Included studies were systematically analysed and summarized using a predefined data extraction sheet.

Results: Of the 2297 studies identified, 9 met inclusion criteria. The review showed moderate to high levels of death anxiety during the pandemic, linked to direct health risks from COVID-19 rather than mitigation measures. The impact of health and personal factors on older people's death anxiety was complex, with a range of health and personal factors such as chronic conditions, loss of capacity, loneliness, occupation, and resilience associated with it, suggesting potential intervention avenues.

Conclusion: The systematic review shows a significant link between COVID-19 and heightened death anxiety among individuals aged 50 and above. Negative attitudes to death can harm physical and mental health, diminish life satisfaction, increase avoidance behaviour, impair coping mechanism and undermine end-of-life decision making. Findings underscore the need for further research into risk and protective factors (personal, health, and environmental) and the importance of standardized data collection to guide interventions and public health strategies aimed at mitigating death anxiety.