Aspects of treatment and care of nursing home residents. Challenges and possibilities.

Background: Elderly people living in nursing homes (NHs) have multiple diseases as well as risk factors that may complicate optimal medication. Malnutrition and impaired renal function are two of those risk factors. Heart failure is common and may often not be treated or diagnosed adequately in elderly patients.Objectives: The aim of this thesis was to explore different risk factors for elderly with multiple diseases, and to relate these risk factors to outcomes such as mortality, morbidity and medical treatment to find factors for optimizing the care of this group of patients. Furthermore, a qualitative interview study was conducted to explore the General Practitioners’ (GPs’) experience of the work with elderly residents in nursing homes in Sweden.Methods: The data for papers I–III come from the SHADES (Study of Health and Drugs in the Elderly living in nursing homes in Sweden) study. SHADES is a prospective cohort study, with more than 400 elderly residents in 11 different nursing homes in Sweden enrolled between 2008 and 2011. The subjects were followed every six months with regular examinations including blood sample analyses, examinations with validated rating scales (Mini Nutritional Assessment, (MNA) for nutritional status and Mini Mental State Examination (MMSE) for cognitive evaluation), and with data collection from medical records concerning medications, diagnoses, hospital referrals and mortality. The qualitative study in paper IV was based on individual semi-structured interviews and a follow-up focus group discussion with 12 GPs. Further, the written text from the interviews was systematically analysed with content analysis.Results: The results in paper I show that the prevalence of patients with heart failure was 15.4% in the study population, but if BNP (B-type natriuretic peptide) values were used to select patients for further examination, the prevalence would probably be higher. The medical treatment of heart failure varied greatly and was often old-fashioned. The adherence to guidelines was generally low. The prevalence of malnutrition was 17.7% in the study population in paper II. About 40% were at risk of malnutrition and 41.6% had normal nutritional state. Malnutrition was associated with lower survival. In the survivors, the prevalence of malnutrition increased and after 24 months follow-up, about 24.6% of the population were malnourished. Factors influencing the nutritional state longitudinally were baseline BMI and hospitalization. In paper III, survival was significantly lower in the groups with lower renal function. Over 60% of the residents had impaired renal function. Those with impaired renal function were older, had a higher number of medications and a higher prevalence of heart failure. Higher numbers of medications were associated with a greater risk of rapid decline in renal function. In paper IV, the GPs found working with elderly patients important and meaningful; the GPs strove for the patient’s well-being with special consideration to the continuum of ageing. A continuous and well-functioning relationship between the GP and the nurse was crucial for the patients´ well-being.Conclusions: In NH residents there is a risk of misdiagnosis of heart failure and the treatment was seldom according to current guidelines. Malnutrition and impaired renal function were common and associated with lower survival. The work with elderly in NHs was engaging and important for the GPs