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Background People with memory disorders often need care and help from family carers and health and social care providers. Due to the deterioration of cognitive capacity and language skills, they may be unable to convey their thoughts and care preferences to other people. As a result, their agency may become restricted. We investigated the descriptions provided by people with memory disorders and spousal carers of their influence on care in encounters with formal care providers. Methods Qualitative thematic analysis was used to identify, analyze, and report themes that describe encounters with professionals in different social or healthcare environments. In-depth interview data were gathered from 19 spouse carers and 15 persons with memory disorders. Findings Three themes out of four describe how people with memory disorders and their spouse carers influence formal care: Acquiescence, negotiating care decisions, and taking control. The fourth theme describes lack of influence. People with memory disorders and their spouse carers have ways to influence care, but spouse carers identified more ways of doing so. Both either accepted and followed the care guidelines by the formal carers or took control of the situation and made their own decisions. Spouse carers also sought to influence care decisions through negotiations with formal carers. When formal carers’ decisions were experienced as inconsistent or the rationale of their actions difficult to follow, the possibilities to influence care were limited. Conclusions People with memory disorders and their family carers are often in a disadvantaged position as they lack power over the health and social care decision-making during the illness, which is often guided by structural factors. To support the agency of people with memory disorders and to promote shared decision-making, clarification of the service structure and clearer communication between the different parties involved in care are required.

Aims: This study aimed to find out how place of death varied between countries with different health and social service systems. This was done by investigating typical groups (concerning age, sex and end-of-life trajectory) of older people dying in different places in Finland and Norway. Methods: The data were derived from national registers. All those who died in Finland or Norway at the age of ⩾70 years in 2011 were included. Place of death was analysed by age, sex, end-of-life trajectory and degree of urbanisation of the municipality of residence. Two-proportion z-tests were performed to test the differences between the countries. Multinomial logistic regression analyses were performed separately for both countries to find the factors associated with place of death. Results: The data consisted of 68,433 individuals. Deaths occurred most commonly in health centres in Finland and in nursing homes in Norway. Deaths in hospital were more common in Norway than they were in Finland. In both countries, deaths in hospital were more common among younger people and men. Deaths in nursing homes were commonest among frail older people, while most of those who had a terminal illness died in health centres in Finland and in nursing homes in Norway. Conclusions: Both Finland and Norway have a relatively low share of hospital deaths among older people. Both countries have developed alternatives to end-of-life care in hospital, allowing for spending the last days or weeks of life closer to home. In Finland, health centres play a key role in end-of-life care, while in Norway nursing homes serve this role. Aims: This study aimed to find out how place of death varied between countries with different health and social service systems. This was done by investigating typical groups (concerning age, sex and end-of-life trajectory) of older people dying in different places in Finland and Norway. Methods: The data were derived from national registers. All those who died in Finland or Norway at the age of ⩾70 years in 2011 were included. Place of death was analysed by age, sex, end-of-life trajectory and degree of urbanisation of the municipality of residence. Two-proportion z-tests were performed to test the differences between the countries. Multinomial logistic regression analyses were performed separately for both countries to find the factors associated with place of death. Results: The data consisted of 68,433 individuals. Deaths occurred most commonly in health centres in Finland and in nursing homes in Norway. Deaths in hospital were more common in Norway than they were in Finland. In both countries, deaths in hospital were more common among younger people and men. Deaths in nursing homes were commonest among frail older people, while most of those who had a terminal illness died in health centres in Finland and in nursing homes in Norway. Conclusions: Both Finland and Norway have a relatively low share of hospital deaths among older people. Both countries have developed alternatives to end-of-life care in hospital, allowing for spending the last days or weeks of life closer to home. In Finland, health centres play a key role in end-of-life care, while in Norway nursing homes serve this role.

Background Comorbidities have major implications for the care of people with dementia. Aim To investigate the patterns of comorbidities in dementia in the last five years of life and how these patterns differed between three cohorts. Methods The study included people who died at age 70 and above in 2001 (n = 13,717), 2007 (n = 34,750) and 2013 (n = 38,087) in Finland. ICD-10 morbidity data for a five-year period prior to death were extracted from national registers. Principal component analysis was employed to identify patterns for several morbidities. The associations of principal component scores with dementia were analysed using binary logistic regression. Linear regression was used to examine changes in the number of morbidities in patterns over time. Results The morbidity patterns identified in the last years of life were (1) cardiometabolic disorders, (2) neurological, (3) cerebrovascular diseases and (4) musculoskeletal, thyroid and psychiatric disorders. Among the patterns, neurological and musculoskeletal, thyroid and psychiatric disorders were associated with dementia. The number of diagnoses in the cerebrovascular pattern increased and those in the musculoskeletal, thyroid and psychiatric pattern decreased over time. Discussion Comorbidity patterns identified in this nationwide register study are largely in line with previous evidence. Time difference in these patterns provide crucial information for service planning. Conclusions Comorbidities in dementia in the last years of life occur in patterns and change over time. More systematic monitoring and updated clinical guidelines are needed for the care of comorbidities with dementia.

While it is known that those who are living their last years are frequent users of social and health services, research about medicines at the end of life is scarce. We examined whether the proportions of purchasers and the types of prescription medicines purchased during a 2-year period differed between community-dwelling old people who died (decedents) in 2002, 2006 or 2011 and old people who lived at least 2 years longer (survivors) in Finland. We also examined how those differences changed over time. The study population was identified from nationwide registers and consisted of 174,097 community-dwelling people who were 70 years of age or older. Of these, 81,893 were decedents and 92,204 survivors. Data on purchases of medicines were gathered from the Finnish prescription database. Along with descriptive analyses, binary logistic regression analysis was used to find the association between decedent status and the purchase of medicines in general and different categories of medicines in particular. Almost all community-dwelling decedents and survivors purchased medicines at least once during the 2-year period. Over time, the proportion of purchasers increased in both groups but especially among survivors, thereby reducing the differences between the groups. However, the probability of purchasing medicines in general and different categories of medicine in particular remained significantly higher for decedents than for survivors after adjustments. This study shows that purchases of medication are concentrated at the end of life, as is the use of social and health services. However, the differences between decedents and survivors diminish over time.

Objectives Delayed discharge, remaining in acute care longer than medically necessary, reflects less than optimal use of hospital care resources and can have negative implications for patients. We studied (1) the change over time in delayed discharge in people with and without dementia, and (2) the association of delayed discharge with discharge destination and with the continuity of primary care prior to urgent admission. Design A retrospective population-based study. Setting and Participants Delayed discharge after urgent admission and length of delayed discharge were studied in all hospital users aged ≥70 years with at least 1 urgent admission in British Columbia, Canada, in years 2001/02, 2005/06, 2010/11, and 2015/16 (N = 276,299). Methods Linked administrative data provided by Population Data BC were analyzed using generalized estimating equations (GEE), logistic regression analysis, and negative binomial regression analyses. Results Delayed discharge increased among people with dementia and decreased among people without dementia, whereas the length of delay decreased among both. Dementia was the strongest predictor of delayed discharge [odds ratio 4.76; 95% confidence interval (CI) 4.59–4.93], whereas waiting for long-term care placement [incidence rate ratio (IRR) 1.56; 95% CI 1.50–1.62] and dementia (IRR 1.50; 95% CI 1.45–1.54) predicted a higher number of days of delay. Continuity and quantity of care with the same physician before urgent admission was associated with a decreased risk of delayed discharge, especially in people with dementia. Conclusions and Implications This study demonstrates the need for better system integration and patient-centered care especially for people with dementia. Population aging will likely increase the number of patients at risk of delayed discharge. Delayed discharge is associated with both the patient's complex needs and the inability of the system to meet these needs during and after urgent care. Sufficient investments are needed in both primary care and long-term care resources to reduce delayed discharges.

Introduction The place of death is suggested as a quality indicator for end-of-life care. We investigated how the place of death changed between 1998 and 2013 among people with dementia. Methods Data from the Finnish national health and social care registers were extracted for all people with dementia, who had died at 70 years old during these years ( N = 140,034). Descriptive analysis and logistic regression analysis were conducted. Results In 2013, the most common place of death was the primary care hospital (39.8%), followed by nursing home and sheltered housing with 24-hour assistance (20.5%). Dying at home was rare (8.1%). During the study years, dying in the hospital decreased while dying in sheltered housing with 24-hour assistance increased. Discussion The place of death for people with dementia has changed from institutions to noninstitutional care facilities. Further research on noninstitutional care facilities' ability to provide high-quality care at the end of life is needed.

Long-term care (LTC) use increases with ageing due to an age-related increase in disability. Both the levels of disability and social resources vary among socioeconomic groups. The association of socioeconomic status with LTC use is largely unexplored for the oldest old. This study examined how occupational class is associated with LTC use among nonagenarians in the context of universal care coverage. A population-based prospective cohort study with 2862 participants who answered the Vitality 90 + Study surveys in 2001, 2003, 2007, or 2010 in Tampere, Finland, was combined with national register data on LTC use. LTC use in total and separately for publicly and privately provided LTC facilities was assessed in a cross-sectional setting and during the 34-month follow-up by using logistic regression and competing-risks regression methods. Functional status, multimorbidity, family relations, and help at home were controlled. In total or public LTC use, only a few differences between occupational classes were found at baseline. However, upper non-manuals used more private LTC than lower non-manuals (OR 0.54, 95% CI 0.35-0.85), skilled manuals (OR 0.40, 95% CI 0.26-0.62), or housewives (OR 0.40, 95% CI 0.22-0.74). There were no statistically significant differences in entering any kind of LTC after adjustments for all independent variables. During the study period, the share of privately provided care out of all LTC increased and the upper non-manuals no more used private care more than other groups. This study underlines the importance of following the structural changes in LTC provision to guarantee that the need for LTC is met equally for all socioeconomic groups.

Background The structure of long-term care (LTC) for old people has changed: care has been shifted from institutions to the community, and death is being postponed to increasingly old age. The aim of the study was to analyze how the use and costs of LTC in the last two years of life among old people changed between 2002 and 2013. Methods Data were derived from national registers. The study population contains all those who died at the age of 70 years or older in 2002–2013 in Finland (N = 427,078). The costs were calculated using national unit cost information. Binary logistic regression and Cox proportional hazard models were used to study the association of year of death with use and costs of LTC. Results The proportion of those who used LTC and the sum of days in LTC in the last two years of life increased between 2002 and 2013. The mean number of days in institutional LTC decreased, while that for sheltered housing increased. The costs of LTC per user decreased. Conclusions Use of LTC in the last two years of life increased, which was explained by the postponement of death to increasingly old age. Costs of LTC decreased as sheltered housing replaced institutional LTC. However, an accurate comparison of costs of different types of LTC is difficult, and the societal costs of sheltered housing are not well known.

The aim of the study is (1) to describe and analyse health and social service use and medicine purchases in the last 2 years of life among older adults who died by suicide and (2) to compare use and purchases between three groups: those who died by suicide, died a natural death or who lived longer. Nation-wide Finnish register data were used. The data consist of 316,639 decedents who died at the age of 70 years or older in 1998-2008 and 222,967 people who lived longer. Use of hospital, long-term care and home care, and the purchase of prescribed psychotropic medications were studied for the 2-year period. Binary logistic regression analyses were applied. 1118 older adults died by suicide (0.4 % of all deaths). A majority of older adults who died by suicide had multiple somatic diseases and mental disorders, especially depression, and had contact with health and social services in the last 2 years of life. At the same level of morbidity, use of hospital and long-term care was less common among those who died by suicide than among those who died of natural causes, but more common than among those who lived longer. Those who died by suicide received less home care than those who lived longer. A high proportion of suicides occurred in the first month following hospital discharge. Health and social services should improve support for older adults with chronic diseases and depression.

Background: Lynch syndrome (LS) is associated with a significant lifetime risk of endometrial cancer (EC). There are limited data on factors modifying the EC risk in LS patients. Methods: The study cohort included 136 LS mutation-positive women. Exposure data were collected by postal questionnaires. Cox regression model was used to estimate the associations between lifestyle, hormonal, reproductive and medical factors and the risk of EC. Results: Increased EC risk was associated with type II diabetes and hypercholesterolaemia in univariable (HR 3.21, (95% CI 1.34–7.78), P=0.009 and HR 2.08, (95% CI 1.11–3.90), P=0.02; respectively) and with diabetes and duration of hormone replacement therapy (HRT) in multivariable analysis (HR 4.18 (95% CI 1.52–11.52), P=0.006 and HR 1.07 (95% CI 1.02–1.13), P=0.010; respectively). Conclusions: Prevention of diabetes and avoiding long-duration HRT are potential targets for reduction of EC risk in women with LS.

Aims: Cross-country comparisons of mortality and longevity patterns of Nordic populations could contribute with novel insights into the compositional changes of these populations. We investigated three metrics of population ageing: the proportion of the population aged 75+ and 90+ years, the proportion of birth cohorts reaching 75 and 90 years, and life expectancy (LE) at age 75 and 90 years in Sweden, Norway, Iceland, Denmark and Finland, in the period 1990–2014. Methods: Demographic information was collected from national statistical databases and the Human Mortality Database. Results: All metrics on population ageing increased during the study period, but there were some cross-country variations. Finland experienced a notably steep increase in the proportion of 75+ and 90+ year olds compared to the other countries. Regarding the proportion reaching old ages, the Finnish lagged behind from the beginning, but females decreased this difference. The Danes were more similar to the other countries at the beginning, but did not experience the same increase over time. Gender-specific LE at age 75 and 90 years was similar overall in the five countries. Conclusions: Developments in cross-country variation suggest that survival until old age has become more similar for Finnish females and more different for Danish males and females compared with the other countries in recent decades. This provides perspectives on the potential to improve longevity in Denmark and Finland. Similarities in LE in old age suggest that expected mortality in old age has been more similar throughout the study period.

ObjectivesThe time of death is increasingly postponed to a very high age. How this change affects the use of care services at the population level is unknown. This study analyses the care profiles of older people during their last 2 years of life, and investigates how these profiles differ for the study years 1996–1998 and 2011–2013.DesignRetrospective cross-sectional nationwide data drawn from the Care Register for Health Care, the Care Register for Social Care and the Causes of Death Register. The data included the use of hospital and long-term care services during the last 2 years of life for all those who died in 1998 and in 2013 at the age of ≥70 years in Finland.MethodsWe constructed four care profiles using two criteria: (1) number of days in round-the-clock care (vs at home) in the last 2 years of life and (2) care transitions during the last 6 months of life (ie, end-of-life care transitions).ResultsBetween the study periods, the average age at death and the number of diagnoses increased. Most older people (1998: 64.3%, 2013: 59.3%) lived at home until their last months of life (profile 2) after which they moved into hospital or long-term care facilities. This profile became less common and the profiles with a high use of care services became more common (profiles 3 and 4 together in 1998: 25.0%, in 2013: 30.9%). People with dementia, women and the oldest old were over-represented in the latter profiles. In both study periods, fewer than one in ten stayed at home for the whole last 6 months (profile 1).ConclusionsPostponement of death to a very old age may translate into more severe disability in the last months or years of life. Care systems must be prepared for longer periods of long-term care services needed at the end of life.

Background The use of long-term care (LTC) is common in very old age and in the last years of life. It is not known how the use pattern is changing as death is being postponed to increasingly old age. The aim is to analyze the association between the use of LTC and approaching death among old people and the change in this association from 2000 to 2011. Methods The data were derived from national registers. The study population consists of 315 458 case-control pairs. Cases (decedents) were those who died between 2000 and 2011 at the age of 70 years or over in Finland. The matched controls (survivors) lived at least 2 years longer. Use of LTC was studied for the last 730 days for decedents and for the same calendar days for survivors. Conditional logistic regression analyses were performed to test the association of LTC use with decedent status and year. Results The difference in LTC use between decedents and survivors was smallest among the oldest (OR 9.91 among youngest, 4.96 among oldest). The difference widened from 2000 to 2011 (OR of interaction of LTC use and year increased): use increased or held steady among decedents, but decreased among survivors. Conclusions The use of LTC became increasingly concentrated in the last years of life during the study period. The use of LTC is also common among the oldest survivors. As more people live to very old age, the demand for LTC will increase.

Variations across Finland in the use of six different long-term care (LTC) services among old people in their last 2 years of life, and the effects of characteristics of municipalities on the variations were studied. We studied variations in the use of residential home, sheltered housing, regular home care and inpatient care in health centre wards by using national registers. We studied how the use of LTC was associated with characteristics of the individuals and in particular characteristics of the municipalities in which they lived. Analyses were conducted with multilevel binary logistic regression. Data included all individuals (34,753) who died in the year 2008 at the age of 70 or over. Of those, 58.3% used some kind of LTC during their last 2 years of life. We found considerable variations between municipalities in the use of different kinds of LTC. A portion of the variation was explained by municipality characteristics. The size and location of the municipality had the strongest association with the use of different kinds of LTC. The economic status of the municipality and morbidity at the population level were poorly associated with LTC use, whereas old-age dependency showed no association. When individual-level characteristics were added to the models, these associations did not alter. Results indicated that the delivery system characteristics had an important effect on the use of LTC services. The considerable variation in LTC services also poses questions with respect to equity in access and to quality of LTC across the country.

e17113Background: Lynch syndrome (LS) is associated with a significant lifetime risk of endometrial cancer (EC) among mutation carrier women. Data are limited concerning the effect of the establish...