• Icelandic Nursing Home residents : Their mortality, health, functional profile, and care quality, using the Minimum Data Set over time

      Ingibjörg Hjaltadóttir; Landspitali The National University Hospital, Reykjavík, Iceland; Department of Health Sciences, Faculty of Medicine, Lund University, Sweden. (Lund University, Faculty of Medicine, 2012-01-27)
      The overall aim of this thesis was to investigate trends over time in residents‟ health status, functional profile and predictors of mortality at admission to Icelandic nursing homes and in addition to determine upper and lower thresholds for Minimum Data Set (MDS) Quality Indicators, to investigate the prevalence of quality indicators over time and their association with the health status and functional profile of residents in Icelandic nursing homes. Studies I and II included 2,206 persons assessed over 11 years (1996-2006). In study III a modified Delphi method and a panel of 12 members were used to determine the thresholds for Minimum Data Set Quality Indicators. Data from residents (N=2,247 representing 47 nursing homes) were analysed, applying the thresholds developed. In study IV the sample was 11,034 MDS assessments of 3,694 residents (2003-2009) and in the framework the sample was 11,912 MDS assessments of 3,704 residents (1999-2009). Study I showed that 28.6-61.4% of residents had intact cognitive performance and 42.5-68% were independent in ADL performance. A weak, but significant, linear trend over the eleven years was seen in residents' health becoming less stable, their cognitive performance improving, more pain being reported and greater participation in social activities. Study II showed that the median survival time was 31 months. No significant difference was detected in the mortality rate between cohorts. Age, gender (HR 1.52), place admitted from (HR 1.27), ADL functioning (HR 1.33-1.80), health stability (HR 1.61-16.12) and ability to engage in social activities (HR 1.51-1.65) were significant predictors of mortality. In study III upper and lower thresholds for 20 Minimum Data Set Quality Indicators were established. Residents not having a quality indicator present numbered from 32.5-99.3% depending on the indicator in question. The quality indicators with the median value above the upper threshold, indicating poor care, were: depression (49.4%); symptoms of depression without antidepressant (18.2%); use of 9 or more medications (63.8%); anti-anxiety or hypnotic drug use (69.2%); little or no activity (52.5%). Findings from study IV showed that 16 out of 20 quality indicators increased in prevalence, indicating a decline in quality of care (p< 0.05) over the study period. In 12 out of 20 indicators the prevalence was lower than 25%. One quality indicator showed improvement, i.e. „Bladder and bowel incontinence without a toileting plan‟ from 17.4% in 2003 decreasing to 11.5% in 2009 (p<0.001). Residents‟ health and functional status partially explained the increased prevalence of the quality indicators over time. At admittance many residents had a relatively high level of independence, the mortality rate did not change over the study period and health stability and ADL performance were strong predictors of mortality. More than 50% died within 3 years, and almost a third of the residents may have needed palliative care within a year of admission. Pain management, social engagement and palliative care are areas where more staff knowledge seems to be needed. The thresholds established aims for Icelandic nursing homes, uncovering areas of care requiring improvement. Icelandic nursing homes seem to be doing best in handling incontinence and nutritional care, and in several quality indicators the prevalence was quite low. The areas of care that indicated poor care and needed improvement included treatment of depression, number of medications and resident activity level. Quality Indicator results and trends over time can be used for improvement, planning of services and staff knowledge.
    • Users of hospital emergency department who are discharged home

      Oddný Sigurborg Gunnarsdóttir; Landspitali The National University Hospital, Reykjavík, Iceland. (2012-01-27)
      The overall aim of the studies was to determine characteristics and prognosis of Emergency Department users, who were discharged home. The specific aims were to record the annual number of discharged users of the ED according to age and gender, their annual number of visits and to assess whether a higher frequency of visits predicted higher mortality; to describe the pattern of discharged diagnoses; to evaluate the association of non-causative diagnoses with mortality in general, and in particular with external causes of death, drug intoxication and suicide; to evaluate risk factors for suicide and fatal drug poisoning; to evaluate the association between death within eight days after discharge home from the ED and non-causative discharge diagnoses. Material and Methods: The data were records of patients, 18 years and older, who attended the Landspitali ED during the years 1995 to 2001. The main diagnoses were registered according to the International Classification of Diseases (ICD). Annual increase in visits was evaluated in relation to the annual population of Reykjavik capital area using the Poisson regression model and 95% Confidence Interval (CI). The pattern of each diagnosis category during the period was analyzed by calculating chi-squares for the linear trend (Mantel extension). Patients’ vital status was obtained by record linking to Statistics Iceland. The mortality of ED users was compared with the mortality of the general population of Iceland using conventional methods of calculating the standard mortality ratio (SMR) and 95% CI. The Hazard ratios (HR) and 95% CI were calculated for all causes and selected causes of death in a time-dependent analysis in which annual visits to the ED were taken into account. Furthermore, the same method was used when comparing groups with different diagnoses at discharge. In the case control studies the discharged diagnoses of mental disorders, use of alcohol, drug intoxication, non-causative diagnoses and factors influencing health status were risk factors for suicide and fatal drug poisoning, and were calculated in a multivariate logistic regression analysis. The adjusted Odd ratio (OR) and exact computation of 95% CI were calculated. Deaths within 8, 15 and 30 days among individuals with a non-causative diagnosis were compared with deaths among those with a causative diagnosis. HR and 95% CI were computed for all causes of death in a time-dependent analysis. Results: Of all visits to the ED in the year 1995, 2,888 or 54.5% resulted in discharge and of all visits in the year 2001, 5,604 or 72.5% resulted in discharge. Discharged patients in total over the study period numbered 19,259 and they made 30,221 visits, with visits by women slightly more frequent than by men. About 84% of users made one visit in a calendar year and 1.5% of users made four or more visits per calendar year. The annual increase of visits to the ED was 7% to 14% depending on the age group, with the highest increase among older men. The most frequent diagnostic category was non-causative diagnoses (R00-R99), accounting for 20% average, and increasing over the period. SMR for all causes of death was 1.81 (95% CI, 1.71 to 1.92) for men and 1.93 (95% CI, 1.81.to 2.05) for women. For patients with non-causative diagnoses, SMR for all causes of death was 1.57 (95% CI, 1.39 to 1.77) for men and 1.83 (95% CI, 1.61 to 2.08) for women; furthermore, for those diagnosed with mental disorders, SMR was 3.72 (95% CI, 2.72 to 4.98) for men and 2.45 (95% CI, 1.76 to 3.36) for women. The most common causes of death were malignant neoplasm, ischemic heart diseases, cerebrovascular disease, and the category of chronic lower respiratory diseases; by adding the category of external causes, these accounted for over 73% of the overall deaths, a total of 2,105. HR for all causes of death was 1.4 (95% CI, 1.2 to 1.5) among patients with two visits in a calendar year and 1.7 (95% CI, 1.4 to 2.0) among those with three or more visits in a calendar year. Comparing those with non-causative diagnoses to those having causative physical diagnoses, the HR for all causes of death was 0.84 (95% CI, 0.76 to 0.93). On the other hand, the HR for the category of external causes was 1.64 (95% CI, 1.07 to 2.52); HR for accidental poisoning was 1.51 (95% CI, 0.56 to 4.08); and the HR for suicide was 2.08 (95% CI, 1.02 to 4.24), all adjusted for age and gender. The OR for suicide among cases and controls was 7.84 (95% CI, 1.66 to 37.06) for patients with mental disorders, 96.89 (95% CI, 11.14 to 843) for those with use of alcohol, 24.51 (95% CI, 6.11 to 98.25) for those with drug intoxications and 2.69 (95% CI, 1.04 to 6.95) for those with non-causative diagnoses. The OR for fatal drug poisoning among cases and controls was 12.26 (95% CI, 2.10 to 71.76) for patients with use of alcohol, 37.22 (95% CI, 3.57 to 388.29) for those with drug intoxications, 5.76 (95% CI, 1.23 to 26.95), for those with factors influencing health status. The HR for non-causative diagnoses was 0.44 (95% CI, 0.20 to 0.96) for death within eight days when compared to causative diagnoses, adjusted for gender and age. Conclusion: There was an increase in visits to the ED in relation to the population of the Reykjavik capital area and this increase contributed to an increased burden at the ED. The most frequent diagnoses were non-causative diagnoses. Number of visits predicted higher mortality. The most common causes of death were due to malignant neoplasm, ischemic heart diseases, cerebrovascular diseases, chronic lower respiratory diseases, and external causes. Mortality was higher among ED users than in the general population. Users with non-causative diagnoses had higher mortality due to external causes, accidental poisoning, and suicide. Frequent visits to the ED were a strong risk factor for suicide and fatal drug poisoning . The discharged diagnoses of mental disorders, alcohol use, drug intoxication and non-causative diagnoses were independent risk factors for suicide. The discharge diagnoses of alcohol use, drug intoxication and factors influencing health status were independent risk factors for fatal drug poisoning. Health professionals at EDs should be careful when users have a number of discharged visits and they need to be aware that patients who have been discharged home present with new risk factors for suicide and fatal drug poisoning. The association of non-causative diagnoses with death within eight days after discharge can be used to evaluate the performance of the ED.
    • Symptoms and quality of life : a cross-sectional, descriptive, correlation study, evaluating the relationship between symptoms and quality of life in patients on opioids with advanced cancer [M.S. Thesis]

      Sigríður Gunnarsdóttir; Sigríður Zoëga (University of Iceland, Faculty of Nursing, 2008-10)
      B A C K G R O U ND : Cancer patients experience multiple symptoms that affect their quality of life (QOL). Cancer related symptoms may be caused by the disease itself or its treatment, but factors like age, gender, and concurrent diseases may also influence the symptomatology. The symptoms-quality of life model shows the relationship between symptoms and QOL in cancer patients. G O A L OF P R O J E C T: To review the literature on quality of life and symptomatology among cancer patients, to pull together a model that explains the relationship between symptoms and quality of life and to test selected aspects of the model. P A R T I C I P A N T S: 150 cancer patients on opioids, 62 (41%) men and 88 (59%) women, all Caucasians. The patients ranged in age from 20-92 years with a mean (SD) age of 64,7 (12,7) years. R E S E A R C H D E S I G N: Descriptive, cross-sectional, and correlational. R E S U L T S: The mean (SD) number of symptoms in the past 24 hours was 6,2 (2,5), and 9,0 (3,3) in the past week. The most common symptoms were fatigue, pain, and weakness. Mean (SD) symptom severity was 0,7 (0,4) in v the past 24 hours and 0,9 (0,5) in the past week on a scale from 0-3. Gender and concurrent diseases were not related to number of symptoms, symptom severity or QOL, but increased age was associated with fewer symptoms and less symptom severity although age difference was not found for global health/QOL score. Adjusted for age and gender, number of symptoms explained 25,8% of the variance in global health/QOL. Also adjusting for age and gender, pain, fatigue, insomnia, and depression explained 33,6% of the variance in global health/QOL. C O N C L U S I O N: The symptomatology of Icelandic cancer patients is similar to cancer patients in other countries. Number of symptoms and the individual symptoms of pain and notably fatigue are associated with diminished QOL. Surprisingly insomnia and depression did not add significantly to the regression model. These results indicate that QOL of cancer patients may be improved by assessing and treating cancer related symptoms.
    • Cognitive development in adult children of Alzheimer’s patients : a neuropsychological reassessment: 7 year follow up [M.S. Thesis]

      Gade, Anders; Magnús Jóhannsson; Landspítali University Hospital, Psychiatric department (2008-08)
      Previous studies on first-degree relatives of Alzheimer’s disease (AD) patients have revealed a higher risk of developing dementia, and that subtle cognitive impairment can be detected before overt clinical signs appear using neuropsychological tests. Findings on children of AD patients are very scarce within the literature. The main aim of this study was to explore the cognitive development of adult children (AC) of AD patients in Icelandic pedigrees selected from an ongoing genetic research, over a seven-year period. The subjects were 83 AC (age range 46-74) with a family history of AD and a control group (NC) constituting 30 individuals (age range 48-73) without any known first-degree relative with dementia. Cognitive abilities were assessed using neuropsychological tests of orientation, verbal and non-verbal memory, abstract reasoning, language, concentration, mental speed, and visuo-spatial and constructional abilities. Participants with known central or peripheral nervous disorders were excluded from the study. Primary results revealed no statistical difference between the two groups on any of the neuropsychological tests from time 1 to time 2, over a seven year period. These findings place the onset of subtle cognitive impairments in adult children of AD patients after the age of 60 years. When comparing the AC group to 76 AD patients and 92 siblings of AD patients, participating in the genetic study, one AC had stronger resemblance to the AD group than other AC on the neuropsychological measures. Furthermore, 10% of the AC group had stronger resemblance to the siblings of AD patient in the neuropsychological measures than the rest of the group, indicating a possible trend within the AC group.
    • A measure of cognitive vulnerability : development and validation of the Anxiety Attitude and Belief Scale [PhD Thesis]

      Solveig E. Jónsdóttir (2008-07)
      The cognitive model of emotional disorders has inspired considerable research effort, much of it self-report and questionnaire-based. This methodological focus has been criticized on several grounds and poses a challenge for those attempting to index relevant cognitive constructs. The aim of the study described here is to further develop and validate the Anxiety Attitude and Belief Scale-Revised (AABS-R). The measure was designed to index attitudes and beliefs that may represent a cognitive vulnerability to anxiety problems. The development of the scale involved an emphasis on avoiding confounding with affect, thus averting some of the criticisms of self-report cognitive measures. First, construct validation through cognitive interviewing was undertaken. Four undergraduate students completed 53 questions on the AABS-R while thinking aloud. The ensuing verbal protocols were coded by a blind rater according to the specific cognitive processes participants engaged in. Results indicated that items generally tap into cognitive rather than affective processes. Subsequently, the reliability, psychometric properties and validity of the scale were investigated in an online anxiety disorder support group and student sample. Participants (N = 346) completed an online battery of tests, which included the AABS-R as well as criterion measures. Exploratory factor analyses suggested the existence of five factors, which index domains of theoretical interest. The final 33-item measure total and factor scores demonstrated adequate internal consistency. A correlational analysis was consistent with convergent, but only partly with the discriminant validity of the AABS-33. As predicted, the AABS-33 appears to be a reliable, valid and potentially clinically useful index of anxiety vulnerability, which may overcome the shortcomings of well-established anxiety measures. The findings are discussed within the broader literature on cognitive theory and its’ operationalization, ‘transdiagnostic processes’ and notions of validity.
    • The efficiency of acupuncture for nulliparas in actuating cervical ripening and spontaneous labour after 41 weeks (± 2 days) of normal pregnancy: Pilot study [M.S. Thesis]

      Helga Gottfreðsdóttir; Anna Sigríður Vernharðsdóttir (University of Sheffield, 2008-06)
      B A C K G R O U N D - Acupuncture is an ideal treatment alternative during pregnancy labour and birth as there are no severe side effects. Many studies report benefits of the use of acupuncture in actuating cervical ripening and spontaneous labour but its effectiveness needs to be assessed further. - O B J E C T I V E - This study serves as a pilot study for a future clinical trial that will evaluate the efficiency of acupuncture in actuating cervical ripening and spontaneous labour after 41 weeks (± 2 days) of normal pregnancy. - M E T H O D S - Healthy nulliparous women at 41 weeks (± 2 days) with a singleton normal pregnancy were randomized to either an acupuncture or control group. The control group received no treatment. The acupuncture group received one or two sessions of treatment: the first treatment at 41 weeks (±2 days) and the second at 41 weeks and 5 days (± 2 days), if they were not yet in spontaneous labour. Each acupuncture treatment consisted of four needles applied to the bilateral points Hegu (LI4) and Sanyinjiao (SP6). Cervical status was assessed using the modified Bishop score. The primary outcomes were: (1) the mean time from randomization to onset of the active phase of labour; (2) the incidences of medical inductions; and (3) ripening of the cervix from 41 weeks (± 2 days) to 41 weeks and 5 days (± 2 days). Secondary 10 outcomes included rates of Caesarean section, duration of labour and use of oxytocin during labour. As this was a pilot study, it was considered sufficient to have 16 participants in the study, eight in the acupuncture group and eight in the control group. - R E S U L T S - Sixteen women were randomized and completed the study procedure. No statistical difference in primary or secondary outcome was noted. - C O N C L U S I O N - As a pilot study, the sample size is small and no statistically significant results are presented. Data collection tools were reliable and no major practical difficulties were encountered. Some changes in the research plan for a future study are suggested. According to the study data, the intervention is probably of small effect size and therefore a large sample will be required to test the effectiveness of this intervention in a future clinical trial.
    • Respiratory movement measuring instrument : reliability, reference values and clinical utility [PhD Thesis]

      María Ragnarsdóttir (University of Iceland, Faculty of Medicine, 2008)
      Methods to evaluae respiratory function such as inspection, palpation, tape measurements, auscultation, chest radiographs and lung volume measurements have been used for a long time. During the last decades several additional evaluation methods have emerged measuring for example respiratory muscle strength and movements. However, few instruments measuring real time bilateral respiratory upper thoracic, lower thoracic and abdominal movements are available and none measuring simultaneously all variables of the respiratory movement pattern. The aims of the studies were to develop an instrument to measure respiratory movements and test its reliability. The instrument, Respiratory Movement Measuring Instrument (RMMI), was developed at the Bioengineering Department at Landspitali University Hospital according to the ideas of the author. Furthermore, to collect reference values for the instrument and investigate its usefulness in clinical practice. The RMMI was used to measure respiratory motion among two groups of healthy individuals in order to obtain reference values and test the reliability of the measurements. To test the clinical usefulness, a group of patients with ankylosing spondylitis (AS) and patients undergoing cardiac surgery (pre- and postoperatively) were studied. Respiratory motion, and lung volumes were measured and abnormal signs on chest radiographs rated among the cardiac surgery patients pre-operatively and one, 12, and 52 weeks postoperatively. Respiratory movements did not decrease significantly with increasing age from 20 to 69 years. The only significant gender difference was that the men had significantly greater abdominal motion during deep breathing. Separate reference values are therefore presented for males and females. Correlations of respiratory movements measured on two consecutive days was strong for both quiet and deep breathing. The AS patients had significantly reduced upper thoracic movements compared with reference values. The cardiac surgery patients had highly significantly reduced average lung volumes, abdominal and lower thoracic movements and showed one or more abnormal sign on a chest radiograph one week post-operatively. Twelve weeks after the operation average abdominal movement was still significantly reduced, but upper thoracic movement had increased. One year after the operation abdominal movement had still not fully recovered but average upper thoracic movement was significantly increased. When the cardiac surgery patients were divided into Mediangroup and IMA-group according to surgical procedure, abdominal motion was significantly more reduced among the IMA-group 12 weeks post-operatively. Both groups had symmetrical abdominal motion pre-operatively, but significantly asymmetrical among the IMA-group 12 week post-operatively. Both groups had symmetrical abdominal movements 52 weeks post-operatively, but the IMA-group had significantly reduced abdominal movements. Abdominal movements were still significantly decreased compared with pre-operative values one year after cardiac surgery. The RMMI is a reliable instrument and is easy to use in clinical practice for measuring respiratory movement and respiratory movement pattern.
    • Use of antimicrobials and carriage of penicillin-resistant pneumococci in children : repeated cross-sectional studies covering 10 years [PhD Thesis]

      Vilhjálmur Ari Arason (Háskólaútgáfan, 2006-10-01)
      Objectives: The overall aim of this thesis was to analyse the use of antimicrobials in pre-school children in Iceland and the connection between such use and the carriage of penicillin-nonsusceptible pneumococci(PNSP). Study populations and methods: Prescription data and medical histories from 2,612 children, aged 1 to 6 years, living in different geographically welldefined study areas in Iceland, and nasopharyngeal specimens from 2,486 children were analysed in three crosssectional studies covering 10 years (Phase I 1993, II 1998, and III 2003). Participation varied from 75% to 88%. Annual analysis of oral antimicrobial sales/prescriptions for whole communities (hospital use excluded) were based on 22,132 prescriptions in 1993, and 15,153 in 1998. Main outcome measures: The prevalence and risk factors for nasopharyngeal carriage of PNSP, total antimicrobial use, antimicrobial use for acute otitis media (AOM), parental expectations and tympanostomy tube placements. Results: • Antimicrobial prescription rates among GPs diminished by about 1/3 over the study period. Prescription habits varied greatly between communites especially because of AOM. • Parents’ expectations of antimicrobial prescriptions were associated with the antimicrobial prescription rate in each area. • The cumulative prevalence of tympanostomy tube placement among pre-school children is high in Iceland (over 30%). In vi areas where the prescription rate was high, broad-spectrum antimicrobials were prescribed relatively more often than in other areas, and the tympanostomy tube placement rate was increasing (up to 44% of all children). In other areas, tympanostomy tube rate among children deceased (down to 17%) at the same time as antimicrobial use for AOM diminished. • There was a strong association between antimicrobial use on the individual level and the nasopharyngeal carriage of PNSP. • PNSP, multiresistant, serotype 6B (phenotypically identical to the Spain6B-2 clone) appeared and disappeared over a 10-year period, in communities with both high and low antimicrobial use. Conclusions: There is a strong association between antimicrobial use for individual children and the nasopharyngeal carriage of PNSP. Pneumococcus is acquired from other children, usually in day-care settings and PNSP selectively colonised when receiving antimicrobials. Spread of novel resistant clones appears to be the main reason for marked changes in pneumococcal resistance rates in individual communities over time. Antimicrobial drug (over)use for AOM my be associated with future episodes of AOM and tympanostomy tube placements.
    • ADHD and its relationship to comorbidity and gender [PhD Thesis]

      Sólveig Jónsdóttir; Rijksuniversiteit Groningen, Groningen, The Netherlands (ÍslandsprentRijksuniversiteit Groningen, Groningen, The Netherlands, 2006)
      Attention deficit hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder of childhood and constitutes approximately 50% of referrals to child and adolescent mental health clinics. The disorder is associated with negative impact on families and both academic and vocational outcomes. Estimated prevalence is approximately 3%- 7% in school-age children according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), published by the American Psychiatric Association in 2000, but rates of ADHD vary depending on race and ethnicity, gender, and age. Diagnostic rates are on the increase with accompanying financial burden to health care services.
    • Studies on child and adolescent mental health in Iceland [PhD Thesis]

      Helga Hannesdóttir (Turku : Turun Yliopiston, 2002)
      Epidemiology investigates the distribution of disease / physiological function in human populations and related factors (Lilienfeld 1976). The field of child psychiatric epidemiology has existed for over 42 years but for many years lacked generally accepted definitions of the various child disorders needed for epidemiological studies. Child psychiatric epidemiologic studies create a framework for the development of academic standards, the facilitation of research and monitoring of training. This information is important in order to be able to plan a national mental health program for children in Iceland and to increase the interest of the academic medical community in child and adolescent psychiatry. The first study in Iceland on the epidemiology of child mental health was undertaken in Reykjavík (Björnsson, 1974). The results of that study showed that the percentage of severely mentally disordered children ranged from 11.8%-30.8%, depending on their syndromes. No significant gender effects were found. Iceland is a Nordic country with a child population ages 0-18 of 82.188 (December 2000). This collection of papers has been compiled at a time of accelerating change for those working in the field of child mental health. No earlier studies on the prevalence of child psychiatric symptoms in the general population of the whole country has been carried out before. There has been little research in child and adolescent psychiatry and communication has mainly been within and between teams rather than with similarly trained colleagues. The taxonomy and methods of assessment have improved dramatically in the past decade (1990-2000) thus providing a possibility to study the prevalence of child and adolescent psychiatric symptoms in a valid and reliable way.