No abstract

Substitution among the providers of old-age care has usually meant a process whereby the state ‘takes over’ what families used to do, but during the 1980s and 1990s, both home help and institutional care were cut back substantially in Sweden as elsewhere. Comparable, nationally representative surveys in Sweden of the provision of care for older people living in the community enable analysis of the effects of these cutbacks on the sources and patterns of care. It emerges that increased inputs from families match the decline of public services, that is, a ‘reverse’ substitution has recently been taking place. Local studies, of older people who have been followed over time as the provision of home help has changed, support these conclusions. Of the increased informal care, most has been provided by daughters, but sons have also contributed. A problematic aspect of these shifting patterns of care is that an increasing number of family carers with increasingly heavy care commitments are now without formal or informal support, whereas in the recent past many could expect their responsibilities to be shared with the state. The evidence from this study also calls into question common metaphors and assumptions about the assumed interdependence between informal care and public services for older people, and challenges the so-called substitution thesis.

Background: In 1992, local municipalities in Sweden took over full responsibility for the long-term care of elderly. This has led to an increased care burden for the various assisted accommodation services run by the municipalities. Objective: Since ageing and chronic diseases are risk factors for protein-energy malnutrition, we evaluated the nutritional status of all individuals in assisted accommodation, i.e., service flats (SF), old people’s homes (OPH), group living for the demented (GLD), and nursing homes (NH), in three Swedish municipalities. Methods: Of 994 eligible subjects, 872 were examined; the average age was 84.5 ± 8 years, and 69% were female. The Mini Nutritional Assessment (MNA) scale (0–30 points) was used, consisting of 18 point-weighted questions in four categories, i.e., anthropometry, global and dietary issues, and self-assessment. Results: MNA <17, i.e., malnutrition, was noted in 36% of the study population. Divided according to accommodation type, the MNA scores were <17 in 21% of individuals in SF, 33% of those in OPH, 38% of those in GLD, and 71% of those in NH. The corresponding values for MNA scores 17–23.5 (risk for malnutrition) were 49, 51, 57, and 29%, respectively. Average body mass index (BMI) values were 24.2 ± 5 (SF), 23.6 ± 5 (OPH), 23.9 ± 4 (GLD), and 22.3 ± 4 (NH). BMI values ≤20 were found in 18% of those in SF, in 25% of those in OPH, in 19% of those in GLD, and in 33% of those in NH. Both MNA and BMI correlated with upper arm and calf circumference, with r values ranging from 0.4 to 0.7 (p < 0.001). MNA and BMI correlated significantly (r = 0.52, p < 0.001). Age correlated with MNA and BMI with r values of 0.1 (p < 0.01) and 0.14 (p < 0.001), respectively. Subjects with signficant help requirements during meals ate fewer whole meals per day than those who could feed themselves. Conclusions: Based on the MNA, one third of the study subjects living in assisted accommodation, and more than half of those living in NH, appeared to be malnourished. Further studies are necessary to assess to what extent these nutritional disturbances are reversible.

Background: Elderly receiving public services and care are often frail, suffer from chronic diseases, and sustain a high risk for malnutrition. Objective: To evaluate nutritional status and long-term outcome in elderly living at home. Methods: Of 507 eligible subjects receiving home care in five Swedish municipalities, we examined 353 (age 82 ± 7 years, 64% females). The subjects were interviewed, and the nutritional status was assessed by means of the Mini Nutritional Assessment (0–30 points; the lower the score, the greater the risk). The Mini Nutritional Assessment consists of 18 questions concerning, e.g., anthropometry (body mass index or BMI; kg/m²) and global and dietary issues. The mortality was evaluated in 224 study participants after a 3-year period. In one municipality, 31 of 64 elderly were reexamined after 3 years. Results: 8 and 41% of the elderly were assessed as malnourished or at risk of malnutrition, respectively. BMIs <20 and <23 were found in 12 and 31% of the subjects, respectively. Chewing and swallowing problems and reduced appetite were more often reported by those at risk of being malnourished compared with the well-nourished study participants (p < 0.001). Meals-on-wheels services were given to one third, of whom 66% used one portion for several meals. The 3-year mortality was 50% for those who were malnourished, 40% for those at risk of malnutrition, and 28% for the well-nourished group (p < 0.05). The corresponding mortality was 50% for subjects with a BMI <20, 35% for those with BMIs 20–28, and 27% for those with a BMI >28 (p = 0.05). After 3 years, a weight loss of 4.0 ± 5.8 kg was registered (p < 0.001). Conclusions: About half of the home-living elderly with public support were malnourished or were at risk of malnutrition. The malnourished subjects often had problems during mealtimes and seldom ate full meals. Elderly with a BMI >28 displayed the lowest risk of death within 3 years.

The results parallel a crisis of legitimacy of public elderly care in Sweden. They also call into question various metaphors used to describe patterns of care.