Susanne Kelfve

Background: The involvement of older adults in research on digital health is uneven with respect to, for example, age, gender, health status, and digital skills. However, little is known regarding the effect of the uneven involvement of older adults in digital health research on researched outcomes. This study helps to fill this knowledge gap, identifies the effects of uneven involvement of older adults in digital health research on researched outcomes, and also develops a correction for this. Methods: Data are retrieved from a digital health intervention for postoperative monitoring of people who underwent day surgery in Sweden. Based on field information on the recruitment process and researched outcomes for the intervention, this study (i) tested intervention effects by using 2 standard unweighted procedures in a sample of 281 individuals aged 50 years or older, and then (ii) used the information on participants, nonparticipants, and their respective probabilities to be involved in the intervention study to perform a weighting of the intervention effects for each step of selection and for the study group membership. Results: The intervention effects were found to be overestimated due to overrepresentation of groups that gained from receiving the intervention. No intervention effects were found after adjustment for participation bias. Conclusions: Selective participation of older adults in digital health research biases research outcomes and can lead to overestimation of intervention effects. Weighting allows researchers to correct and describe the effect of selective participation on researched outcomes.

Participation of older workers in the labor market depends, among other things, on older workers employment chances. This study examines age differences regarding risk of unemployment and reemployment outcomes in late working life in Sweden. Using Swedish registry data, we analyzed the probability of unemployment as well as work-related activity following unemployment (wage- or self-employment; exit; downward mobility) of all people born between 1954 and 1968 (aged 49-63) and registered in Sweden between the years 2012 and 2018. Results show that although risk of unemployment does not differ significantly across age groups, younger age groups are more likely to be reemployed as wage-employed while older age groups are more likely to be reemployed as self-employed or exit working life. After an unemployment period, older employees are more likely to have a lower wage than during their previous employment or become part-time unemployed. We conclude that different age groups have unequal chances in late working life in terms of reemployment, risk of exit, and risk of downward mobility following unemployment. Policies for extending working life and promoting inequality should include measures for increasing employability of older workers such as anti-discriminatory laws and dealing with skills mismatch.

Aims: There is substantial evidence that previous working conditions influence post-retirement health, yet little is known about previous working conditions’ association with old-age dependency. We examined job strain, hazardous and physical demands across working life, in relation to the risk of entering old-age dependency of care. Methods: Individually linked nationwide Swedish registers were used to identify people aged 70+ who were not receiving long-term care (residential care or homecare) at baseline (January 2014). Register information on job titles between the years 1970 and 2010 was linked with a job exposure matrix of working conditions. Random effects growth curve models were used to calculate intra-individual trajectories of working conditions. Cox regression models with age as the timescale (adjusted for living situation, educational attainment, country of birth, and sex) were conducted to estimate hazard ratios for entering old-age dependency during the 24 months of follow-up ( n = 931,819). Results: Having initial adverse working conditions followed by an accumulation throughout working life encompassed the highest risk of entering old-age dependency across the categories (job strain: HR 1.23, 95% CI 1.19–1.27; physical demands: HR 1.36, 95% CI 1.31–1.40, and hazardous work: HR 1.35, 95% CI 1.30–1.40). Initially high physical demands or hazardous work followed by a stable trajectory, or initially low-level physical demand or hazardous work followed by an accumulation throughout working life also encompassed a higher risk of dependency. Conclusions: A history of adverse working conditions increased the risk of old-age dependency. Reducing the accumulation of adverse working conditions across the working life may contribute to postponing old-age dependency.

There is a gap in knowledge about factors associated with the duration of late life dependency. In this study, we measured how the age at onset of late life dependency relates to the time spent with late life dependency. Using Swedish register data, we identified people 70 + who entered the period of late life dependency (measured by entering long-term care for help with PADLs) between June and December 2008. We followed this cohort (n = 17,515) for 7 years, or until death. We used Laplace regression models to estimate the median number of months with late life dependency by age group, gender, level of education and country of birth. We also calculated the crude percentiles (p10, p25, p50, p75 and p90) of month with late life dependency, by age group, gender and cohabitation status. Results show that the majority spent a rather long period with dependency, the median number of months were 40.0 (3.3 years) for women and 22.6 (1.9 year) for men. A higher age at entry was associated with a shorter duration of dependency, an association that was robust to adjustment for cohabiting at baseline, gender, education and country of birth. Our results suggest that older adults who postpone the start of dependency also compress the time with dependency, this lends support to the ambitions of public health initiatives and interventions targeting maintained independence in older adults.

Based on Swedish National Registry Data, this paper investigates the social structure of exclusion risks in late working life in Sweden by analyzing exit from working life, employment breaks, and late employment trajectories according to gender and education. Individuals born in 1950 (n = 107,830) are followed between the years 2010 and 2018. Results show that women with low education exit working life earlier and have a higher risk of employment breaks due to reduced working ability, while men with low education have a higher risk of employment breaks due to unemployment. Men in general and people with high education have a higher probability of moving to self-employment in late working life. We conclude that research and social policies require an understanding of multifarious late work trajectories to unearth the inequality of exclusion risks in the late phases of working life and the potential for interventions towards equal and inclusive prolongation.

Dementia is a non-curable disease that progressively affects people’s ability to handle their everyday life. Still, previous Swedish research found that many people living with dementia (PlwD) do not use any eldercare. In this study, we investigated the association between not using eldercare services and key social background factors: years with dementia, hospital care, and country of birth for PlwD. We identified all people aged 65+ diagnosed with dementia between January 2006 and March 2015 (n = 43,372) using secondary data analysis of information taken from multiple Swedish nationwide registers. Results showed that not using eldercare was more common among younger age groups and men. The likelihood of having no eldercare was three times higher for those cohabiting; notably, almost a fifth of the PlwD who had the diagnosis for four years or more did not have eldercare at all. Finally, people born outside Europe used eldercare less than persons born in Sweden. Since the public dementia policy in Sweden is basically geared toward PlwD in a later stage and primarily in residential care, there has been almost no policy development around the needs and rights of PlwD in their homes. This study provides a ground for reconsidering dementia policy regardless of the ethnic and cultural backgrounds of PlwD.

Background: Due to population aging, it is essential to examine to what extent rises in life expectancy (LE) consist of healthy or unhealthy years. Most health expectancy studies have been based on single health measures and have shown divergent trends. We used a multi-domain indicator, complex health problems (CHP), indicative of the need for integrated medical and social care, to investigate how LE with and without CHP developed in Sweden between 1992 and 2011. We also addressed whether individuals with CHP more commonly lived in the community in 2011 compared to earlier years. Methods: CHP were defined as having severe problems in at least two of three health domains related to the need for medical and/or social care: symptoms/diseases, cognition/communication, and mobility. The Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD), a nationally representative survey of the Swedish population aged ≥ 77 years with waves in 1992, 2002 and 2011 (n≈2000), was used to estimate the prevalence of CHP. Age- and gender-specific death rates were obtained from the Human Mortality Database. The Sullivan method was deployed to calculate the remaining life expectancy with and without CHP. The estimates were decomposed to calculate the contribution of changes from morbidity and mortality to the overall trends in LE without CHP. Results: Between 1992 and 2011, both total LE (+ 1.69 years [95% CI 1.56;1.83] and LE without CHP (+ 0.84 years [-0,87;2.55]) at age 77 increased for men, whereas LE at age 77 increased for women (+ 1.33 [1.21;1.47]) but not LE without CHP (-0.06 years [-1.39;1.26]). When decomposing the trend, we found that the increase in LE with CHP was mainly driven by an increase in the prevalence of CHP. Among individuals with CHP the proportion residing in care homes was lower in 2011 (37%) compared to 2002 (58%) and 1992 (53%). Conclusions: The findings, that an increasing number of older people are expected to live more years with CHP, and increasingly live in the community, point towards a challenge for individuals and families, as well as for society in financing and organizing coordinated and coherent medical and social services.

Much research is conducted to evaluate digital-based solutions for health-care services, but little is known about how such evaluations acknowledge diversity in later life. This study helps fill this gap and analyses participation in the evaluation of a web-based mobile phone system for monitoring the post-operative progress of patients after day surgery. Participation is conceptualised as resulting from three processes: pre-screening, recruitment and self-selection. Based on field information and survey data, this study models (a) the (non-)participation in a sample of 498 individuals aged 60 and older that includes non-screened, non-recruited, decliners and participants in the evaluation, and (b) the individual decision to participate in a sample of 210 individuals aged 60 and older who were invited to take part in the evaluation. Increasing age enhances the likelihood of not being screened, not being recruited or declining the invitation. Those not recruited were most often ineligible because of technology-related barriers. Decliners and participants differed by age, gender, job, health status, digital skills, but not by social participation. Results suggest that highly specific groups of older people are more likely to be involved than others. Old-age diversity is not properly represented in digital health research, with implications for the inclusivity of new digital health technologies. This has implications for increased risks of old-age exclusion and exacerbation of social and digital inequalities in ageing societies.

Background: In old age, many people experience a period of functional decline and require long-term care. Sweden has a universal largely tax-financed health and social care system that is used by all societal groups. However, few studies have investigated if educational groups use publicly paid long-term care equitably. The aim of this study was to explore educational differences in the use of long-term care, including both home care and institutional care, during the last two years of life in Sweden. Methods: We used linked register data on mortality and long-term care use, including all adults aged ⩾67 years who died in Sweden in November 2015 (N=6329). We used zero-inflated negative binomial regression models to analyse the number of months with long-term care by educational level, both crude and adjusted for age at death and cohabitation status. Men and women were analysed separately. Results: People with tertiary education died more commonly without using any long-term care compared to primary educated people (28.0% vs. 18.6%; pConclusions: Older adults spend considerable time in their last two years of life with long-term care. Only minor educational differences in long-term care use remained after adjustment for cohabitation status and age at death. This suggest that Sweden’s publicly financed long-term system achieves relatively equitable use of long-term care at the end of life.