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Objective: This study aimed to evaluate the efficacy of integrated multidomain interventions and primary health care on intrinsic capacity (IC) and related biomarkers., Design: An ancillary analysis from the Taiwan Integrated Geriatric Care (TIGER) study: a randomized controlled trial., Setting and Participants: A total of 398 community-dwelling older adults aged ≥65 years with ≥3 chronic conditions., Methods: Participants were randomized into the 12-month pragmatic multidomain intervention or usual care groups. The primary outcome was the change in IC and its subdomains (locomotion, cognition, vitality, psychological, and sensory) at baseline and 3-, 6-, 9-, and 12-month follow-ups. Generalized linear mixed models were used to evaluate the multidomain intervention effects on these changes., Results: The intervention arm had greater improvement in IC than the usual care arm (overall difference 1.5; 95% CI 0.5-2.5; P = .005), mainly from subdomains of locomotion (overall difference 1.4; 95% CI 0.5-2.4; P = .004) and cognition (2.9; 95% CI 2.1-3.7; P < .001). Changes in neutrophil-to-lymphocyte ratio (NLR -2.4; 95% CI -3.9 to -0.8, P = .003), serum levels of albumin (35.1; 95% CI 23.1-47.2; P < .001), dehydroepiandrosterone sulfate (DHEA-S 2.8; 95% CI 1.9-3.8; P < .001), free androgen index (FAI 1.5; 95% CI 1.1-1.9; P < .001), and vitamin D (4.0; 95% CI 2.0-6.1; P < .001) were associated with changes in IC over time., Conclusions and Implications: The incorporation of multidomain interventions into primary health care significantly enhanced IC over the 12-month program. Changes in NLR, FAI, and serum levels of albumin, DHEA-S, vitamin D were associated with changes in IC over time., Trial Registration: ClinicalTrials.gov Identifier: NCT03528005., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Cognitive impairment (COIM) is a major challenge for healthcare systems and is associated with an increased risk of adverse outcomes in older people visiting emergency departments (EDs). Owing to global aging, both cognitive screening and comprehensive geriatric assessment (CGA) application in ED settings are developing areas of geriatric emergency medicine. Meanwhile, the association between clinical outcomes of COIM; cognitive impairment, no dementia (CIND); and dementia in the ED could be better investigated. Our study aims to identify individuals with COIM from older patients in the ED via CGA and to describe the association of CIND and dementia with prognosis in ED visits., Methods: A prospective cross-sectional study was conducted in the ED of the Taipei Veterans General Hospital, a medical center located in Taipei, Taiwan, from August 2018 to November 2020. Patients aged ≥75 years with and without COIM were compared using data obtained from the CGAs conducted by trained nurses., Results: A total of 823 older patients were enrolled in the study and underwent CGA. Of these, 463 (56.3%) were diagnosed with COIM, of which 292 (35.5%) were diagnosed with dementia; and 171 (20.8%), CIND. Between the no-COIM and COIM groups, the COIM group had a higher rate of hospital admission (p = 0.002) and mortality at 3 months (p < 0.05). Among the no-COIM, CIND, and dementia groups, ED disposition (p = 0.001) and the rate of revisit/readmission (p < 0.05) showed significant differences. In particular, the dementia group had a significantly higher rate of revisit/readmission as compared to the CIND group among the three groups., Discussion/conclusion: Older patients with COIM had a higher rate of hospital admission and mortality at the 3-month follow-up than older patients without COIM. Among the no-COIM, CIND, and dementia groups, patients with dementia had significantly increased risks of hospital admission and revisit/readmission. The early detection of COIM, and even dementia, could help ED physicians formulate strategies with geriatric specialists to improve mortality outcomes and revisit/readmission., (© 2022 S. Karger AG, Basel.)

Purpose: To develop a predictive model to identify hospitalized older patients at risk of functional decline., Methods: This retrospective cohort study recruited participants aged 65 years and over admitted to internal medicine wards of a tertiary medical center in Taiwan during May to October 2017 for developing predictive model (n = 1698) and those admitted during November to December 2017 for validation study (n = 530) of the model. Demographic data, geriatric assessments and hospital conditions (admission route and length of hospital stay) were collected for analysis., Results: Overall, of the 1698 participants (mean age 75.8 ± 7.9 years, 60.9% male) enrolled in the development study, 20.1% had functional decline. Results of multivariate logistic regression showed that older age, hearing impairment, history of falls within one year, risk of malnutrition, physical restraint, admission via emergency department and hospital stay ≥ 5 days were independent predictive factors for decline. A scoring system, HAD-FREE Score, constructed from the above predictive factors ranged from 0 to 18 points and ≥ 6 points was chosen as the cut-off point. The area under the receiver operating characteristic analysis was 0.748 (95% confidence interval: 0.720-0.776), the sensitivity was 65.3% and the specificity was 71.3%. Validation of the HAD-FREE Score showed moderate discriminative ability in the validation study., Conclusion: A HAD-FREE Score developed from seven independent factors could predict functional decline with moderate discriminative ability and good validation. This scoring system can be the basis of an automatic dynamic tracking within the electronic medical record to identify those older patients at risk of functional decline during hospitalization., (© 2021. European Geriatric Medicine Society.)

Frailty is common among older people and results in adverse health outcomes. We investigated whether exposure to PM 2.5 is associated with frailty. This cross-sectional study involved 20,606 community-dwelling participants aged ≥ 65 years, residing in New Taipei City, Taiwan. Analytic data included phenotypic frailty, disease burden by Charlson Comorbidity Index (CCI), urban or rural residence, and household income. PM 2.5 exposure was calculated from air quality monitoring records, with low exposure defined as the lowest quartile of the study population. 1,080 frail participants (5.2%) were older, predominantly female, had more comorbidities, lived rurally, and had low PM 2.5 exposure (all p < 0.001). In multinomial logistic regression analyses, the likelihood of high PM 2.5 exposure was higher in prefrail (OR 1.4, 95% CI 1.3-1.5) and frail adults (OR 1.5, 95% CI 1.2-1.9) than in robust individuals, with stronger associations in those who were male (frail: OR 2.1, 95% CI 1.5-3.1; prefrail: OR 2.2, 95% CI 1.9-2.6), ≥ 75 years old (frail: OR 1.8, 95% CI 1.3-2.4; prefrail: OR 1.5, 95% CI 1.3-1.8), non-smokers (frail: OR 1.6, 95% CI 1.3-2.0; prefrail: OR 1.4, 95% CI 1.2-1.5), had CCI ≥ 2 (frail: OR 5.1, 95% CI 2.1-12.6; prefrail: OR 2.1, 95% CI 1.2-3.8), and with low household income (frail: OR 4.0, 95% CI 2.8-5.8; prefrail: OR 2.7, 95% CI 2.2-3.3). This study revealed a significant association between PM 2.5 exposure and frailty, with a stronger effect in vulnerable groups.

The coronavirus disease 2019 (COVID-19) pandemic has casted a huge impact on global public health and the economy. In this challenging situation, older people are vulnerable to the infection and the secondary effects of the pandemic and need special attention. To evaluate the impacts of COVID-19 on older people, it is important to balance the successful pandemic control and active management of secondary consequences. These considerations are particularly salient in the Asian context, with its diversity among countries in terms of sociocultural heritage, healthcare setup and availability of resources. Thus, the Asian Working Group for Sarcopenia summarized the considerations of Asian countries focusing on responses and difficulties in each country, impacts of health inequity related to the COVID-19 pandemic and proposed recommendations for older people, which are germane to the Asian context. More innovative services should be developed to address the increasing demands for new approaches to deliver healthcare in these difficult times and to establish resilient healthcare systems for older people. Geriatr Gerontol Int 2020; 9999: n/a-n/a., (© 2020 Japan Geriatrics Society.)

Objectives: To evaluate the negative effect of physical restraint use on the hospital outcomes of older patients., Design: A retrospective cohort study., Setting: Internal medicine wards of a tertiary medical center in Taiwan., Participants: Subjects aged 65 years and over who were admitted during April to Dec 2017 were recruited for study., Measurements: Demographic data, geriatric assessments (polypharmacy, visual impairment, hearing impairment, activities of daily living before and after admission, risk of pressure sores, change in consciousness level, mood condition, history of falls in the previous year, risk of malnutrition and pain) and hospital conditions (admission route, department of admission, length of hospital stay and mortality) were collected for analysis., Results: Overall, 4,352 participants (mean age 78.7±8.7 years, 60.2% = male) were enrolled and 8.3% had physical restraint. Results of multivariate logistic regression showed that subjects with physical restraints were at greater risk of functional decline (adjusted odds ratio 2.136, 95% confidence interval 1.322-3.451, p=0.002), longer hospital stays (adjusted odds ratio 5.360, 95% confidence interval 3.627-7.923, p<0.001) and mortality (adjusted odds ratio 4.472, 95% confidence interval 2.794-7.160, p<0.001) after adjustment for covariates., Conclusion: The use of physical restraints during hospitalization increased the risk of adverse hospital outcomes, such as functional decline, longer length of hospital stay and mortality., Competing Interests: All authors have no conflicts of interest to declare

Competing Interests: No Conflicts of Interest: ACJ, BD, BV, CT, CWW, HA, IA, JohnB, Justin B, JGR, JL, JW, LuigiF, LeonF, LKC, LR-M, MAL, MS, PSB, RAM, YR, JV. SA: Reports grant from EU programs, Fondation de l/avenir, and the AMPA and France Alzheimer Associations; personal fees from Nestlé, Nestec SA, Sanofi, and MSD; and non-financial support from Biogen, Pfizer, and Icon outside the submitted work. ED: Supported by an Australian NHMRC Early Career Fellowship (#112672); MC: Honoraria for presentations at Scientific meetings and for serving as expert consultant for Nestlé. RF: Dr. Fielding reports grants from National Institutes of health (National Institute on Aging), during the conduct of the study; grants, personal fees and other from Axcella Health, stock options from Inside Tracker, grants and personal fees from Biophytis, grants and personal fees from Astellas personal fees from Cytokinetics, personal fees from Amazentis, grants and personal fees from Nestle’, personal fees from Glaxo Smith Kline, outside the submitted work. Also: This work is supported in part by the US Department of Agriculture, under agreement no. 58-1950-4-003. JYR: Consulting fees or paid advisory boards: IBSA-GENEVRIER, MYLAN, RADIUS HEALTH, PIERRE FABRE, FAES PHARMA, REJUVENATE BIOMED, SAMUMED, TEVA, THERAMEX, PFIZER, MITHRA PHARMACEUTICALS. Lecture fees when speaking at the invitation of sponsor: IBSA-GENEVRIER, MYLAN, CNIEL, DAIRY RESEARCH COUNCIL (DRC), NUTRICIA, DANONE, AGNOVOS. Grant Support from Industry (All through Institution): IBSA-GENEVRIER, MYLAN, CNIEL, RADIUS HEALTH, TRB. JMB: Consulting fees or paid advisory boards: Danone Nutricia, Nestlé, Bayer, Rejuvenate Biomed, Daiichi Sankyo; Lecture fees: Nutricia Danone, Nestlé, Fresenius, Pfizer, Novartis, Bayer. All income from the above goes to JMB’s institution. DLW: Consulting fees or paid advisory boards: Danone Nutricia.

Objectives: To determine whether nutritional status can predict 3-year cognitive and functional decline, as well as 4-year all-cause mortality in older adults., Design: Prospectively longitudinal cohort study., Setting and Participants: The study recruited 354 men aged 65 years and older in the veteran's retirement community., Measures: Baseline nutritional status was evaluated using the Mini-Nutritional Assessment-Short Form (MNA-SF). Cognitive function and Activities of Daily Living (ADL) function were determined by the Mini-Mental State Examination (MMSE) and the Barthel Index, respectively. Three-year cognitive and functional decline were respectively defined as a >3 point decrease in the MMSE scores and lower ADL scores than at baseline. Univariate and multivariable logistic regression analyses were conducted to identify nutritional status as a risk factor in poor outcome. The Kaplan-Meier method and Cox proportional regression models were used to estimate the effect of malnutrition risk on the mortality., Results: According to MNS-SF, the prevalence of risk of malnutrition was 53.1% (188/354). Multivariate logistic regression found risk of malnutrition significantly associated with 3-year cognitive decline (Adjusted odds ratio [OR] 2.07, 95% Confidence Interval [CI] 1.05-4.08, P =0.036) and functional decline (Adjusted OR 1.83, 95% CI 1.01-3.34, P =0.047) compared with normal nutritional status. The hazard ratio (HR) for all-cause mortality was 1.8 times higher in residents at risk of malnutrition (Adjusted HR 1.82, 95% CI 1.19-2.79, P =0.006)., Conclusions: Our results provide strong evidence that risk of malnutrition can predict not only cognitive and functional decline but also risk of all-cause mortality in older men living in a veteran retirement's community. Further longitudinal studies are needed to explore the causal relationship among nutrition, clinical outcomes, and the effect of an intervention for malnutrition., Competing Interests: All authors declare no conflicts of interest for this study

Objectives: Reciprocal age-related impairments in physical and cognitive functioning have been termed 'cognitive frailty', which is associated with adverse health outcomes and is a potential target for preventing or delaying the onset of disability in older people. However, cognitive frailty as currently defined is challenging to diagnose. To facilitate earlier diagnosis and intervention, we conducted this study to develop and validate a simple evidence-based instrument to identify community-dwelling elders at risk of cognitive frailty., Design: Retrospective analyses of data from the I-Lan Longitudinal Aging Study (ILAS) to develop a prediction model, and from the Longitudinal Aging Study of Taipei (LAST) for external validation., Setting: Community-dwelling adults from Taipei City, New Taipei City and Yilan (I-Lan) County, Taiwan., Participants: 1271 community residents ≥65 years old, without impaired global cognition or dependency for activities of daily living/instrumental activities of daily living., Measurements: Demographic characteristics, anthropometric measurements, medical history, Mini-Mental State Examination, Montreal Cognitive Assessment, Functional Autonomy Measuring System, Functional Assessment Staging Test, Center for Epidemiologic Studies Depression Scale, handgrip strength, 6-metre walk speed., Methods: Baseline characteristics of groups with/without cognitive frailty were analyzed and factors differing significantly in univariate analysis input to binary logistic regression to develop a cognitive frailty risk (CFR) score., Results: The prevalence of cognitive frailty was 15.8% overall; ILAS 21.4%, LAST 8.4%. Predictors of CFR comprised: age ≥75 years; female sex; waist circumference ≥90 cm (male), ≥80 cm (female); calf circumference <33 cm (male), <32 cm (female); memory deficits; and diabetes mellitus. CFR ≥5/14 had sensitivity of 70%, specificity of 60%, and predictive accuracy of 72%., Conclusions: A CFR score based on simple history-taking and anthropometric measurements integrates age, sex, cardiometabolic risk, memory deficits, sarcopenia, and nutrition, with validated predictive accuracy, and could be performed easily in community settings to identify seniors with cognitive frailty for appropriate interventions., Competing Interests: All authors declare no conflict of interest

Objectives: To explore the association between orthostatic hypotension (OH) and frailty for hospitalized older patients and their vulnerable subgroups., Design: A prospective, observational cross-sectional study., Participants: 693 older patients admitted to a geriatric evaluation and management unit., Measurements: Barthel Index, Lawton's instrumental activities of daily living, clinical frailty scale, mini-mental state examination, geriatric depression scale, mini-nutritional assessment, and polypharmacy., Results: Overall, the prevalence of OH and frailty was 26% and 36%, respectively. Subjects with OH were older, thinner, more commonly to have weakness, slowness, poorer physical function and higher levels of frailty. The prevalence of OH was substantially increased as higher levels of CFS (p for trend <0.001). Multivariate logistic regression showed significant association between OH and frailty (OR: 1.8, 95% CI: 1.2-2.7), but the association attenuated after adjustment for physical function. (OR: 1.4, 95% CI: 0.7-2.6). Nevertheless, associations between OH and frailty remained significant among vulnerable subgroups like women, subjects having weakness, slowness, poor cognitive function, polypharmacy or any IADL limitation., Conclusions: OH in hospitalized older patients was associated with frailty and multiple complex care needs, especially in the vulnerable subgroups. Further study is needed to clarify the roles of OH in clinical practice., Competing Interests: No potential conflict of interest was reported by the authors.

Background: Myostatin is a negative regulator of muscle growth but the relationship between serum myostatin levels and muscle mass is unclear. This study investigated the association between serum myostatin levels and skeletal muscle mass among healthy older community residents in Taiwan, to evaluate the potential of serum myostatin as a biomarker for diagnosing sarcopenia and/or evaluating the effect of its treatment., Methods: Study data were excerpted from a random subsample of the I-Lan Longitudinal Aging Study population. Serum myostatin levels were determined and categorized into tertiles (low, medium, high). Relative appendicular skeletal muscle mass (RASM) was calculated as appendicular lean body mass by dual-energy X-ray absorptiometry divided by height squared (kg/m 2 ). Low muscle mass was defined as recommended by the Asian Working Group for Sarcopenia., Results: The analytic study sample comprised 463 adults (mean age: 69.1 years; 49.5% men). Compared with subjects with normal RASM, those with lower RASM were older and frailer, with significantly higher prevalence of malnutrition, lower serum dehydroepiandrosterone (DHEA) levels, and were more likely to have low serum myostatin status. Multivariable logistic regression analysis showed that male sex (OR 3.60, 95% CI 1.30-9.92), malnutrition (OR 4.39, 95% CI 1.56-12.36), DHEA (OR 0.99, 95% CI 0.99-1.00), and low myostatin (OR 3.23, 95% CI 1.49-7.01) were all independent risk factors for low RASM (all P < 0.05). In men, DHEA (OR 0.99, 95% CI 0.98-1.00) and low myostatin (OR 4.89, 95% CI 1.79-13.37) were significantly associated with low RASM (both P < 0.05); however, only malnutrition was associated with low RASM in women (OR 13.59, 95% CI 2.22-83.25, P < 0.05)., Conclusions: Among healthy community-living older adults, low serum myostatin levels were associated with low skeletal muscle mass in men, but not in women. Our results do not support using serum myostatin levels to diagnose sarcopenia, or to monitor how it responds to treatments. Further research is needed to understand why men apparently differ from women in the interrelationship between their myostatin levels and muscle mass., (© 2018 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of the Society on Sarcopenia, Cachexia and Wasting Disorders.)

Background: To evaluate the predictive validity of sarcopenia defined by the Foundation for the National Institutes of Health (FNIH) Sarcopenia Project among Asian older adults., Methods: Data of the I-Lan Longitudinal Aging Study were obtained for analysis. Overall, 1,839 community-dwelling people aged 50 years and older, capable of completing a 6-m walk, with life expectancy of more than 6 months, and not institutionalized at time of data collection were enrolled for study. Data for subjects aged 65 years and older were obtained for study. The outcome measures were all-cause mortality and a composite adverse outcome which includes hospitalizations, emergency department visits, institutionalization, and falls., Results: Data of 728 eligible elderly participants (73.4 ± 5.4 years; 52.9% males) were analyzed. The prevalence of FNIH-diagnosed sarcopenia was 9.5%: 11.9% males; 6.7% females. Participants having FNIH-defined sarcopenia were considerably older, frailer, more obese, with poorer physical performance than nonsarcopenic subjects (All p < .001); during mean follow-up of 32.9 ± 8.8 months, they also had 3.8 times higher risk of dying, independent of age, sex, multimorbidity, cognitive function, and nutritional status (hazard ratio = 3.8; 95% confidence interval = 1.26-11.45; p = .018). Moreover, sarcopenia defined by grip strength-BMI ratio (WeakBMI) showed stronger association with composite adverse outcomes than traditional handgrip strength (hazard ratio = 1.99; 95% confidence interval = 1.01-3.93; p = .047 vs hazard ratio = 1.80; 95% confidence interval = 0.89-3.62; p = .102 in fully-adjusted model)., Conclusion: Among community-dwelling older people in Taiwan, participants with FNIH-defined sarcopenia had a significantly greater risk of all-cause mortality and composite falls, emergency department visits, institutionalization, and hospitalization.

Objective: We evaluated effects of the interrelationship between physical disability and cognitive impairment on long-term mortality of men aged 80 years and older living in a retirement community in Taiwan., Methods: This prospective cohort study enrolled older men aged 80 and older living in a Veterans Care Home. Those with confirmed diagnosis of dementia were excluded. All participants received comprehensive geriatric assessment, including sociodemographic data, Charlson's Comorbidity Index (CCI), geriatric syndromes, activities of daily living (ADL) using the Barthel index and cognitive function using the Mini-Mental State Examination (MMSE). Subjects were categorized into normal cognitive function, mild cognitive deterioration, and moderate-to-severe cognitive impairment and were further stratified by physical disability status. Kaplan-Meier log-rank test was used for survival analysis. After adjusting for sociodemographic characteristics and geriatric syndromes, Cox proportional hazards model was constructed to examine associations between cognitive function, disability and increased mortality risk., Results: Among 305 male subjects aged 85.1 ± 4.1 years, 89 subjects died during follow-up (mean follow-up: 1.87 ± 0.90 years). Kaplan-Meier unadjusted analysis showed reduced survival probability associated with moderate-to-severe cognitive status and physical disability. Mortality risk increased significantly only for physically disabled subjects with simultaneous mild cognitive deterioration (adjusted HR 1.951, 95% CI 1.036-3.673, p = 0.038) or moderate-to-severe cognitive impairment (aHR 2.722, 95% CI 1.430-5.181, p = 0.002) after adjusting for age, BMI, education levels, smoking status, polypharmacy, visual and hearing impairment, urinary incontinence, fall history, depressive symptoms and CCI. Mortality risk was not increased among physically independent subjects with or without cognitive impairment, and physically disabled subjects with intact cognition., Conclusions: Physical disability is a major risk factor for all-cause mortality among men aged 80 years and older, and risk increased synergistically when cognitive impairment was present. Cognitive impairment alone without physical disability did not increase mortality risk in this population.

Objective: To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty., Methods: An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation., Recommendations: Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan., Conclusions: The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Aim: To identify potentially modifiable risk factors for cognitive decline among veterans' home residents in Taiwan METHODS: The present retrospective cohort study was part of the Veteran Affairs-Comprehensive Geriatric Assessment study that retrieved data of the comprehensive geriatric assessment for 946 residents living at four veterans' homes in Taiwan. The study participants were interviewed every 3-6 months from January 2012 and December 2014. Demographic characteristics,multimorbidity by Charlson's Comorbidities Index, physical function by the Barthel Index, cognition by the Mini-Mental State Examination (MMSE), depression by the five-item Geriatric Depression Scale and nutritional status by the Mini-Nutrition Assessment-Short Form were collected for analysis. A generalized estimating equation model was used after it was adjusted for age, educational level, five-item Geriatric Depression Scale, and problem of communication difficulty to identify potential modifiable risk factors for cognitive decline., Results: The mean age of the participants was 85.7 ± 5.2 years, with a mean follow-up period of 41 ± 21.6 weeks. The prevalence of cognitive impairment (defined by MMSE <24) was 65.6%, whereas 34% of the study participants were positive for depressive symptoms. Approximately one-fifth of the study participants were using psychotropic agents, which was higher among participants with cognitive impairment (23.6% vs 15.6%, P < 0.05) than those without. In the generalized estimating equation model, physical function, nutritional status, depressive symptoms, ex-drinker, multimorbidity and stool incontinence were positively correlated with MMSE score; whereas advanced age, low educational level (<6 years), presence of communication difficulty and use of psychotropic agents were inversely associated with the MMSE score., Conclusions: Physical function and nutritional status were positively associated with the MMSE score, and use of psychotropic agents was negatively correlated with cognitive function. Further intervention study is required to improve the cognitive health of older adults living in the veterans' retirement communities. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 7-13., (© 2017 Japan Geriatrics Society.)

Aim: Our previous work showed that non-pharmacological interventions could effectively reduce the severity of behavioral and psychological symptoms of dementia (BPSD), while the factors influencing the effect of intervention were less explored. Therefore, the main purpose of the present study was to investigate the predictors of the non-pharmacological intervention effect for old veterans with dementia and BPSD., Methods: A total of 141 old veterans with dementia living in two veterans' homes in northern Taiwan were recruited. The participants received an organized non-pharmacological intervention program of physical activity/exercise, music therapy, reality orientation, art therapy, reminiscence therapy and horticultural therapy once every week for 6 months. All participants were evaluated by the Barthel Index, Lawton-Brody Instrumental Activities of Daily Living Scale, Mini-Mental State Examination, neuropsychiatric inventory (NPI), and the Cornell Scale for Depression in Dementia before and after the intervention. Logistic regression was used to investigate factors associated with improvement/maintenance of cognition (measured by the Mini-Mental State Examination), and improvement of BPSD (measured by NPI) and its subdomains during the intervention period., Results: Multivariate logistic regression analysis showed that the improvement/maintenance of cognitive function was independently associated with a lower Mini-Mental State Examination score at baseline (odds ratio [OR] 0.88, 95% CI 0.80-0.97, P = 0.008), whereas participants with antipsychotic use were less likely to gain the effect (OR 0.42, 95% CI 0.17-1.04, P = 0.061). In addition, the improvement of BPSD was associated with a higher baseline total NPI score (OR 1.33, 95% CI 1.15-1.55, P < 0.001), and the result was consistent in different NPI subdomains (psychotic domain: OR 1.96, 95% CI 0.83-4.58, P = 0.123; affective domain: OR 1.63, 95% CI 1.25-2.13, P < 0.001; behavior domain: OR 2.25, 95% CI 1.53-3.30, P < 0.001) and caregiver burden (OR 1.63, 95% CI 1.24-2.14, P < 0.001). In addition, a higher Cornell Scale for Depression in Dementia score was correlated with an improvement in the NPI behavior domain (OR 1.48, 95% CI 1.01-2.18, P = 0.047), whereas participants with hearing impairment had a lower chance of improvement in the NPI behavior domain (OR 0.11, 95% CI 0.01-1.23, P = 0.073) and care burden (OR 0.17, 95% CI 0.03-0.99, P = 0.050)., Conclusions: Our findings show that non-pharmacological intervention programs have a significant effect on reducing overall NPI score, NPI caregiver burden score and NPI subdomains - psychotic, affective and behavior syndrome - in old veterans with dementia. In addition, participants with lower cognitive performance, more severe BPSD and depressive symptoms at baseline were more likely to gain benefit from the intervention, whereas antipsychotic use and hearing impairment were negative predictors of improvement of cognition and BPSD, respectively. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 28-35., (© 2017 Japan Geriatrics Society.)

Background: Frailty Index, defined as an individual's accumulated proportion of listed health-related deficits, is a well-established metric used to assess the health status of old adults; however, it has not yet been developed in Taiwan, and its local related structure factors remain unclear. The objectives were to construct a Taiwan Frailty Index to predict mortality risk, and to explore the structure of its factors., Methods: Analytic data on 1,284 participants aged 53 and older were excerpted from the Social Environment and Biomarkers of Aging Study (2006), in Taiwan. A consensus workgroup of geriatricians selected 159 items according to the standard procedure for creating a Frailty Index. Cox proportional hazard modeling was used to explore the association between the Taiwan Frailty Index and mortality. Exploratory factor analysis was used to identify structure factors and produce a shorter version-the Taiwan Frailty Index Short-Form., Results: During an average follow-up of 4.3 ± 0.8 years, 140 (11%) subjects died. Compared to those in the lowest Taiwan Frailty Index tertile (< 0.18), those in the uppermost tertile (> 0.23) had significantly higher risk of death (Hazard ratio: 3.2; 95% CI 1.9-5.4). Thirty-five items of five structure factors identified by exploratory factor analysis, included: physical activities, life satisfaction and financial status, health status, cognitive function, and stresses. Area under the receiver operating characteristic curves (C-statistics) of the Taiwan Frailty Index and its Short-Form were 0.80 and 0.78, respectively, with no statistically significant difference between them., Conclusion: Although both the Taiwan Frailty Index and Short-Form were associated with mortality, the Short-Form, which had similar accuracy in predicting mortality as the full Taiwan Frailty Index, would be more expedient in clinical practice and community settings to target frailty screening and intervention.

Background: Malnutrition is prevalent among hospitalized geriatric patients., Purpose: The aim of this study was to explore the impact of cognitive status and its associated factors on the nutritional status of hospitalized geriatric patients., Methods: A descriptive and cross-sectional study design was conducted. Two instruments, the Mini Nutritional Assessment and the Mini-Mental State Examination (MMSE), were administered to 401 geriatric participants. Linear regression was used to examine the contribution of cognitive status and its associated factors to the nutritional status of participants., Results: Participants had a mean age of 85 years, and three quarters (73.6%) were men. Participants earned a mean MMSE score of 19.1 ± 8.0 and a mean Mini Nutritional Assessment score of 20.2 ± 5.2. Two thirds (67.1%) were at risk for malnutrition, and 22.7% experienced malnutrition. One third (33.1%) had mild-to-moderate cognitive impairment, and 32.2% had severe cognitive impairment. The MMSE scores accounted for 21% of the total variability in nutritional status. In addition, the Charlson Comorbidity Index score and care status were also significant predictors of malnutrition and, together with the MMSE scores, accounted for 53% of the variability in the nutritional status of participants in the regression model., Conclusions: Findings indicate that cognitive status, concomitant comorbidities, and care status are significant predictors of malnutrition. The results of this study provide information to help clinicians identify at-risk populations for malnutrition and develop appropriate nutrition programs based on individual needs.

Background: The impact of postoperative delirium on post-discharge functional status of older patients remains unclear, and little is known regarding the interrelationship between cognitive impairment and post-operative delirium. Therefore, the main purpose was to evaluate the post-discharge functional status of patients who experience delirium after undergoing orthopaedic surgery and the interrelationship of postoperative delirium with underlying cognitive impairment., Method: This prospective cohort study, conducted at a tertiary care medical center from April 2011 to March 2012, enrolled all subjects aged over 60 years who were admitted for orthopaedic surgery. The baseline characteristics (age, gender, BMI, and living arrangement), surgery-related factors (ASA class, admission type, type of surgery, and length of hospital stay), results of geriatric assessment (postoperative delirium, cognition, depressive mood, comorbidity, pain, malnutrition, polypharmacy, ADL, and instrumental [I]ADL) and 1-12-month postoperative ADL and IADL functional status were collected for analysis., Results: Overall, 9.1% of 232 patients (mean age: 74.7 ± 7.8 years) experienced postoperative delirium, which was significantly associated with IADL decline at only 6 and 12 months postoperatively (RR: 6.22, 95% CI: 1.08-35.70 and RR: 12.54, 95% CI: 1.88-83.71, respectively). Delirium superimposed on cognitive impairment was a significant predictor for poor functional status at 6 and 12 months postoperatively (RR: 12.80, 95% CI: 1.65-99.40 for ADL at the 6th month, and RR: 7.96, 95% CI: 1.35-46.99 at the 12th month; RR: 13.68, 95% CI: 1.94-96.55 for IADL at the 6th month, and RR: 30.61, 95% CI: 2.94-318.54 at the 12th month, respectively)., Conclusion: Postoperative delirium is predictive of IADL decline in older patients undergoing orthopaedic surgery, and delirium superimposed on cognitive impairment is an independent risk factor for deterioration of ADL and IADL functional status. Early identification of cognitive function and to prevent delirium are needed to improve functional status following orthopaedic surgery.

Aim: Although patients admitted to post-acute care (PAC) units are usually clinically stable, unexpected medical conditions requiring acute ward readmissions still occur and can jeopardize the clinical effectiveness of PAC services. The main purpose of the present study was to evaluate predictive factors for clinical instability of patients in PAC units to improve the quality of PAC services., Methods: This was a nationwide multicenter cohort study that recruited patients from five PAC units in Taiwan between July 2007 and June 2009. All patients received the comprehensive geriatric assessment (CGA) within 72 h of PAC unit admissions. Conditions requiring acute ward re-admissions from PAC units were defined as clinical instability. Causes of clinical instability for all patients and data of CGA were collected for analysis., Results: Of 918 enrolled participants, 119 (12.9%) experienced acute ward readmissions, including 106 (89.1%) admissions related to medical conditions and 13 (10.9%) for surgical causes. Common conditions included diseases of the respiratory system (n = 32, 26.9%), genitourinary system (n = 24, 20.2%) and digestive system (n = 14, 11.8%). Surgical conditions, mainly fractures and dislocation of upper limbs, were significantly more likely to occur later (P = 0.05) in the PAC unit admissions than medical conditions. Compared with the non-readmission group, the readmission group was leaner (mean body mass index 21.1 ± 2.8 vs 22.0 ± 3.8 kg/m(2) , P = 0.007), having poorer functional status (mean Barthel Index 41.0 ± 19.4 vs 45.4 ± 20.3, P = 0.02; mean IADL: 1.3 ± 1.6 vs 1.7 ± 1.8, P = 0.016), poorer cognitive function (mean Mini-Mental State Examination: 16.8 ± 6.4 vs 18.3 ± 6.4, P = 0.022), poorer ambulation (mean Timed Up & Go test 32.7 ± 18.7 vs 26.6 ± 11.7 s, P = 0.039) and poorer nutritional status (mean Mini-Nutrition Assessment 13.3 ± 5.7 vs 15.4 ± 5.8, P < 0.001), but similar in depression status (mean Geriatric Depression Score 3.7 ± 3.3 vs 3.4 ± 2.8, P = 0.247). In multivariate logistical regression model, lower Mini-Mental State Examination score was the only independent predictor for clinical instability (odds ratio 3.8, 95% confidence interval 1.348-10.870, P = 0.012)., Conclusion: Approximately 13% of PAC patients might experience acute ward readmissions, and nearly 90% of them are caused by medical conditions. Poor cognitive function is a significant predictive factor for clinical instability in PAC, which deserves more clinical attention for all PAC patients., (© 2013 Japan Geriatrics Society.)

Aim: To evaluate the association of cognitive impairment, depressive mood and sarcopenia among older men living in the veterans retirement community in southern Taiwan, Methods: This cross-sectional study recruited 353 men aged 65 years and older. In addition to demographic characteristics, all participants were measured for gait speed, handgrip strength and muscle mass by using bioelectrical impedance analysis (BIA). The diagnosis of sarcopenia was made according to the European Working Group on Sarcopenia in Older People criteria. Slow walking speed was defined as ≤ 0.8 meter/second. Low muscle strength was defined as the handgrip strength less than 22.5 kg which was adjusted according to Taiwanese norms. A height-adjusted muscle mass of 8.87 kg/m2 from a previous Taiwanese study was defined as low muscle mass. Cognitive function was evaluated by the Mini-Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15) was used for screening of depressive symptoms., Results: Among the 353 participants (mean age 82.7 ± 5.3 years), 30.9% (109/353) were classified as sarcopenic. Multivariate logistic regression showed that sarcopenia was independently associated with cognitive impairment (adjusted OR 3.03, 95% CI 1.63-5.65, P < 0.001) and depressive symptoms (adjusted OR 2.25, 95% CI 1.03-4.89, P = 0.04)., Conclusions: Sarcopenia was significantly associated with cognitive impairment and depressive symptoms among otherwise healthy older men living in the veterans retirement community. Further outcome study is required to explore the interrelationship of cognition, depressive symptoms and sarcopenia in older adults., (© 2014 Japan Geriatrics Society.)

Aim: Sarcopenia and sarcopenic obesity are significant associative factors for functional impairment related to aging. The main aim of the present study was to investigate the prevalence of sarcopenia and sarcopenic obesity, and their associations with functional status among men aged 80 years and older in Beijing., Methods: A total of 75 young healthy volunteers, and 101 older men aged 80 years and older participated in the present study. Demographic characteristics, anthropometry, skeletal muscle mass measured by dual X-ray absorptiometry (DXA), 6-m gait speed and handgrip strength were collected. Relative appendicular skeletal muscle index (RASM) and percentage skeletal muscle index (SMI) were obtained., Results: Overall, the prevalence of sarcopenia was 45.7% by using RASM. By the weight-adjusted skeletal muscle index definition (SMI), the prevalence of sarcopenia was 53.2%. The prevalence of sarcopenic obesity was lower by using RASM than SMI (4.9% vs 11.5%, P < 0.05). When we compared the sarcopenia prevalence (%) in obese participants, it was also remarkably lower by using RASM (40.0%) than SMI (95.0%). By using either RASM or SMI, gait speed was of no significant difference among the pure sarcopenia group, pure obese group and sarcopenic obesity group (0.76 ± 0.27 vs 0.82 ± 0.37 vs 0.82 ± 0.27 m/s, P > 0.05, by RASM; 0.75 ± 0.25 vs 0.92 ± 0.27 vs 0.82 ± 0.35 m/s, P > 0.05 by SMI), respectively. Multiple linear regression analyses showed that thigh skeletal muscle mass was positively correlated with gait speed independently (β = 0.221, P = 0.011), and total body fat (β = -0.216, P = 0.002) and age (β = -0.524, P = 0.000) were negatively correlated with gait speed independently., Conclusions: The prevalence of sarcopenia is high either based on RASM or SMI among Chinese men aged 80 years and older. Functional limitations were significantly associated with older age, skeletal muscle mass and total body fat., (© 2014 Japan Geriatrics Society.)

Unlabelled: Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate., Objectives: The purpose of this paper is to present expert's positions on the main aspects of the frailty syndrome in the older persons., Participants: Workshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG)., Results: Frailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from "very fit" to "severely frail", but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice., Conclusion: Frailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

As Taiwan has become the fastest aging country in the world, developing elderly-friendly health care services is of great importance. Compared with traditional health-care service models, healthcare needs of older people may differ extensively. It has been reported that geriatric evaluation and management (GEM), helps to differentiate the atypical presentations of frail older patients, to discover hidden health-social problems, and to promote long-term clinical outcome. The main purpose of this study was to explore the demographic characteristics of older patients visiting outpatient GEM service and its impact to health-care utilization in a tertiary medical center in Taiwan. From January to October of 2008, 1054 patients visited the outpatient GEM service, and comprehensive geriatric assessment was performed for 140 patients (62.9% males with the mean age was 81.0 ± 6.6 years), and 34.8% of them were college graduates. Overall, the prevalence of functional impairment was 11.4%, depressive symptoms 20.7%, cognitive impairment 32.1%, and abnormal timed up-and-go test 32.1%. During the 12-month follow-up, items of mean oral medications were significantly reduced (3.2 ± 2.7 vs. 3.8 ± 2.8, p<0.001) and the health-related quality of life was significantly improved (64.6 ± 8.0 vs. 61.6 ± 4.0, p<0.001). In conclusion, patients visiting outpatient GEM services in Taiwan are old and well-educated, and they possessed various functional impairments. The outpatient GEM services significantly reduced the items of oral medications and improved quality of life. The possible better compliance of this cohort due to high educational status may overestimate the clinical effectiveness of outpatient GEM services. Further investigations are needed to clarify the long-term benefits of outpatient GEM services., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To compare the effectiveness of the Minimum Data Set-based Depression Rating Scale (MDS-DRS) and Geriatric Depression Scale (GDS) in screening depression among older institutionalized Chinese men living in Taiwan., Method: MDS Nursing Home 2.1 Chinese version, Mini-Mental State Examination (MMSE), and short form Geriatric Depression Scale (GDS-15) were used among elderly residents in Banciao Veterans Home. Screening results of MDS-DRS and GDS-15, and relationship between 16 MDS Mood and Anxiety symptoms and depression were evaluated., Results: The prevalence of depression defined by MDS-DRS and GDS were 0.2% and 8.7%, respectively. Multiple logistic regression disclosed that E1a (OR: 12.9, 95% CI: 2.8-58.8, p = 0.001), E1k (OR: 15.6, 95% CI: 5.6-43.5, p < 0.001), and E1l (OR: 22.2, 95% CI: 6.1-83.3, p < 0.001) were all independent associative factors for GDS-defined depression but only explained 51.9% of all depressive subjects., Conclusions: The effectiveness of MDS-DRS is limited, and a new MDS-based depression screening instrument is needed.

Fear of falling (FF) can have multiple adverse consequences in the elderly. Although there are various fall prevention programs, little is known of FF and its associated characteristics. This study examined FF-associated physical and psychosocial factors in older Chinese men living in a veterans home in southern Taiwan. Subjects with a recent episode of delirium, of bed-ridden or wheelchair-bound status, severe hearing impairment or impaired cognition were excluded. Overall, 371 residents (mean age 82.1 ± 5.11 years, all males) participated. The prevalence of FF was 25.3%. Univariate analysis revealed that subjects in the FF group were older age, having lower education level, poorer sitting and standing balance, poorer activities of daily living (ADL), more depressive symptoms, higher chances of using walking aids, neurologic diseases, and a history of fall within the past 6 months. Logistic regression showed that depressive symptoms (odds ratio = OR = 6.73, 95%CI: 3.03-14.93, p < 0.001), activities of daily living (OR = 2.48, 95%CI: 1.08-5.71, p = 0.033), history of fall in the past 6 months (OR = 2.47, 95%CI: 1.04-5.9, p = 0.041), and neurological diseases (OR = 2.75, 95%CI: 1.15-6.56, p = 0.023) were all independent risk factors for FF., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Unexplained unintentional weight loss (UUWL) is a common health problem in older adults, and raises significant diagnostic challenges. Currently, there is no consensus or guideline to help physicians approach these patients. The main purpose of this study is to evaluate physicians' behaviors in evaluating elderly patients with UUWL and to compare the diagnostic strategy of internists and geriatricians. From January of 2008 to December of 2009, medical records of all elderly patients admitted to Taipei Veterans General Hospital with UUWL were obtained for study. All diagnostic procedures used during admissions were evaluated and the final diagnosis for each patient was obtained. Overall, data of 136 patients (mean age: 79.8±6.3 years, 80.9% males) were obtained for study with their mean weight loss of 8.6±6.4 kg. Among them, 79 (58.1%) patients were admitted to the geriatric evaluation and management unit (GEMU) and 57 (41.9%) patients were admitted to the general medical wards. There were no statistically significant differences in terms of age, sex, mean age and average weight loss between these two groups. After extensive diagnostic effort, the most common diagnostic entity was benign organic disease (33.8%), followed by unknown (25.7%), neuropsychiatric disorder (23.5%), and malignancy (16.9%). Tumor markers are commonly used, including carcinoembryonic antigen (CEA) (80.9%), prostate specific antigen (PSA) (81.8%), and carbohydrate 19-9 (CA 19-9) (65.4%). Imaging studies were also commonly used diagnostic tools, including gastrointestinal endoscopy (70.6%), colonoscopy (42.6%) and computerized tomography (44.1%). Compared with internists, geriatricians were more likely to order PSA testing (70.5% vs. 89.4%, p=0.021). In contrast, internists were more likely to order CA-199 (75.4%% vs. 58.2%, p=0.045), and to arrange gastrointestinal endoscopy than geriatricians (82.4% vs. 62.0%%, p=0.013). In conclusion, cancer accounts for only 16.9% of all elderly patients with UUWL in this study, tumor markers are very commonly used for screening of occult cancer. Compared with internists, geriatricians are more likely to order PSA and to establish neuropsychiatric diagnosis, and internists are more prone to order carbohydrate (CA 19-9) and gastrointestinal endoscopy., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Evidence supporting community hospital (CH)-based post-acute care (PAC) on long-term mortality is lacking., Methods: A 4-week comprehensive geriatric assessment-based interdisciplinary care was introduced to reable post-acute older patients who volunteered to participate in this study without randomization. The effectiveness of CH-based PAC in functional gain and 12-month mortality were evaluated., Results: Of 688 acute hospital admissions, 330 patients fulfilled the enrolment criteria; there were 96 (mean age 85.7 ± 5.1 years) in the intervention group and 234 (mean age 85.4 ± 5.3 years) in the reference group. Patients with experience of geriatric services (26.0% versus 16.2%; P = 0.04) and longer length-of-stay (18.0 ± 6.0 versus 15.2 ± 11.8 days; P = 0.028) were more likely to participate in the study. The pre-acute hospital discharge Barthel Index was significantly lower in the intervention group (46.3 ± 29.0 versus 85.1 ± 24.7; P < 0.001). The 4-week PAC programme significantly improved physical function, cognitive status, depressive moods, and pain. At the 12-month follow-up, 71 (21.5%) patients had died, and 3 (0.9%) were lost to follow-up. Adjusted for pre-acute hospital discharge Barthel Index and acute hospital length-of-stay, the intervention group was less likely to die (HR 0.38; 95% CI = 0.19-0.76; P = 0.006)., Conclusion: A 4-week CH-based interdisciplinary PAC programme significantly promoted functional recovery and reduced 12-month mortality by 62% for older post-acute patients.