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Objective The combined effects of individual and neighborhood socioeconomic status (SES) on survival rates of patients with Alzheimer's disease (AD) remain unclear. Design Retrospective cohort study. Setting National Health Insurance Bureau of Taiwan data (2003–2012). Participants Patients with AD. Measurements The authors aimed to analyze the effects of neighborhood and individual SES on the 5-year survival rates of patients with AD. The author defined individual and neighborhood SES based on income-related insurance payment amounts and residence in advantaged versus disadvantaged areas and compared survival rates using the Cox proportional hazards model after adjusting for risk factors. Results A total of 1,754 patients with AD were identified. Each patient was followed for 5 years or censored. The 5-year overall survival rates were worst for those with a low individual SES in a disadvantaged area. After adjustment for sex, age, and comorbidities, patients with a low individual SES living in disadvantaged areas had the worse survival rate than those with a high SES (hazard ratio: 2.19; 95% confidence interval [CI]: 1.53–3.13). In contrast, after the adjustment for characteristics, patients with a high individual SES in disadvantaged areas had a similar mortality rate to those with a high individual SES in advantaged areas (hazard ratio: 0.93; 95% CI: 0.64–1.35). Conclusion Despite universal health coverage, patients with AD and a low individual SES in disadvantaged areas exhibited the worst survival rate. The socioeconomic survival gradient among patients with AD in Taiwan may result from differences in major attributes of individual and neighborhood SES.

Background: Early identification of different stages of cognitive impairment is important to provide available intervention and timely care for the elderly. Objective: This study aimed to examine the ability of the artificial intelligence (AI) technology to distinguish participants with mild cognitive impairment (MCI) from those with mild to moderate dementia based on automated video analysis. Methods: A total of 95 participants were recruited (MCI, 41; mild to moderate dementia, 54). The videos were captured during the Short Portable Mental Status Questionnaire process; the visual and aural features were extracted using these videos. Deep learning models were subsequently constructed for the binary differentiation of MCI and mild to moderate dementia. Correlation analysis of the predicted Mini-Mental State Examination, Cognitive Abilities Screening Instrument scores, and ground truth was also performed. Results: Deep learning models combining both the visual and aural features discriminated MCI from mild to moderate dementia with an area under the curve (AUC) of 77.0% and accuracy of 76.0%. The AUC and accuracy increased to 93.0% and 88.0%, respectively, when depression and anxiety were excluded. Significant moderate correlations were observed between the predicted cognitive function and ground truth, and the correlation was strong excluding depression and anxiety. Interestingly, female, but not male, exhibited a correlation. Conclusion: The study showed that video-based deep learning models can differentiate participants with MCI from those with mild to moderate dementia and can predict cognitive function. This approach may offer a cost-effective and easily applicable method for early detection of cognitive impairment.

To evaluate the negative effect of physical restraint use on the hospital outcomes of older patients. A retrospective cohort study. Internal medicine wards of a tertiary medical center in Taiwan. Subjects aged 65 years and over who were admitted during April to Dec 2017 were recruited for study. 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. 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

To determine whether nutritional status can predict 3-year cognitive and functional decline, as well as 4-year all-cause mortality in older adults. Prospectively longitudinal cohort study. The study recruited 354 men aged 65 years and older in the veteran’s retirement community. 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. 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). 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.

Older adults often experience functional decline following acute medical care. This functional decline may lead to permanent disability, which will increase the burden on the medical and long-term care systems, families, and society as a whole. Post-acute care aims to promote the functional recovery of older adults, prevent unnecessary hospital readmission, and avoid premature admission to a long-term care facility. Research has shown that post-acute care is a cost-effective service model, with both the hospital-at-home and community hospital post-acute care models being highly effective. This paper describes the post-acute care models of the United States and the United Kingdom and uses the example of Taiwan’s highly effective post-acute care system to explain the benefits and importance of post-acute care. In the face of rapid demographic aging and smaller household size, a post-acute care system can lower medical costs and improve the health of older adults after hospitalization.

Summary Background Integrating primary prevention into care pathways for older adults is a core strategy of healthy ageing, but evidence remains limited. We aimed to determine whether incorporating a multidomain intervention into primary health care could improve standard value-based health outcomes and quality of life. Methods For this Taiwan Integrated Geriatric Care (TIGER) study, a pragmatic randomised controlled trial, we recruited community-dwelling outpatients aged 65 years or older with at least three chronic medical conditions. We excluded people with malignancies undergoing chemotherapy, people with a life expectancy of less than 12 months, or people who were insufficiently able to communicate with study staff. Participants were randomly assigned (1:1) to usual care or to the integrated multidomain intervention using block randomisation. The integrated multidomain intervention entailed 16 2-h sessions per year, comprising communal physical exercise, cognitive training, nutrition and disease education, plus individualised treatment by specialists in integrated geriatric care. The primary outcome was changes from baseline quality of life, based on 36-item Short Form Health Survey (SF-36) scores, at 3, 6, 9, and 12 months. Intervention effects were analysed per protocol using a generalised linear mixed model. This trial is registered with ClinicalTrials.gov , NCT03528005 . Findings Between June 25, 2018, and Feb 15, 2019, 628 participants were screened, of whom 398 were assigned to the integrated multidomain intervention (n=199) or to usual care (n=199). 335 (84%) participants completed the 12-month follow-up. Compared with the usual care group, the integrated multidomain intervention group had significantly higher mean SF-36 physical component scores across all timepoints (overall difference 0·8, 95% CI 0·2–1·5; p=0·010), but differences at 3, 6, 9, and 12 months did not reach statistical significance. The SF-36 mental component scores did not differ significantly overall, but were significantly higher in the integrated multidomain intervention group at the 12-month follow-up (55·3 [SD 7·6] vs 57·2 [7·0]; p=0·019). No serious adverse events occurred. Interpretation Incorporating multidomain interventions into integrated health care improved quality of life. Our standardised protocol is amenable to inclusion in policies to promote value-based care and healthy ageing. Funding National Health Research Institutes, Taiwan, and Ministry of Science and Technology, Taiwan.

Backgrounds To investigate the efficacy of a community group-based intervention among community-dwelling older adults with physio-cognitive decline syndrome (PCDS). Methods A prospective cluster randomized controlled trial included 733 community-dwelling older adults with adjusted Montreal Cognitive Assessment (MoCA adj) scores >18 from 40 community-based sites across Taiwan. PCDS was defined as the concomitant presence of physical declines, i.e., slowness and/or weakness plus dysfunction in any cognitive domain. The multidomain intervention integrated physical exercise, cognitive training, nutritional advices and health education lessons. Conventional health education in control group entailed periodic telephone calls to offer participants health education and advice. The primary outcome was the mean differences of MoCA adj total scores and all domains of MoCA adj between baseline and 6- and 12-month follow-up in each group of PCDS, cognitive dysfunction, mobility-type frailty and normal functioning, and the secondary outcomes included the changes of frailty score, handgrip strength, gait speed and physical activity. Intervention effects were analysed using a generalized linear mixed model. Results Overall, 18.9% of the study sample had PCDS. Multidomain intervention for 12 months significantly improved cognitive performance in people with PCDS, and those with cognitive dysfunction only. An early benefit on visuo-spatial executive function was seen in older adults with mobility-type frailty. Intervention also improved frailty scores among participants with mobility-type frailty, handgrip strength for participants with PCDS, and gait speed in the normal group. Conclusions PCDS is a potentially reversible condition that may prevent subsequent disability and dementia, which deserves further investigation to confirm the long-term effects.

Background Longitudinal adverse outcomes are unclear among adults with diabetes according to the age of onset. Objective To investigate the longitudinal diabetes-related outcomes in adults with new-onset diabetes stratified by age. Design Retrospective cohort study. Setting Taiwan National Health Insurance Research Database claims data from 2000 to 2015. Subjects In total, 115,751 participants aged ≥40 years with new-onset diabetes in 2003 were recruited and stratified by the ages 40–64 (64.3%), 65–74 (21.2%), 75–84 (11.8%) and ≥85 years (2.7%) at the time of diagnosis. Methods Time-varying multivariate Cox proportional hazards model adjusted for covariates was used to examine the associations between the ages of the patients at diabetes onset and the outcomes of interest [all-cause mortality, cardiovascular (CV) mortality, major cardiovascular events (MACE) and hypoglycaemia] during a 10-year follow-up period. Results The results showed that compared with those patients aged 40–64 at diagnosis, patients with older-onset diabetes had significantly higher comorbidities (P Conclusions Patients with diabetes onset at an older age was associated with increased risks of all-cause mortality, CV mortality, MACE and hypoglycaemia after adjusting for the severity of diabetes and anti-diabetic treatment.

Background Chronic kidney disease (CKD), low serum albumin, and anemia are known risk factors for cognitive decline in older people. We investigated the association between kidney function and cognitive impairment severity in oldest-old people with a diagnosis of Alzheimer’s disease (AD). Methods A cross-sectional study of patients aged 80 years and older was conducted at a veterans’ home in Taiwan between 2012 and 2016. Their estimated glomerular filtration rate (eGFR) was determined using the Modification of Diet in Renal Diseases (MDRD) equation. Cognitive function was evaluated with the Mini-Mental State Examination (MMSE) and Clinical Dementia Rating (CDR). Results A total of 84 patients (age mean ± SD, 86.6 ± 3.9 years) had MMSE scores of 10.1 ± 6.7, and CDR scores of 1.6 ± 0.7. The average eGFR was 61.7 ± 21.5 mL/min/1.73m2. The mean hemoglobin concentration was 12.7 ± 1.7 g/dl, and the mean albumin concentration was 4.5 ± 4.8 g/dl. Multivariate regression analyses showed that scores of CDR were significantly correlated with eGFR after adjustment for potential confounders. The scores of MMSE were significantly correlated with serum albumin and hemoglobin after adjustment for potential confounders. Conclusions We found dementia severity was significantly associated with kidney function, serum albumin, and hemoglobin in the oldest-old with AD. We recommend that oldest-old people with a diagnosis of AD be evaluated to determine kidney function, as well as nutritional and hematological status. Further study is needed to establish whether prevention of CKD deterioration, and correction of malnutrition and anemia may help to slow cognitive decline in oldest-old people with dementia.

The study aimed to evaluate the impact of osteoporosis (OP) medication persistence on subsequent fractures and all-cause mortality in patients with hip fracture.In this retrospective cohort study, we included patients aged ≥ 40 years with fragility hip fracture from the Taiwan's National Health Insurance Research Database. OP medication persistence was categorized as yes (≥ 12 months) or no (12 months). A multivariate Cox proportional hazard model was used to evaluate the association between OP medication persistence and recurrent fractures (including hip, vertebral, and upper and lower limb fractures) and all-cause mortality.A total of 946 patients were included in the study (86.5 % of them aged ≥ 65 years) and 210 patients persistently received OP medications. Persistent OP medication use was associated with lower fracture risk (adjusted hazard ratio [aHR] = 0.64; 95 % CI = 0.41-0.99; P = .043) in the follow-up period. The strongest predictors for all-cause mortality were age ≥ 80 years (HR = 5.68, 95 % CI = 1.36-23.64, P = .017), male sex (HR = 1.55; 95 % CI = 1.18-2.03; P = .002), and Charlson Comorbidity Index ≥ 3 (aHR = 1.56; 95 % CI = 1.07-2.27; P = .022). Kaplan-Meier curves showed a lower cumulative incidence of recurrent fractures in the persistent group than that in the non-persistent group (P = .028).Persistent OP medication use was associated with a lower risk of recurrent fractures but not with mortality in patients with hip fracture.

We evaluated the trend of end-of-life healthcare utilization and life-sustaining interventions for older adults with dementia 3 to 4 years after the change in hospice policy.Population-based retrospective cohort study.We used the National Health Insurance Research database of enrolled patients ≥65 years of age diagnosed with dementia who died in 2010-2013 (n = 2062).Aggressive treatments, including healthcare utilization and life-sustaining interventions, were recorded within 6 months of death. Aggressive healthcare utilization included ≥1 emergency department visits, ≥1 hospitalizations,14 days of hospitalization, intensive care unit admission, and death in an acute care hospital. Life-sustaining interventions were enteral tube, artificial nutrition, blood transfusion, hemodialysis, invasive ventilation, and cardiopulmonary resuscitation.Compared with 2010‒2012, 2013 rates significantly decreased for all measures (P .001). Composite scores of healthcare utilization and life-sustaining treatments in 2013 were significantly lower than for 2010‒2012, after controlling for confounding variables (both P .001).Older patients with dementia had a trend of reduced healthcare utilization and fewer life-sustaining treatments near the end of life from 2010 to 2013 after a policy change.

No studies have yet examined the interrelationship of malnutrition and low handgrip strength in terms of mortality. The aim of the present study was to evaluate the potential synergistic effects of malnutrition and low handgrip strength on mortality among older adults living in a retirement community.This prospective longitudinal cohort study recruited subjects aged 65 years and over from a veterans care home in Taiwan in 2013. Nutritional status was assessed using the Mini-Nutritional Assessment-Short Form (MNA-SF, malnutrition was MNA-SF12); muscle strength was measured by handgrip strength (low handgrip strength was handgrip strength26 kg). The Kaplan-Meier method with the log-rank test was used to estimate survival differences between groups and Cox proportional regression model was used to estimate the adjusted difference in 4-year all-cause mortality between groups.Recruited for the present study were 333 male participants (mean age 85.4 ± 5.7 years). Of these, 50.2% had malnutrition and 54.7% had low handgrip strength. Compared with subjects with no malnutrition and low handgrip strength, those with malnutrition had significantly greater risk of 4-year all-cause mortality (adjusted hazards ratio: 2.05, 95% confident interval [CI]: 1.04-4.01); hazard ratio increased to 3.41 (95% CI 1.93-6.04) for those with both malnutrition and low handgrip strength.Malnutrition was an independent risk factor for 4-year all-cause mortality and low handgrip strength with malnutrition synergistically increased the mortality risk. Further study is needed to confirm the effectiveness of integrated programs to assist those at risk.

Objectives This study aimed to investigate the effects of a modified Hospital Elder Life Program (mHELP) on post-discharge cognition and physical function among older adults undergoing total knee arthroplasty (TKA), and to evaluate the incidence of postoperative delirium. Design Non-randomized intervention trial. Setting and participants A total of 140 patients aged 60 years and older scheduled for elective orthopedic surgery at our institution between August 2017 and December 2018 were included. Methods Ward-level stratification was used with one surgical ward receiving mHELP (intervention group), including orientation communication, early mobilization, vision/hearing impairment equipment, and dehydration prevention, and another ward providing usual care (control group). All participants were assigned to two surgical wards. Outcome measures were collected using MMSE telephone version (tMMSE), activities of daily living (ADL) and instrumental activities of daily living (IADL) instruments at 1, 6, and 12 months after discharge. Multiple linear regression analysis was used to measure effects of mHELP intervention on mean differences in tMMSE, ADL and IADL scores from baseline to 1-, 6- and 12-months. Results Effects of mHELP intervention significantly preserved cognitive function at 1 and 12 months, but not at 6 months, compared with controls, regardless of adjustments for confounders. However, no intervention effects were noted in ADL and IADL scores. Postoperative delirium in the whole cohort was 3.6 % (2.5 % in intervention group, 5.1 % in control group, P = 0.41). Conclusions mHELP intervention preserves post-discharge cognitive function, but has no notable effect on ADL and IADL function in older adults undergoing elective TKA surgery.

The risk of diabetes mellitus increases with age but its characteristics, treatment patterns, and outcomes in people with onset at different ages are little studied. The aim of this study is Investigate longitudinal clinical characteristics, complications, anti-diabetes medication usage, and diabetes-related outcomes among people diagnosed at different ages.This retrospective cohort study using Taiwan National Health Insurance Research Database claims data from 2000 to 2013, recruited 123,172 ≥ 40-year-olds with newly diagnosed diabetes, stratified by age at diagnosis: 40-64 years (62.2 %), 65-74 (21.9 %), 75-84 (12.9 %), and ≥ 85 (3.0 %). Baseline characteristics, 10-year follow-up of anti-diabetes drug usage, and cumulative incidence of diabetes-related complications and outcomes, stratified by age.Compared to people with younger-onset, those diagnosed when older had more multimorbidity, higher prevalence of diabetes-related complications, and proportionally lower anti-diabetes drug usage (all p0.01). During 10-year follow-up, people diagnosed when older had higher risks for cardiovascular and cerebrovascular disease, nephropathy, and peripheral artery disease, but lower cumulative incidence of retinopathy and peripheral neuropathy (all p0.001). People with later versus earlier onset had higher rates of all-cause mortality, cardiovascular mortality, major adverse cardiovascular events, and diabetes-related hospitalization (all p0.001).Over 10-year follow-up, people who are older versus younger at diabetes diagnosis have higher cumulative incidence of macrovascular complications but lower rates of microvascular complications (except nephropathy); they also have higher cumulative incidence of diabetes-related hospitalization, all-cause mortality, and cardiovascular morbidity and mortality.

Clinical and research interest in sarcopenia has burgeoned internationally, Asia included. The Asian Working Group for Sarcopenia (AWGS) 2014 consensus defined sarcopenia as “age-related loss of muscle mass, plus low muscle strength, and/or low physical performance” and specified cutoffs for each diagnostic component; research in Asia consequently flourished, prompting this update. AWGS 2019 retains the previous definition of sarcopenia but revises the diagnostic algorithm, protocols, and some criteria: low muscle strength is defined as handgrip strength

Objectives To evaluate the roles of preoperative anemia and intraoperative blood transfusion in the development of postoperative delirium among older patients undergoing elective orthopedic surgery. Methods This prospective cohort study recruited subjects aged 60 years old and above who were admitted for elective orthopedic surgery in a tertiary medical center during April 2011 to December 2013. Demographic data (age, gender, body mass index [BMI], and educational level), surgery-related factors (American Society of Anesthesiology [ASA] class, type of anesthesia and surgery, and intraoperative blood transfusion), results of geriatric assessment (hearing/visual impairment, cognition, depressive mood, comorbidity, malnutrition, polypharmacy, activities of daily living [ADL], and instrumental activities of daily living [IADL]), laboratory data, length of hospital stay, and the development of postoperative delirium were collected for analysis. Results Overall, 461 patients (mean age: 73.5 ± 7.5 years, 42.1% males) were enrolled for study, and 37 (8.0%) of them developed postoperative delirium. We categorized all subjects into four groups based on anemia on admission and blood transfusion during operation or not. Multivariate logistic regression showed that subjects with anemia on admission and received intraoperative blood transfusion were at higher risk of developing postoperative delirium (adjusted odds ratio 3.090; 95% confidence interval [CI], 1.070-8.926) and those without anemia on admission but received intraoperative blood transfusion were at marginal risk (adjusted odds ratio 2.906; 95% CI, 0.912-9.259) after adjustment for covariates. Conclusions Anemic older patients receiving intraoperative blood transfusion during operation were at the greatest risk for postoperative delirium when they underwent elective orthopedic surgery. Further intervention study is needed to reduce the risk of postoperative delirium for these patients.

This study aimed to develop a prediction model for post-operative delirium among older patients receiving elective orthopedic surgery and to evaluate its effectiveness in predicting long-term health outcomes. This prospective cohort study screened all subjects aged over 60 years who were admitted for elective orthopedic surgery in a tertiary medical center in Taiwan from April, 2011, to December, 2013. Demographic characteristics, surgery-related factors, and results of comprehensive geriatric assessment (CGA) were all used to develop the prediction model. Long-term health outcomes, including mortality, nursing home admission, and functional status in the first year after surgery, were used to further evaluate the effectiveness of the prediction model. Overall, 461 patients (median age, 73 years; interquartile range [IQR], 67-80 years; 42.3% males) were enrolled, and 37 patients (8.0%) developed post-operative delirium. Prediction models were developed on the basis of demographic characteristics and surgery-related factors (model 1) and of demographic characteristics, surgery-related factors, and geriatric assessment variables (model 2). Although both models effectively predicted the occurrence of post-operative delirium, duration of post-operative delirium, total hospital days, nursing home admission, and mortality, model 2 was more likely to differentiate cases with functional decline during the first year after surgery. In conclusion, a prediction model developed by using demographic characteristics, surgery-related factors, and results of CGA was highly predictive for post-operative delirium, as well as long-term health and functional outcomes.

Older patients with diabetes mellitus are at a higher risk of developing diabetic macro- and micro-vascular complications and cardiovascular diseases than younger diabetes mellitus patients. However, older diabetes mellitus patients are very heterogeneous in their clinical characteristics, diabetes mellitus-related complications and age at disease onset. This study aimed to evaluate the all-cause mortality rates and adverse health outcomes among older adults with new-onset diabetes mellitus through a nationwide population-based study. A retrospective cohort study. 2001-2011 data of the National Health Insurance database. Nationally representative sample of Taiwanese adults aged 65 years and older with propensity score-matched controls. All-cause mortality and adverse health outcomes. During the study period, 45.3% of patients in the diabetes mellitus cohort and 38.8% in the non-diabetes mellitus cohort died. The adjusted relative risk for mortality in the diabetes mellitus cohort compared to the non-diabetes mellitus cohort was 1.23 (95% Confidence Interval [CI]=1.16-1.30) for males and 1.27 (95%CI=1.19-1.35) for females. During the follow-up period, 8.9% of the diabetes mellitus cohort and 5.8% of the non-diabetes mellitus cohort developed cardiovascular diseases; the diabetes mellitus cohort had an adjusted relative risk of cardiovascular complications compared to the non-diabetes mellitus cohort of 1.54 (95%CI=1.36-1.75) for men and 1.70 (95%CI=1.43-2.02) for women. The adjusted relative risk of mortality in the patients with hypoglycemia compared to non-hypoglycemia patients in the diabetes mellitus cohort was 2.33 (95%CI=1.81-3.01) for men and 2.73 (95%CI=2.10-3.52) for women after adjustment for age, Charlson comorbidity index, acute coronary syndrome, respiratory disease, cancer, infectious disease and nervous system disease at baseline. New-onset diabetes in older adults is associated with an increased risk of mortality, and hypoglycemia is an important marker of this association. Individualized care plans stratified by age at onset, duration of disease, comorbidity and functional status, as well as hypoglycemia avoidance, would benefit the management of diabetes in older adults.

PURPOSE To evaluate the effectiveness of adding gait speed to the history of falls in predicting falls among men aged 80years and older in Taiwan. METHODS This prospective cohort study recruited 230 ambulatory men aged 80years and older in 2012 and followed for 12months. In addition to demographic characteristics and history of falls, a comprehensive geriatric assessment was performed for all study subjects. Gait speed was obtained by the 6-m walk and three different cut-offs (RESULTS Among all subjects (mean age: 85.5±4.0years), 26.1% (60/230) reported falls during follow-up period. Univariate analysis showed that polypharmacy, urinary incontinence, history of falls, pain, poorer baseline physical function, depressive mood, and gait speedCONCLUSIONS Combined history of falls and gait speed is a simple and effective tool in risk assessment of falls among older old population.

The aim of this study was to assess the home care needs and task difficulty of community-dwelling aged hip fracture and the association of functional recovery with care received. A cohort of hip fracture patients admitted to orthopedic wards for surgery was collected from August 2009 to December 2010. Patients transferred to long-term care facilities after surgery were excluded. Functional status (feeding, clothing, grooming, bathing, getting in/out of bed, walking, toileting, standing up/sitting down, and walking up/down stairs) and task difficulty for caregivers were recorded at discharge, one week and one month after discharge. In total, 116 patients (mean age: 79.4 ± 8.5 years, 51.7% males) were enrolled. The mean age of primary caregivers was 53.4 ± 14.2 years, and most were daughters or sons (54.3%), spouses (34.5%) or foreign workers (11.0%). The most common care needs were wound care (95.7%), medical visits (94.8%), cleaning and maintaining living quarters (92.2%) and vigilance to ensure patient safety (92.2%). The care needs and task difficulty significantly correlated with physical function before, one week and one month after discharge (r=-0.530, p

Purpose The purpose of this study was to evaluate risk factors for frequent emergency department (ED) visits among older Chinese men living in a veterans home in northern Taiwan Methods In 2006, all residents of Banciao Veterans Home were invited for study. Minimum Data Set Nursing Home 2.1 Chinese version, Chinese version of Geriatric Depression Scale (GDS) short form, mini-mental status examinations (MMSE), and Charlson Comorbidity Index (CCI) were used for study. ED records of all study participants were obtained from Taipei Veterans General Hospital, and frequent ED visitors were defined as who visited ED for three times or more in 1 year. Results Overall, 609 residents (mean age = 80.9 ± 5.3 years, all men) were enrolled, and 169 (27.8%) of them visited the ED for at least once. Among all participants, 30 (4.9%) were frequent ED visitors. Frequent ED visitors were significantly older, disabled, cognitively impaired, depressed, urinary incontinent, having poorer social engagement score, and higher Charlson’s comorbidity index (CCI). Adjustments for age, activities of daily living, depression, cognitive impairment (adjusted odds ratio: 3.19; 95% confidence interval: 1.37–7.46, p = 0.004) and higher CCI (adjusted odds ratio: 1.69; 95% confidence interval: 1.20–2.39, p = 0.003) were independent risk factors for frequent ED visits. Conclusion The cumulative incidence of ED visit was 51 visits per 100 person-years, and the prevalence of frequent ED visitors was 4.9% among older veterans living in a Veterans Home. Cognitive impairment and higher Charlson’s comorbidity index were independent risk factors for frequent ED visitors. Further study is needed to explore the unmet health-care needs for frequent ED visitors in the veterans home.

PurposeTo evaluate the postacute care (PAC) needs of elderly patients in a tertiary teaching hospital.MethodsAll elderly veterans admitted to a tertiary medical center were screened for their needs for PAC services from May 1 to October 31, 2009. Case managers evaluated the inclusion/non-inclusion criteria while visiting patients before their discharge. Comprehensive geriatric assessment (CGA) was performed before their transfer, if they agreed to receive the PAC service in addition to the complete medical history review.ResultsOverall, 409 elderly patients (96.8% male; mean age = 80.4 ± 5.4 years) meeting the inclusion/exclusion criteria were screened, and 103 (25.2%) had PAC service needs. All patients diagnosed with central nervous system and musculoskeletal conditions displayed a significant decrease (93.1 ± 10.8 to 43.6 ± 33.3, p

Objectives To compare the differences in plasma brain-derived neurotrophic factor (BDNF) levels among institutionalized ethnic Chinese elderly participants with major depression, those with subclinical depression, and a nondepressed control group. Design A cross-sectional study. Setting The veterans' home in southern Taiwan. Participants One hundred sixty-seven residents. Measurements Questionnaires including the Minimum Data Set Nursing Home 2.1, Chinese-language version, and the short-form Geriatric Depression Scale, Chinese-language version. Depressive disorder was diagnosed by a well-trained psychiatrist using DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision) criteria. We measured plasma BDNF levels in the following 3 groups: nondepressive subjects (n = 122), subclinically depressive subjects (n = 33), and subjects with major depression (n = 12). Plasma BDNF was assayed using the sandwich ELISA method. Results We noted a significantly negative association between age and plasma BDNF in the regression model. There was no significant correlation between BDNF plasma levels and body weight or platelet counts. We found that plasma BDNF was significantly lower in the major depressive group (mean, 115.1 pg/mL; SD, 57.2) than in the nondepressive group (mean, 548.8 pg/mL; SD, 370.6; P < .001). The BDNF plasma concentrations in the subclinically depressive group (mean, 231.8 pg/mL; SD, 92.4; P < .001) and control group were also significantly different. Conclusions Our findings revealed that plasma BDNF levels were reduced not only in ethnic Chinese elderly patients with major depressive disorder but also in those with subclinical depression. This makes the plasma BDNF level a potential biological marker for clinical or subclinical depression.

Delirium is a common and serious acute neuropsychiatric syndrome characterized by inattention and global cognitive dysfunction. The etiologies of delirium are diverse, multifactorial, and often reflect the pathophysiologic consequences of an acute medical illness, medical complication, or drug intoxication. At present, the diagnosis of delirium depends on the presence of certain clinical features. Many recent studies have sought to identify biomarkers for delirium to predict its onset, severity, recovery rate, or prognosis. In this narrative review, we examine six approaches to identify serum biomarkers of delirium: serum chemistry, genes, neurotransmitters, inflammatory factors, serum cortisol levels, and end products of delirium. Moreover, we discuss the limitations of current research and the challenges of serum biomarker studies.

Nutritional status is important in stroke care, but little is known regarding to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. The main purpose of this study was to evaluate to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. Data of acute stroke registry in Kaohsiung Veterans General Hospital were retrieved for analysis. Overall, 483 patients (mean age = 70.7 ± 10.3 years) with first-ever stroke were found. Among them, 95 patients (19.7%) were malnourished at admission, 310 (mean age = 70.4 ± 10.1 years, 63.5% males) survived for 6 months, and 244 (78.7%) had good functional outcomes. Subjects with poor functional outcomes were older (74.7 ± 8.9 vs. 69.0 ± 10.1 years, p < 0.001), more likely to be malnourished (56.2% vs. 26.6%, p < 0.001), to develop pneumonia upon admission (23.3% vs. 12.7%, p = 0.027), had a longer hospital stay (23.5 ± 13.9 vs. 12.5 ± 8.2 days, p < 0.001), had a higher National Institutes of Health Stroke Scale (NIHSS) score (12.9 ± 9.3 vs. 4.9 ± 4.3, p < 0.001), poorer stroke recovery (NIHSS improvement: 6.9% vs. 27.4%, p = 0.005), and poorer functional improvement (Barthel index = BI improvement in the first month: 31.4% vs. 138%, p < 0.001). Older age (odds ratio = OR) = 1.07, 95% confidence interval (CI = 1.03-1.11, p

Background Although all classes of antihypertensive treatment can successfully reduce morbidity and mortality of cardiac pathology, prevention of target organ damages is of great importance beyond blood pressure lowering. Unlike most dihydropyridines, lercanidipine dilates both afferent and the efferent arterioles of nephrons, so it may provide renoprotective effects, which other CCBs may not have. The main purpose of this study is to compare the renoprotective effect of lercanidipine and amlodipine among hypertensive people aged 55 years and older with newly diagnosed hypertension or those who were treatment-naive for one month. Methods The study is a prospective, open-labelled, randomized, controlled trial to enrol 232 hypertensive patients aged ≥55 years. Subjects will be randomized into lercanidipine arm (10–20 mg/day) and amlodipine arm (5–10 mg/day) by 1:1 ratio. The dosage can be up-titrated to 20 mg/day (lercanidipine group) and 10 mg/day (amlodipine group), respectively, at week 4 or any following visit thereafter. Efficacy and safety data will be collected at week 4, 12 and 24 by evaluating the blood pressure lowering, estimated glomerular filtration rate, creatinine clearance, and urine albumin-creatinine ratio. Conclusions The reno-protective effects of new generation of CCBs such as lercanidipine administered to patients with hypertension are not investigated well. After all, this study will bring benefit to older patients who need drugs with both excellent anti-hypertensive and reno-protective efficacy. And the results will be provided for future treatment guideline of elder population in Taiwan.

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, p0.001), 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.

Nutritional status is important in various health care settings, long-term care is no exception. The relationship between protein-energy malnutrition and clinical outcomes in care homes has been reported. However, little is known about the roles of trace elements in clinical outcomes of care home residents. In 2002, 75 severely disabled care home residents (mean age: 77.7+/-8.2 years, 64.3% males) were enrolled for study. The status of protein-energy malnutrition at enrollment was as follows: 47.9% underweight (body mass index, BMI

Objective To evaluate the benefits of the national stroke postacute care (PAC) program on clinical outcomes and subsequent healthcare utilization. Design Propensity score-matched case-control study using the National Health Insurance data. Participants A total of 1480 stroke cases receiving PAC services and 3159 matched controls with similar stroke severity but without PAC services. Measurements Demographic characteristics, functional outcomes (modified Rankin Scale, Barthel Index, Lawton-Brody Instrumental Activities of Daily Living, Functional Oral Intake Scale, Mini-Nutritional Assessment, Berg Balance Test, Usual Gait Speed Test, 6-Minute Walk Test, Fugl-Meyer Assessment (modified sensation and motor), Mini-Mental State Examination, Motor Activity Log, and the Concise Chinese Aphasia Test), subsequent healthcare utilization (90-day stroke re-admission and emergency department visits), and 90-day mortality. Results After propensity score matching, baseline characteristics, stroke severity, and status of healthcare utilization before index stroke admission were similar between cases and controls. After PAC services, the case group obtained significant improvement in all functional domains and may have reduced subsequent disability. Among all functional assessments, balance was the most significantly improved domain and was suggestive for the reduction of subsequent falls risk and related injuries. Compared with controls, patients receiving PAC services had significantly lower 90-day hospital re-admissions [11.1% vs 21.0%, adjusted odds ratio (aOR) 0.47 with 95% confidence interval (CI) 0.34–0.64], stroke-related re-admissions (2.1% vs 8.8%, aOR 0.22, 95% CI 0.12–0.41), and emergency department visits (13.5% vs 24.0%, aOR 0.49, 95% CI 0.37–0.65), but the 90-day mortality rate remained similar between groups (1.4% case group vs 2.0% control group, aOR 0.68, 95% CI 0.29–1.62). Conclusions PAC significantly improved the recovery of stroke patients in all functional domains through the program, with universal interorganizational staff training, periodic functional assessment, and high-intensity rehabilitation. Further longitudinal research is needed to evaluate the long-term survival benefits and healthcare utilization.

The dermatologic diseases of the dependent elderly require special attention. This screening and treatment service of dermatological diseases was conducted in a Veterans Home in Southern Taiwan. A total of 337 male residents were screened with mean age 83 years (range 46–99). 271 (80.4 %) residents were in dependent status. Their skin diseases were recorded and the distribution pattern was compared with those in the other studies. Comparing by Chi-square test, scabies, bacterial infection, chronic ulcers, pruritus, and brown spots on the legs were present significantly in certain major systemic diseases, respectively. Higher prevalence of certain skin diseases was related to the severity of disability or major systemic diseases of the residents. Actinic keratosis and non-melanoma skin cancers were early detected and managed. The distribution patterns of skin diseases in a Veterans Home were unique. It provides the evidences on appropriate management and key nursing points for dependent elderly.

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.

Introduction: Delirium, the acute deterioration of cognitive function and attention, is the most frequent mental disorder in elderly. Its correct diagnosis and adequate management are of crucial importance for the patient’s health and functional outcome. The aim was to highlight potential intervention points to offset the risk of incurring a hip fracture and delirium its attendant disability. Methods: We conducted a retrospective chart review study carried out in our Orthogeriatric Unit. A total of 542 consecutive hip fracture, we selected those with delirium during the admission. Underwent comprehensive geriatric assessment that evaluates co morbidities, medication use, ability to perform basic activities of daily living and instrumental activities of daily living, place of residence and family support. Results: We found 163 patients with delirium and hip fracture; the mean age of our cohort was 87.23±9.6 years (76–98 years). 46 (28%) patients were male. The mean duration of the hospital stay was 13.62±9.6 days (range 2–41 days). 42.3% of the patients with pre-existing neurological conditions. In 44 patients, we were able to identify possible precipitating cause of an acute confusional state. Anemia and hyponatremia were frequent factors associated with delirium. Surgical treatment was performed 90.18%. Conclusions: • Delirium is a very prevalent condition in patients with hip fracture. • Delirium may increase the complications after hip fracture. • Patients, in whom a cause was found out, had better prognosis in terms of lesser mortality and the duration of hospital stay. P468 Interrelationship of delirium and cognitive impairment on adverse functional outcomes of older patients receiving orthopedic surgery: a prospective cohort study M.Y. Chou, C.K. Liang, C.L. Chu, Y.T. Lin, T. Lu, C.J. Hsu, L.K. Chen Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Taipei Veterans General Hospital, Taipei, Taiwan

Being older as a risk factor for vomiting in those undergoing spinal anesthesia [Journal of Clinical Gerontology & Geriatrics 3 (2012) 68–72] Wei-Hung Lien, MD , Ming-Yueh Chou, MD, Chih-Kuang Liang, MD , Kang Liu, MD , Yu-Mei Chou, MD, MS a,* Department of Anesthesiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan Department of Family Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan Geriatric Medicine Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan National Yang-Ming University, School of Medicine, Taipei, Taiwan

PurposeTo explore the effect of older age (≥ 65 years) as a risk factor for nausea and vomiting in the context of spinal anesthesia by assessing patient-, surgery- and anesthesia-related variables.MethodsThis is an observation study using a survey instrument in a tertiary general hospital. Patients scheduled to undergo surgery with spinal anesthesia were surveyed by questionnaire and record review to prospectively and consecutively study all patients consenting to spinal anesthesia for surgery during the intraoperative and 24-hour postoperative periods. Risk factors were examined via univariate and multivariate analysis.ResultsOf the 903 patients (69.7% were men) scheduled to undergo surgery with spinal anesthesia, 421 of them (46.6%) were older than 65 years of age. During the intraoperative and postoperative 24-hour observation period, 87 patients (28.1%) experienced nausea and 55 (17.7%) vomited. The incidence of nausea did not differ between elderly (≥ 65 years) and nonelderly patients. However, being elderly was a risk factor for vomiting (24.7% vs. 15.6%, p

Summary Background Hip fractures in the elderly are significant with mortality. Most of the deaths occur during the early period after the operation. Hence, defining the risk factors may assist in preventive measures. The aim of this study is to determine the risk factors for mortality in elders with fracture hip in one year after hospitalization. Methods This study included 195 elderly and ambulatory patients before fracture who receiving surgery for hip fracture at a medical center of Southern Taiwan for non-pathologic hip fractures from August 2011 to December 2013. Patients were treated with hip arthroplasty or open reduction internal fixation (ORIF). Participants' demographic, medical characteristics and functional status were collected at this study. Patients were followed for one year after surgery or until death. Results In total, 39 patients died during the one-year period. Patient survival was 91.4% at one month, and 79.9% at one year. The predictors of one-year mortality that remained in the final Cox's proportional hazard regression model were COPD (chronic obstructive pulmonary disease) (HR: 6.5), diabetes (HR: 4.0), solid tumors with metastasis (HR: 6.5) and Type of operation (HR: 3.3). Additionally, COPD was a strong predictor of death in this cohort. Conclusion This study showed that THR, COPD, diabetes, and solid tumors with metastasis were associated with an increase in one-year mortality in aged with fracture hip.

Falls are common among elderly patients who present at the emergency department (ED). When elderly patients suffer from an acute illness or the exacerbation of a chronic condition, they are frail, and, consequently, their balance may be affected. However, falls are not yet reported as the initial presentation of acute appendicitis. This is a case report of such. A 70-year-old gentleman called for emergency medical services help due to a fall. He presented at the ED with abrasion and contusion to his forehead and bilateral knees. He was taken to the traumatic division of the ED. However, some hours later, he developed fever and right lower abdominal pain. Acute appendicitis was diagnosed and appendectomy was performed. He had a smooth recovery without complications. Because surgical intervention is the only definitive treatment for acute appendicitis, emergency physicians should be aware of this rare presentation.