Diagnosis and outcomes of cachexia in Asia: Working Consensus Report from the Asian Working Group for Cachexia.

Chronic diseases often lead to metabolic disorders, causing anabolic resistance and increased energy consumption, which result in cachexia. Cachexia, in turn, can lead to major clinical consequences such as impaired quality of life, shortened life expectancy, and increased healthcare expenditure. Existing international diagnostic criteria for cachexia employ thresholds derived from Western populations, which may not apply to Asians due to differing body compositions. To address this issue, the Asian Working Group for Cachexia (AWGC) was initiated. The AWGC comprises experts in cachexia research and clinical practice from various Asian countries and aims to develop a consensus on diagnostic criteria and significant clinical outcomes for cachexia in Asia. The AWGC, composed of experts in cachexia research and clinical practice from several Asian countries, undertook three-round Delphi surveys and five meetings to reach a consensus. Discussions were held on etiological diseases, essential diagnostic items for cachexia, including subjective and objective symptoms and biomarkers, and significant clinical outcomes. The consensus highlighted the importance of multiple diagnostic factors for cachexia, including chronic diseases, either or both weight loss or low body mass index, and at least one of the following: anorexia, decreased grip strength (<28 kg in men and <18 kg in women), or elevated C-reactive protein levels (>5 mg/L [0.5 mg/dL]). The AWGC proposed a significant weight change of 2% or more over a 3-6 month period and suggested a tentative cut-off value of 21 kg/m2 for low body mass index in diagnosing cachexia. Critical clinical outcomes were determined to be mortality, quality of life as assessed by tools such as EQ-5D or the Functional Assessment of Anorexia/Cachexia Therapy, and functional status as measured by the Clinical Frailty Scale or Barthel Index, with significant emphasis on patient-reported outcomes. The AWGC consensus offers a comprehensive definition and user-friendly diagnostic criteria for cachexia, tailored specifically for Asian populations. This consensus is set to stimulate future research and enhance the multidisciplinary approach to managing cachexia. With plans to develop further guidelines for the optimal treatment, prevention, and care of cachexia in Asians, the AWGC criteria are expected to drive research across chronic co-morbidities and cancer in Asia, leading to future refinement of diagnostic criteria.

The association of potentially inappropriate medications, polypharmacy and anticholinergic burden with readmission and emergency room revisit after discharge: A hospital-based retrospective cohort study.

AIMS: While certain drug-use indicators are known to be associated with clinical outcomes, the relationship is unclear for some highly prevalent conditions in in patients aged ≥65 years. We examine correlations between 3 drug-use indicators and postdischarge healthcare services use by older patients according to the presence of dementia, advanced age and frailty. METHODS: This retrospective cohort study analysed data collected from hospital electronic health records between April and December 2017. Potentially inappropriate medications (PIMs) and anticholinergic burden were assessed using the 2015 Beers Criteria and anticholinergic cognitive burden scale (ACBS) score. Minor and major polypharmacy were defined as the use of 5-9 and ≥10 drugs, respectively. Outcomes were set as emergency room revisits and readmissions at 1, 3 and 6 months postdischarge. The correlation between drug-use indicators and outcomes was analysed by multivariable logistic regression. RESULTS: The final cohort included 3061 patients for the analysis, and 2930, 2671 and 2560 patients were followed up to 1, 3 and 6 months after discharge. After controlling for confounders, all 3 drug-use indicators were significantly associated with readmission and emergency room revisits except for the relationship between PIMs and readmission within 6 months. These associations were significantly observed among patients without dementia, aged >80 years and with frailty. CONCLUSION: PIMs, polypharmacy and anticholinergic burden are common at discharge and correlate with future use of healthcare services. In older patients, the absence of dementia, advanced age and frailty should be given extra consideration with regard to medication safety.

Muscle-to-fat ratio identifies functional impairments and cardiometabolic risk and predicts outcomes: biomarkers of sarcopenic obesity.

BACKGROUND: Sarcopenic obesity aims to capture the risk of functional decline and cardiometabolic diseases, but its operational definition and associated clinical outcomes remain unclear. Using data from the Longitudinal Aging Study of Taipei, this study explored the roles of the muscle-to-fat ratio (MFR) with different definitions and its associations with clinical characteristics, functional performance, cardiometabolic risk and outcomes. METHODS: (1) Appendicular muscle mass divided by total body fat mass (aMFR), (2) total body muscle mass divided by total body fat mass (tMFR) and (3) relative appendicular skeletal muscle mass (RASM) were measured. Each measurement was categorized by the sex-specific lowest quintiles for all study participants. Clinical outcomes included all-cause mortality and fracture. RESULTS: Data from 1060 community-dwelling older adults (mean age: 71.0 ± 4.8 years) were retrieved for the study. Overall, 196 (34.2% male participants) participants had low RASM, but none was sarcopenic. Compared with those with high aMFR, participants with low aMFR were older (72 ± 5.6 vs. 70.7 ± 4.6 years, P = 0.005); used more medications (2.9 ± 3.3 vs. 2.1 ± 2.5, P = 0.002); had a higher body fat percentage (38 ± 4.8% vs. 28 ± 6.4%, P < 0.001), RASM (6.7 ± 1.0 vs. 6.5 ± 1.1 kg/m2 , P = 0.001), and cardiometabolic risk [fasting glucose: 105 ± 27.5 vs. 96.8 ± 18.7 mg/dL, P < 0.001; glycated haemoglobin (HbA1c): 6.0 ± 0.8 vs. 5.8 ± 0.6%, P < 0.001; triglyceride: 122.5 ± 56.9 vs. 108.6 ± 67.5 mg/dL, P < 0.001; high-density lipoprotein cholesterol (HDL-C): 56.2 ± 14.6 vs. 59.8 ± 16 mg/dL, P = 0.010]; and had worse functional performance [Montreal Cognitive Assessment (MoCA): 25.7 ± 4.2 vs. 26.4 ± 3.0, P = 0.143, handgrip strength: 24.7 ± 6.7 vs. 26.1 ± 7.9 kg, P = 0.047; gait speed: 1.8 ± 0.6 vs. 1.9 ± 0.6 m/s, P < 0.001]. Multivariate linear regression showed that age (ß = 0.093, P = 0.001), body mass index (ß = 0.151, P = 0.046), total percentage of body fat (ß = 0.579, P < 0001) and RASM (ß = 0.181, P = 0.016) were associated with low aMFR. Compared with those with high tMFR, participants with low tMFR were older (71.7 ± 5.5 vs. 70.8 ± 4.7 years, P = 0.075); used more medications (2.8 ± 3.3 vs. 2.1 ± 2.5, P = 0.006); had a higher body fat percentage (38.1 ± 4.7 vs. 28 ± 6.3%, P < 0.001), RASM (6.8 ± 1.0 vs. 6.5 ± 1.1 kg/m2 , P < 0.001), and cardiometabolic risk (fasting glucose: 104.8 ± 27.6 vs. 96.9 ± 18.7 mg/dL, P < 0.001; HbA1c: 6.1 ± 0.9 vs. 5.8 ± 0.6%, P < 0.001; triglyceride: 121.4 ± 55.5 vs. 108.8 ± 67.8 mg/dL, P < 0.001; HDL-C: 56.4 ± 14.9 vs. 59.7 ± 15.9 mg/dL, P = 0.021); and had worse functional performance (MoCA: 25.6 ± 4.2 vs. 26.5 ± 3.0, P = 0.056; handgrip strength: 24.6 ± 6.7 vs. 26.2 ± 7.9 kg, P = 0.017; gait speed: 1.8 ± 0.6 vs. 1.9 ± 0.6 m/s, P < 0.001). Low tMFR was associated with body fat percentage (ß = 0.766, P < 0.001), RASM (ß = 0.476, P < 0.001) and Mini-Nutritional Assessment (ß = -0.119, P < 0.001). Gait speed, MoCA score, fasting glucose, HbA1c and tMFR were significantly associated with adverse outcomes, and the effects of aMFR were marginal (P = 0.074). CONCLUSIONS: Older adults identified with low MFR had unfavourable body composition, poor functional performance, high cardiometabolic risk and a high risk for the clinical outcome.

Effects of modified version of the Hospital Elder Life Program on post-discharge cognitive function and activities of daily living among older adults undergoing total knee arthroplasty.

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.

Effects of Socioeconomic Status on Alzheimer Disease Mortality in Taiwan.

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.

Hash Transformation and Machine Learning-Based Decision-Making Classifier Improved the Accuracy Rate of Automated Parkinson's Disease Screening.

Digitalized hand-drawn pattern is a noninvasive and reproducible assistive manner to obtain hand actions and motions for evaluating functional tremors and upper-limb movement disorders. In this study, spirals and straight lines in polar coordinates are used to extract polar expression features such as the key parameters deviation (cm) and accumulation angle (rad). These parameters are quantitative manner to scale the variations of functional tremors in normal control subjects and patients with Parkinson's disease (PD) and essential tremor (ET). However, difficulty arises in using nonlinear polar expression features in the two-dimensional feature space to separate normal control subjects from those with PD and ET. To solve the nonlinear separable classification problem, hash transformation is used to map polar expression features to a high-dimensional space using hash weighing function and modulo operation. Then, a machine learning method, such as the generalized regression neural network (GRNN), is implemented to train a decision-making classifier using the particle swarm optimization (PSO) algorithm for possible class assessment. With the enrolled data from 50 subjects, the fivefold cross validation, mean true positive, mean true negative, and mean hit rates of 98.93%, 98.96%, and 98.93%, respectively, are obtained to quantify the performance of the proposed decision-making classifier to identify normal controls and subjects with PD or ET. The experimental results indicate that the proposed screening model can improve the accuracy rate compared with the conventional machine learning classifier.

Intraoperative blood transfusion predicts postoperative delirium among older patients undergoing elective orthopedic surgery: A prospective cohort study.

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.

Association Between Polymorphisms in Dopamine-Related Genes and Orthopedic Pain Expression in a Chinese Elderly Population.

OBJECTIVES: The dopaminergic pathway plays a vital role in pain expression. Here, our aim was to investigate the effects of polymorphisms in genes encoding the dopamine active transporter (SLC6A3) and dopamine receptor D2 (DRD2) on preoperative pain expression among patients preparing for orthopedic surgery. METHODS: Chinese elderly patients scheduled for orthopedic surgery were enrolled. The VAS was used to evaluate pain intensity (score range 0 to 10; 0 = no pain; 10 = worst pain possible). Depressive symptoms were evaluated via the 15-item Geriatric Depression Scale. DNA was isolated from venous blood samples, and single-nucleotide polymorphisms of SLC6A3 and DRD2 were genotyped. Multiple linear regressions analyses were carried out to adjust the results for confounders. RESULTS: A total of 294 patients with a mean age of 73.82 ± 8.03 years were enrolled in this study. After adjustment for confounders, rs393795 in SLC6A3 showed a significant association with preoperative VAS scores. Patients with the A/A genotype reported lower mean pain scores than did those with the A/C genotype (P = 0.026). Subsequent depression-stratified analysis of rs6276 in DRD2 revealed that patients with the A/A genotype had higher pain scores than did those with the G/G genotype (P = 0.043). No associations were found for DRD2 rs6277 in the whole study population or depression-stratified groups. CONCLUSION: Genetic variations in SLC6A3 and DRD2 may play an important role in pain expression among the elderly prior to orthopedic surgery.

Synergistic effects of cognitive impairment on physical disability in all-cause mortality among men aged 80 years and over: Results from longitudinal older veterans study.

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.

Mini-Nutritional Assessment Short-Form as a useful method of predicting poor 1-year outcome in elderly patients undergoing orthopedic surgery.

AIM: The present study aimed to determine whether the Mini-Nutritional Assessment Short-Form (MNA-SF) can predict the 1-year outcome of orthopedic fracture surgery in elderly patients. METHODS: This 1-year prospective study assessed nutrition using the MNA-SF at baseline, and postoperatively at 6 and 12 months. Repeated measures analysis of covariance was used to examine functional change over time for two MNA-SF categories. Multivariable logistic regression analysis with forward stepwise modeling was carried out to identify risk factors of functional decline, emergency department visit, hospital readmission and mortality at follow up. RESULTS: There were 312 participants, 11 of whom died (3.53%) during 1-year follow up. The mean age was 74.04 ± 7.65 years. A total of 88.1% and 11.9% of the participants were well nourished (MNA-SF 12-14 points) or at risk of undernutrition (0-11 points), respectively. For MNA-SF as a continuous variable, lower MNA-SF scores were associated with a significantly higher risk of emergency department visit at 6-month follow up, and mortality at 12-month follow up (emergency room visit, adjusted odds ratio 0.78, 95% CI 0.63-0.96, P < 0.05; mortality, adjusted odds ratio 0.73, 95% CI 0.57-0.94, P < 0.05). No association was found between functional decline and hospital readmission, and MNA-SF scores. For MNA-SF categories, functional decline was more profound in patients at risk of undernutrition than in well-nourished patients, especially 6-12 months postoperatively. CONCLUSIONS: The MNA-SF could be an effective and non-invasive preoperative screening tool to predict functional decline, emergency department visit and mortality during the year after surgery. Geriatr Gerontol Int 2017; 17: 2361-2368.

Delaying cognitive and physical decline through multidomain interventions for residents with mild-to-moderate dementia in dementia care units in Taiwan: A prospective cohort study.

AIM: To develop experimental multi-domain interventions for older people with mild-to-moderate dementia, and to evaluate the effect of delaying cognitive and physical decline, and improvement or prevention of geriatric syndromes during 1-year follow up. METHODS: Participants aged 65 years and older with mild-to-moderate dementia (clinical dementia rating [CDR] 1 or 2) were grouped as intervention in Jia-Li Veterans Home and usual care model in the community (Memory clinic). All residents in Jia-Li Veterans Home received comprehensive intervention, including Multi-disciplinary team consultation and intervention, Multi-component non-pharmacological management, geriatric syndromes survey and intervention by CGA, and a dementia friendly medical Green channel Approach (2MCGA). The decline of cognitive and physical function are determined by the change of Mini-Mental State Examination score, CDR and the sum of CDR box, as well as activities of daily living based on the Barthel Index. We also screened geriatric syndromes at baseline and 1 year later. RESULTS: Participants in the intervention group were older and had a lower educational level, lower body mass index, poor baseline activities of daily living function, lower visual impairment, and higher rates of hearing impairment, polypharmacy and risk of malnutrition. The residents receiving 2MCGA had lower baseline Mini-Mental State Examination scores, and higher CDR. For residents in Jia-Li Veterans Home, all cognitive measurements except Mini-Mental State Examination were significantly associated with delaying the decline of cognition after analyzing by multiple linear regression, and multivariate logistic regression also showed that patients living in the community was independently associated with a higher odds ratio for activities of daily living decline (3.180, 95% CI 1.384-7.308, P = 0.006). There are also more improvement in their baseline geriatric syndromes and suffered less from new geriatric syndromes, including falls, urinary incontinence, and risk of malnutrition. CONCLUSIONS: The 2MCGA intervention shows strong delays in the decline of cognition and physical function for older residents with mild-to-moderate dementia. Furthermore, this strategy can also improve or prevent the onset of new geriatric syndromes, especially fall episodes, urinary incontinence and risk of malnutrition. Geriatr Gerontol Int 2017; 17 (Suppl. 1): 36-43.

Slow gait speed as a predictor of 1-year cognitive decline in a veterans' retirement community in southern Taiwan.

AIM: Slow gait speed has been associated with mortality, poor physical function and disability in older people. Our aim was to evaluate the association between slow gait speed and rapid cognitive decline among oldest-old men in Taiwan. METHODS: We carried out a longitudinal cohort study in a veterans' retirement community, and enrolled 249 male residents aged 80 years and older. Slow gait speed was defined as <1 m/s, and rapid cognitive decline was defined as a Mini-Mental State Examination (MMSE) decline of ≥3 points over 1 year. Body mass index, Charlson's Comorbidity Index, handgrip strength, gait speed and Mini-Mental State Examination datasets were collected, and a logistic regression model was built to evaluate the association between fast cognitive decline and slow gait speed. RESULTS: In all, 249 residents (mean age 86.4 ± 4.01 years) were recruited, including 58 (23.3%) with rapid cognitive decline. Univariate analysis showed that slow gait speed could predict rapid cognitive decline (OR 4.10, 95% CI 1.20-14.00, P = 0.024). After adjusting for age, Charlson's Comorbidity Index, polypharmacy, psychiatric drug usage, cigarette smoking experience, baseline cognitive function, depressive mood, handgrip strength, nutritional status and history of fall, slow gait speed was still independently associated with rapid cognitive decline (adjusted OR 4.58, 95% CI 1.22-17.2, P = 0.024). CONCLUSIONS: Slow gait speed was thus an independent predictor of rapid cognitive decline in oldest-old men in a veterans' retirement community in Taiwan. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 14-19.

Soluble ICAM-1, Independent of IL-6, Is Associated with Prevalent Frailty in Community-Dwelling Elderly Taiwanese People.

BACKGROUND: Activation of inflammatory pathway with elevation of inflammatory biomarkers such as Interleukin 6 (IL-6) has been considered a pathophysiological feature of frailty. In recent years, the association between Intercellular adhesive molecule -1 (ICAM-1) and vascular inflammatory was established. Provocation of inflammatory cascades from ICAM-1 is potential IL-6 related, although the association between the inflammatory process and frailty is little to known. The study was intended to evaluate the relationship between serum ICAM-1, IL-6 and frailty. MATERIALS AND METHODS: Data was derived from a representative national sampling cohort in Taiwan. The cross-sectional study included nine-hundred-forty-six community-dwelling people aged 53 and older. Frailty was defined as having three or more components (including, muscle shrinkage, slowness, weakness, exhaustion, and low activity) Serum IL-6 and ICAM-1 levels were measured using standard enzyme-linked immunosorbent assays. RESULTS: Soluble ICAM-1 (sICAM-1) levels were stepwise increased in non-frail, pre-frail and frail elderly people (the median levels were 255 vs. 265 vs. 285 ng/ml, respectively p<0.001). A multivariate multinomial logistic regression, which was adjusted for age, sex, smoking, education, BMI, and chronic disease number, was utilized to determine that the probability of being frail due to increased log (ICAM-1) and log (IL-6) standard deviation levels were 1.44 (95% CI 1.09-1.91) and 1.54 (95%CI 1.07-2.20), respectively. CONCLUSION: sICAM-1 was significantly associated with frailty, independent of IL-6. This implied that leukocyte migration and inflammation cascade activation might contribute to frailty, in addition to monocyte/macrophage-mediated immuno-inflammation.

Short-Form Mini Nutritional Assessment as a useful method of predicting the development of postoperative delirium in elderly patients undergoing orthopedic surgery.

OBJECTIVE: Postoperative delirium (POD) is a major cause for concern among elderly patients undergoing surgery, often resulting in poor outcome. It is therefore important to predict and prevent POD. The aim of this study was to evaluate the Mini Nutritional Assessment Short-Form (MNA-SF) as a predictor of POD after orthopedic surgery. METHODS: Elderly patients undergoing orthopedic surgery between April 2011 and March 2013 were included in the study (n=544; mean age, 74.24 ± 7.92 years). The MNA-SF was used to evaluate preoperative nutritional status. Delirium was assessed daily after surgery using the confusion assessment method. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria were used to confirm delirium diagnosis. Univariate and multivariate logistic regression analyses were performed to identify key factors associated with POD. RESULTS: POD occurred in 52 patients (9.6%). According to the MNA-SF, 17.5% of subjects were at risk of undernutrition. Adjusting for all potential factors in the final model, age, male gender and lower Mini-Mental State Examination and higher Charlson Comorbidity Index scores were associated with significantly increased likelihood of POD. Subjects who were identified preoperatively as at risk of undernutrition were 2.85 times more likely to develop POD compared to normally nourished subjects (odds ratio: 2.85, 95% confidence interval: 1.19-6.87). CONCLUSIONS: These results suggest that the MNA-SF is a simple and effective tool that can be used to predict incident delirium in elderly patients after orthopedic surgery.

Developing a Prediction Model for Post-Operative Delirium and Long-Term Outcomes Among Older Patients Receiving Elective Orthopedic Surgery: A Prospective Cohort Study in Taiwan.

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.

A survey of dermatological diseases among older male adults of a Veterans Home in Southern Taiwan.

BACKGROUNDS: The dermatologic diseases of the dependent elderly require special attention. METHODS: This screening and treatment service of dermatological diseases was conducted in a Veterans Home in Southern Taiwan. RESULTS: 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. CONCLUSIONS: 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.

Interrelationship of postoperative delirium and cognitive impairment and their impact on the functional status in older patients undergoing orthopaedic surgery: a prospective cohort study.

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.

Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia.

Sarcopenia, a newly recognized geriatric syndrome, is characterized by age-related decline of skeletal muscle plus low muscle strength and/or physical performance. Previous studies have confirmed the association of sarcopenia and adverse health outcomes, such as falls, disability, hospital admission, long term care placement, poorer quality of life, and mortality, which denotes the importance of sarcopenia in the health care for older people. Despite the clinical significance of sarcopenia, the operational definition of sarcopenia and standardized intervention programs are still lacking. It is generally agreed by the different working groups for sarcopenia in the world that sarcopenia should be defined through a combined approach of muscle mass and muscle quality, however, selecting appropriate diagnostic cutoff values for all the measurements in Asian populations is challenging. Asia is a rapidly aging region with a huge population, so the impact of sarcopenia to this region is estimated to be huge as well. Asian Working Group for Sarcopenia (AWGS) aimed to promote sarcopenia research in Asia, and we collected the best available evidences of sarcopenia researches from Asian countries to establish the consensus for sarcopenia diagnosis. AWGS has agreed with the previous reports that sarcopenia should be described as low muscle mass plus low muscle strength and/or low physical performance, and we also recommend outcome indicators for further researches, as well as the conditions that sarcopenia should be assessed. In addition to sarcopenia screening for community-dwelling older people, AWGS recommends sarcopenia assessment in certain clinical conditions and healthcare settings to facilitate implementing sarcopenia in clinical practice. Moreover, we also recommend cutoff values for muscle mass measurements (7.0 kg/m(2) for men and 5.4 kg/m(2) for women by using dual X-ray absorptiometry, and 7.0 kg/m(2) for men and 5.7 kg/m(2) for women by using bioimpedance analysis), handgrip strength (<26 kg for men and <18 kg for women), and usual gait speed (<0.8 m/s). However, a number of challenges remained to be solved in the future. Asia is made up of a great number of ethnicities. The majority of currently available studies have been published from eastern Asia, therefore, more studies of sarcopenia in south, southeastern, and western Asia should be promoted. On the other hand, most Asian studies have been conducted in a cross-sectional design and few longitudinal studies have not necessarily collected the commonly used outcome indicators as other reports from Western countries. Nevertheless, the AWGS consensus report is believed to promote more Asian sarcopenia research, and most important of all, to focus on sarcopenia intervention studies and the implementation of sarcopenia in clinical practice to improve health care outcomes of older people in the communities and the healthcare settings in Asia.

Association of home care needs and functional recovery among community-dwelling elderly hip fracture patients.

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<0.001; r=-0.326, p=0.001; r=-0.432, p<0.001; r=-0.684, p<0.001; and r=-0.475, p<0.001, respectively). The complex and taxing home care needs of community-dwelling elderly hip fracture patients were significantly associated with functional recovery. Comprehensive geriatric assessment and related special medical services may greatly help caregivers and promote the practice of aging in place. Further study is needed to develop appropriate caregiver education to promote the functional recovery of elderly hip fracture patients at home.

Urinary incontinence: an under-recognized risk factor for falls among elderly dementia patients.

AIMS: Elderly people with dementia are at increased risk of falls and intervention trials to prevent falls have failed to demonstrate clinical effectiveness in this population. This study evaluates the role of urinary incontinence as a fall risk factor in older patients with dementia, with the aim of developing relevant intervention strategies. METHODS: Elderly patients with dementia visiting our center were recruited. All subjects underwent a Comprehensive Geriatric Assessment (CGA), and patients were divided into two groups (fall and non-fall) according to their history of falls in the past year. Components of the CGA, including physical function, mental function, depressive symptoms, incontinence, and nutritional status, were evaluated according to fall history. RESULTS: Overall, 159 patients with dementia (mean age 77.3 ± 9.0 years, 59.1% male) participated. Fifty-four patients (34.0%) had experienced falls in the past year. Among all subjects, 50.3% were diagnosed with mild dementia, 37.7% with moderate dementia, and 12.0% with severe dementia according to an established Clinical Dementia Rating scale. Subjects in the fall group displayed poorer physical function, balance, depressive mood, nutritional status, urinary incontinence, and had an increased prevalence of polypharmacy. However, multivariate analysis revealed urinary incontinence as the only independent risk factor for falls (OR = 4.9 ± 2.2, 95% CI: 2.0-12.0, P < 0.001). CONCLUSIONS: Urinary incontinence is a previously unidentified risk factor for falls among elderly dementia patients. An interventional study with the focus of urinary incontinence could improve the effectiveness of fall prevention among these patients.