Effectiveness of the medication safety review clinics for older adults prescribed multiple medications.

BACKGROUND/PURPOSE: Polypharmacy is common among Taiwanese older adults. We aim to determine the effectiveness of the medication safety review clinics (MSRCs) for solving drug-related problems (DRPs) among older adults prescribed multiple medications. METHODS: This prospective case-series intervention study was conducted at the outpatient department of the National Taiwan University Hospital and its BeiHu Branch. Older adults (≥65 years) who either had been prescribed ≥8 chronic medications (drugs prescribed for ≥28 days) or had visited ≥3 different physicians during the 3-month screening period were enrolled (N = 193). DRPs were identified after baseline assessments from a team of geriatricians and pharmacists. Prescribers were contacted with proposed interventions to be administered within 12 weeks. Problem-solving rates (PSRs) at both Week 12 and Week 24 visits were recorded. Stepwise multivariate logistic regression was applied to identify correlates of having at least one unsolved DRP at 24 weeks. Participants (N = 139) who completed four visits to the MSRCs were analyzed. RESULTS: The mean age was 75.6 ± 6.1 years and 56% of them were men. The mean chronic medication per patient was 9.0 ± 3.1, and the mean DRP per patient was 2.1 ± 1.5. The PSR was 76% at Week 12 and 87% at Week 24. Thirty-two patients (22%) had at least one unsolved DRP. Correlates of the unsolved DRP included a higher geriatric depression scale, a higher chronic medication per patient, and a higher DRP per patient. The mean chronic medication per patient (9.0 vs. 8.6, p < 0.05) decreased, and the number of participants rating good or better health status improved from 22% to 38% in 24 weeks (p < 0.001). Participants were highly satisfied (96% at all times) with the service. CONCLUSION: DRPs were common in geriatric outpatients taking multiple medications and most were solved with appropriate interventions. The MSRC service may improve prescription quality in Taiwan if widely available.

Potentially inappropriate medications in geriatric outpatients with polypharmacy: application of six sets of published explicit criteria.

AIM: Our aim was to compare the practicability of six different potentially inappropriate medication (PIM) criteria in geriatric outpatients with polypharmacy. METHODS: We analysed baseline data from the Medication Safety Review Clinic in Taiwanese Elders (MSRC-Taiwan) study. The prevalence and correlates of PIMs were determined on the basis of criteria developed in the USA, Canada, France, Norway, Ireland and Thailand. The percentage of PIMs considered as drug-related problems and the problem-solving rate are reported. RESULTS: In the 193 participants, the prevalence of PIM varied from 24 to 73%. Application of the criteria revealed that a high number of chronic medications was a common risk factor for having at least one PIM. Of the 1713 medications reviewed, 5.6-14.8% were considered PIMs. Only 30-40% of the identified PIMs were reported as drug-related problems by the MSRC team experts. Criteria with a higher number of statements and a higher percentage of local market/institution drug availability tended to detect more PIMs. CONCLUSIONS: The prevalence of PIM varied significantly when different criteria were applied. Caution should be exercised in applying PIM criteria developed in other regions when medication availability in the local market is limited.

Polypharmacy among disabled Taiwanese elderly: a longitudinal observational study.

BACKGROUND AND OBJECTIVE: It is not known whether the correlates of polypharmacy among disabled elderly are similar to those for older adults in general. Furthermore, data on polypharmacy in the Taiwanese population are limited. Therefore, this study was conducted to determine the prevalence and correlates of polypharmacy among disabled Taiwanese elderly (aged >or=65 years). METHODS: This was a longitudinal observational study conducted on information obtained between July 2001 and June 2002. Study participants consisted of nationally representative samples of 11,788 disabled Taiwanese elderly from the ANLTCNT (Assessment of National Long-Term Care Need in Taiwan) study. Polypharmacy and major polypharmacy were defined as prescription of >or=5 and >or=10 medications, respectively, on the day of maximum numbers of prescriptions of the study year. Subject characteristics were derived from the ANLTCNT study survey data. Healthcare-related characteristics, including medication prescriptions, were obtained from the National Health Insurance (NHI) claims data. Multivariate logistic regression was performed for statistical analysis. RESULTS: One-fifth (21.5%) of the sample were aged >or=85 years, and 58% were female. The prevalence of polypharmacy and major polypharmacy among disabled Taiwanese elderly was 81% and 38%, respectively. Nearly one-third (32.5%) of disabled Taiwanese elderly were exposed to polypharmacy for >or=181 days in 1 year. Compared with those with a low tendency for visiting multiple providers, those with intermediate tendency (odds ratio [OR] 3.61; 95% CI 3.11, 4.18) and those with high tendency (OR 10.24; 95% CI 8.56, 12.24) were more likely to be exposed to polypharmacy. Other significant correlates of polypharmacy in the multivariate logistic regression model included age <85 years, living in urban areas, higher number of chronic conditions, poorer physical functioning, preference for visiting independent clinics and not being institutionalized. CONCLUSION: The prevalence of polypharmacy was extremely high among disabled Taiwanese elderly. Visiting multiple healthcare providers was one of the strongest correlates. Policies that encourage the disabled elderly to establish primary care relationships and that promote geriatric care models may decrease the prevalence of polypharmacy and associated adverse outcomes in this group.

Characteristics of outpatient prescriptions for frail Taiwanese elders with long-term care needs.

OBJECTIVE: To describe medication prescription patterns and associated factors among frail Taiwanese elders with long-term care needs defined as having physical or cognitive functioning impairments. DESIGN: Longitudinal observational study from July 2001 to June 2002. SETTING: Community and Institutions. PARTICIPANTS: Nationally representative samples of 11 338 elders from the 'Assessment of National Long-Term Care Need in Taiwan' (ANLTCNT). MEASUREMENTS: National identification number for each subject was linked to the National Health Insurance (NHI) claims data for outpatient clinic visits, diagnoses and medication prescriptions. For point prevalence calculation, the day of maximum number of medications prescribed during the study year was used. RESULTS: The mean age was 78.2 +/- 7.4 years old, of whom 61% were women. The mean number of chronic condition categories was 2.9 +/- 1.8. On average, subjects visited 4.1 +/- 2.5 different healthcare organizations, 7.7 +/- 5.3 different physicians, and received 32.9 +/- 26.4 outpatient cares. The mean maximum number of prescriptions of the study year was 8.6 +/- 4.3; Eighty-four per cent of our experienced polypharmacy (prescribed with > or=5 drugs) and 31% had persistent polypharmacy (polypharmacy for > or =181 days). Increased contact with healthcare professionals and greater number of chronic condition categories were associated with the development of polypharmacy and persistent polypharmacy. CONCLUSION: The excessive number of medication prescriptions and high prevalence of polypharmacy among frail Taiwanese elders raised major drug-safety concern. Multiple healthcare providers and clinic visits were strong correlates of polypharmacy. Policies should be directed to encourage the elderly to establish primary care relationships and to promote geriatric prescription principles to improve clinical managements and outcomes.

Prognostic value of mortality in emergency department sepsis score, procalcitonin, and C-reactive protein in patients with sepsis at the emergency department.

The prognostic value of procalcitonin (PCT) in patients with sepsis at the emergency department (ED) has not been evaluated. We conducted a prospective observational study to compare the prognostic value of PCT on sepsis and compared with a validated score, Mortality in Emergency Department Sepsis (MEDS) score, and C-reactive protein (CRP) in the setting of ED of an urban, university-based medical center. Five hundred twenty-five consecutive adult patients admitted to the ED fulfilling the American College of Clinical Pharmacists/Society of Critical Care Medicine Consensus Conference definition of sepsis were prospectively enrolled. Serum PCT and CRP were evaluated for each patient. Clinical characteristics and laboratory results on ED admission were recorded using a standardized form. Each patient was followed for at least 30 days. The main outcome was early (5-day) and late (6- to 30-day) mortality. The median age of the study sample was 64.0 (interquartile range, 47-76) years old, and the overall 30-day mortality rate was 10.5%. The c-statistic in the prediction of early mortality was 0.89 for MEDS, 0.76 for PCT, and 0.68 for CRP. The c-statistic in the prediction of late mortality was 0.78 for MEDS, 0.70 for PCT, and 0.63 for CRP. Overall, MEDS score has the best discriminative capability among the three tested markers. Under the best cutoff value, PCT was the most sensitive, and MEDS score was the most specific marker. We suggest further combining the information on PCT and MEDS score to enhance the accuracy in predicting ED sepsis mortality.

Geographical variations in elderly disability in Taiwan.

Inequality in health has long been a topic of discussion. The purpose of this research was to provide estimates of the proportions of elderly who had difficulties in activities of daily living in each of the 23 administrative areas of Taiwan, and to assess if there was geographical disparity in disability across areas. A nationally representative sample of 303,545 subjects was selected for interview. Among the subjects selected for interview, 239,861 completed the survey, a completion rate of about 80%. For the purpose of this research, only those aged 65 years or older were included (N = 114,873) in the analyses. Non-standardized and standardized prevalences of disability were presented for each of the 23 administrative areas in Taiwan, and geographical distribution of elderly disability was plotted. Results show that significant difference in disability prevalence exists among administrative districts, even after adjusting for age and sex structure of the population. Moreover, the extent of gender disparity also varied from one area to another. The western region, in general, had lower disability prevalence than the eastern region. Findings imply that since disability prevalence varied significantly across administrative areas, funding for long-term care should not be allocated based on the number of elderly population in an administrative area. Areas with high prevalence should identify reasons for their high prevalence rates and implement proper interventions.

Comparison of clinical manifestations and outcome of community-acquired bloodstream infections among the oldest old, elderly, and adult patients.

Valid studies comparing the clinical characteristics among adult, elderly, and the oldest old bacteremic patients are lacking. We conducted a prospective, observational study in the emergency department (ED) of a university medical center between June 2001 and June 2002. All patients >18 years of age who registered in the ED with a clinically significant, culture-positive, bloodstream infection (BSI) were enrolled. Patients were divided into 3 groups based on age: 1) oldest old (> or =85 yr), 2) elderly (65-84 yr), and 3) adult (18-64 yr). The clinical and laboratory manifestations and 30-day mortality were recorded. Group comparisons were performed using the chi-square test or analysis of variance (ANOVA) test, as indicated. Survival was analyzed using the Kaplan-Meier method and the Cox-regression model, adjusted for potential confounders.A total of 890 cases of community-acquired BSI were eligible for analysis. Compared to the adult group, both the elderly and the oldest old patients had more atypical clinical manifestations, a higher propensity to develop organ failure, and a worse prognosis. Elderly patients had significantly less tachycardia (p = 0.001), but more acute respiratory (p = 0.007) and renal failure (p = 0.037); the oldest old patients had more afebrile episodes (p = 0.006), leukocytosis (p = 0.012), and more patients developed respiratory failure (p = 0.009), acute renal failure (p = 0.011), septic shock (p = 0.022), and altered mental status (p = 0.013). Urinary tract infections were the main source of BSI for both the elderly and oldest old, while the oldest old patients had significantly more pneumonia than the elderly or adults. As a group, older patients had fewer signs and symptoms of BSI, but a higher risk of organ failure and a worse prognosis than younger patients.

A prospective cohort study on the effect of sexual activity, libido and widowhood on mortality among the elderly people: 14-year follow-up of 2,453 elderly Taiwanese.

BACKGROUND: Sexual activity in elderly people is a topic of growing interest but the relationships of sexual activity, libido and widowhood to mortality have been barely investigated. METHODS: A total of 2,453 subjects enrolled from a nationwide survey on health status of residents aged 65 years or older in Taiwan between 1989 and 1991 were followed up until 31 December 2003 for ascertaining cause of death. Information on the frequency of sexual activity, libido (sexual desire), widowhood, disease status and relevant risk factors for risk of death at baseline were collected. RESULTS: After controlling for age and relevant confounding factors, sexual activity was found to be inversely related to mortality {adjusted hazard ratio (aHR) = 0.67 [95% confidence interval (CI):0.56-0.80] for males, aHR = 0.84 (95% CI:0.65-1.09) for females and aHR = 0.72 (95% CI: 0.62-0.84) for both sexes combined}. Men having libido had lower mortality [aHR = 0.81 (95% CI:0.68-0.97)]. Widowhood status was positively correlated with mortality [aHR = 1.66 (95% CI: 1.25-2.19) for males, aHR = 1.33 (95% CI: 1.09 to -1.62) for females and aHR = 1.43 (95% CI: 1.21-1.68) for both sexes combined]. Sexual activity was also inversely related to mortality from stroke [aHR = 0.64 (95% CI: 0.41-1.00)]. CONCLUSIONS: Sexual activity was associated with all-cause and cause-specific mortality independently of other risk factors. This finding was consistent with the elevated risk of death associated with widowhood for both men and women, and by the decreased mortality risk in men having libido.

Establishing the minimal clinically important difference of the Barthel Index in stroke patients.

BACKGROUND: The interpretation of the change scores of the Barthel Index (BI) in follow-up or outcome studies has been hampered by the fact that its minimal clinically important difference (MCID) has not been determined. OBJECTIVE: This article was written to establish the MCID of the BI in stroke patients. METHODS: Both anchor-based and distribution-based methods were used to establish the MCID. In the anchor-based method, 43 stroke inpatients participated in a follow-up study designed to determine the MCID of the BI using patients' global ratings of the activities of daily living function on a 15-point Likert-type scale. The mean change scores on the 20-point scale of the BI of the MCID group, based on the patients' ratings on the Likert-type scale, served as the first estimate of the MCID. In the distribution-based method, 56 chronic stroke patients participated in the test-retest reliability study to determine the MCID of the BI. One standard error of measurement (SEM) served as the second estimate for the MCID. The larger MCID value of the 2 estimates was chosen as the MCID of the BI. RESULTS: In the anchor-based study, there were 20 patients in the MCID group, with a mean change score of 1.85 points (ie, the first MCID estimate). In the distribution-based study, the SEM based on test-retest agreement was 1.45 points (ie, the second MCID estimate). The MCID of the BI in stroke patients was estimated to be 1.85 points. CONCLUSION: The authors' results, within the limitations of their design, suggest that if the mean BI change score within a stroke group has reached 1.85 points in a study, the change score on the BI can be perceived by patients as important and beyond measurement error (ie, such a change score is clinically important).

Post-hospital care of stroke patients in Taipei: use of services and policy implications.

BACKGROUND AND PURPOSE: Population ageing in Taiwan is proceeding at an accelerating rate. The percentage of elderly is expected to increase from 9.7% in 2005 to 20% in 2025. As the population ages, more people will suffer from chronic conditions and will need more post-hospital care. Health policies need to adapt itself to meet the changing needs of society. The purposes of this study were to describe the use of post-hospital care among stroke patients in Taipei and to discuss policy implications. METHODS: This research used a longitudinal prospective study design, recruiting stroke patients from seven hospitals in the Taipei area. Patients were followed-up for 6 months after discharge with surveys at 1, 3, and 6 months. Information on their needs and uses of post-hospital care was collected. RESULTS: About 9% of patients were institutionalized at 1 month, and the percentage did not vary much throughout the 6 months of the study. Little movement occurred between institutions and homes within 6 months after discharge. Most patients relied on family members to provide assistance with activities of daily living. Little utilization of formal services occurred. The use of foreign care attendants was common, and it increased with time. Few unmet needs were observed for nursing care, while significant unmet needs were observed for rehabilitative services. DISCUSSIONS: Taiwan is not prepared to adequately meet the care demands of an ageing society. Continuing to support family members with additional home- or community-based services resources should be a policy priority. More efforts should be placed on educating family caregivers about the availability and benefits of community-based services during discharge planning. The use of foreign care attendants has become a mainstream practice. Regulations to protect the rights of foreign care attendants and to improve their quality of care need to be established.

Reduction of disability after stroke is a more informative predictor of long-time survival than initial disability status.

PURPOSE: Few studies have evaluated the roles of reducing disability after stroke in predicting survival. This study aimed to investigate the effects of improvement in the Barthel Index (BI) and other prognostic factors on survival in patients with first-time noncardioembolic ischemic stroke. METHOD: BI effectiveness was defined as the improvement of BI between initial stroke (within 3 days) and 2 months after stroke. Cox regression analysis and Kaplan-Meier methods were used to evaluate the predictive roles of various prognostic factors. RESULTS: A total of 111 patients were enrolled. Mean age at the time of stroke was 68 (+ or - 11.2) years. Median follow-up time was 77.4 months. Mean initial BI was 36.1 (+ or - 28.5) and mean BI effectiveness was 46.9 + or - 29.0. Overall, 55 deaths (49.5%) of the cohort were ascertained. The BI effectiveness had significant effects on long-time survival while initial BI was not a significant predictor. Higher BI effectiveness led to lower risk of mortality (hazard ratio = 0.44, 95% CI 0.24 - 0.80, p = 0.007). Elder age was correlated with poor survival (overall p = 0.006). Subjects in the eldest age group (> or = 70 years) showed a significant elevated risk for death (hazard ratio = 3.42, 95% CI 1.18 - 9.92). There was a trend indicating that the smaller the lesion size, the more favourable the prognosis (overall p = 0.057). CONCLUSIONS: BI effectiveness in the first 2 months after first-time noncardioembolic stroke was more informative than initial disability status for predicting long-time mortality. It highlights the potential benefit in maximizing functional performance in patients with stroke.

Location and size of infarct on functional outcome of noncardioembolic ischemic stroke.

PURPOSE: Studies regarding the effects of location and size of infarct on the functional outcome after stroke have yielded inconsistent results. This study aimed to investigate the relationships of neuroimage findings and longitudinal Barthel index (BI) scores in patients with first-ever ischemic stroke. METHOD: The neuroimage findings of enrolled subjects were grouped by anatomical location. The size of infarct was determined by the largest diameter of the lesion. Patients were followed up prospectively at onset, 2 weeks, 1, 2, 4, and 6 months after stroke. Linear mixed model was employed for the repeated measurement analysis of BI at these six time points in each patient. RESULTS: A total of 111 patients were enrolled. The BI increased rapidly during the first two months, and reached plateau after four months. The location and size of the lesion had significant effects on serial measurements of BI. After adjustment for age, sex, treatment mode, and baseline BI score, the posterior cerebral artery infarct group showed the largest improvement in BI. There was a trend that the smaller the lesion size, the more favourable the functional outcome. CONCLUSIONS: Both location and size of lesion in noncardioembolic stroke were significant prognostic factors for functional outcome.

Kinship moderates the association between a demented individual's behavioral disturbance and a caregiver's burden: Findings from a national survey in Taiwan.

AIM: The present study aimed to assess the moderating role of kinship between the behavioral disturbance of care recipients (CRs) with dementia and the caregivers' (CGs') burden in Taiwan. METHODS: The data of 965 CG-CR dyads on the behavioral disturbance of CR with dementia, CG burden, CG kinship to CR and other relevant variables were obtained from the Assessment of the National Long-Term Care Need in Taiwan (ANLTCNT). To test the moderating effect of CG-CR kinship on the association between behavioral disturbance of CR and CG burden, a series of hierarchical multiple linear regression models were used after controlling for potential factors associated with CG burden. RESULTS: Different kinships had significant differences in terms of burden, except for relational burden. The interaction terms (of CRs' behavioral disturbance by kinship) were not significant on burden of time and emotional burden. On relational burden, the impact of CRs' behavioral disturbance on CG burden was significantly higher for a wife than for a daughter-in-law or a son. The impact of CRs' behavioral disturbance on financial burden was lower for a wife than for a daughter-in-law. In terms of the total burden, the impact of CRs' behavioral disturbance was higher for a daughter than for a son. CONCLUSION: These findings highlight the importance of CG kinship to CR moderating the association between the CRs' level of behavioral disturbance and the CGs' relational, financial, and total burden, when refining kinship-oriented interventions for community services to CRs with dementia and their CGs. Geriatr Gerontol Int 2016; 16: 1272-1280.

Geriatric conditions, rather than multimorbidity, as predictors of disability and mortality among octogenarians: A population-based cohort study.

AIM: To examine the impact of geriatric conditions and multimorbidity on the risk of incident disability and mortality among young-old and old-old adults. METHODS: The present study used nationally-representative data from the "Survey of Health and Living Status of the Elderly in Taiwan" for the years 2003 and 2007. Non-disabled older adults were divided into two age groups (65-79 years and ≥80 years). Chronic morbidities and geriatric conditions were assessed in 2003. Incident disability was defined as dependency in one or more activities of daily living in 2007. Vital statistics of the participants was linked to death registration data through 31 December 2007. Multivariable logistic regression and Cox regression were used to determine the effect of multimorbidity and geriatric conditions on health outcomes. RESULTS: Among those aged 65-79 years (n = 1874), the presentation of multimorbidity or two or more geriatric conditions was related to incident disability. Among octogenarians, the presentation of one or more geriatric conditions, but not multimorbidity, was shown to be independently associated with the risk of disability. Multimorbidity was related to a higher adjusted risk of mortality in the young-old group (hazard ratio 1.54; 95% confidence interval 1.1-2.2) but not in the old-old group. Among octogenarians, those with two or more geriatric conditions had a higher adjusted risk of mortality (hazard ratio 1.7; 95% confidence interval 1.2-2.5), compared with those with 0-1 geriatric conditions. CONCLUSIONS: The risk of incident disability and mortality increased in octogenarians with geriatric conditions, but not in cases with multimorbidity.

Exploring the associations between long-term care and mortality rates among stroke patients.

Information on types of long-term care received by stroke patients after hospital discharge is essential for the formulation of long-term care resource development policy. Comparisons of outcomes resulting from different types of long-term care can provide important considerations in the selection of long- term care services. The purpose of this study is to describe the patterns of long-term care received, and to explore if associations exist between long-term care services and mortality status among stroke patients after hospital discharge. Using a longitudinal quasi-experimental study design, this study collected information on the type of long-term care received at 1, 3, and 6 months after discharge for 714 patients. At one month after discharge, 4.5 % had died, and 22.1 % had regained all functions in activities of daily living and instrumental activities of daily living. The percentage of patients receiving institutional care, home or community-based care, and family care only were 10.4 % , 22.4 % , and 40.7 % respectively. The respective percentages at 3 months after discharge were 11.2 % , 18.7 % , and 38.0 % , and, at 6 months after discharge, 10.3 % , 19.4 % , and 30.9 % . After adjusting for age, sex, previous incidence of stroke, and physical functions, the odds of dying within 6 months after discharge for stroke patients receiving home or community-based care was significantly lower than those in institutions ( OR = 0.39; 95 % CI = 0.15 to 0.97 ). It is not clear why a lower mortality rate was observed among patients receiving home or community-based services. Differences in quality of care and quality of life among users of different types of long-term care services should be investigated. More research is needed to assess the causes of the disparity in mortality rates among users of different types of long-term care services.

Identifying factors associated with hospital readmissions among stroke patients in Taipei.

Hospital readmissions contribute significantly to the cost of medical care, and may reflect unresolved problems at discharge or a lack of resources in post-hospital care. The purpose of this paper is to assess the effects of patient characteristics at discharge, the need for nursing care, discharge planning program, post-hospital care arrangements, and caregiver characteristics on readmissions of stroke patients. Patients discharged from neurological wards in seven hospitals in the Taipei area were recruited into the study. Surveys were conducted before their discharge, and at one month after discharge. Of the 489 patients included in the study, 24.3% were readmitted. After controlling for other variables, factors associated with readmissions were number of limitations in activities of daily living (ADL), first incidence of stroke, the need for wound nursing care, the adoption of a care plan, and the discharge locations. Contrary to expectation, age, length of stay, counseling before discharge, and caregiver burden were not associated with readmissions. The findings of this study indicate that ADL limitation is an effective predictor of readmissions. Increasing home nursing resources to meet the demand for wound nursing care may also be effective in reducing readmissions. Discharging patients into institutions for a short period of time may also prove to be more economically viable due to the reduction in readmissions.

Risk of cognitive impairment in relation to elevated exposure to electromagnetic fields.

Occupational exposure to power-frequency electromagnetic fields (PF-EMF) has been suspected of being associated with adverse neurological outcomes. We performed a case-control study to assess the relationship between exposure to PF-EMF and the risk of cognitive impairment, an indication of certain adverse neurological diseases such as Alzheimer's disease and dementia. Among 2198 elderly individuals aged 65 years or older, 290 persons with score-based cognitive impairment were compared with 580 sex-matched controls to assess the risk of cognitive impairment in relation to PF-EMF exposure. Participants who were former electrical workers or living within 100 meters of high-voltage transmission lines were considered to have higher exposure. Compared with background exposure, the risk was equal or close to unity for participants with higher exposure from a previous occupation (odds ratio [OR], 1.3; 95% confidence interval [CI], 0.7 to 2.3), higher residential exposure (OR, 0.9; 95% CI, 0.3 to 2.6), or higher exposure in both occupation and residential environments (OR, 1.0; 95% CI, 0.2 to 4.6). Our findings provide little support for the link between PF-EMF and cognitive impairment. Nevertheless, the study results do not preclude the possible association between PF-EMF and any specific neurodegenerative disease previously investigated.

Unplanned hospital readmission and its predictors in patients with chronic conditions.

BACKGROUND AND PURPOSE: Unplanned hospital readmission is a devastating experience for patients and is costly for society. This study determined the 60-day unplanned readmission rate and its predicting factors in patients with chronic conditions. METHODS: A total of 334 patients discharged from five hospitals were followed for 2 months after discharge. Patients enrolled in the study were disabled and had a diagnosis of progressive chronic disease (congestive heart failure, chronic pulmonary disease, cancer) or chronic impairment following an acute episode (stroke, traumatic brain injury, hip fracture). Patients were assessed before discharge to collect in-hospital variables. Telephone interviews with patients and families were used to collect data on hospital readmission. RESULTS: Of the 334 patients followed, 76 had unplanned readmission (24.4%). Patients with progressive chronic disease had a higher readmission rate (40.9%) than those with chronic impairment following an acute episode (15.1%). Frailty and abnormal respiratory pattern were significant predictors of readmission for patients with progressive chronic disease. The predictors of readmission for patients with chronic impairment following an acute episode included frailty, clinical instability and discharge from a regional hospital. The major reasons for hospital readmission were exacerbation of the initial major disease (33/76, 43.4%) and infection (21/76, 27.7%). CONCLUSIONS: Exacerbation of chronic diseases and infection are the two major reasons for unplanned readmission. Patients with a progressive chronic disease are more likely to be readmitted.

Lifetime principal occupation and risk of cognitive impairment among the elderly.

We used a nested case-control design with study participants sampled from two cohorts, for a total of 2,198 elderly people 65 years or older and completed cognitive tests between 1993 and 1997, to assess the association between an individual's lifetime principal occupation and the subsequent risk of cognitive impairment. Cases consisted of 290 older adults with impaired cognitive functioning. For each case, two controls with comparable age (within 5 years) and sex frequencies were randomly sampled from the seniors free of cognitive impairment. Occupational data were collected through interviews. Individual's job content was coded into one of the occupational categories or the occupation-based social classes. Compared to those who were former legislators, government administrators, or business executives and managers, a significantly elevated risk of cognitive impairment was estimated for those who were employed as agriculture/animal husbandry/forestry/fishing workers (odds ratio (OR)=3.2), craft and related trades workers (OR=2.2), plant and machine operators and assemblers (OR=14.7), workers of elementary occupations (OR=3.2), or housekeepers (OR=2.6). We also observed health inequalities in the risk of cognitive impairment across social classes with a significant dose-response trend in which unskilled blue-collar workers had the highest risk. After adjustment for education, we still observed an inverse relationship between risk of cognitive impairment and occupational class. This may mean that lifetime longest-held occupation is more intimately involved in the causal pathways leading to cognitive impairment. Further studies that collect information on specific work hazards would help make specific interpretations of the observed effect of lifetime longest-held occupation in early adulthood on risk of cognitive decline in late life.

The assessment of a hospital-based care management model for long-term care services.

The purpose of this research was to assess the effectiveness of a hospital-based care management model on disabled elderly people. A before-and-after quasi- experimental design was adopted. A total of 331 disabled elderly people, residing in the Da-An District of Taipei City, participated in the study. Among them, 166 received care management, while the other 165 did not. The latter served as controls. Baseline and follow-up data collection were carried out before and after care management intervention. Logistic regression analysis was used to test the effects of care management on medical care expenditure, self-rated health, and satisfaction with long-term care arrangement. The results showed that those under care management, compared to the controls, were more likely to experience a decrease in medical care expenditure, and less likely to have a decrease in satisfaction with long-term care. The effects were statistically significant. However, there was no effect on self-rated health. The findings show that hospital-based care management is a viable option and has the potential to become an important segment in the delivery of long-term care services. More effort should be expended in its development and in the evaluation of its effectiveness.