Factors affecting cognitive frailty improvement and progression in Taiwanese older adults.

BACKGROUND: Knowledge of predictors of cognitive frailty (CF) trajectories is required to develop preventive strategies to delay or reverse the progression from CF to dementia and other adverse outcomes. This 2-year prospective study aimed to investigate factors affecting the progression and improvement of CF in older Taiwanese adults. METHODS: In total, 832 community-dwelling people aged ≥ 65 years were eligible. Fried's five frailty criteria were used to measure prefrailty and frailty, while cognitive performance was assessed by the Clinical Dementia Rating and Mini-Mental State Examination. Each component of reversible CF and potentially reversible CF was assigned a score, with a total score ranging 0 to 5 points. Two annual follow-up CF assessments were conducted. The group-based trajectory model was applied to identify latent CF trajectory groups, and a multinomial logistic regression was used to examine relationships of explanatory variables with CF trajectories. RESULTS: According to data on 482 subjects who completed the two annual follow-ups, three CF trajectories of robust, improvement, and progression were identified. After adjusting for the baseline CF state, CF progression was significantly associated with an older age (odds ratio [OR] = 1.08; 95% confidence interval [CI], 1.02 ~ 1.14), a lower Tinetti balance score (OR = 0.72; 95% CI, 0.54 ~ 0.96), a slower gait (OR = 0.98; 95% CI, 0.97 ~ 0.99), and four or more comorbidities (OR = 2.65; 95% CI, 1.19 ~ 5.90), while CF improvement was not significantly associated with any variable except the baseline CF state. In contrast, without adjusting for the baseline CF state, CF progression was significantly associated with an older age, female sex, balance scores, gait velocity, regular exercise, the number of comorbidities, and depression, while CF improvement was significantly associated with female sex, balance scores, and the number of comorbidities. CONCLUSIONS: The baseline CF state, an older age, poorer balance, slower gait, and a high number of comorbidities may contribute to CF progression, while the baseline CF state may account for associations of engaging in regular exercise and depression with CF development.

Effects of Age, Sex, and Postconcussive Symptoms on Domain-Specific Quality of Life a Year After Mild Traumatic Brain Injury.

OBJECTIVE: To identify the factors influencing longitudinal changes in patients' scores across 6 domains of the Quality of Life after Brain Injury (QOLIBRI) instrument 1 year after mild traumatic brain injury (mTBI). DESIGN: This was a longitudinal cohort study. PARTICIPANTS AND SETTING: Eligible patients with a new diagnosis of mTBI were recruited from the outpatient clinics of the neurosurgery departments of 3 teaching hospitals in Taipei City, Taiwan. In total, 672 patients participated in the baseline assessment. Postinjury follow-up was conducted at 6 and 12 months. MAIN OUTCOME MEASURE: Six domains of the 37-item QOLIBRI: Cognition, Self, Daily Life and Autonomy, Social Relationships, Emotions, and Physical Problems. RESULTS: Linear mixed-effects analyses revealed that, among patients younger than 60 years, the scores of the Cognition, Self, Daily Life and Autonomy, and Social Relationships domains significantly increased 6 months after injury; furthermore, their scores of the Cognition, Self, and Daily Life and Autonomy significantly increased 12 months after injury. By contrast, among patients 60 years and older, the scores of these domains reduced from baseline to 6 and 12 months. No significant sex-based difference was observed in the changes in scores of any QOLIBRI domain. At 6 and 12 months post-injury, the scores of the Cognition, Emotions, and Physical Problems domains were significantly higher for patients with postconcussive symptoms than for those without these symptoms. CONCLUSIONS: Although multiple characteristics of patients significantly affected their baseline scores on the 6 domains of the QOLIBRI, only age and postconcussive symptoms were significantly associated with longitudinal changes in their scores 6 and 12 months after mTBI.

Effects of home-based computerized cognitive training and tai chi exercise on cognitive functions in older adults with mild cognitive impairment.

BACKGROUND: A randomized trial was conducted to investigate the effects of computerized cognitive training (CCT) and tai chi exercise (TCE) vs. health education (HE) on cognitive functions in 189 older adults with mild cognitive impairment (MCI). METHODS: Cognitive functions were assessed by the five-domain Mattis Dementia Rating Scale (MDRS) (attention, initiation/perseveration, construction, conceptualization, and memory) and the modified Telephone Interview of Cognitive Status (TICS-M), while the timed up and go (TUG), Tinetti's balance, activities of daily living (ADLs), and Activities-specific Balance Confidence (ABC) were also evaluated. Each intervention was delivered once a week for 6 months. All outcomes were followed up at 6 and 12 months of the study. RESULTS: Compared to HE, CCT increased scores on the MDRS's total, initiation/perseveration, construction, and conceptualization domains and on the TICS-M at 6 months and those on the MDRS's total, attention, construction, conceptualization, and memory domains and on the TICS-M at 12 months; TCE increased scores on the MDRS's total and construction domains and on the TICS-M at 6 months and those on the MDRS's total, attention, initiation/perseveration, and conceptualization domains and on the TICS-M at 12 months. Moreover, CCT improved the TUG at 6 and 12 months and Tinetti's balance at 12 months, and TCE improved the TUG at 6 and 12 months, Tinetti's balance, and ABC at 6 and 12 months, and ADLs at 12 months. CONCLUSIONS: The effects of CCT and TCE on improving global cognition and certain cognitive domains for older MCI adults may have been small but they lasted for at least 12 months.

Predictors of incident reversible and potentially reversible cognitive frailty among Taiwanese older adults.

BACKGROUND: Few studies emphasize on predictors of incident cognitive frailty (CF) and examine relationships between various gait characteristics and CF. Therefore, we conducted a 2-year prospective study to investigate potential predictors, including gait characteristics, of incident reversible CF (RCF) and potentially RCF (PRCF) among Taiwanese older adults. METHODS: Eligible participants were individuals aged ≥ 65 years, who could ambulate independently, and did not have RCF/PRCF at the baseline. The baseline assessment collected information on physical frailty and cognitive measures, in addition to sociodemographic and lifestyle characteristics, preexisting comorbidities and medications, gait characteristics, Tinetti's balance, balance confidence as assessed by Activities-specific Balance Confidence (ABC) scale, and the depressive status as assessed by the Geriatric Depression Scale. The Mini-Mental State Examination (MMSE), Mattis Dementia Rating Scale, and Digit Symbol Substitution Test were used to evaluate cognitive functions. Incident RCF and PRCF were ascertained at a 2-year follow-up assessment. RESULTS: Results of the multinomial logistic regression analysis showed that incident RCF was significantly associated with older age (odds ratio [OR] = 1.05) and lower ABC scores (OR = 0.97). Furthermore, incident PRCF was significantly associated with older age (OR = 1.07), lower ABC scores (OR = 0.96), the presence of depression (OR = 3.61), lower MMSE scores (OR = 0.83), slower gait velocity (OR = 0.97), and greater double-support time variability (OR = 1.09). CONCLUSIONS: Incident RCF was independently associated with older age and lower balance confidence while incident PRCF independently associated with older age, reduced global cognition, the presence of depression, slower gait velocity, and greater double-support time variability. Balance confidence was the only modifiable factor associated with both incident RCF and PRCF.

Specific cognitive domains and frailty trajectories among older Taiwanese adults.

Objective: To investigate the associations of specific cognitive functions and with the frailty trajectory among older Taiwanese adults.Methods: At baseline, 730 community-dwelling older adults were recruited from outpatient clinics of a general hospital. Frailty status was defined using phenotype criteria. Global cognition was assessed using the modified Telephone Interview of Cognitive Status and Mini-Mental State Examination (MMSE). The Mattis Dementia Rating Scale (MDRS) and Digit Symbol Substitution Test were used to evaluate 6 cognitive domains: attention, initiation/perseveration, construction, conceptualization, memory, and processing speed. The group-based trajectory model was used to identify latent frailty trajectory groups and the multinomial logistic regression was to examine the relationships of specific cognitive functions with frailty trajectory.Results: Among 485 participants (168 men, 317 women, and mean age: 71.1 ± 5.5 years) completed 2 annual follow-up assessments, three frailty trajectory groups of improvement, no-change, and progression were identified. After adjusting for baseline frailty status, age, sex, global cognition, regular exercise habit, and number of comorbidities, higher scores on MDRS's initiation/perseveration (odds ratio [OR] = 0.85; 95% CI = 0.75-0.95) and attention (OR = 0.63; 95% CI = 0.38-1.00), respectively, were significantly associated with lower risk of frailty progression. Conversely, no significant association was detected between MMSE or TICSM scores and frailty improvement or progression.Conclusion: Specific cognitive functions of initiation/perseveration and attention, rather than global cognition, may be more useful to predict frailty progression, thus allowing the identification of at-risk older adults.

Potentially inappropriate medication use, polypharmacy, and falls among hospitalized patients.

AIM: This matched case-control study investigated potentially inappropriate medication (PIM) use, polypharmacy, and other potential risk factors for falls among hospitalized older adults in Taiwan. METHODS: During an 18-month study period, 131 case patients who experienced a fall during hospitalization in an acute-care hospital were identified and matched by the time of day, hospital ward, and age to controls (five for each case) who were selected through random systematic sampling. Data on demographics, medical characteristics, and all orally and intravascularly administered medications during hospitalization prior to a fall were collected. PIMs were assessed using the 2019 Beers criteria. RESULTS: A conditional logistic regression analysis revealed that admission to the departments of internal medicine (odds ratio [OR] = 2.33; 95% confidence interval [CI] = 1.09-4.91) and neurology and rehabilitation (OR = 4.67; 95% CI = 2.08-10.5), diabetes with end-organ damage (OR = 2.07; 95% CI = 1.11-3.86), PIM use of central nervous system drugs (OR = 1.81; 95% CI = 1.15-2.86), use of colchicine (OR = 5.49; 95% CI = 1.34-22.5) and spironolactone (OR = 4.54; 95% CI = 1.31-15.8) for renal function impairment, and polypharmacy (≥5 medications; OR = 1.81; 95% CI = 1.05-3.10) significantly increased the risk of falls. By contrast, being overweight or obese (OR = 0.47; 95% CI = 0.29-0.78) was associated with a significantly lower risk of falls. CONCLUSIONS: PIM use may increase the risk of falls in hospitalized older patients, and PIM identification and evaluation can reduce this risk. Geriatr Gerontol Int 2022; 22: 857-864.

Gender Differences in Personal and Situational Risk Factors for Traumatic Brain Injury Among Older Adults.

OBJECTIVE: To investigate differences between older men and women in Taiwan in personal and situational risk factors for sustaining a traumatic brain injury (TBI) versus soft-tissue injury (STI) due to a fall. DESIGN: Matched case-control study. PARTICIPANTS AND SETTINGS: Cases were defined as patients with a primary diagnosis of TBI due to a fall and were identified from those 60 years or older who visited the emergency department (ED) of 3 university-affiliated hospitals in 2015. Matched by the same hospital ED, gender, and time of falling, 3 controls who had no TBI and who had sustained only soft-tissue injury (STI) due to falling were selected for comparison with each case. Personal factors and situational exposures were compared between the control and case groups. In total, 96 cases and 288 controls in men and 72 cases and 216 controls in women participated in this study. MAIN MEASURES: Personal factors (sociodemographic and lifestyle factors, medical characteristics, and functional abilities) and situational exposures (location, activities before the fall, center-of-mass change, type of fall, falling direction, protective response, and impact during the fall). RESULTS: In men, after adjusting for other variables, older age (odds ratio [OR] = 1.04), regular alcohol use (OR = 2.03), an indoor fall (OR = 1.92), activity of getting in/out of bed (OR = 2.56), a fall due to dizziness (OR = 4.09), and falling backward (OR = 2.95) were independently associated with a higher odds of TBI. In women, an older age (OR = 1.03), the presence of Parkinson disease (OR = 10.4), activities of toileting (OR = 2.50), getting in/out of bed (OR = 4.90), and negotiating stairs (OR = 7.13), a fall due to dizziness (OR = 5.05), and falling backward (OR = 2.61) were independently associated with a higher odds of TBI. CONCLUSIONS: Our results demonstrated similarities and differences in personal and situational risk factors for fall-related TBIs versus STIs between older men and women, and gender differences should be considered when developing intervention strategies.

Variations in situational risk factors for fractures of the distal forearm, hip, and vertebrae in older women.

BACKGROUND: Situational factors during a fall among three common types of fractures of the distal forearm, hip, and vertebrae among older women in Taiwan were investigated. METHODS: In 2016 ~ 2017, study participants were identified from those aged ≥65 years who visited emergency departments due to a fall in two university-affiliated hospitals in Taipei. In addition to individual characteristics, situational factors during the fall (location, activity, change of center of mass, fall mode, fall direction, initiating a protective response, and being hit) were collected. A sample of 203 distal-forearm fractures, 189 vertebral fractures, and 375 hip fractures was recruited, while 717 women with a soft-tissue injury were used as a control group. The identification of situational risk factors for each type of fracture was validated by using those who sustained one of the other two types of fracture as a control group. RESULTS: After adjusting for age and other individual characteristics, compared to soft-tissue injuries, distal-forearm fractures were significantly more likely to occur with slips (odds ratio [OR] = 11.0; 95% confidence interval [CI] = 4.76 ~ 25.4), trips (OR = 3.40; 95% CI = 1.42 ~ 8.17), step-downs (OR = 4.95; 95% CI = 2.15 ~ 11.4), and from sideways falls (OR = 1.73; 95% CI = 1.12 ~ 2.67) and significantly less likely to occur indoors (OR = 0.62; 95% CI = 0.42 ~ 0.90) or from backwards falls (OR = 0.62; 95% CI = 0.41 ~ 0.95). Hip fractures were significantly more likely to occur with step-downs (OR = 1.76; 95% CI = 1.13 ~ 2.75) and from backwards (OR = 3.16; 95% CI = 2.15 ~ 4.64) or sideways falls (OR = 5.56; 95% CI = 3.67 ~ 8.41) and significantly less likely when hitting an object (OR = 0.26; 95% CI = 0.13 ~ 0.52) or initiating a protective response (OR = 0.58; 95% CI = 0.36 ~ 0.93). Vertebral fractures were significantly more likely to occur with slips (OR = 2.42; 95% CI = 1.30 ~ 4.50), step-downs (OR = 2.53; 95% CI = 1.43 ~ 4.48), and backwards falls (OR = 2.15; 95% CI = 1.39 ~ 3.32). Similar results were found in the validation analyses. CONCLUSIONS: Large variations in situational risk factors for the three types of fracture in older women existed. A combination of individual and situational risk factors may display a more-comprehensive risk profile for the three types of fracture, and an intervention that adds training programs on safe landing strategies and effective compensatory reactions may be valuable in preventing serious injuries due to a fall.

Effects of Computerized Cognitive Training and Tai Chi on Cognitive Performance in Older Adults With Traumatic Brain Injury.

OBJECTIVE: To compare the effects of computerized cognitive training (CCT) and tai chi (TC) with usual care (UC) on cognitive functions and secondary outcomes in older adults with traumatic brain injury. PARTICIPANTS AND SETTINGS: Ninety-six patients aged 55 years and older who had a diagnosis of traumatic brain injury requiring hospital admission. DESIGN: Randomized controlled trial. MAIN MEASURES: The Mattis Dementia Rating Scale (MDRS), Mini-Mental State Examination, modified Telephone Interview of Cognitive Status, and Trail Making Tests A and B. RESULTS: Compared with UC, CCT increased scores on the MDRS's total, attention, and memory and those on the Mini-Mental State Examination and Telephone Interview of Cognitive Status over the 6-month intervention; TC increased scores on the MDRS's total and conceptualization and those on the Mini-Mental State Examination over the 6-month intervention, while it also increased scores on the MDRS's total and initiation/preservation and those on the Telephone Interview of Cognitive Status and reduced the time to complete the Trail Making Test B over the 12-month study. Furthermore, compared with UC, CCT increased handgrip strength and TC reduced the time to complete 5 sit-to-stands over the 6-month intervention. CONCLUSION: Both CCT and TC may improve global cognition and different specific cognitive domains in older traumatic brain injury patients; the TC's effect may last for at least an additional 6 months.

Patient-Proxy Agreement on the Health-Related Quality of Life One Year After Traumatic Brain Injury.

OBJECTIVE: To examine the level of agreement between patients and their proxies on a measure of health-related quality of life (HRQL) 1 year after traumatic brain injury (TBI). DESIGN: A cross-sectional study. SETTING: Four hospitals in Taipei. PARTICIPANTS: Participants (N=176) were patients with TBI (n=88) identified from discharge records of 4 hospitals in Taiwan and family members or friends (n=88) who could answer questions regarding the patient's health and HRQL 1 year after the injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A health profile of the brief Taiwanese version of the World Health Organization Quality of Life (WHOQOL-BREF) and 2 health utility measures of the time tradeoff (TTO) and standard gamble (SG). RESULTS: Compared with proxy responses, patients provided higher ratings on the domains of the WHOQOL-BREF and lower ratings on the TTO and SG. Intraclass correlation coefficients between patient and proxy ratings varied among the 4 domains of the WHOQOL-BREF, in which levels of agreement were moderate or good for physical capacity (.69) and low for psychological well-being (.45), social relationships (.24), and the environment (.32). Levels of agreement were extremely low for the TTO (0.0) and SG (.10). A profile analysis showed that patients' ratings on the WHOQOL-BREF, on average, were significantly greater than those of their proxies (mean difference, 3.07), with a similar distribution of scatter responses (mean difference, .002) and shape agreement (mean difference, .57). Greater variations in the patient-proxy level of agreement appeared in patients who were younger and had more severe injuries, and also with parent and child proxies. CONCLUSIONS: To assess the HRQL of patients with a TBI, the level of patient-proxy agreement was adequate for the physical domain but was lower for the social and environmental domains, and the agreement was very low for the TTO and SG. Furthermore, a patient's age and injury severity, and the patient-proxy' relationship may affect the agreement.

Injury severity measures for predicting return-to-work after a traumatic brain injury.

This study compared the ability of five injury severity measures, namely the Abbreviated Injury Scale to the Head (AIS-H), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), Extended Glasgow Outcome Scale (GOSE), and Injury Severity Score (ISS), to predict return-to-work after a traumatic brain injury (TBI). Furthermore, factors potentially associated with return-to-work were investigated. In total, 207 individuals aged ≤65 years newly diagnosed with a TBI and employed at the time of injury were recruited and followed-up for 1year by telephone every 3 months. A bivariate proportional hazards model analysis revealed that all five injury severity measures were significantly associated with return-to-work after a TBI. The AIS-H and non-head ISS explained 23.8% of the variation in the duration of returning to work from discharge after hospitalization for a TBI; similarly, the GCS, GOS, GOSE, and ISS respectively accounted for 4.7%, 21.4%, 12.9%, and 48.4% of the variation. A multivariable analysis revealed that individuals with higher injury severity as measured by the ISS (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.92-0.97), a lack of autonomy in transportation (HR, 2.55; 95% CI, 1.23-5.32), cognitive impairment (HR, 0.47; 95% CI, 0.28-0.79), and depression (HR, 0.97; 95% CI, 0.95-0.99) were significantly less likely to be employed after a TBI. In conclusion, of the five injury severity measures, the ISS may be the most capable measure of predicting return-to-work after a TBI. In addition to injury severity, autonomy in transportation, cognitive function, and the depressive status may also influence the employment status during the first year after a TBI.

Comparisons of Different Screening Tools for Identifying Fracture/Osteoporosis Risk Among Community-Dwelling Older People.

A prospective study was conducted to compare criterion, predictive, and construct validities of 9 fracture/osteoporosis assessment tools, including calcaneal quantitative ultrasonography (QUS), Age Bulk One or Never Estrogens (ABONE), body weight criterion (BWC), Fracture Risk Assessment Tool (FRAX), Garvan fracture risk calculator (GARVAN), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), Osteoporosis Self-Assessment Tool for Asians (OSTA), and Simple Calculated Osteoporosis Risk Estimation (SCORE), among older men and women in Taiwan.Using the femoral neck dual-energy x-ray absorptiometry (DXA) T-score as an external criterion, the sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and the area under the receiver operating characteristic curve (AUC) for each tool were calculated. The ability of these tools to predict injurious falls was examined. A principal component analysis was applied to understand whether these tools were measuring the same underlying construct.The FRAX, BWC, ORAI, OSIRIS, OSTA, and SCORE had AUCs of ≥0.8 in men, while the GARVAN, OSIRIS, OSTA, and SCORE had AUCs of ≥0.8 in women. The sensitivity, negative predictive value, and likelihood ratio of the ABONE, BWC, ORAI, OSIRIS, OSTA, and SCORE tools in both men and women were 100%, ≥90%, and 0.0, respectively; the specificity and positive predictive value and likelihood ratio were far from satisfactory. The GARVAN displayed the best predictive ability of a fall in both men (AUCs, 0.653-0.686) and women (AUCs, 0.560-0.567), despite being smaller in women. The 9 screening tools and 2 central DXA measurements assessed 5 different factors, while the ABONE, BWC, ORAI, OSIRIS, OSTA, and SCORE measured the same one.Simple self-assessment tools can serve as initial screening instruments to rule out persons who have osteoporosis; however, these tools may measure a different construct other than fracture/osteoporosis risk.

Effects of Home-Based Tai Chi and Lower Extremity Training and Self-Practice on Falls and Functional Outcomes in Older Fallers from the Emergency Department-A Randomized Controlled Trial.

OBJECTIVES: To compare the effects of guided home-based tai chi chuan (TCC) and lower extremity training (LET) and of levels of self-practice on falls and functional outcomes in older fallers. DESIGN: Randomized controlled trial. SETTING: Taipei, Taiwan. PARTICIPANTS: Individuals aged 60 and older who had fall-related emergency department visits at least 6 months before participating in the study and ambulated independently at baseline (N = 456). INTERVENTION: Six months of TCC or LET. MEASUREMENTS: Four types of fall measures (falls, time to first fall, fallers, recurrent fallers) and six functional measures (handgrip strength, balance, mobility, fear of falling, depression, cognitive function). RESULTS: The TCC group was significantly less likely than the LET group to experience any falls during the 6-month intervention (incidence rate ratio (IRR) = 0.30, 95% confidence interval (CI) = 0.15-0.60), and the effects remained significant after 12 months of follow-up (IRR = 0.32, 95% CI = 0.14-0.71). These effects remained significant for injurious falls during the 6-month intervention (IRR = 0.33, 95% CI = 0.16-0.68) and the entire 18-month study (IRR = 0.39, 95% CI = 0.18-0.83). Similar results were obtained when another two fall measures (time to first fall, number of fallers) were used. Moreover, participants who independently practiced TCC or LET seven times per week or more were significantly less likely to experience injurious falls during the 6-month intervention (IRR = 0.41, 95% CI = 0.20-0.83) and the 18-month study (IRR = 0.43, 95% CI = 0.21-0.87) than their counterparts, had a significantly longer time to first injurious fall, and were significantly less likely to have an injurious fall during the 6-month intervention. Cognitive function improved to a greater extent in the TCC group than in the LET group over the 18-month study. CONCLUSION: Home-based TCC may reduce the incidence of falls and injurious falls more than conventional LET in older fallers, and the effects may last for at least 1 year.

Suitability of the Quality of Life after Brain Injury Instrument for Older People with Traumatic Brain Injury.

We prospectively investigated the psychometric properties of the Quality of Life after Brain Injury (QOLIBRI) instrument among older patients with traumatic brain injury (TBI). The 37-item QOLIBRI comprises six domains (cognition, self, daily life and autonomy, social relationships, emotions, and physical problems). We recruited 333 patients ≥60 years of age with TBI from the neurosurgery clinics and emergency departments of three hospitals in Taipei, Taiwan. The ceiling and floor values for most QOLIBRI domains were <5%, and the internal consistency and test-retest reliability ranged from 0.84 to 0.97 and 0.83 to 0.96, respectively. For the known-groups validity, patients with TBI attained lower scores for all QOLIBRI domains, except physical problems, compared with those with soft-tissue injuries. Patients with intact cognition who had higher levels on the Glasgow Outcome Scale Extended (GOSE) and the Glasgow Coma Scale, fewer limitations in activities of daily living, and fewer chronic conditions obtained higher scores for almost all the QOLIBRI domains, compared with their counterparts. For convergent validity, the correlation coefficients for the QOLIBRI domains and the selected functional measures conceptually related to that domain were all ≥0.4. A confirmatory factor analysis revealed that the original six-domain structure fit the data with a comparative fit index of ≥0.9. Effect sizes for changes in the GOSE over a 6-month follow-up period were clinically meaningful (≥ 0.2) for all the QOLIBRI domains except emotions. For older people with TBI, the use of the QOLIBRI is generally appropriate, and adding the domain of environment to the scale would be beneficial.

[Flipped Classroom: A New Teaching Strategy for Integrating Information Technology Into Nursing Education].

The traditional "teacher-centered" instruction model is still currently pervasive in nursing education. However, this model does not stimulate the critical thinking or foster the self-learning competence of students. In recent years, the rapid development of information technology and the changes in educational philosophy have encouraged the development of the "flipped classroom" concept. This concept completely subverts the traditional instruction model by allowing students to access and use related learning activities prior to class on their smartphones or tablet computers. Implementation of this concept has been demonstrated to facilitate greater classroom interaction between teachers and students, to stimulate student thinking, to guide problem solving, and to encourage cooperative learning and knowledge utilization in order to achieve the ideal of student-centered education. This student-centered model of instruction coincides with the philosophy of nursing education and may foster the professional competence of nursing students. The flipped classroom is already an international trend, and certain domestic education sectors have adopted and applied this concept as well. However, this concept has only just begun to make its mark on nursing education. This article describes the concept of the flipped classroom, the implementation myth, the current experience with implementing this concept in international healthcare education, and the challenging issues. We hope to provide a reference for future nursing education administrators who are responsible to implement flipped classroom teaching strategies in Taiwan.

Risk Factors for Traumatic Brain Injuries During Falls in Older Persons.

OBJECTIVE: To identify risk factors for traumatic brain injuries (TBIs) during falls in older Taiwanese people. PARTICIPANTS: Case patients consisted of 113 patients aged 60 years or older with a moderate/severe TBI due to a fall. Two control groups: (1) 339 older patients with a soft-tissue injury; and (2) 113 with a mild-TBI due to a fall. Proxies were required to provide information for a considerable number of patients. DESIGN: Matched case-control study. SETTINGS: The emergency departments of 3 general hospitals. MEASURES: Sociodemographic, lifestyle behavior, chronic condition, medication use, functional abilities, and fall-related characteristics. RESULTS: When patients with a soft-tissue injury were assigned to the control group, men were 2.06-fold more likely to have a moderate/severe TBI than women. Subjects who took antiarrhythmics within 4 hours of a fall were 2.59-fold more likely to have a moderate/severe TBI than those who took none. Subjects who were negotiating stairs and getting in/out of the bed/chair were 3.12-fold and 2.97-fold, respectively, more likely to have a moderate/severe TBI than those who fell while walking. Falling backward and sideways was 4.07-fold and 2.30-fold, respectively, more likely to cause a moderate/severe TBI than falling forward. When patients with a mild-TBI were assigned to the control group, results were similar, with the exception that the effect of antiarrhythmic use became nonsignificant and subjects who took 2 or more medications were 3.07-fold more likely to have a moderate/severe TBI than those who took none. CONCLUSION: Avoiding a head impact during a backward or sideways fall, reducing unnecessary use of polypharmacy and antiarrhythmics, and maintaining safety during stair negotiation and bed/chair transfer may protect an elderly person from a severe brain injury.

Medication use and fall-risk assessment for falls in an acute care hospital.

AIM: A nested case-control study was carried out to examine relationships of a fall-risk score and the use of single medications and polypharmacy with falls among hospitalized patients aged 50 years and older in Taiwan. METHODS: There were 83 patients who experienced a fall during hospitalization in an acute-care hospital. Matched by age and sex, five control patients for each case were randomly selected from all other inpatients who had not experienced any fall at the time of the index fall. RESULTS: Patients who took tricyclic antidepressants, diuretics, and narcotics were 3.36-, 1.83- and 2.09-fold, respectively, more likely to experience a fall than their counterparts. Conversely, patients who took beta-blockers were 0.34-fold more likely than those who did not take them to experience a fall. Patients taking ≥6 medications were 3.08-fold more likely than those taking fewer medications to experience a fall, whereas those with anxiety were 4.72-fold more likely to experience a fall than those without. A high fall-risk score was not significantly associated with the occurrence of falls. CONCLUSIONS: Among older hospitalized patients, tricyclic antidepressants, diuretics, narcotics, and polypharmacy should be mindfully prescribed and reviewed on a regular basis. A fall-risk scale developed from community-dwelling older people might not accurately predict falls in hospitalized patients. Further research to validate the negative effect of beta-blocker use on falls is required.

Effects of fall injury type and discharge placement on mortality, hospitalization, falls, and ADL changes among older people in Taiwan.

A longitudinal study was conducted to investigate the effects of injury type and discharge placement on mortality, falls, hospital admissions, and changes in activities of daily living (ADLs) over a 12-month period among older fallers. Of 762 community-dwelling people aged 65 years or older who visited an emergency department (ED) of a general hospital in Taiwan due to a fall, 273 sustained a hip fracture, 157 had a vertebral fracture, 47 had a distal forearm fracture, 102 had a traumatic brain injury, and 183 had soft-tissue injuries. Results showed that, compared to patients with a soft-tissue injury, those with TBI had significantly higher risks of dying (rate ratio (RR)=3.59) and hospital admissions (RR=3.23) and better improvement in ADLs (1.93 points) at 6 months post-injury, and those who sustained a hip fracture (4.26 and 4.41 points), a vertebral fracture (3.81 and 3.83 points), or a distal-forearm fracture (2.80 and 2.80 points) had significantly better improvement in ADLs at 6 and 12 months post-injury. Patients discharged to a nursing home had a significantly increased risk of death (RR=2.08) and hospital admission (RR=2.05) than those returning to their usual residence during the first year post-injury. No significant differences in the occurrence of falls during the first post-injury year were found among patients with different injury types or between those with different discharge placements. In conclusion, among the five major fall injury types in older people, TBIs result in the highest risk of death and hospital admissions, while hip and vertebral fractures exhibited the largest improvement during the first year after injury. Additionally, nursing home care may be associated with increased risks of death and hospital admissions than home care. In addition to primary prevention of falls, further research to investigate mechanisms leading to TBIs during a fall is needed to facilitate effective secondary fall-prevention programs for older people.

Effect of fracture type on health-related quality of life among older women in Taiwan.

OBJECTIVE: To investigate changes in health-related quality of life (HRQOL) during the first year after injury in elderly Taiwanese women who had fractured a hip, vertebra, distal forearm, or multiple sites. DESIGN: Longitudinal cohort study. SETTING: Personal or telephone interviews of patients from 3 teaching hospitals. PARTICIPANTS: Women (N=347; mean age ± SD, 78.0±6.6y) who had sustained a fracture of the hip, vertebra, or distal forearm due to a fall participated in the baseline assessment, in which both current and prefracture HRQOL data were collected. At 6 and 12 months after the fracture, 285 and 254 women, respectively, completed the follow-up assessments. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The 4 domains of physical capacity, psychological well-being, social relationships, and environment of the brief version of the World Health Organization Quality of Life questionnaire were assessed. RESULTS: After adjusting for prefracture HRQOL scores and baseline characteristics, women with a hip fracture showed a significant improvement in physical capacity (3.5 points) and a significant decline in social relationships (-3.7 points). Relative to women with a hip fracture at 12 months after injury, those with a vertebral fracture exhibited significantly greater improvement (5.2 points) in physical capacity; those with a distal forearm fracture had significantly greater improvements in physical capacity (11.5 points), psychological well-being (8.4 points), social relationships (7.2 points), and environment (10.9 points), while those with multiple fractures displayed significantly greater improvement in physical capacity (16.5 points), psychological well-being (13.3 points), and environment (10.3 points). CONCLUSIONS: Among the 4 fracture types in elderly women, hip fractures may result in the smallest improvement in the physical domain and the greatest declines in the psychological, social, and environmental domains during the first year. The magnitude of the impact of each fracture type varied across different domains.

Use of quantitative ultrasound for identifying low bone density in older people.

OBJECTIVE: This study examined criterion, convergent, and discriminant validities of quantitative ultrasound (QUS) for identifying low bone density among people aged 55 years and older in Taiwan. METHODS: We recruited 453 community-dwelling volunteers and 30 patients with lower extremity fractures. Bone density was assessed using both calcaneal QUS and femoral neck dual-energy x-ray absorptiometry (DXA). Two QUS parameters, speed of sound (SOS) and broadband ultrasound attenuation (BUA), were also used to estimate heel bone mineral density (HBMD). RESULTS: Using DXA as the criterion for identifying low bone density (DXA T score of 1.0 or lower), likelihood ratios for BUA and SOS at the 50th percentile and HBMD for men were 1.50, 1.75, and 1.28, respectively; the counterparts for women were 1.54, 2.13, and 1.29. As for identifying osteoporosis (DXA T score of -2.5 or lower), higher likelihood ratios of the 3 QUS parameters were gained. For convergent validity, Pearson correlation coefficients for DXA with BUA, SOS, and HBMD ranged from 0.40 to 0.43 for men and from 0.48 to 0.53 for women. For the ability to discriminate men and women with lower extremity fractures from those without, no significant differences in the area under the receiver operating characteristic curve were detected between BUA, SOS, and HBMD and DXA after adjusting for age, body mass index, fall history, and current smoking. CONCLUSIONS: Although having very good convergent and discriminant validities and fair criterion validity, calcaneal QUS may be a screening tool for identifying low bone density.