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.

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.

Measurement structure of the caregiver burden scale: findings from a national community survey in Taiwan.

AIM: There is no appropriate understanding of community family caregiver burden. The object of the present study was to evaluate the measurement structure of a caregiver burden scale from a nationally representative Taiwanese community sample. METHODS: Data from nationally representative subjects completing face-to-face interviews on caregiver burden were analyzed. A total of 9020 primary adult family caregivers were enrolled. All of the valid respondents were equally divided into three subsamples. The first sample was used to explore the factor structure of burden scale. The second sample was used to validate the factor structure. The third sample was used to verify the adequacy and stability of the factor structures developed in the former steps. RESULTS: A total of 8826 valid data were included for analysis. Exploratory and confirmatory factor analysis identified the four-factor, 15-item Caregiver Burden Scale (CBS-15) in the present study. The extracted four factors were predominantly accounted for by the items measuring "burden of time," "relational burden," "financial burden" and "emotional burden". All the goodness-of-fit indices reported for this model were acceptable. CONCLUSION: The present study supports the usefulness of the CBS-15 as a tool to understand the measurement structure of burden in a nationally representative Taiwanese community family caregivers sample. The CBS-15 can be used to identify community caregiver needs.

Multidimensional health-transition patterns among a middle-aged and older population.

AIM: Previous studies on health transition have focused on single-dimension outcomes and minimally evaluated heterogeneity. This study aimed to explore heterogeneous and multidimensional health-transition patterns on comorbidity, frailty and disability while examining the factors predicting different patterns of health transition. METHODS: This study drew on data from a nationwide and longitudinally-followed sample of 5131 Taiwanese aged 50 years and older who were interviewed in 1996, 1999, 2003 and 2007. Latent class analysis (LCA) and multinomial logistic regression were applied to identify health-transition patterns and their predictors. RESULTS: We identified six health-transition classes by applying LCA, including "persistently healthy", "well-managed comorbidity", "originally comorbid and gradually deteriorating to disability", "deteriorating gradually and died in late stage of the follow-up period", "deteriorating and died in middle stage of the follow-up period", and "originally comorbid and died in early stage of the follow-up period". Using the "well-managed comorbidity" class as the reference group, men had higher probabilities of being in the categories of dying in the follow-up period, but a lower risk of deteriorating to disability. Younger baseline age, higher education, having social engagement and non-smoking were predictors of "persistently healthy" and were associated with a lower risk of deteriorating to disability and death. Having a spouse and health examinations were associated with a lower risk of death, and also a lower probability of "persistently healthy". CONCLUSIONS: Heterogeneous and multidimensional health-transition patterns exist in middle-aged and older populations. Several factors might have an effect on health-transition patterns.

Sex differences in the impact of diabetes on the risk of geriatric conditions.

AIM: To examine whether sex differences exist in the relationship between diabetes and geriatric conditions. METHODS: This was a cross-sectional analysis of 2629 community-dwelling older adults, drawn from the 2003 wave of the "Survey of Health and Living Status of the Elderly in Taiwan." Selected geriatric conditions included cognitive impairment, depression, falls and urinary incontinence (UI). Diabetes and comorbid conditions (heart disease, hypertension, chronic lung disease, stroke, hip fracture, arthritis, chronic kidney disease and cancer) were assessed using questionnaires. RESULTS: A greater proportion of older women, compared with men, had cognitive impairment (15.8% vs 7.3%), depression (22.6% vs 10.4%), falls (26.7% vs 16.3%), and UI (20.9% vs 15.1%). After adjustment for basic demographics and comorbid conditions, diabetes was associated with increased risk for cognitive impairment (RR 1.85 [CI 1.12-3.05], P=0.017), depression (RR 2.03 [CI 1.39-2.97], P=0.0003) and falls (RR 1.72 [CI 1.2-2.48], P=0.003), but not UI (RR 1.4 [CI 0.9-2.1], P=0.067) among older women. However, we did not find any associations in men. CONCLUSIONS: Diabetes was associated with excessive risk for geriatric conditions among older women, but not men. The effect of sex differences on the relationship between diabetes and geriatric conditions requires further exploration.

Medication adherence among geriatric outpatients prescribed multiple medications.

BACKGROUND: Poor medication adherence (PMA) is associated with higher risks of morbidity, hospitalization, and mortality. Polypharmacy is not only a determinant of PMA but is also associated with many adverse health outcomes. OBJECTIVE: We aimed to determine the prevalence and correlates of PMA in an older population with polypharmacy. METHODS: Baseline data from 193 older adults from the Medication Safety Review Clinic Taiwan Study were analyzed. Patients were either prescribed ≥8 long-term medications or visited ≥3 different physicians between August and October 2007. PMA was defined as taking either <80% or >120% of prescribed amounts of a medication. Patients were classified as no (0%), low level (>0 but <25%), and high level (≥25%) PMA depending on what percentage of entire medication regimen taken reached PMA. RESULTS: Mean (SD) age was 76 (6) years, and mean number of medications was 9 (3), with a mean medication class number of 4 (1). Of the 1713 medications reviewed, 19% had PMA. However, at patient level, 34%, 32%, and 34% of patients were classified as no, low level, and high level PMA, respectively. Correlates varied by levels of PMA. Compared with patients without PMA, higher medication class number and use of alimentary tract, psychotropic, and hematologic agents were associated with both low and high level PMA. History of dizziness was associated with low level PMA, and higher Mini Mental Status Examination score was associated with high level PMA. CONCLUSIONS: To enhance medication adherence in older adults prescribed multiple medications, medication class numbers and certain high-risk medication classes should be taken into account. Physicians should also routinely assess systemic (eg, cognition) or drug-specific characteristics (eg, side effects).

Drug-related problems (DRPs) identified from geriatric medication safety review clinics.

Drug-related problems (DRPs) were identified from baseline data of 193 Medication Safety Review Clinic (MSRC) patients. MSRCs enroll older adults (≥ 65 years) with either (1) prescriptions of ≥ 8 chronic medications (drugs prescribed for ≥ 28 days) or (2) a visit to ≥ 3 different physicians at the two participating hospitals in Taipei, Taiwan from August to October 2007. The Pharmaceutical Care Network Europe (PCNE) Classification Version 5.01 was used to report DRPs. Mean age was 76.2 ± 6.2 years and 53% of participants were male. Participants had, on average, 9.0 ± 2.6 chronic conditions and took 8.9 ± 3.1 chronic medications and 1.7 ± 1.8 dietary supplements. Eighty-seven percent had at least one DRP. Being older, having orthostatic hypotension and taking more chronic medications were associated with higher likelihood of having at least one DRP. For the 1713 medications and 331 diet supplements reviewed, 427 DRPs were found, 490 causes (1.1 ± 0.4 per problem) identified and 1067 interventions proposed (2.5 ± 0.6 per problem). The most common DRP category was "drug not taken/administered" (35%), and the most common offending drug category was cardiovascular agents (33%). Prevalence of DRPs was high among geriatric outpatients prescribed multiple medications. Careful medication review is needed in routine clinical practice to improve prescription quality.

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.

Multiple morbidity combinations impact on medical expenditures among older adults.

This study aims to explore the medical needs of patients who have different combinations of multiple chronic diseases in order to improve care strategy for chronic patients. This study was based on a national probability proportional to size (PPS) sampling to older adults over 50 years old. We collaborated the files of the 2000-2001 health insurance claims and selected 8 types of common chronic diseases among seniors, for the discussion of multiple combinations of chronic diseases, including hypertension, diabetes, heart disease, stroke, dementia, cancer, arthritis and chronic obstructive pulmonary disease. Among the NHI users, there are 50.6% of the cases suffering from at least one chronic disease, 27.3% suffering from two types of chronic diseases and above. From possible combinations of eight common chronic diseases, it is found hypertension has the highest prevalence rate (7.5%); arthritis ranks the next (6.2%); the combination of hypertension and heart disease ranks the third (3.4%). In the 22 types of major chronic disease clusters, the average total medical expense for people who have five or more chronic diseases ranks the highest, USD 4465; the combination of hypertension, diabetes, heart disease, and arthritis ranks the next, USD 2703; the combination of hypertension, diabetes, and heart disease ranks the third, USD 2550; cancer only ranks the fourth, USD 2487. Our study may provide statistical data concerning co-morbidity among older adults and their medical needs. Through our analysis, the major population that exhausts the medical resources may be discovered.

The prevalence of chronic conditions and medical expenditures of the elderly by chronic condition indicator (CCI).

The aim of this study was to understand the prevalence of chronic conditions and medical expenditures of the elderly for health care planning development of chronic conditions. This research is based on the representative sample (N=114,873) of seniors over 65 years nationwide. The CCI by the U.S. Agency for Healthcare Research and Quality (AHRQ), and clinical classifications software (CCS) were adopted to determine chronic condition diagnosis codes and classify the diseases. The results are presented by descriptive and multiple regression analysis. The chronic condition prevalence for seniors is 70.4% and the medical expenditures for seniors with chronic conditions accounts for 92.7% of the total medical expenditures for seniors, while 25% of the medical expenditure is spent on 8.2% of seniors who have five chronic conditions and above. Chronic conditions suffered by the elderly, in the order of its prevalence, are hypertension (36.1%), COPD (23.7%), and cataracts (16.7%). From the viewpoint of annual average medical expenditures, cardiovascular diseases rank the most costly diseases, with average medical expenditures as high as $4291. Urinary disease and diabetes ranks the second and the third most costly with an average expenditure of $3644 and $3594. This research showed that the average medical expenditure for seniors with chronic conditions is 5.4 times higher compared with seniors without chronic conditions. It is recommended to further study the characteristics of the target population that spends the most in medical expenditures to outline a more beneficial disease management model, reduce avoidable medical costs and achieve the goal of saving medical resources.

Health, financial stresses, and life satisfaction affecting late-life depression among older adults: a nationwide, longitudinal survey in Taiwan.

The purpose of this study was to determine the incidence of depression in late life and to explore associated risk factors among Taiwanese elderly. The analyses were based on nationally representative data from the Survey of Health and Living Status of the Elderly in 1999 and 2003. A total of 1,487 respondents aged 65 years and older who completed the 10-item Center for Epidemiological Survey Depression (CES-D) scale in these two surveys and without depression in 1999 were included in the final analyses. Depression was defined as a CES-D score equal to or greater than 10. The independent variables included sociodemographic characteristics, occurrence of new diseases, social support, perceived health and financial stresses, life satisfaction, and functional condition. The incidence rate of depression over 4 years was 19.7%. Multivariate regression analyses revealed that women who perceived greater health or financial stress and who had greater life dissatisfaction or worsened functional condition were more likely to suffer depression. These findings imply that healthcare programs for older adults should include cognitive and behavioral interventions in order to prevent the development of depression in late life.

The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized, controlled trial.

This randomized, controlled trial assessed the effectiveness of comprehensive geriatric assessment (CGA) and subsequent intervention in pre-frail and frail community-dwelling elderly based on the Fried Frailty Criteria (FFC) and the Barthel Index (BI) A total of 310 pre-frail or frail elderly from a single community were identified using the FFC. Of these, 152 were randomly assigned to the intervention group for CGA and appropriate intervention by medication adjustment, exercise instruction, nutrition support, physical rehabilitation, social worker consultation, and specialty referral. Clinical outcome was re-evaluated by the FFC and BI 6 months later. Compared to the control group, the intervention group tended to have a better outcome, with an odds ratio (OR) = 1.19, 95% confidence interval (95% CI) = 0.48-3.04, p = 0.71) and 3.29 (95% CI = 0.65-16.64, p = 0.15), respectively, and were less likely to deteriorate, with an OR = 0.78 (95% CI = 0.34-1.79, p = 0.57) and 0.94 (95% CI = 0.42-2.12, p = 0.88), respectively. Although no significant differences were observed, the CGA and subsequent intervention showed a favorable outcome in frail and pre-frail elderly based on the frailty status and BI. Inability to complete the CGA and poor compliance with the intervention program appear to be the main reasons for unfavorable outcomes.

The prevalence of subjective frailty and factors associated with frailty in Taiwan.

This study estimated the prevalence of frailty and identified the factors associated with frailty in Taiwan using data from the Survey of Health and Living Status of the Elderly. A nationwide probability sample including 2,238 individuals aged > or =65 years was interviewed in 2003. Based on the Cardiovascular Health Study conducted by Fried, five phenotypes of frailty were selected: poor appetite, exhaustion, low physical activity, poor walking ability, and poor twisting ability of fingers. Participants were classified as nonfrail, prefrail, and frail if they met 0, 1 or 2, and > or =3 criteria. The prevalences of nonfrailty, prefrailty, and frailty were 55.1%, 40.0%, and 4.9%, respectively. The prevalence of frailty increased with age and was greater in women. Frailty was associated with less education, no spouse, disability, higher rates of comorbid chronic diseases, depressive symptoms, and geriatric syndromes. Specific drug use, such as hypnotics, analgesics, herbal drugs, and parenteral fluid supplements was positively associated with frailty. The use of multivitamins, fish oil, and vitamin E was negatively associated with frailty. The prevalence of frailty is lower in Taiwan than in Western countries. Depressive symptoms, geriatric syndromes, and specific medication use are potential fields for frailty prevention in community-dwelling older adults.

Social determinants of emergency utilization associated with patterns of care.

PURPOSE: To investigate the emergency room (ER) utilization among disabled Taiwanese older adults with different patterns of care arrangement. METHOD: A national probability sample of 13,957 disabled older adults (aged 50 and above) was recruited. Individual interview data and National Health Insurance administrative data were used to examine the effects of care arrangements on ER utilization 1 year after the baseline interview. RESULTS: One-third (33.5%) of the subjects used emergency room at least once in the follow-up year. The ER utilization rates among individuals living in institutions, in home with foreigner worker, in home with informal caregiver, and in home without caregiver, were 34.5%, 43%, 32.5% and 25% respectively. After controlling for other predisposing, enabling, need factors, and healthcare services use with multivariate logistic regression model, comparing with subjects staying home with informal caregivers, those who were institutionalized were less likely to use ER services during the study year (OR=0.64, 95%CI=0.54-0.76), those who staying home cared by foreigner worker were more likely to use ER services (OR=1.16, 95%CI=1.05-1.29), and those who staying home without caregiver were less likely to use ER services (OR=0.89, 95%CI=0.78-1.01). CONCLUSIONS: Disabled older adults staying at home were more likely to use ER compared to institutionalized individuals. More research is needed to identify the unmet healthcare needs and the quality of home care that may explain the high ER utilization rate.

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.

Home environmental problems and physical function in Taiwanese older adults.

Environmental hazards play an important role in the disablement process. The purpose of this study was to investigate the relationship between home environmental problems and personal physical function. Data were based on a two-stage nationwide survey and evaluation on the needs of long-term care in Taiwan. A total of 10,596 individuals aged 65 and over were included in this study. These participants were identified with physical or cognitive problems at the screening interview and further evaluated at the second interview on health condition, functional status, needs of long-term care, and home environmental problems. Six items of environmental hazards were assessed at the participants' homes with direct observation. The prevalence rates of home environmental problems were similar among older adults with different levels of physical function. No grab bars (79.6-85.1%) and no protections against slip (81.9-92.8%) in the bathroom were two commonly present hazards in older adults' homes. Older adults with a higher income (Odds ratio=OR=0.75), without income information (OR=0.78) or living with other persons (OR=0.74) were less likely to experience environmental problems at home. Results from this study revealed that home environment condition was associated with factors other than personal disabling conditions for the elderly. Modifying home environment, especially the bathroom, should be attached with great importance for physically disabled older adults.

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.

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.

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.