The updated PIM-Taiwan criteria: a list of potentially inappropriate medications in older people.

BACKGROUND: Explicit criteria for potentially inappropriate medications (PIMs) developed for other countries are difficult to apply to a specific territory. This study aimed to update the PIM-Taiwan criteria from a qualitative review of several published PIM criteria, followed by consensus among regional experts in Taiwan. METHODS: After a review of the literature, we selected four sets of published PIM criteria to construct preliminary core PIMs. The Beers criteria, Fit fOR The Aged (FORTA), and Japan criteria were used for PIMs, without consideration of chronic diseases. The Beers criteria, Screening Tool of Older Persons' Prescriptions (STOPP) criteria, and Japan criteria were used for PIMs with respect to chronic diseases. We asked experts (n = 24) to rate their agreement with each statement, including in the final PIM criteria, after two rounds of modified Delphi methods. The intraclass coefficient (ICC) was used to examine the reliability of the modified Delphi method. RESULTS: Overall, two categories of PIMs were established: 131 individual drugs and 9 drugs with combinations that should generally be avoided; and 9 chronic diseases with their corresponding PIMs that have drug-disease interactions. The ICC estimates for PIMs to be avoided generally were 0.634 and 0.557 (round 1 and 2) and those for PIMs with respect to chronic diseases were 0.866 and 0.775 (round 1 and 2) of the Delphi method, respectively. CONCLUSIONS: The 2018 version of PIM-Taiwan criteria was established and several modifications were made to keep the criteria updated and relevant. Clinicians can use them to reduce polypharmacy and PIMs among older patients.

The application of updating PIM-Taiwan criteria in clinic-visiting older patients with polypharmacy.

BACKGROUND: PIM-Taiwan criteria were first established in 2010 for potentially inappropriate medications (PIMs). Currently, updating of PIM criteria is mandatory because of newly established evidence and newly developed medications. This study aims to evaluate the prevalence of PIM based on country-specific PIM criteria and factors associated with PIM use by applying 2010 version and newly updating PIM-Taiwan criteria in a cohort with polypharmacy. METHODS: The baseline data of Medication Safety Review Clinic Taiwan (MSRC-Taiwan) study were used to investigate the prevalence of PIMs. Older patients (aged ⩾65 years) who were either having polypharmacy or visited ⩾3 different physicians were enrolled between August and October 2007. Bivariate analysis and multivariate logistic regressions were used to evaluate the factors associated with PIM use. RESULTS: The prevalence of having at least one PIM was 46.1% for 2010 version and increased to 74.6% for 2018 version. The average number of PIMs generally to be avoided per patient also increased for 2018 version (0.2 versus 1.2, p < 0.0001). In contrast, the average number of PIMs considering chronic conditions per patient decreased (0.6 versus 0.3, p < 0.001). The associated chronic conditions of PIM users were distinct between 2010 and 2018 version. The major leading PIMs were benzodiazepines (BZDs) in both versions of criteria. CONCLUSIONS: As there were significant differences in medication lists between PIM-Taiwan version 2010 and 2018, the prevalence of PIM and factors associated with PIM users varied accordingly. Physicians should pay special attention before prescribing BZDs which keep being the major leading PIM.

Prescription of potentially inappropriate medication to older patients presenting to the emergency department: a nationally representative population study.

Potentially inappropriate medication (PIM) was associated with adverse clinical outcomes and higher healthcare resource utilization among older patients. In order to investigate the prevalence of PIM use based on three different sets of criteria and their associated factors among older patients in the emergency department (ED) in Taiwan. The National Health Insurance Research Database was used for this cross-sectional study. Older patients who visited the ED at least once in 2009 were enrolled. PIMs were identified based on the Beers Criteria, PIM-Taiwan criteria, and PRISCUS criteria. Average patient age was 76.7 ± 7.4 years and patients visited the ED 1.8 ± 2.1 times in 2009. The prevalence and frequency of being prescribed at least one PIM at each visit were high according to all three sets of criteria. Performance of the PIM-Taiwan criteria was only inferior to that of the Beers Criteria. The most important factor associated with PIM was the number of medications prescribed in the ED, and PIM use was associated with higher annual health resource utilization in the ED. PIM use was a significant issue and was associated with higher annual emergency care resource utilization in the ED.

Single and dual antiplatelet therapy in elderly patients of medically managed myocardial infarction.

BACKGROUNDS: To examine the comparative effectiveness between dual and single antiplatelet therapies in real-world, medically managed elderly patients with acute myocardial infarction (AMI). METHODS: This retrospective study identified very elderly (> 85 years) patients, who were medically managed, with their first AMI from the Taiwan National Health Insurance claims database from 2007 to 2010. Patients were classified as dual antiplatelet therapy (DAPT) group, aspirin only group and clopidogrel only group. Study outcomes included all-cause death, cardiovascular death and gastrointestinal bleeding. Treating DAPT group as the reference, we employed a multivariable Cox regression model to compare the relative risks of outcomes between 3 groups using pairwise comparison approach. RESULTS: Among 1469 patients with incident ST-elevation myocardial infarction (STEMI, 14%) or non-STEMI (86%), 390 patients were prescribed DAPT, 549 aspirin only, and 530 clopidogrel only. After 9 months of follow-up, aspirin only group had similar risks of all-cause death (adjusted HR 1.21, 95% CI 0.77-1.89, p = 0.41), cardiovascular death (adjusted HR 1.16, 95% CI 0.66-2.04, p = 0.60) and gastrointestinal bleeding (adjusted HR 1.66, 95% CI 0.77-3.57, p = 0.20) in comparison with DAPT group. Clopidogrel users had a higher risk of all-cause death (adjusted HR 1.50, 95% CI 1.00-2.25, p = 0.049) but similar risks of cardiovascular death and gastrointestinal bleeding when compared with DAPT. CONCLUSIONS: Among very elderly patients who were medically managed after AMI, single antiplatelet therapy had comparable protective effect as DAPT. But clopidogrel only strategy was associated with a higher risk of all-cause death.

Application of three different sets of explicit criteria for assessing inappropriate prescribing in older patients: a nationwide prevalence study of ambulatory care visits in Taiwan.

OBJECTIVE: To investigate the national prevalence of potentially inappropriate medications (PIMs) prescribed in ambulatory care clinics in Taiwan according to three different sets of regional criteria and the correlates of PIM use. DESIGN: Cross-sectional study. SETTING: This analysis included older patients who visited ambulatory care clinics in 2009 and represented half of the older population included on the Taiwanese National Health Insurance Research Database. PARTICIPANTS: We identified 1,164,701 subjects who visited ambulatory care clinics and were over 65 years old in 2009. PRIMARY AND SECONDARY OUTCOME MEASURES: PIM prevalence according to the 2012 Beers criteria, the PIM-Taiwan criteria and the PRISCUS criteria was estimated separately, and characteristics of PIM users were explored. Multivariate logistic regression analysis was used to determine patient factors associated with the use of at least one PIM. Leading PIMs for each set of criteria were also listed. RESULTS: The prevalence of having at least one PIM at the patient level was highest with the Beers criteria (86.2%), followed by the PIM-Taiwan criteria (73.3%) and the PRISCUS criteria (66.9%). Polypharmacy and younger age were associated with PIM use for all three sets of criteria. The leading PIMs detected by the PIM-Taiwan and PRISCUS criteria were all included in the 2012 Beers criteria. Non-COX-selective non-steroidal anti-inflammatory drugs in the Beers criteria and benzodiazepines in the PIM-Taiwan and PRISCUS criteria accounted for most leading PIMs. CONCLUSIONS: The prevalence of PIMs was high among older Taiwanese patients receiving ambulatory care visits. The prevalence of PIM and its associated factors varied according to three sets of criteria at the population level.

Association between inflammatory markers and frailty in institutionalized older men.

OBJECTIVES: To determine whether higher serum levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high sensitivity C-reactive protein (CRP) were associated with frailty in the older institutionalized men. PARTICIPANTS: The study enrolled 386 residents from a veterans care home in northern Taiwan in 2007. All participants were men. Residents younger than 65 years or with acute illness were excluded. METHODS: Frailty status was determined based on the frailty phenotype (indicators include weight loss, exhaustion, and low grip strength, slow walking speed). Participants with 3 or more of the indicators were defined as frail, with 1 or 2 as intermediate frail, with no as non-frail. Serum IL-6, TNF-α, and hsCRP levels were measured using enzyme-linked immunosorbent assay and modeled as tertile for severely skewed distributions. RESULTS: The mean age of the participants was 81.5±4.9 years. The percentages of frail were 33.2%, intermediate frail 59.1% and nonfrail 7.8%. Higher IL-6 level was positively associated with the frail status. Adjusting for age, body mass index, smoking status, and comorbid conditions, serum IL-6 showed significant trend across frailty categories (P=0.03 [95% CI 1.40-5.24]). No significant associations of TNF-α, and CRP level with frailty were observed. An IL-6 level of 1.79pg/mL had the optimal predictive value for frailty, with an area under the receiver operating characteristic (ROC) curve of 0.66 (P=0.01 [95% CI 0.53-0.78]). CONCLUSION: Higher serum levels of IL-6 were associated with frailty status in the older institutionalized men with multiple comorbidities.

PEGylation site-dependent structural heterogeneity study of monoPEGylated human parathyroid hormone fragment hPTH(1-34).

The structures of C- and N-terminally monoPEGylated human parathyroid hormone fragment hPTH(1-34) as well as their unmodified counterparts, poly(ethylene glycol) (PEG) and hPTH(1-34), have been studied by small-angle neutron scattering (SANS). The scattering results show that free hPTH(1-34) in 100 mM phosphate buffer (pH 7.4) aggregates into clusters. After conjugation with PEG, the PEG-peptide conjugates self-assemble into a supramolecular core-shell structure with a cylindrical shape. The PEG chains form a shell around the hPTH(1-34) core to shield hPTH(1-34) from the solvent. The detailed structural information on the self-assembled structures is extracted from SANS using a model of the cylindrical core with a shell of Gaussian chains attached to the core surface. On the basis of the data, because of the charge-dipole interactions between the conjugated PEG chain and the peptide, the conjugated PEG chain forms a more collapsed conformation compared to free PEG. Moreover, the size of the self-assembled structures formed by the C-terminally monoPEGylated hPTH(1-34) is about 3 times larger than that of the N-terminally monoPEGylated hPTH(1-34). The different aggregation numbers of the self-assembled structures, triggered by different PEGylation sites, are reported. These size discrepancies because of different PEGylation sites could potentially affect the pharmacokinetics of the hPTH(1-34) drug.

Patient- and clinic visit-related factors associated with potentially inappropriate medication use among older home healthcare service recipients.

OBJECTIVES: Taiwanese National Health Insurance (TNHI) provides home healthcare services to patients with skilled nursing needs who were homebound or lived in nursing homes. Studies on potentially inappropriate medications (PIMs) for older home healthcare service recipients (HHSRs) are growing, but comparisons among newer criteria of PIMs have not been applied. The aim of this study was to explore the prevalence and correlates of PIMs based on three different instruments published after 2010 among older HHSRs. MATERIALS AND METHODS: We performed cross-sectional analysis of the TNHI Research Database. A total of 25,187 HHSRs aged more than 65 years in 2009 were included. Medication lists independent of chronic conditions from the 2012 Beers criteria, PIM-Taiwan criteria, and the PRISCUS (Latin for "old and venerable") criteria were used. Analysis was performed separately at patient and clinic-visit level. T-tests, chi-square analysis, and multivariate logistic regressions were used where appropriate. RESULTS: The prevalence of having at least one PIM at patient and clinic-visit level was highest with the Beers (82.67%, 36.14% respectively), followed by the PRISCUS (68.49%, 25.13%) and PIM-Taiwan (63.04%, 19.21%) criteria. At patient level, polypharmacy (odds ratio (OR) 2.53 to 4.90), higher number of clinic (OR 1.15 to 1.41), hospital (OR 1.24 to 1.64), and physician (OR 1.15 to 1.41) visits were associated with PIM use for all 3 sets of criteria. At clinic-visit level, internist/family physicians (OR 1.26 to 1.72) and neurologists/psychiatrists (OR 1.73 to 5.87) were more likely to prescribe PIMs than others. Psychotropic drugs and first generation antihistamines accounted for most of the top ten PIMs. CONCLUSION: The prevalence of PIMs was high among older Taiwanese HHSRs. Polypharmacy and certain medical specialties were associated with a higher likelihood of PIM prescriptions. Provider education and medication review and reconciliation should be considered.

Utilization and patterns of community healthcare services for senior residents in long-term care facilities in Taiwan: a nationwide study.

BACKGROUND: Community healthcare is one of the many important services used to care for the disabled elderly in aging societies. The aim of this study was to evaluate the utilization and patterns of community healthcare services used by senior residents in long-term care facilities (LTCFs) in Taiwan. METHODS: Secondary data analyses were conducted of the Taiwan National Health Insurance Research Database for 9338 LTCF senior residents receiving community healthcare services throughout the 2004 calendar year. The community healthcare services used by male and female LTCF senior residents were also compared by Chi-square testing. Descriptive statistics are used to present the patterns of professional visits and services by contracted healthcare facilities. RESULTS: About one-third of those senior residents living in LTCFs in Taiwan in 2004 received community healthcare services. Female residents received a higher percentage of community healthcare services than males in all age groups (p<0.001). Community home nursing care institutions provided 67% of healthcare visits and professional visits. Of those services provided to patients, the majority of the skilled nursing services were attributable to replacement of nasogastric tube (55%) and urinary catheter (38%). CONCLUSION: Whether or not the replacement of nasogastric tubes and urinary catheters among the LTCF senior resident population is an appropriate use of time and targeted medical resources needs further investigation. When addressing concerns about the community healthcare needs of senior residents of LTCFs, policymakers should carefully consider the current shortage of professional healthcare workers as they assess strategies to best meet the needs of the elderly in Taiwan.

Using published criteria to develop a list of potentially inappropriate medications for elderly patients in Taiwan.

BACKGROUND: Explicit criteria for potentially inappropriate medications (PIMs) developed from other regions were often difficult to apply to a specific territory without significant modifications. PURPOSE: To describe a process of developing a country-specific explicit PIM criteria from quality review of several published PIM criteria, followed by consensus among regional experts in Taiwan. METHODS: After a review of the literature, we selected seven sets of published PIM criteria. Medications/medication classes listed in at least three of the seven sets of criteria were selected as preliminary core PIMs. We asked a group of 21 experts from various specialties to rate how appropriate they found inclusion of each medication/medication class in final PIM criteria after two rounds of modified Delphi methods. RESULTS: Table 1 of the instrument included 24 medication/medication classes to be generally avoided in older adults irrespective of co-morbidities, and Table 2 included 12 chronic conditions with six medication/medication classes that patients with these conditions should avoid. The Taiwan criteria contained only half the number of statements that were included in the Beers criteria (36 vs 68 statements) but detected nearly 70-75% as many PIMs in older patients with polypharmacy in a secondary data analysis. Features included straightforward statement arrangements, suggestions of alternatives, and clear definitions of long-acting benzodiazepine and anticholinergic drugs for Table 1 PIMs. CONCLUSION: A user-friendly instrument was developed to detect PIMs for Taiwanese older adults. Further prospective studies are needed to validate its use in clinical and research settings.

Diabetes mellitus, glycemic control, and pneumonia in long-term care facilities: a 2-year, prospective cohort study.

OBJECTIVE: To determine the relationships among diabetes mellitus (DM), glycemic control, and long-term care facility (LTCF)-acquired pneumonia. DESIGN: Prospective cohort study. SETTING: Ten private LTCFs in Taiwan. PARTICIPANTS: Participants were 233 LTCF residents. MEASUREMENTS: Barthel index (BI), Charlson comorbidity index (CCI), hemoglobin A1c, episodes of LTCF-acquired pneumonia. INTERVENTION: None. RESULTS: A total of 233 residents (76.9 ± 10.6 years, 54.9% males, 27.9% diabetic) from 10 private LTCFs participated. There were 173 LTCF-acquired pneumonia episodes. The incidence of LTCF-acquired pneumonia between patients with and without diabetes, or between diabetic subjects with different status of glycemic control was similar. Adjusted for baseline BI, CCI, feeding tube placement, and baseline serum albumin, DM was not a significant risk factor for LTCF-acquired pneumonia. Poorer glycemic control (HbA1c >7%) was not a significant risk factor for LTCF-acquired pneumonia in diabetic subjects. CONCLUSIONS: Tighter glycemic control did not protect diabetic LTCF residents from pneumonia. A prospective randomized controlled trial is needed to determine the optimal goal of glycemic control for LTCF residents.

Who determines the rehabilitation needs of care home residents? An observational survey.

Determining the rehabilitation needs is of great importance in long-term care setting, but the perception of rehabilitation needs may vary extensively between service provider and recipients. The purpose of this study was to assess the differences between the self-perceived and carer-evaluated rehabilitation needs among care home residents. Data of Longitudinal Older Veterans (LOVE) study were sorted for study. Overall, this study enrolled 581 (mean age=80.9±5.4 years) male participants. Among them, 539 (92.8%) were physically independent, and 463 (79.7%) were cognitively intact. Of these participants, 367 (63.2%) believed they would be physically improved by certain rehabilitation services, but only 57 (9.8%) residents were considered to have rehabilitation potential by their carers. Over half of physically dependent, but only 16.7% of physically independent residents were considered to have positive rehabilitation potential by their carer. Similarly, carers considered that residents with cognitive deficits were more likely to be improved by rehabilitation (24.6% vs. 6.0%, p<0.001) but cognitively intact residents considered themselves more likely to benefit from rehabilitation (67.6% vs. 45.8%, p<0.001). In conclusion, a significant disagreement in rehabilitation potential was noted between residents' self-perception and carer assessment. Residents with physical dependence and intact cognition may be more likely to receive rehabilitation. An intervention study is needed to develop practice guidelines to provide cost-effective rehabilitation for care home residents.

Immunogenicity and safety of an AS03(A)-adjuvanted H5N1 influenza vaccine in a Taiwanese population.

BACKGROUND/PURPOSE: A multicenter study (NCT00449670) conducted across Taiwan, Singapore, Hong Kong and Thailand evaluated the safety and manufacturing consistency of four formulations of an AS03(A)-adjuvanted H5N1 vaccine in terms of immune response against the vaccine-homologous strain (A/Vietnam/1194/2004). This manuscript presents data from the Taiwanese population. METHODS: A total of 400 individuals, aged 18-60 years, were randomized into six groups (2:2:2:2:1:1 ratio) to receive two doses (21 days apart) of one of the four adjuvanted formulations (H5N1-AS03(A)-groups) or one of the two nonadjuvanted formulations (H5N1-DIL-groups). Blood samples collected before vaccination (Day 0) and 21 days after each vaccine dose were analyzed using hemagglutination inhibition (HI) assay. Adverse events were recorded. RESULTS: All four AS03(A)-adjuvanted formulations induced comparable immune responses against the A/Vietnam/1194/2004 strain; following the second dose, immune response in terms of HI antibodies was higher in the H5N1-AS03(A)-groups {seroprotection rate=91.6% [95% confidence interval (CI): 87.9-94.4]; geometric mean titer (GMT)=177.6 (95% CI: 153.2-206.0)} compared with the H5N1-DIL-groups [seroprotection rates=5.0% (95% CI: 1.4-12.3); GMT=6.3 (95% CI: 5.4-7.4)]. Immune response against the heterologous A/Indonesia/05/2005 strain was also stronger in the H5N1-AS03(A)-groups [seroprotection rate=45.6% (95% CI: 40.0-51.4); GMT=20.5 (95% CI: 17.8-23.7)] compared with the H5N1-DIL groups [seroprotection rate=0.0% (95% CI: 0.0-4.5); GMT=5.0 (95% CI: 5.0-5.0)]. The overall reactogenicity profile of the adjuvanted formulations was clinically acceptable. CONCLUSION: The AS03(A)-adjuvanted H5N1 influenza vaccine formulations induced stronger immune response against the vaccine-homologous and heterologous strains than the nonadjuvanted formulations. The AS03(A)-adjuvanted H5N1 vaccine demonstrated a good immunogenicity and an acceptable safety profile in the Taiwanese population.

Predicting mortality of older residents in long-term care facilities: comorbidity or care problems?

OBJECTIVE: Accurate prediction of life expectancy in long-term care facilities (LTCFs) is important, but previous studies emphasized demographic characteristics, disease diagnosis, or comorbidity. The purpose of this study was to evaluate the roles of geriatric care problems and comorbidity in predicting 12-month mortality in LTCFs. DESIGN: Prospective, observational. SETTING: Veterans Care Home. PARTICIPANTS: Residents of Banciao Veterans Care Home. MEASUREMENTS: A minimum data set (MDS) was implemented, and resident assessment protocol (RAP) triggers were collected as geriatric care problems. Comorbidity of the residents was evaluated using Charlson's comorbidity index (CCI). RESULTS: A total of 559 residents (mean age = 80.9 ± 5.3 years, all males) were successfully followed, and 50 residents (7.9%) died during the study period. Compared with survivors, deceased subjects had a higher sum of RAP triggers (4.9 ± 2.0 versus 4.1 ± 2.0, P = .004) and CCI (1.2 ± 1.2 versus 0.7 ± 0.9, P = .014), and were more likely to be hospitalized (1.6 ± 1.9 versus 0.4 ± 0.9, P < .001) and visit the emergency department (0.9 ± 1.2 versus 0.5 ± 1.2, P = .012). Moreover, deceased subjects were more prone to have cognitive loss, urinary incontinence, and behavioral symptoms than survivors (P all < .05). A Cox proportional hazards model showed that both CCI (HR = 1.44, 95% CI: 1.13-1.82, P = .003) and the sum of RAP triggers (HR = 2.03, 95% CI: 1.08-3.82, P = .028) were significantly associated with 12-month mortality. CONCLUSION: Independent of comorbidity, the sum of geriatric care problems is a significant predictor of 12-month mortality in a veterans care home. Further intervention studies are needed to evaluate whether elimination of these care problems can improve survival in the long-term care setting.

Home healthcare services in Taiwan: a nationwide study among the older population.

BACKGROUND: Home healthcare services are important in aging societies worldwide. The present nationwide study of health insurance data examined the utilization and delivery patterns, including diagnostic indications, for home healthcare services used by seniors in Taiwan. METHODS: Patients ≥65 years of age who received home healthcare services during 2004 under the Taiwanese National Health Insurance Program were identified and reimbursement claims were analyzed. Age, gender, disease diagnoses, distribution of facilities providing home healthcare services, and patterns of professional visits, including physician and skilled nursing visits, were also explored. RESULTS: Among 2,104,978 beneficiaries ≥65 years of age, 19,483 (0.9%) patients received 127,753 home healthcare visits during 2004 with a mean number of 6.0 ± 4.8 visits per person. The highest prevalence of home healthcare services was in the 75-84 year age group in both sexes. Females received more home healthcare services than males in all age groups. Cerebrovascular disease was the most frequent diagnosis in these patients (50.7%). More than half of home healthcare visits and around half of the professional home visits were provided by community home nursing care institutions. The majority of the home skilled nursing services were tube replacements, including nasogastric tubes, Foley catheter, tracheostomy, nephrostomy or cystostomy tubes (95%). CONCLUSIONS: Nine out of 1,000 older patients in Taiwan received home healthcare services during 2004, which was much lower than the rate of disabled older people in Taiwan. Females used home healthcare services more frequently than males and the majority of skilled nursing services were tube replacements. The rate of tube replacement of home healthcare patients in Taiwan deserves to be paid more attention.

Evaluating probability of cancer among older people with unexplained, unintentional weight loss.

Unexplained, unintentional weight loss (UUWL) in older people is usually multi-factorial and poses a diagnostic challenge, with cancer being the major concern. The main purpose of this study was to evaluate the effectiveness of a cancer scoring system for predicting cancer in elderly UUWL patients. From 2006 to 2007, 50 patients (mean age, 78.8+/-4.7 years, 82% male) who lost > 5% of usual body weight were enrolled. The subjects' mean body weight loss was 14.1%+/-6.6% (8.7+/-4.6 kg). After evaluation, the common diagnoses were non-malignant organic disorder (22/50, 44%), neuropsychiatric disorder (17/50, 34%), unknown (8/50, 16%), and cancer (3/50, 6%). The most rapid weight loss occurred with cancer (6.5% per month), followed by non-malignant organic disorders (5.6% per month), neuropsychiatric disorders (2.8% per month), and unknown causes (2.4% per month); the difference among the groups was significant (p = 0.023). Using a previously proposed scoring system, 42 patients (84%) had a low probability of cancer; all three cancer patients were in this category. In conclusion, the annual incidence of cancer among elderly UUWL patients was 6%, and the previously developed cancer scoring system did not effectively predict cancer occurrence. Further study is needed to develop an effective instrument to predict cancer in elderly UUWL patients.

Association between serum copper, zinc and hospital admissions among care home residents.

Nutritional status is important in various health care settings, long-term care is no exception. The relationship between protein-energy malnutrition and clinical outcomes in care homes has been reported. However, little is known about the roles of trace elements in clinical outcomes of care home residents. In 2002, 75 severely disabled care home residents (mean age: 77.7+/-8.2 years, 64.3% males) were enrolled for study. The status of protein-energy malnutrition at enrollment was as follows: 47.9% underweight (body mass index, BMI<20 kg/m(2)), 15.5% hypoalbuminemia (serum albumin <3.5 mg/dl), and 29.6% hypocholesterolemia (serum total cholesterol <160 mg/dl), respectively. During the 6-month follow-up, anthropometric measurements (i.e., BMI and mid-arm circumferences) remained similar, but the biochemical markers of nutritional status (i.e., albumin, total cholesterol) were significantly deteriorated, and both serum zinc and copper were significantly increased. Compared with subjects without hospitalizations during the follow-up period, subjects ever hospitalized had significantly lower mean serum levels of albumin (3.6+/-0.3 mg/dl vs. 3.9+/-0.3 mg/dl, p=0.002), zinc (74.3+/-12.1 vs. 89.6+/-20.5 microg/dl, p=0.020), and higher serum levels of copper (110.6+/-14.1 vs. 95.2+/-21.1 microg/dl, p=0.023) at baseline screening. Adjusted for age, sex, and protein-energy malnutrition, baseline serum copper (odds ratio=OR=1.08, 95% CI=1.02-1.15, p=0.015) and zinc (OR=0.92, 95% CI=0.84-1.00, p=0.053) were significant independent predictive factor for hospital admissions. In conclusion, adjusted for age, sex, and protein-energy malnutrition, serum levels of copper and zinc both were independent predictive factors for hospitalizations among care home residents. Further interventional study is needed to clarify the prognostic roles of serum copper and zinc among care home residents.

Metabolic characteristics of breakfast-vegetarian (BV) elderly people in rural Taiwan.

Breakfast-vegetarianism (BV) is a special dietary habit in Chinese society, which is related to religious beliefs rather than health concerns. The purpose of this study was to compare metabolic characteristics of community-living middle-aged and elderly BV and non-vegetarians (NVs) in Taiwan. In 2000, people aged over 40 in I-Lan County were invited for study. In total, 367 people (mean age: 62.0+/-11.2 years, 57.8% female) participated in this study and 68 of them were BV. The BV subjects were less likely to consume oily food (29.4% vs. 43.1%, p=0.025), to smoke (5.9% vs. 23.1%, p<0.001) and to habitually consume alcohol (2.9% vs. 19.1%, p<0.001). Compared with NVs, the BVs were more prone to be females (86.8% vs. 44.7%, p<0.001), having lower glomerular filtration rate (GFR) (64.5+/-13.7 vs. 69.9+/-14.6ml/(kgmin), p=0.006), higher prevalence of metabolic syndrome (69.1% vs. 45.8%, p<0.001) and chronic kidney disease (CKD) (44.1% vs. 22.7%, p<0.001). By using logistic regression, females and chronic kidney disease were independently associated with the breakfast-vegetarianism. In conclusion, Taiwanese BVs seemed to lead a healthier life, but their metabolic characteristics were not significantly different from the NVs. Outcome study is needed to clarify the impact of BV habits on health.

Pain and health-care utilization among older men in a veterans care home.

Pain is a common health-care issue, and the prevalence increases with advancing age. Although it is often assumed that people with chronic pain are associated with a higher consumption of health care, evidence supporting this assertion is insufficient. Data from the Longitudinal Older VEterans (LOVE) study were stratified to explore the prevalence of pain and its relationship with health-care utilization. In total, data from 574 residents (mean age: 80.9+/-5.4 years, all male) were obtained. Among them, 92.8% were physically independent and 20.2% of them had mild to moderate cognitive impairment. Overall, 153 (26.3%) subjects reported pain; 114 (74.5%) subjects with mild pain and the remaining 39 (25.5%) subjects with moderate pain. The most commonly reported pain was lower back pain (40.5%, 62/153), which was followed by joint pain (29.4%, 45/153). Subjects with pain were more likely to have higher scores on the Geriatric Depression Scale (2.4+/-2.4 vs. 1.8+/-2.2, p = 0.023) and care-complexity problems (4.7+/-2.0 vs. 3.9+/-1.9, p < 0.001), despite being similar in age (81.3+/-5.0 vs. 80.8+/-5.5, p = 0.271), cognitive status and physical independence. Compared with pain-free subjects, subjects with pain were more likely to be hospitalized in the 12-month study period (0.71+/-1.20 vs. 0.46+/-1.00, p = 0.010), but the utilization of emergency department treatment (1.74+/-1.23 vs. 1.88+/-1.63, p = 0.560) was not statistically significant. In conclusion, the prevalence of pain among residents in a Taiwanese veterans care home was 26.3%; subjects with pain having more depressive symptoms, higher clinical-care complexity, and more likely to be hospitalized during the 12-month follow-up.