Ding-Cheng Chan

Comparison of Published Explicit Criteria for Potentially Inappropriate Medications in Older Adults

Several sets of explicit criteria for potentially inappropriate medications (PIMs) have been developed by expert consensus. The purpose of this review is to summarize and compare existing criteria to enable more informed choices about their use. After a systematic literature search was conducted, seven examples of criteria published between 1991 and 2009 were included in the review and their individual characteristics are presented. Common medications listed in the majority of these criteria are also summarized. PIMs listed regardless of co-morbidities in all seven criteria sets were long-acting benzodiazepines and tricyclic antidepressants. PIMs regardless of co-morbidities were most similar among the Beers, Rancourt and Winit-Watjana criteria. Several drug-disease interactions such as benzodiazepines and falls were cited in most criteria. With respect to drug-drug interactions, most criteria agreed that concomitant use of warfarin and NSAIDs should be avoided. The prevalence of PIMs varied with patient population, availability of medications in local markets, the specialties of the prescribing physicians and the assessment instruments used. The associations between PIMs use and health outcomes were largely inconclusive because of limited data. Further research is necessary to validate these published criteria in terms of reducing the incidence of adverse drug reactions and improving health outcomes among older adults. Incorporation of these criteria into computer-assisted order entry systems would increase their utilization in daily practice.

Vitamin D insufficiency and frailty syndrome in older adults living in a Northern Taiwan community

This study explored the association between vitamin D insufficiency and frailty syndrome defined by the Fried Frailty Index (FFI) and the Edmonton Frail Scale (EFS) in a northern Taiwan community. Data of 215 subjects participating in an integrated interventional trial involving community-dwelling older adults with a high frailty risk were analyzed. Subjects were first screened by telephone interview and then evaluated at a local hospital with questionnaires, physical performance tests, and serum 25(OH)D measurements. Of the 215 participants, 31% had 25(OH)D insufficiency (< 20 ng/ml). Frail subjects based on the FFI were older, had lower Mini-Mental Status Exam (MMSE) scores, Barthel Index (BI) scores, and 25(OH)D levels. Using the EFS, frailer cases were more likely to be female, have less education, higher comorbid conditions, lower MMSE scores, lower Barthel Index scores, and lower 25(OH)D levels. The associations between insufficient 25(OH)D status and both frailty scales were significant. After adjustment of variables, the odds ratio of 25(OH)D insufficiency was 10.74 (95% CI 2.60-44.31) for frail versus robust individuals. The prevalence of vitamin D insufficiency was high in this population. There was a strong association between vitamin D insufficiency and the FFI. Vitamin D measurements and supplements are suggested for high-risk older people.

Honokiol, a low molecular weight natural product, prevents inflammatory response and cartilage matrix degradation in human osteoarthritis chondrocytes.

Proinflammatory cytokine interleukin‐1β (IL‐1β) stimulates several mediators of cartilage degradation and plays an important role in the pathogenesis of osteoarthritis (OA). Honokiol, a low molecular weight natural product isolated from the Magnolia officinalis, has been shown to possess anti‐inflammatory effect. Here, we used an in vitro model of cartilage inflammation to investigate the therapeutic potential of honokiol in OA. Human OA chondrocytes were cultured and pretreated with honokiol (2.5–10 µM) with or without IL‐1β (10 ng/ml). Nitric oxide (NO) production was quantified by Griess reagent. Prostaglandin (PG)E2, metalloproteinase‐13 (MMP‐13), and interleukin‐6 (IL‐6) productions were quantified by enzyme‐linked immunosorbent assay. The expressions of collagen II, cyclooxygenase‐2 (COX‐2), inducible nitric oxide synthase (iNOS), and nuclear factor κB (NF‐κB)‐related signaling molecules were determined by Western blotting. Our data showed that IL‐1β markedly stimulated the expressions of iNOS and COX‐2 and the productions of NO, PGE2, and IL‐6, which could be significantly reversed by honokiol. Honokiol could also suppress the IL‐1β‐triggered activation of IKK/IκBα/NF‐κB signaling pathway. Moreover, honokiol significantly inhibited the IL‐1β‐induced MMP‐13 production and collagen II reduction. Taken together, the present study suggests that honokiol may have a chondroprotective effect and may be a potential therapeutic choice in the treatment of OA patients.

Prevalence and Correlates of Geriatric Frailty in a Northern Taiwan Community

BACKGROUND/PURPOSE Frailty is the core of geriatric syndromes in the elderly. However, there is no solid prevalence data in Taiwan even with the rapid growth of the elderly population. The aim of this study was to explore the prevalence of frailty defined by different instruments and to identify the factors associated with frailty in a northern Taiwan community. METHODS The 65-79-year old community-dwelling residents randomly selected from Toufen were first screened with a telephone version of the Chinese Canadian Study of Health and Aging Clinical Frailty Scale (CCSHA-CFS; level 1-7). Those who scored 3-6 with this instrument were evaluated at a local hospital with the Fried Frailty Index (FFI) and the Edmonton Frail Scale (EFS). Other baseline characteristics including health and functional performance were also evaluated. RESULTS Among the 2900 population representative samples, 845 (29.1%) completed the CCSHA-CFS telephone interview with the prevalence of frailty approximately 11.0% [95% confidence interval (CI) 8.9-13.1]. Among the 275 who completed assessments with FFI and EFS, prevalence of frailty was 11.3% (95% CI = 7.6-15.0) by FFI and 14.9% (95% CI = 10.7-19.1) by EFS. About 57.5% of respondents had memory impairment, 29.8% experienced pain, 25.1% experienced falls, 16.7% had depression, 14.5% had urinary incontinence, and 5.8% had polypharmacy. Being older, having more complaints with falls, pain, dysphagia, polypharmacy, depression, comorbidity, longer time for the Timed Up and Go test, less education, lower Mini-Mental State Examination score, and lower Barthel Index were associated with frailer status. In multinomial logistic regression analysis, increasing age, less education status, lower Barthel Index score and depression were positively associated with physical frailty. CONCLUSION In this study, the prevalence of frailty was from 11.0% to 14.9% by different criteria and methodology. Various correlates were independently associated with frailty status. It is suggested that intervention for frailty requires an interdisciplinary approach.

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).

Clinical practice guidelines for the prevention and treatment of osteoporosis in Taiwan: summary

Osteoporosis is recognized as a major public health problem worldwide and in Taiwan. However, many patients with osteoporotic fractures do not receive appropriate assessments or treatments. This guideline, proposed by the Taiwanese Osteoporosis Association, is to serve as a quick reference for healthcare providers to improve the assessment of osteoporosis and development of optimal strategies for osteoporotic management in Taiwan. To review and update osteoporosis management, the guideline is constituted with Taiwan-specific osteoporosis epidemiological data, medication protocols, and the 10-year FRAX®. The guideline is based on evidence-based medicine and public health considerations. Recommendations are not limited to the reimbursement regulations permitted by the National Health Insurance of Taiwan.

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

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.

Polypharmacy among Disabled Taiwanese Elderly A Longitudinal Observational Study

Background and objectiveIt 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 ≥65 years).MethodsThis 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 ≥5 and ≥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.ResultsOne-fifth (21.5%) of the sample were aged ≥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 ≥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.ConclusionThe 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.

Validation of the Chinese-Canadian study of health and aging clinical frailty scale (CSHA-CFS) telephone version

This was a cross-sectional validation study of the Chinese-Canadian study of health and aging clinical frailty scale telephone version (CSHA-CFS TV). The study pool consisted of 67 patients of outpatient clinics at a tertiary medical center in Taipei, Taiwan. They were enrolled in the program comprehensive geriatric assessment and the frailty study of elderly patients (CGAFSEP). The Chinese-Canadian study of health and aging clinical frailty scale physician version (CSHA-CFS PV) is a 7-point scale assigned after comprehensive geriatric assessments. Higher score indicates frailer status. The Chinese-Canadian study of health and aging clinical frailty scale (CSHA-CFS) telephone version (TV) included 17 questions adapted from the physician version. Two trained research assistants conducted the telephone interviews. Administration time was <3 min. Standard reliability and validity measures were applied. Three-fifths of the subjects were older than 75 years, and half of them were females. Inter-rater reliability was achieved with weighted kappa of 0.684, (p=0.002) between first 20 ratings from 2 interviewers. Criterion validity was achieved with weighted kappa of 0.689 (p<0.0001) and Kendals tau of 0.612 (p<0.0001) between the TV and the PV scores. Divergent validity was demonstrated with significant correlation but only fair agreements comparing both TV and PV scores with the cardiovascular health survey (CHS) phenotypic definition of frailty. One could conclude that the CSHA-CFS TV appears to be a quick, reliable, and valid frailty screening instrument for community-dwelling elderly.

Polypharmacy among Disabled Taiwanese Elderly

Background and objectiveIt 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 ≥65 years).MethodsThis 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 ≥5 and ≥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.ResultsOne-fifth (21.5%) of the sample were aged ≥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 ≥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.ConclusionThe 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.