Prevalence of geriatric conditions: A hospital-wide survey of 455 geriatric inpatients in a tertiary medical center

Prevalence

of

geriatric

conditions:

A

hospital-wide

survey

of

455

geriatric

inpatients

in

a

tertiary

medical

center

Cheryl

Chia-Hui

Chen

*

,

Chung-Jen

Yen

,

Yu-Tzu

Dai

,

Charlotte

Wang

,

Guan-Hua

Huang

a_{DepartmentofNursing,NationalTaiwanUniversity,1Jen-AiRd.,Section1,Taipei100,Taiwan,ROC} b

CollegeofMedicine,NationalTaiwanUniversity,1Jen-AiRd.,Section1,Taipei100,Taiwan,ROC

c

InstituteofStatistics,NationalChiaoTungUniversity,1001TaHsuehRoad,Hsinchu300,Taiwan,ROC

1. Introduction

Olderpatientsaged65andolderareatincreasedriskofsuffering adverse outcomes of hospitalization. Indeed, the prevalence of geriatric conditions for hospitalized patients has been reported between7%and78%(Nairetal.,2000;Covinskyetal.,2003;Flood etal.,2006,2007;AnpalahanandGibson,2008).Thiswiderangein figuresis dueto differencesin the conditions studied, methods employed,andindicatorsusedfordefininggeriatricconditions.

Geriatric conditionssuchas incontinence,falls,malnutrition, depression, pressure ulcers, functional dependence, cognitive impairment,delirium,insomnia,andpolypharmacyarenotpart of the traditional disease model of medicine and may be overlooked in the care of geriatric inpatients (Cigolle et al., 2007).Thegeriatricconditionscommonlyseeninthehospitalhave beencalledgeriatricsyndromes(Reubenetal.,1996).Thisterm has been embraced by geriatricians to capture the clinical conditions in geriatric patients that are a necessary focus in managingpatients (Inouye et al., 2007). The presence ofthese geriatricsyndromesorconditionshasbeenreported tostrongly predictadverseoutcomesofhospitalization,includingprolonged

lengthofhospitalstay,nursinghomeplacement,andevendeath (AnpalahanandGibson,2008).However,nodefinitionofgeriatric syndromeorconditionisgenerallyaccepted,leadingtovariationin what is considered a geriatric syndrome or geriatric condition (Flacker,2003). For instance,most health care researchersand providers agree that incontinence, pressure ulcers, cognitive impairment,and fallsare geriatricsyndromes,but there isless agreementthatdepression,polypharmacy,anddehydrationalso qualify (Cigolle et al., 2007). In this study, we used the term ‘‘geriatric conditions’’ to indicate a collection of signs and symptomscommoninolderinpatients,butnotnecessarilyfitting intodiscretediseasecategories.Weincludedallgeriatric condi-tionsforwhichoursurveydatawereavailable.

Themajorityofreportedprevalencedatahasbeendrawnfrom samplesofgeriatricinpatientsatspecialgeriatricunitsoratbest, fromselectedmedicalunits (Covinskyet al.,2003; Floodet al., 2006,2007).However, theprevalenceofgeriatricconditionsfor geriatricpatientsadmittedtosurgicalserviceshasbeenlessclear. With the number of older adults increasing dramatically and advances in surgical technology, those requiring surgery will proportionally increase in number. Furthermore, data on the prevalenceofthesecommongeriatricconditions,bothatsurgical andmedicalunitsarenotavailableintheTaiwanesecontext.For cliniciansandhospitaladministrators,knowingprevalencedatais important for resource allocation and quality improvement.

ARTICLE INFO Articlehistory:

Received26February2010 Receivedinrevisedform31May2010 Accepted1June2010

Availableonline16July2010 Keywords:

Geriatricsyndromes Geriatricconditions Geriatricsurgery Acutecarefortheelderly

ABSTRACT

Theaimofthisstudywastoinvestigatetheprevalenceofcommongeriatricconditionsinatertiary medicalcenter.Weconductedacross-sectional,hospital-widesurveyof455inpatients,aged65and older,from24medicalandsurgicalunitsofa2200-bedurbanacademicmedicalcenterinTaiwan. Patientswerescreenedinface-to-faceinterviewsfor15geriatricconditions.Theprevalenceofgeriatric conditions was determined and compared by medical versus surgical services. Our sample of participants had a meanage of 75.36.1 years (S.D.), range=65–92. The prevalence ofgeriatric conditionsrangedfrom5%(pressureulcers)to57%(polypharmacy;taking>5prescriptions).Themajority wasvisuallyimpaired(74%)andcomplainedofsleepdisturbanceduringtheirhospitalstay(58%).Prevalence ratesofcertaingeriatricconditionsdifferedsignificantlybetweenmedicalandsurgicalunits,suggestingthat careshouldaddress notonlycommonconditions butalsothosewithhigherrates ondifferentunits. Furthermore,highratesofgeriatricconditionsindicatestrongneedsforcarethatdoesnotfitintotraditional diseasemodelsofmedicine.Careshouldbebettertargetedtoaddressdifferentrisksforgeriatricconditions ofmedicalversussurgicalgeriatricinpatientsinacutecaresettings.

ß2010ElsevierIrelandLtd.Allrightsreserved.

*Correspondingauthor.Tel.:+886223123456/88438;fax:+886223219916. E-mailaddress:cherylchen@ntu.edu.tw(C.-H.Chen).

ContentslistsavailableatScienceDirect

Archives

of

Gerontology

and

Geriatrics

j ou rna l h om e pa ge : w w w. e l s e v i e r. co m/ l oc a t e / a rch ge r

0167-4943/$–seefrontmatterß2010ElsevierIrelandLtd.Allrightsreserved. doi:10.1016/j.archger.2010.06.003

Therefore,thepurposeofthiscross-sectionalhospital-widesurvey wastoexaminetheprevalenceofgeriatricconditionscommonly occurring in geriatric inpatients of a tertiary medical center in Taiwan.Weexamined15commongeriatricconditions:cognitive impairment, depression, functional dependence, malnutrition, polypharmacy, urinary or fecal incontinence, pressure ulcers, anemia, dehydration, visual and hearing impairment, chewing and swallowing difficulties, and sleep disturbance. We also comparedtheprevalenceofgeriatricconditionsbetweenmedical andsurgicalservices.

2. Methods 2.1. Design

For this population-based, hospital-wide survey of geriatric inpatients,subjectswererecruitedbyprobabilitysamplingwith rotationmethodandassessedonceduringtheirhospitalstay.This approachallowedtherandomsurveyofasmanyolderhospitalized patientswithina2200-bedmedicalcenteraspossible.Allmedical andsurgicalunitsexcepttheintensivecareandspecialoncology units (in another building) were randomly assigned a serial numberfrom1to24.Startingwiththefirstunitintheseries,two researchnursesvisitedoneunita day,wheretheyenrolledand screenedallqualifiedsubjects(seecriteriainSection2.2).Thenext day, researchnurses moved tothe next unit and screened all eligiblesubjectsonthatunit.Therotationprocesscontinuedinthis manneruntilallunitshadbeenvisited.Intotal,fiveroundsof 24-unitvisitswerecompletedwith455subjectsenrolledtoensurea representativesampleintermsofprevalenceandriskfactorprofile forthestudiedgeriatricconditions.

2.2. Studypopulation

All24surgicalandmedicalunitsata2200-bedtertiarymedical centerinurbanTaipei, Taiwan,wererandomlyassigneda serial number.Asdescribedabove,researchnursesvisitedoneunitaday andscreenedallinpatientsfortwoinclusioncriteria:age65years andabletocommunicate.Ofthe1149elderlypatientsscreened,474 didnotmeettheinclusioncriterionforabilitytocommunicatedue tocoma(n=75),intubation(n=85),verbaldysfunctionoraphasia (n=118),severehearingloss(n=81),respiratoryisolation(n=105), andothers(n=10).Ofthe675eligiblepatients,455(67.4%)were enrolled.Thereasonsgivenfornotparticipatingwereconflictwith scheduleddiagnosticprocedures(n=112),notfeelingwell(n=50), and declined to consent (n=58). Subjects who declined to participate(n=108)and thosein our analysis (n=455) didnot differ significantly with respect to age (p=0.422), gender (p=0.354), education (p=0.711), and type of specialty unit (p=0.562).

2.3. Datacollectionandmeasures

Beforedata were collected, the study was approved by the Research Ethics Review Committee of the National Taiwan University Hospital. Dataon study variables were collected by twotrainedresearchnurseswhoapproachedalleligiblepatients, explainedthenatureandpurposeofthestudy,andinvitedthemto participate. After patients signed informed consent, they were screenedonetimein face-to-faceencountersfor demographics, comorbidities, medications taken, cognitive status, depressive symptoms,functional dependence(performance of activitiesof dailyliving=ADL),nutritionalstatus,urinaryorfecalincontinence (yes/no),pressureulcers (yes/no),dehydration(yes/no),anemia (yes/no),visual/hearingimpairment (yes/no), chewing/swallow-ingdifficulty(yes/no),andsleepdisturbance(yes/no).

Demographics, number of prescriptive medications, and comorbidities were obtained from the medical record and confirmed by patient interview. Polypharmacy was defined as taking more than 5 prescriptive medications daily (Fulton and Allen, 2005).Comorbiditieswerebased ontheCharlson comor-bidityindex(CCI)whichcategorizespatients’mortalityriskbythe sumofweightedcomorbiditiesintothreegroupsbyscore:0,1,or 2(Charlsonetal.,1987).

Cognitivestatuswasmeasuredbythe11-itemChinese mini-mental stateexamination(MMSE),withscores<20(out of30) indicating cognitiveimpairment(Folsteinetal.,1975;Shyu and Yip,2001).Depressivesymptomsweremeasuredbythe15-item Chineseversiongeriatricdepressionscale(GDS-15),withsummed scores>10indicatingdepression(Yesavageetal.,1982–1983;Liu etal.,1998).

Functionalstatus(performanceofADL)wasmeasuredbythe 10-item Chinese version Barthel Index (BI), with scores <60 indicatingfunctionaldependence(yes/no;MahoneyandBarthel, 1965;Chenetal.,1995).Nutritionalstatuswasmeasuredbythe 18-itemChineseversionmini-nutritionalassessment(MNA),with summedscores<17.5indicatingmalnutrition(Guigozetal.,1996; Tsaietal.,2007).

Ageriatricconditionschecklistwasusedtoassessurinaryor fecalincontinence(yes/no),visualimpairment(yes/no;definedas correctedvisionworsethan20/70usingaspecialhand-heldcard), self-reportedhearingimpairmentandchewing/swallowing diffi-culty (yes/no), self-reported sleep disturbance (yes/no), and pressureulcers (yes/no;confirmedbyraters).Sleepdisturbance wasscreenedbyaskingpatients,‘‘Howhaveyoubeensleepingin the hospital?’’ When patients complained of sleep disturbance, probequestionswereaskedtoidentifythecause(environmental problems,pain-ordyspnea-related).

Laboratorydata(serumhemoglobin,bloodureanitrogen,and creatinine) were extracted from medical records. Dehydration (yes/no)wasdefinedastheratioofplasmabloodureanitrogento creatinine18(Inouyeetal.,2000).Anemia(yes/no)wasdefined asaserumhemoglobinlevel<12g/dlforfemalesand<13g/dlfor males(WHO,1994).

2.4. Statisticalanalysis

Thedataweredoubleenteredtoensureaccuracy.Significance wassetatp<0.05.Descriptivestatisticswereusedtocharacterize thesampleandexamineprevalenceratesofgeriatricconditions. For continuous measureswhose values were dichotomized for analyticpurposes,standardcutoffscoreswereemployed. 3. Results

3.1. Participants

Our study samplewas relatively diverse in age, gender, and educationallevel(Table1).Mostofthesamplewasmarried,living with others, and retired. The participants had a mean age of 75.36.1years,range=65–92).Almosthalfthesample(42.9%)was illiterate,withameanof5.35.4ofeducation(Table1).Overall,59.3% wereadmittedforsurgicalservice.ThemeanCCIwas2.82.2with only14%ofparticipantsscoring0and73%scoring2,suggestingavery highmortalityrisk.

3.2. Overallprevalenceofgeriatricconditions

Geriatric conditions were highly prevalent among the 455 participants(Table2).Cognitiveimpairmentwascommon,with 21% of older participantshaving anMMSE score <20 and 45% scoringlessthan24of30possiblepoints.Depressionwasfoundin

30%ofparticipants,withaGDS-15score>10.Malnutritionwas foundin33%ofparticipants,withanMNAscore<17.5.Functional dependencewascommon,with42%severelydependent(BI<60) in10ADLs.Polypharmacywasprevalent,with57%ofthesample takingatleast5prescribedmedicationsperdayand13%taking9 ormore.Urinaryorfecalincontinencewasidentifiedin14and8% ofthesample,respectively,andpressureulcersin5%.Anemiawas identified in 55% of subjects,and dehydration in 34%. Sensory impairmentwascommon,with74%havingvisualand8%having hearing impairment. Chewing and swallowing difficulties were reportedby50%and15%ofthesample,respectively.Themajority ofparticipants(58%)complainedofsleepdisturbance, with20% attributingtheirpoorsleeptopain.

3.3. Prevalenceofgeriatricconditions:medicalversussurgicalunits Giventhepossibilityofunitdifferencesingeriatricconditions, weexaminedprevalenceratesbymedicalversussurgicalunits.As shown in Table 3, rates of certaingeriatric conditions differed significantlyfrommedicaltosurgicalunits.Theprevalenceratesof malnutrition, functional dependence, both urinary and fecal incontinence,sleepdisturbance, andpercentageof sleep distur-bance due to pain were significantly higher among surgical

patients (p<0.05). Conversely, pressure ulcers and swallowing difficultyweremoreprevalentamonggeriatricinpatientsinmedical service(p<0.05).Polypharmacy,depression,cognitiveimpairment, anemia,visualandhearingimpairment,andchewingdifficultywere prevalentacrossbothmedicalandsurgicalinpatients.

4. Discussion

Theprevalenceratesoftheindividualgeriatricconditionsinour studyaregenerallyconsistentwiththosereported(Inouyeetal., 2000;Nairetal.,2000;Congdonetal.,2004;Cigolleetal.,2007; Flood et al., 2007; Chan et al., 2009; Chen et al., 2009). Some conditions,e.g.,polypharmacy(56.6%),anemia(55.4%),functional dependence (41.9%), malnutrition (32.5%), depression (29.5%) wereasprevalentascommonchronicdiseases,suchas hyperten-sion(66.3%for60yearsandolder)anddiabetes(23.1%for60years andolder)(ADA,2007;Ongetal.,2007).Atleasthalfofgeriatric inpatientsreportedvisualimpairmentorchewingdifficultyand had experiencedpolypharmacy, anemia, and sleep disturbance duringtheirhospitalstay.Thesehighratesofgeriatricconditions reflect the complexity of care that clinicians face today in the hospitalsetting.

Amongthesehighratesofgeriatricconditions,polypharmacyis apracticehabitthatcanbemodifiedifenoughattentionispaid. ‘‘Prescribingcascade’’isaknownproblem,inwhichamedication results in an adverse drug event (ADE) that is mistaken for a separateconditionandtreatedwithmoremedications,placingthe patientatriskforadditionalADEs(RochonandGurwitz,1997).The complexpracticeofpolypharmacycanbecurrentlyaddressedby severalstrategies.OnestrategyisSTOPP(screeningtoolofolder person’spotentiallyinappropriateprescriptions)criteria,auseful guidetoidentifypotentiallyinappropriatemedications, particu-larly in the hospital setting (Gallagher and Mahoney, 2008). Althoughnotasubstituteforclinicaljudgment,STOPPencourages clinicianstoconsidermedicationsasapossiblecauseofsymptoms in older people, thereby avoiding unnecessary and potentially harmfulprescribingcascades.Asafirststep,cliniciansshouldbe awareofahighprevalenceofpolypharmacyandunderstandthat lessismorewhenprescribingforolderpatients.

Table1

Samplecharacteristicsandoverallfunctionality,meanS.D.,orn(%). Variables Age(years) 75.36.1 Education(years) 5.15.4 Females 229(50.3) Maritalstatus Married 351(77.1) Widowed 100(22.0)

Livingwithothers 430(94.5)

Retired 416(91.4)

Monthlyincome>NTD$(10K)a _315(69.2)

Admittedforsurgeryservices 270(59.3)

CCI 2.82.2

Numberofmedicationstaken 5.22.9

BIscore 61.226.1

MMSEscore 23.44.6 GDS-15score 7.73.8

MNA-score 18.74.2

a

NTD=NewTaiwanDollar;32.5NTD=1USD.

Table2

Overallprevalenceofgeriatricconditionsinthesampleof455subjects,n(%). Geriatriccondition

Cognitiveimpairment,MMSE<20 95(20.9) Depression,GDS>10 134(29.5) Malnutrition,MNA<17.5 148(32.5) Functionaldependence,BI<60 191(41.9) Polypharmacy(>5medicines) 257(56.5) Polypharmacy(>9medicines) 59(13.0) Urinaryincontinence 103(22.6) Fecalincontinence 38(8.4) Pressureulcers 24(5.3) Anemiaa _252(55.4) Dehydrationb 156(34.3) Visualimpairment 335(73.6) Hearingimpairment 36(7.9) Chewingdifficulty 227(49.9) Swallowingdifficulty 70(15.4) Sleepdisturbance 264(58.0) Sleepdisturbanceduetopain 91(20.0)

a

AnemiawasdefinedasHb<12g/dlforfemalesand<13g/dlformales.

b

Dehydration was defined as the ratio of serum urea nitrogen to creatinine18.

Table3

Frequencyofgeriatricconditions:Medicalversussurgicalinpatients,comparedby

x2

-test,withexceptionofpressureulcers,whereFisher’sexacttestwasused;n(%). Geriatriccondition Medical Surgical p

Number 185 270

Importantinbothgroups

Cognitiveimpairment,MMSE<20 40(21.6) 55(20.4) 0.747 Depression,GDS>10 49(26.5) 85(31.5) 0.251 Polypharmacy,5 104(56.2) 153(56.7) 0.924 Polypharmacy,9 28(15.1) 31(11.5) 0.254 Dehydrationa _{59(31.9) 97(35.9) 0.084} Anemiab _{101(54.6) 151(55.9) 0.746} Visualimpairment 137(74.1) 198(73.3) 0.864 Hearingimpairment 15(8.1) 21(7.8) 0.898 Chewingdifficulty 98(53.0) 129(47.8) 0.276 Dominantinsurgicalservices

Malnutrition 47(25.4) 101(37.4) 0.007 Functionaldependence,BI<60 44(23.8) 147(54.4) <0.001 Urinaryincontinence 24(13.0) 79(29.3) <0.001 Fecalincontinence 9(4.9) 29(10.7) 0.026 Sleepdisturbance 95(51.4) 169(62.6) 0.017 Sleepdisturbanceduetopain 21(11.4) 70(25.9) <0.001 Dominantinmedicalservices

Pressureulcers 15(8.1) 9(3.3) 0.025 Swallowingdifficulty 36(19.5) 34(12.6) 0.046

a_{AnemiawasdefinedasHb<12g/dlforfemalesand<13g/dlformales.} b

Thehighrateofdehydrationfoundinthisstudyisalsoworth attention.Dehydrationis commoninolderpatients becauseof decreasedmusclemass(resultinginlessfreeextracellularwater), bluntedthirstresponse,treatment-relatedfactorssuchasa fluid-restricteddietornothing-by-mouthorder,andacceleratedfluid loss due to illness or medical procedures (Hodgkinson et al., 2003).Inoursampleofolderhospitalizedpatients,34.3%hada highBUN/creatinineratio(18).Althoughsuchanelevatedratio couldbeexplainedbypoorperfusioncausedbycongestiveheart failureorabnormalwatermetabolism relatedtosarcopeniaor autonomicneuropathy,itismoreoftenameasureofdehydration (Lindemanetal.,2000;Stookeyetal.,2005).Milddehydration correspondingtoonly1–2%ofbodyweightlossinadultshasbeen shown to lead to significant impairment in both cognitive function (alertness, concentration, short-term memory) and physical performance (endurance, sports skills) (Shirreffs, 2005).Better identification andprompt managementof dehy-drationareclinicallyindicatedinbothmedicalandsurgicalolder hospitalizedpatients.

Ourstudyresultsallowclinicianstobetterprioritizeandtarget care, thus adding to the geriatric literature by clarifying the prevalence of 15 common geriatric conditions on medical and surgicalunits.Wefoundthatcognitiveimpairment,depression, polypharmacy, dehydration, anemia, sensory impairment, and chewingdifficultywerehighlyprevalentandcommonamongboth medicalandsurgicalinpatients.Generalpracticeshouldcoverthe aspectsofcarefortheseconditionssolessmedicationisprescribed and more attention is paid to screening and identifying older patients who are cognitively impaired, depressive, dehydrated, anemic,sensorydeprived,andhavingdifficultychewing.

Ontheotherhand,geriatricinpatientsonsurgicalunitswere foundtohavesignificantlyhigherratesoffunctionaldependence, malnutrition, urinary/fecal incontinence,sleep disturbance, and sleepdisturbancedue topain,suggesting thattheseconditions need more attention. For example, better pain control would enhance sleep quality and reduce barriers to postsurgical mobilization.Enforcing mobilizationwould decrease functional dependenceandpromptgastricemptyingsointakemightimprove aswell(Balzanoetal.,2008).Earlyfeeding/providingnutritional assistance for older postoperative patients hastens recovery (CorreiaandDaSilva,2004).Furthermore,earlycatheterremoval reducesurinarytractinfectionsandmightavoiddevelopmentof urinaryincontinence(Phippsetal.,2006).

Suchfindingsechocurrentresearchon‘‘fast-tracksurgery.’’The conceptoffast-tracksurgery,orenhancedrecoveryaftersurgery, hasevolvedfromrecentevidence-basedadvancesinthecareof surgical patients (Wilmore and Kehlet, 2001). These advances include epidural or regional anesthesia, minimally invasive techniques, and aggressive postoperative rehabilitation, which optimizepainrelief,earlymobilization,andnutrition(earlyoral feeding).Thecombinationoftheseapproachesreducesthestress response,organdysfunction,and complications,thusimproving postoperativerecovery(WilmoreandKehlet,2001).Incaringfor geriatric patients undergoing surgical procedures, these approaches might be even more important. Our study further suggests that care of older inpatients with surgical conditions should address not only the common issues of cognition, depression,medication,andsensory/chewingdifficulties,butalso prioritizepaincontrol,earlymobilization,and nutritional assis-tance with closer attention paid to identifying and managing incontinence.

Conversely,geriatric inpatients from medical units reported higher prevalence rates of pressure ulcers and swallowing difficulty than surgicalinpatients. This difference might reflect the chronicity of geriatric patients commonly seen in medical units.Nevertheless, this findingsuggeststhat thecare of older

patients onmedical unitsshouldaddressnot onlythecommon issuesofcognition,depression,medication,andsensory/chewing difficulties, but also pay closer attention to identifying and managingpressureulcersandswallowingdifficulty.

In conclusion, the high rates of functional dependence, malnutrition, cognitiveimpairment,and depression reported in this study have previously been linked to poor outcomes.For example,BIscores<60havenotonlybeenassociatedwithpoor outcomes, but also suggested to be a pivotal point at which patientsmovedfromassistedindependencetodependence(Sulter etal.,1999).Malnutritionisamajorcauseoffunctionaldeclineand increased morbidity and mortality in geriatric patients (Olde Rikkert and Rigaud, 2003). Similarly, cognitiveimpairment has been shown to predict functional decline in geriatric patients (Mehta et al., 2002). Indeed, geriatric patients who developed cognitivedeclineduringhospitalizationwerefoundtobe16times more likely to develop functional decline than non-cognitive decliners (Pedone et al., 2005). These geriatric conditions are suggested bygrowing evidencetobemarkersfor decline since their commonality has been associated with poor outcomes. Therefore,futurestudiesshouldexaminealltheseconditionsin thecontextofadiversegeriatricpopulation(notlimitedtocertain disease categories), soa unified approach can bedeveloped to targetperformanceofADLs,nutrition,cognition,anddepressive symptoms(Chenetal.,inpress).

4.1. Strengthsandweaknessesofthestudy

A major strength of the present study is that 15 common geriatric conditions werestudied in a large and representative sampleofhospitalizedgeriatricinpatients.Thestudyhada few limitations.First,subjectswererecruitedfromonemedicalcenter, which might limit the generalizability of our findings. Second, most conditions were identified by self-report questionnaires. Third,weusedMMSEscores<20toindicatecognitiveimpairment, recognizing that important conditions such as delirium and dementiawerenotassessed.Further,allinstrumentsarescreening tools;althoughtheyarereasonabletouse,theiroutcomesshould befollowedupbymorethoroughassessments.

5. Conclusion

This researchhas relevanceto theongoing care of geriatric patients.Geriatricconditionsfalloutsidethediseasemodelsthat nowgovernmuchofhealthcare,resultingingeriatricconditions beinghighlyprevalentaswellaspoorlyrecognizedandmanaged (Oliver,2008).Onegoalofaresponsivehealthcaresystemisto promotethewell-beingofthosesufferingfromillness. Compre-hensivegeriatricassessment(CGA)isamultidisciplinary evalua-tion in which the multiple problems of older persons are uncovered, described, and explained, if possible,and in which theresourcesandstrengthsofthepersonarecataloged,needfor servicesassessed,anda coordinatedcareplandeveloped(Chen etal.,2004;AGS,2006).RandomizedtrialsofCGA,appliedacross multiplehealthservicesettings,showthisapproachtobea cost-effective intervention that improves quality of life, quality of health, and quality of social care. Its benefits have been most robustlydemonstratedwhenappliedinahospitalorrehabilitation unit (AGS, 2006).Our studyfindingssupporttheuseof CGAto screenanddevelopcareplanstomanagethesehighlyprevalent geriatric conditions, with different priorities for older patients admittedformedicalversussurgicalconditions.

Conflictofintereststatement None.

Acknowledgements

ThisstudywassupportedbytheTaiwanNationalScienceCouncil Grant # 95-2314B002-188-MY3 and in part, by the career developmentgrantfundedbytheNationalHealthResearchInstitute (Grant#NHRI-EX98-9820PC).TheauthorsthankMs.Hui-JaneTu andHui-LinChenfortheirassistancewithdatacollection. References

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