International Journal of Gerontology xxx (2016) 1e4 Contents lists available at ScienceDirect International Journal of Gerontology journal homepage: www.ijge-online.com Original Article Factors Associated with Quality of Life Among Older Adults with Chronic Disease in Taiwan*,** Hsiao-Mei Chen 1, 2, Ching-Min Chen * Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Cheng Ching Hospital, Taichung City, National Cheng Kung University, Taiwan Department of Nursing, a r t i c l e i n f o s u m m a r y Article history: Received October 2015 Received in revised form 29 June 2016 Accepted 27 July 2016 Available online xxx Background: There have been many studies reviewing quality of life (QoL) of older population and found an inverse association between QoL and chronic diseases However, previous studies have focused only on that of people with specific diseases In this study, we identified critical quality of life determinants, especially risk for disability, in older adults suffering from chronic diseases Methods: A cross-sectional, correlational design was used A purposive sample of 115 older patients, diagnosed with co-morbidity was recruited from an outpatient medical center in Southern Taiwan Results: Results of a stepwise multiple regression analysis indicated that the overall regression model explained 49% of the variance in QoL After controlling the sociodemographic factors and health status of older patients, the risk for disabilities in social isolation and depression were negatively correlated with QoL Alzheimer disease-8 (AD-8) had the strongest association with the total QoL score, and it alone explained 27% of the variance Conclusion: Understanding the importance of determining factors of poor QoL, such as potential cognitive impairment, potential social isolation and depression, inadequate family income, and diminished ability to perform practical and social activities (IADLs) among older adults with chronic diseases is critical for geriatric health care providers Awareness of these factors can assist providers in identifying people at risk and guide new intervention programs to improve care for these invaluable members of our communities Copyright © 2016, Taiwan Society of Geriatric Emergency & Critical Care Medicine Published by Elsevier Taiwan LLC This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/) Keywords: chronic disease, disability risk, older adults, quality of life Introduction Aging is a global issue1 The older population (aged 65 years and over) in Taiwan crossed the 7% threshold of an aging society in 1993, and the percentage of aging population has reached 12.50%2 The disability of older adults is closely related to the degree of their weakness, which is determined by aging, diseases and lack of exercise3,4 Aging is frequently accompanied by a larger burden of comorbid conditions and greater illness severity3,5 Aging- * Conflict of interest: The authors declare that there is no conflict of interest Funding: The work was supported by the “Aim for the Top University Plan” of the National Cheng Kung University and the Ministry of Education, Taiwan, R.O.C None of the study sponsors or funding sources had a role in the design, conduct, analysis or reporting of the study * Correspondence to: Dr Ching-Min Chen, National Cheng Kung University, Department of Nursing, University Rd, Tainan, 70101, Taiwan Fax: ỵ886 62377550 E-mail address: chingmin@mail.ncku.edu.tw (C.-M Chen) ** associated diseases, such as heart disease, stroke, degenerative arthritis and fractures caused by falls often reduce older adult's capability of activity6,7 Disability can be defined in several ways, including difficulties with activities of daily living (ADL), difficulties with instrumental activities of daily living (IADL), and mobility limitations, impairments, and participation restrictions4,5 Globally, co-morbidity is a common problem and increases with age3,8 The prevalence of chronic diseases among older adults aged 65 and above accounts for approximately 70%, and about one-third of the older adults suffer from co-morbidity8 In addition, chronic diseases and co-morbidity have a considerable degree of influence on the health functions of older adults8,9 With the Charlson Comorbidity Index (CCI), the co-morbidity situation and the disease burden of the chronic disease patients can be understood10 Disabilityadjusted life-year (DALY) is a measure of overall disease burden, and mortality and morbidity are combined11 Dementia causes major disability in older adults and is a global public health burden12 The Alzheimer disease is, however, quite sensitive to http://dx.doi.org/10.1016/j.ijge.2016.07.002 1873-9598/Copyright © 2016, Taiwan Society of Geriatric Emergency & Critical Care Medicine Published by Elsevier Taiwan LLC This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Please cite this article in press as: Chen H-M, Chen C-M, Factors Associated with Quality of Life Among Older Adults with Chronic Disease in Taiwan, International Journal of Gerontology (2016), http://dx.doi.org/10.1016/j.ijge.2016.07.002 H.-M Chen, C.-M Chen detecting early cognitive changes associated many common dementing illness13 Older adults who suffer from multiple chronic diseases and cognitive dysfunction are often rendered physically impaired14 Therefore, the preventing disability from happening among older adults has become a government priority in Taiwan Previous studies on the quality of life (QoL) of older adults have found an inverse association between QoL and chronic diseases, but most of the data focused on patients with a specific disease or have used a wide variety of instruments Thus, studies on the factors affecting QoL among older adults with multiple chronic diseases are limited15,16, particularly those on the correlation between risk for disability and QoL Therefore, the objectives of this study were (1) to understand QoL of older adults with chronic diseases in physical and mental health, social relations, and environment components; (2) to examine the correlations among the sociodemographic characteristics, health status, risk for disabilities, and QoL; and (3) to identify impact of disability risk on QoL of older adults with chronic diseases Materials and methods The risk for disability scale was adopted from Japan21 The scale comprises five subscales, movement (5 items), nutrition (4 items), cognition (5 items), social relations (5 items), and depression (5 items), yielding a total of 24 yes/no questions A score of or above in each subscale shows disability risk in that domain A higher score indicates that the person is at higher risk of disability22 Quality of Life comprises 28 questions across four domains, physical health, mental health, social relations, and environmental The scoring is based on a 5-point Likert scale The average score of all the questions within the same domain is multiplied by as the score of that domain, which ranges from to 20 The sum of the scores of the four domains represents the overall QoL score23 2.3 Statistical methods Statistical analysis was conducted using the SPSS17.0 Chinese version The frequency, percentage, mean, standard deviation were reported for variable description Independent t test, Pearson correlation, one-way analysis of variance (ANOVA), and stepwise multiple regression analysis were used to determine correlations between predicting variables on QoL 2.1 Design and sample A cross-sectional study design was adopted Participants were recruited from October to December of 2011 at the outpatient center of a medical center (Neurology, Cardiology, Metabolism, Rehabilitation, Family Medicine, etc.) in Southern Taiwan Purposive sampling was used, and the inclusion criteria included older adults aged 65 years or over who were (1) physician-diagnosed with more than one common chronic diseases, (2) able to communicate in either Mandarin or Taiwanese, (3) willing to participate in interviews and to complete the questionnaire independently or with assistance, and (4) agreed to participate in the study and signed the letter of consent The exclusion criteria were severe dementia, disability, visual or hearing impairments, and inability to communicate Among the participants, 115 were willing to participate in the interview and complete the questionnaire, 29 declined, and six did not meet the criteria The response rate for this study was 79.86% 2.2 Data collection process and definitions Ethical approval for the study was obtained from the institutional review board (IRB) (No: ER-100-359), National Cheng Kung University Hospital After obtaining agreement from the case hospital and outpatient departments, we explained the research purposes to the recruited participants to obtain their agreement and signed consent forms before beginning data collection Data on socio-demographic characteristics included age, gender, marital status, living conditions, religion, level of education, and economic condition Health status were measured according to diagnosis, charlson comorbidity index (CCI), Alzheimer disease (AD8), Activities of daily living (ADL) and instrumental activities of daily living scale (IADL) CCI was developed in 1987 to predict a relative risk of death within 12 months10 For calculation of CCI, a standardized weight was assigned in each indicated 19 diagnoses and added together to provide a total CCI score The scores are calculated as (no condition occurs), 1, and 2, 3, and points A higher score indicates a more severe burden of co-morbidity10,17 The AD8 contains items that test for memory, orientation, judgment, and function An AD8 score of !2 indicates possible cognitive impairment and that further diagnosis is required18 The ADL consists of 10 items The total score ranges from to 10019 The IADL score of each item ranges from to points, with a total score of 24 points20 Results Among the 115 participants, there were more women (62.6%) than men The average age was 70.87 (SD ¼ 8.39) Married participants accounted for 79.1% of the total sample, and a great part of them (53.3%) had a high school (vocational) degree Regarding the income, 69 (62.7%) participants considered it was sufficient, (6.4%) considered it was slightly inadequate, and (3.6%) considered it was very inadequate The prevalence of chronic diseases among subjects were hypertension (43.6%), cardiovascular disease (24.5%), diabetes (22.6%), hypercholesterolemia (12.7%), and arthritis (11.3%) Based on age-unadjusted CCI score, 63 older adults (54.8%) had a disease burden The average score of the ADL was 98.83, with a range of 97e99.6 The average IADL score was 22.68 (out of 24), with a range of 93%e97.50% of each item, indicating that majority of older adults with chronic conditions having intact physical functions The mean AD8 score was 1.56, and 40 subjects (34.7%) obtained scores equal to or greater than 2, indicating an early sign of dementia 3.1 Quality of life of older adults with chronic diseases The average QoL score of older adults with chronic diseases was 58.30 (out of 80), showing a medium level of QoL From each QoL dimension, the environmental category scored the highest, with an average of 15.02 (SD ¼ 1.97), followed by the physiological health (14.69 ± 2.37) and the social relation (14.35 ± 2.23), whereas the psychological category scored the lowest, with an average of 14.21 (SD ¼ 2.42) For overall health satisfaction, 87 (77.9%) reached moderate or higher satisfaction regarding their health 3.2 Disability risk and health status of older adults with chronic diseases The five components of disability risk assessment were movement, nutrition, cognition, social relations and depression Fiftyseven (49.6%) older adults obtained scores equal to or higher than 5, and a higher score indicated a higher risk of disability Nearly half (49.6%) of older adults with chronic diseases had a higher risk for disability (Table 1) Correlational analyses among the socio-demographic characteristics, health status, disability risk, and quality of life of older Please cite this article in press as: Chen H-M, Chen C-M, Factors Associated with Quality of Life Among Older Adults with Chronic Disease in Taiwan, International Journal of Gerontology (2016), http://dx.doi.org/10.1016/j.ijge.2016.07.002 Risk for Disability on Quality of Life Among Older Adults 3.4 Correlations between disability risk and QoL Table Risk of disability among older adults with chronic diseases (N ¼ 115) Item Number (%) Mean (SD) Movement (5) Nutrition (4) Cognition (5) Social (5) Depression (5) 74 82 66 33 60 1.39 1.23 1.18 0.66 1.10 (65.5) (71.9) (57.9) (28.9) (53.1) (±1.39) (±1.08) (±1.30) (±1.46) (±1.57) adults with chronic diseases Correlations between sociodemographic characteristics and quality of life The results showed that education level and economic conditions (whether the income is adequate) of older adults with chronic diseases were significantly correlated Older adults with a high school or higher education showed significantly higher score in QoL than did those who were illiterate/literate (self-study) in physiological health (F ¼ 5.564, p < 0.05) and psychological status (F ¼ 4.678, p < 0.01) Regarding economic conditions, the adequacy of income reached a significant level in the four aspects of QoL Participants whose financial status were ‘more than sufficient’ reported higher QoL compared with those whose financial status was ‘sufficient’ or ‘slightly inadequate/very inadequate’ Results of Pearson correlation analyses indicated that older people in age had worsened QoL in the physiological health (r ¼ À0.233; p < 0.05) 3.3 Correlations between health status and quality of life The Pearson correlation analysis indicated that the ADL, IADL, co-morbidity, and early sign of dementia were significantly correlated with QoL, whereas the other variables were not Higher ADL scores showed positive correlations with physiological health (r ¼ 0.372; p < 0.01), psychological status (r ¼ 0.433; p < 0.01), social relations (r ¼ 0.228; p < 0.05), and environmental QoL (r ¼ 0.273; p < 0.01) The higher in IADL, the higher QoL were in physiological health (r ¼ 41; p < 0.01), psychological status (r ¼ 0.41; p < 0.01), social isolation (r ¼ 0.26; p < 0.01), and environmental QoL (r ¼ 0.26; p < 0.01) A lower CCI score (age unadjusted CCI score) indicated a higher psychological status (r ¼ À0.237; p < 0.05) A lower AD8 score indicated a more positive QoL in physiological health (r ¼ À0.465; p < 0.01), psychological status (r ¼ À0.546; p < 0.01), social isolation (r ¼ À0.391; p < 0.05), and environmental QoL (r ¼ À0.336; p < 0.01; Table 2) Table The correlations of sociodemographic characteristics, health status, risk for disability on quality of life among older adults with chronic diseases (N ¼ 115) Variables Physiological Sociodemographic characteristics Agea À0.233* Health status ADLa,b 0.372** IADLa,b 0.413** b CCI a,b Age adjusted CCI À0.153 AD8a,b À0.465** Risk for disability Overalla À0.609** Movementa À0.472** a Nutrition À0.394** a Cognition À0.416** a Social À0.298** Depressiona À0.394** a Psychological Social Environment À0.069 0.138 0.400 0.433** 0.408** 0.228* 0.255** 0.273** 0.261** À0.237* À0.546** À0.147 À0.391** À0.111 À0.336** À0.521** À0.344** À0.279** À0.362** À0.245** À0.420** À0.174 À0.174 À0.116 À0.181 À0.139 À0.202* À0.304** À0.304** À0.258** À0.310** À0.203* À0.154 *p < 0.05, **p < 0.01, ***p < 0.001 ADL ¼ activities of daily living; IADL ¼ instrumental activities of daily living; CCI ¼ charlson comorbidity index; Age adjusted CCI score ¼ age adjusted charlson comorbidity index score; AD8 ¼ alzheimer disease b Pearson product-moment correlation was applied to analyze the correlations between risk for disability and QoL The results show that a sum of disability risk was correlated with QoL in physiological health (r ¼ À0.609; p < 0.01), psychological status (r ¼ À0.521; p < 0.01), and environmental domain (r ¼ À0.304; p < 0.01) Table shows that the five disability risk domains, namely movement, nutrition, cognition, social relations, and depression, have significant correlations with the QoL in physiological health, psychological status, social relations, and environmental factors, indicating that the fewer the disability risk were, the higher QoL was perceived 3.5 Predicting factors of the quality of life To identify primary determinants affecting QoL, multiple linear regression models were conducted in three steps in order to examine the independent contributions of measures when entered together (Table 3) In the first step, economic status was found significant in explaining 10% of the variance in overall QoL (F ¼ 10.50; p < 0.001) In the second step, the predictors with the most predicting power was an early sign of dementia, followed by physical function and the adequacy of the income These three variables effectively explained 39% of the variance in overall QoL (F ¼ 19.79; p < 0.001) In the third step, the AD8 score was determined to be the most effective predictor, followed by risk for depressive disability, income (more than sufficient), and risk for social relations disability These three variables effectively explain 49% of variance in overall QoL (F ¼ 17.56; p < 0.001) The results show that, when controlling socio-demographic characteristics and health status, the differences between both risks of depression and social isolation and QoL were significant (Table 3) Table Summary of hierarchical regression analysis predicting quality of life among older adults with chronic diseases (N ¼ 115) Item Step1 Step2 Standardized R2 regression coefficient Sociodemographic characteristics Age À0.030 Level of education ①Primary/Junior 0.110 High School/Junior ②High school more À0.040 The adequacy of the cost of living ①Sufficient and 0.320** more thana ②Roughly enough 0.280 Health status ①ADLb ②IADLa,b ③Age adjusted CCI scoreb ④AD8a,b Risk for disability ①Movement ②Nutrition ③Cognition ④Sociala ⑤Depressiona F valuea 10.500*** R2 value 0.10 0.10 Step3 Standardized R2 regression coefficient Standardized R2 regression coefficient 0.010 0.120 0.080 0.050 À0.060 À0.060 0.023** 0.05 0.150 0.260** 0.04 0.160 0.050 0.290*** À0.110 0.07 0.100 0.160* À0.050 À0.380*** 0.27 À0.280*** 19.790*** 0.39 À0.050 À0.060 À0.040 À0.0210** À0.270*** 17.560*** 0.49 0.04 0.27 0.04 0.10 a *p < 0.05, **p < 0.01, ***p < 0.001 ADL ¼ activities of daily living; IADL ¼ instrumental activities of daily living; Age adjusted CCI score ¼ age adjusted charlson comorbidity index score; AD8 ¼ alzheimer disease b Please cite this article in press as: Chen H-M, Chen C-M, Factors Associated with Quality of Life Among Older Adults with Chronic Disease in Taiwan, International Journal of Gerontology (2016), http://dx.doi.org/10.1016/j.ijge.2016.07.002 H.-M Chen, C.-M Chen 3.6 Discussion Based on the analysis, older adults with chronic diseases may suffer from various diseases that lead to poor control of movement and limit the performance of various activities Older adults are therefore worried about themselves (physiologically and psychologically), causing emotional distress that could generate negative thoughts and feelings24,25 The regression analysis indicated that the AD8 score had the most predictive power for older patients' QoL, which explains 27% of the variance Empirical data concerning AD8 and QoL were limited However, previous results have indicated that one of the negative factors was cognitive impairment18,26 The IADL is also a crucial predictor of QoL The use of IADL is appropriate for assessing the level of independence of older adults with chronic diseases27 Previous studies have also indicated that greater IADL functions in chronic patients indicate enhanced higher QoL25 The stepwise regression analysis showed that risk for depression and social relations are primary factors related to QoL and explain 14% of the variance Depression and social relations reflect the QoL of patients with chronic diseases28,29 Faller et al.29 addressed that if depression issues are not emphasized, then the quality of care cannot be improved, severely affecting patients'prognosis and QoL will be followed Our results have significant implications for clinical practice To reduce the risk of disability conditions, it is necessary to strengthen the patients' self-care ability, encourage them to participate in social activities, focus on their mental health, and enhance their economic conditions30,31 An increasing number of co-morbidities leads also to a decrease of health-related QoL in older adults32 Therefore, to maintain and to promote independent living of those with disabilities, health care service system and the disability assessment tools such as ADL, IADL, and AD8 are used to screen the elderly at high risk of disability of activities of daily living and cognitive function12,33 The application of DALY index can also be applied to learn about the diseases and control them from a macro perspective to make a preliminary assessment of the existing measures so that limited resources can have greater effectiveness34,11 to increase the quality of life among the elderly with disabilities35 We adopted purposive sampling and cross-sectional correlation analysis, and the participants enrolled were limited to patients in a medical center in Southern Taiwan In addition, DALY index was not included Therefore, it is difficult to obtain comprehensive reasoning and long-term discussion about the disability risks of patients with chronic diseases If possible, a more rigorous evaluation of the effectiveness can be conducted with experimental or quasi-experimental design along with a longitudinal study design for in-depth exploration of the ways DALY index can also be included to help us adopting the best interventions to prevent the priority disease, enhance the self-management of older adults, improve their quality of life so as to decrease the risk of disabilities References Wan-Ibrahim W, Zainab I, Asyraf H, et al Elderly care issues in east asia through novel kokotsu no hito Middle East J Sci Res 2014;20:1453e1456 Ministry of Health and Welfare, Taiwan, ROC Resident population by single year of age Available at http://www.mohw.gov.tw/cht/DOS/Statistic.aspx?f_list_ no¼312&fod_list_no¼4194 Statistic.aspx?f_list_no¼312&fod_list_no¼4194 Accessed 29 February 2016 Afilalo J, Mottillo S, Eisenberg MJ, et al Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity Circ Cardiovasc Qual Outcomes 2012;5:222e228 Wong E, Backholer K, Gearon E, et al Diabetes and risk of physical disability in adults: a systematic review and meta-analysis Lancet Diabetes Endocrinol 2013;1:106e114 World Health Organization (WHO) Disability and health Available at http:// www.who.int/mediacentre/factsheets/fs352/en/ Accessed 29 November 2015 Karlsson MK, Magnusson H, von Schewelov T, et al Prevention of falls in the elderly: a review Osteoporos Int 2013;24:747e762 Zheng G, Huang M, Liu F, et al Tai chi chuan for the primary prevention of stroke in middle-aged and elderly adults: a systematic review Evid Based Complement Alternat Med 2015:ID 742152 http://dx.doi.org/10.1155/2015/ 742152 Barnett K, Mercer SW, Norbury M, et al Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study Lancet 2012;380:37e43 Alfredsson J, Alexander KP Multiple chronic conditions in older adults with acute coronary syndromes Clin Geriatr Med 2016;32:291e303 10 Charlson ME, Pompei P, Ales KL, et al A new method of classifying prognostic comorbidity in longitudinal studies: development and validation J Chron Dis 1987;40:373e383 11 Ock M, Han JW, Lee JY, et al Estimating quality-adjusted life-year loss due to noncommunicable diseases in Korean adults through to the year 2040 Value Health 2015;18:61e66 12 Cordell CB, Borson S, Boustani M, et al Alzheimer's association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting Alzheimers Dement 2013;9:141e150 13 Chatterji S, Byles J, Cutler D, et al Health, functioning, and disability in older adultsdpresent status and future implications Lancet 2015;385:563e575 14 Chan QL, Xu X, Shaik MA, et al Clinical utility of the Informant AD8 as a dementia case finding instrument in primary healthcare J Alzheimers Dis 2015;49:121e127 15 Chung IC, Wang RH, Chiao SM, et al Quality of life and related factors in adult patient with asthma J Nurs Healthc Res 2009;5:149e157 [In Taiwan, English abstract] 16 Shih M, Chen H, Chou F, et al Quality of life and associated factors in patients with heart failure Hu li za zhi J nurs 2010;57:61e71 17 Inouye SK, Wagner DR, Acampora D, et al A predictive index for functional decline in hospitalized elderly medical patients J Gen Intern Med 1993;8: 645e652 18 Galvin JE, Roe CM, Coats MA, et al Patient's rating of cognitive ability: using the AD8, a brief informant interview, as a self-rating tool to detect dementia Arch Neurol 2007;64:725e730 19 Shah S, Vanclay F, Cooper B, et al Improving the sensitivity of the Barthel Index for stroke rehabilitation J Clin Epidemiol 1989;42:703e709 20 Chiu HY, Chen YC, Mau LY, et al An evaluation of the reliability and validity of the Chinese-versionoars multidimentional functional assessment questionnaire Chin J Public Health 1997;16:119e131 [In Taiwan, English abstract] 21 Longevity Foundation charity Division Promotion Foundation, Janpan (On line) Preventive health care referrals life function tests (25 Q) Available at http:// www.tyojyu.or.jp/hp/menu000001000/hpg000000954.htm#top Accessed 22 February 2015 22 Chen HM, Tzeng CY, Chen CM, et al Validation and reliability testing of the patient continuity of care questionnaire in elderly with chronic diseases in Taiwan J Nurs Healthc Res 2013;9:261e270 [In Taiwan, English abstract] 23 Yau KG Condensed edition of the World Health Organization quality of life questionnaire development and user manual (The first edition of revised) Taipei: World Health Organization quality of life questionnaire development Group; 2001 24 daCosta DiBonaventura M, Paulose-Ram R, Su J, et al The impact of COPD on quality of life, productivity loss, and resource use among the elderly United States workforce COPD: J Chron Obstruct Pulmon Dis 2012;9:46e57 25 Leach MJ, Gall SL, Dewey HM, et al Factors associated with quality of life in 7year survivors of stroke J Neurol Neurosurg Psychiatry 2011;82:1365e1371 26 Hopkins RO, Jackson JC Short-and long-term cognitive outcomes in intensive care unit survivors Clin Chest Med 2009;30:143e153 27 Su LQ, Huang YL The reinforcement of senior welfare policy: to promote the policy of aging in place Community Dev J 2005;110:5e14 28 Cully JA, Phillips LL, Kunik ME, et al Predicting quality of life in veterans with heart failure: the role of disease severity, depression, and comorbid anxiety Behav Med 2010;36:70e76 €rk S, Schuler M, et al Depression and disease severity as predictors 29 Faller H, Sto of health-related quality of life in patients with chronic heart failureda structural equation modeling approach J Card Fail 2009;15:286e292 30 Chen HM, Chang HJ Factors associated with quality of life in a group of dependent elders using home care services J Longterm Care 2007;11:247e265 [In Taiwan, English abstract] 31 Heller T, Fisher D, Marks B, et al Interventions to promote health: crossing networks of intellectual and developmental disabilities and aging Disabil Health J 2014;7:S24eS32 CA, Carrara G, et al Cardiovascular comorbidities relate more 32 Crepaldi G, Scire than others with disease activity in rheumatoid arthritis PLoS One 2016;11: e0146991 http://dx.doi.org/10.1371/journal.pone.0146991 33 Wu CY, Lee JI, Lee MB, et al Predictive validity of a five-item symptom checklist to screen psychiatric morbidity and suicide ideation in general population and psychiatric settings J Formos Med Assoc 2016;115:395e403 34 Chen A, Jacobsen KH, Deshmukh AA, et al The evolution of the disabilityadjusted life year (DALY) Socioecon Plann Sci 2015;49:10e15 35 Galvin JE, Tolea MI, George N, et al Publiceprivate partnerships improve health outcomes in individuals with early stage Alzheimer's disease Clin Interv Aging 2014;9:621e630 Please cite this article in press as: Chen H-M, Chen C-M, Factors Associated with Quality of Life Among Older Adults with Chronic Disease in Taiwan, International Journal of Gerontology (2016), http://dx.doi.org/10.1016/j.ijge.2016.07.002 ... risk, and quality of life of older Please cite this article in press as: Chen H-M, Chen C-M, Factors Associated with Quality of Life Among Older Adults with Chronic Disease in Taiwan, International... than 2, indicating an early sign of dementia 3.1 Quality of life of older adults with chronic diseases The average QoL score of older adults with chronic diseases was 58.30 (out of 80), showing a... Please cite this article in press as: Chen H-M, Chen C-M, Factors Associated with Quality of Life Among Older Adults with Chronic Disease in Taiwan, International Journal of Gerontology (2016),