• Including physical health, mental health, social functioning, quality of life, daily functioning, and health care resource utilizations. Feasibility analysis is applied to assess the possibility for large scale disseminations of the proposed project. [ Time Frame: Center for Health Policy Research and Development ] [ Designated as safety issue: Yes ]
  

• The results of the proposed study will help shaping the geriatric healthcare policy toward the goal of "active aging" in Taiwanese community-dwelling elders. [ Time Frame: Center for Health Policy Research and Development ] [ Designated as safety issue: Yes ]
  

Subjects are community-dwelling Taiwanese elders older than 65 years of age, living in the catchment area of Tofun Twon in Maoli County, Taiwan. Subjects are first screened with telephone interviews. Potential enrollees are invited to community hospitals in the catchment areas for second stage interviews. Subjects meeting criteria of "prefrailty or frailty"- the frailty group, "osteopenia or osteoporosis"- the osteoporosis group, and "sub-threshold depression or major depression"- the depression group are enrolled. Subjects are randomised into the "usual care group" or the "integrated care group" by study care managers with prespecified protocol.

Interventions in the "usual care group" and the "integrated care group" among subjects with three geriatric syndromes are described below:

"Usual care- frailty and osteoporosis group": Educational materials on general knowledge of the two syndromes are provided. Subjects are encouraged to have balanced nutrition, regular exercises or rehabilitations when appropriate. It is at the subjects' discretions to decide the intensities of interventions.

"Integrated care- frailty and osteoporosis group": The interdisciplinary geriatric care team (IGCT) will provide educational sessions on general knowledge of the two syndromes to subjects. The team will also assess nutritional needs, rehabilitation need, and exercise capacities of the subjects with personalized management strategies. Supervised rehabilitation/ exercise programs are also provided. If subjects do not improve on any of the 5 frailty indicators in 6 months, comprehensive geriatric assessments (CGA) are performed to look for other potential modifiable factors with appropriate interventions.

"Usual care- depression group": Educational materials of late-life depression are provided. Again, it is at the subjects' discretions to determine the intensities of their interventions.

"Integrated care- depression group": All subjects are referred to primary care physicians (PCPs). Treatment guidelines for the optimal management of late-life depression will be provided to the PCPs. Care managers in the IGCT will provide telephone counseling, education sessions to subjects and their caregivers. Care mangers will also coordinate their care with the PCPs and follow on the treatment effects. Treatments typically include antidepressants in subjects with major depressive disorder and antidepressants or omega-3 PUFAs in cases with sub-threshold depressions.