European Geriatric Medicine 4 (2013) 335–338

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Hot topic in geriatric medicine

Lists of geriatric syndromes in the Asian-Pacific geriatric societies

C.W. Won a,b, H.J. Yoo b,c,*, S.H. Yu b,c, C.O. Kim b,d, L.C.I. Dumlao e, E. Dewiasty f, J. Rowland g,
H.H. Chang h, J. Wang i, M. Akishita j, T.-L. Tan k, C. Lum l, O. Prakash m
a
Department of Family Medicine, College of Medicine and East-West Medical Research Institute, Kyung Hee University, Seoul, South Korea
b
Geriatric Syndrome Committee, Korean Geriatrics Society, Seoul, South Korea
c
Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University, 948-1, Daerim-1dong, Yongdeungpo-gu, 150-950 Seoul, South Korea
d
Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
e
Geriatric Center, Saint-Luke’s Medical Center, Quezon City, Philippines
f
Department of Internal Medicine, University of Indonesia, Jakarta, Indonesia
g
The Prince Charles Hospital, Rode Road, Brisbane, Australia
h
Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
i
Institute for Geriatric Clinic and Rehabilitation, Beijing Geriatric Hospital, Beijing, PR China
j
Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
k
Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore
l
Medical and Geriatrics Unit, Shatin Hospital, Hong Kong SAR, PR China
m
Department of Psychiatry, Institute of Human Behavior and Allied Sciences (IHBAS), New Delhi, India

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Geriatric syndromes are conditions that are highly prevalent, multifactorial, and associated
Received 14 May 2013 with substantial morbidity and poor outcomes in the elderly. Geriatricians agree on its definition, but the
Accepted 9 July 2013 lists of geriatric syndromes vary based on the purpose. The aim of this article is to attempt to reach a
Available online 6 August 2013
consensus on the list of geriatric syndromes within the Asian-Pacific geriatric societies.
Methods: We surveyed Asian-Pacific expert geriatricians using a questionnaire that asked whether each
Keywords: country’s geriatric society recognized the presented items as a geriatric syndrome.
Geriatrics
Results: Expert geriatricians from 10 Asian-Pacific nations/regions completed the questionnaire.
Asia
Dementia, incontinence, delirium, falls, hearing impairment, visual impairment, sarcopenia, malnutri-
Consensus
Geriatric syndromes tion, and frailty were agreed on as geriatric syndromes by all 10 respondents. Immobility, gait
disturbance, and pressure ulcers were included as geriatric syndromes by 90% of the respondents while
osteoporosis, failure to thrive, sleep disorder, and functional dependency were included by 80%. Less
than 50% of the respondents included self-neglect, anorexia, and emesis as geriatric syndromes.
Conclusions: Dementia, incontinence, delirium, falls, hearing impairment, visual impairment, sarcopenia,
malnutrition, frailty, immobility, gait disturbance, and pressure ulcers were included as geriatric
syndromes by at least 90% of the respondents. These lists seem to be consented to be geriatric syndromes
in Asian-Pacific geriatric societies. These lists are generally similar to the lists of geriatric syndromes
provided by professors from the western world, but with some differences.
ß 2013 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.

1. Introduction ‘‘geriatric syndromes’’ involved conditions ‘‘experienced by older –

In the elderly population, a decline in organ function,
concomitant risk factors, and chronic diseases altogether lead to
atypical disease presentations [1], and simple, single diagnoses
only explain health problems in less than 50% of these patients [2].
The term ‘‘geriatric syndrome’’ has been used to define those
complex clinical conditions that are common in the elderly and do
not fit into discrete disease categories. A previous definition of
* Corresponding author. Tel.: +82 2 829 5381.
E-mail address: hjoonyoo@gmail.com (H.J. Yoo).
particularly frail – persons, which may be triggered by acute insults,
and often are linked to subsequent functional decline’’ [3]. Until the
early 2000s, the term ‘‘geriatric syndrome’’ still meant any
commonly encountered condition in elderly persons. Many condi-
tions had been called ‘‘geriatric syndrome’’, including delirium,
dementia, depression, dizziness, emesis, falls, gait disorders, hearing
loss, insomnia, urinary incontinence, language disorders, functional
dependence, lower extremity problems, oral and dental problems,
malnutrition, osteoporosis, pain, pressure ulcers, silent angina
pectoris, sexual dysfunction, syncope, and vision loss [4].
Recently, Inouye et al. stated that geriatric syndromes are
conditions that are highly prevalent, multifactorial, and associated

1878-7649/$ – see front matter ß 2013 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
http://dx.doi.org/10.1016/j.eurger.2013.07.005
336 C.W. Won et al. / European Geriatric Medicine 4 (2013) 335–338

with substantial morbidity and poor outcomes in the elderly; and
they selected five geriatric syndromes including pressure ulcers,
incontinence, falls, functional decline, and delirium [5].
Thereafter, many geriatricians agreed on this definition of
geriatric syndrome, but the lists of geriatric syndromes still vary
depending on usage. The Education Committee Writing Group
(ECWG) of the American Geriatrics Society recommended the 13
most common geriatric syndromes for which undergraduate
students should receive extensive training [1]. This list consists
of dementia, inappropriate prescribing of medications, inconti-
nence, depression, delirium, iatrogenic problems, falls, osteoporo-
sis, sensory alterations including hearing and visual impairment,
failure to thrive, immobility and gait disturbances, pressure ulcers,
and sleep disorders [5]. Still, new geriatric syndromes such as
anorexia [6] and self-neglect [7] are being suggested. On the other
hand, of the previously suggested geriatric syndromes, osteo-
porosis and dementia should be excluded as they are categorized
as diseases. Thus, we postulate that there is, yet, no worldwide
consensus between the lists of geriatric syndromes. This dis-
cordance causes confusion in communication within the geriatric
community. As a start, our study aimed to obtain consensus on the
list of geriatric syndromes used among the Asian-Pacific geriatric
societies.
2. Methods
The questionnaire was developed by the Geriatric Syndrome
Committee of the Korean Geriatrics Society and translated into
English by a bilingual expert (Appendix A). Initially, the committee
decided what items should be asked. We selected the 13 geriatric
syndromes recommended by the Education Committee Writing
Group (ECWG) of the American Geriatrics Society, these being
dementia, inappropriate prescribing of medications, incontinence,
depression, delirium, iatrogenic problems, falls, osteoporosis,
sensory alterations including hearing and visual impairments,
failure to thrive, immobility and gait disturbances, pressure ulcers,
and sleep disorders [1]. Then we added ‘functional decline’, which
Inouye defined as a geriatric syndrome [5]. Also included were
malnutrition, emesis, dizziness, and syncope, mentioned by
Flacker as geriatric syndromes [4]. Anorexia [6], self-neglect [7],
sarcopenia [8], and frailty [9] were added based on their specified
articles.
The next step was to find geriatricians to represent each Asian-
Pacific country. The target nations/regions were Korea, Japan,
Taiwan, China, Hong Kong, Malaysia, Indonesia, Singapore,
Australia, the Philippines, and India. We searched for the
presidents of geriatric societies in Asian-Pacific countries or
experts from each country on geriatric syndromes through the
Pubmed database and by personal networks. We then mailed each
contact the questionnaire asking whether each nation’s geriatric
society recognizes the presented items as geriatric syndromes. We
asked them to complete the questionnaire themselves, or to
appoint an appropriate respondent to complete the questionnaire
on behalf of each nation’s geriatric society. We asked the
respondents whether their geriatric societies recognize the
presented items as geriatric syndromes and requested that they
involve geriatric society members to increase the accuracy of their
answers. We also asked for their definition of geriatric syndromes.
The representative geriatricians from Taiwan, Japan, China,
Australia, Indonesia, and Korea mailed back to us completed
questionnaires. For the non-respondent countries/regions (Hong
Kong, Singapore, the Philippines, and India), we delivered the
questionnaires directly to the experts during the International
Conference on Frailty (2011, Taiwan). In the end, we received
completed questionnaires from 10 Asian-Pacific nations/regions.
We were unable to contact the Malaysian geriatric experts.
3. Results
Dementia, incontinence, delirium, falls, hearing impairment,
visual impairment, sarcopenia, malnutrition, and frailty were
agreed on as geriatric syndromes by all 10 countries. Immobility,
gait disturbance, and pressure ulcers were agreed on as geriatric
syndromes by 90% of the countries. Osteoporosis, failure to thrive,
sleep disorder, and functional dependency were agreed on by 80%.
Less than 50% of the countries agreed on self-neglect, anorexia, and
emesis as geriatric syndromes (Table 1). Table 2 summarized for
comparison the items chosen to be asked in the questionnaire with

Table 1
Recognition of the following items as a geriatric syndrome in each country/region. Round circle means agreement.

Taiwan Japan China Korea Australia Indonesia Singapore Hong Kong Philippines India

Dementia O O O O O O O O O O
Inapprop Px O O O O O
Incontinence O O O O O O O O O O
Depression O O O O O O O O O
Delirium O O O O O O O O O O
Iatrogenicity O O O O O
Falls O O O O O O O O O O
Osteoporosis O O O O O O O O
Hearing imp O O O O O O O O O O
Visual imp O O O O O O O O O O
FTT O O O O O O O O
Immobility O O O O O O O O O
Gait disturb O O O O O O O O O
Pressure ulcer O O O O O O O O O
Sleep disorder O O O O O O O O
Dizziness O O O O O O O
Syncope O O O O O O
Sarcopenia O O O O O O O O O O
Self-neglect O O O
Func depend O O O O O O O O
Malnutrition O O O O O O O O O O
Emesis O
Anorexia O O O O
Frailty O O O O O O O O O O

Inapprop Px: inappropriate prescribing of medications; iatrogenicity: iatrogenic problems; hearing imp: hearing impairment; visual imp: visual impairment; FTT: failure to
thrive; gait disturb: gait disturbances; Func depend: functional dependence.
 C.W. Won et al. / European Geriatric Medicine 4 (2013) 335–338 337

Table 2
The items chosen to be asked in the questionnaire and their references. The last column presents the items consented as geriatric syndromes in Asian-Pacific geriatric
societies.

ECWG [1] Flacker [4] Inouye [5] Others Asian-Pacific geriatric societies

Dementia O O O
Inapprop Px O
Incontinence O O O O
Depression O O
Delirium O O O O
Iatrogenicity O
Falls O O O O
Osteoporosis O O
Hearing imp O O O
Visual imp O O O
FTT O
Immobility O O
Gait disturb O O O
Pressure ulcer O O O O
Sleep disorder O O
Dizziness O
Syncope O
Sarcopenia Cruz-Jentoft et al., [8] O
Self-neglect Pavlou et al., [7]
Func depend O O
Malnutrition O O
Emesis O
Anorexia Landi et al., [6]
Frailty Ahmed et al., [9] O

Inapprop Px: inappropriate prescribing of medications; iatrogenicity: iatrogenic problems; hearing imp: hearing impairment; visual imp: visual impairment; FTT: failure to
thrive; gait disturb: gait disturbances; Func depend: functional dependence; ECWG: Education Committee Writing Group of the American Geriatrics Society.
Flacker also called language disorders, lower extremity problems, oral and dental problems, pain, silent angina pectoris, and sexual dysfunction as geriatric syndromes.

their references and the items consented as geriatric syndromes in
Asian-Pacific geriatric societies.
In addition to these items, several of the respondents suggested
additional geriatric syndromes. The Korean geriatricians proposed
weight loss, body ache, cachexia, Parkinsonism, impaired home-
ostasis, constipation, and osteoarthritis. The Hong Kong geria-
tricians suggested elderly abuse and dysphagia/swallowing
problems. The Indonesian geriatricians proposed impotence, stool
impaction, immunodeficiency/immunosenescence, and insomnia
as geriatric syndromes. The Japanese geriatricians suggested the
followings as geriatric syndromes: disturbance in consciousness,
headache, numbness, speech disorder, lumbago, fracture, con-
stipation, bedridden state, disuse, dehydration, edema, dysphagia,
melena, fever, hypothermia, stridor, cough, dyspnea, diarrhea, joint
deformity, nocturia, aspiration, obesity, weight loss, arrhythmia,
and chest pain.
From these additions, it was obvious the geriatricians are not
satisfied with the present list of geriatric syndromes. The reason
may originate from the differences in the definitions or meanings
of geriatric syndrome. The Indonesian geriatricians define geriatric
syndrome as ‘‘signs and symptoms frequently occurring in
geriatric patients’’. The Chinese geriatricians use the definition,
the multifactorial health conditions that occur when the accumu-
lated effects of impairments in multiple systems render an older
person vulnerable to situational challenges. The Singaporean
geriatricians define geriatric syndrome as functional decline as a
manifestation of medical illness.
4. Discussion
The definition of geriatric syndrome provided by Inouye et al. is
believed to be the most up to date, best encompassing modern
concepts. Of pressure ulcers, incontinence, falls, functional decline,
and delirium proposed by Inouye et al. as geriatric syndromes,
incontinence, falls and delirium were agreed on by all the
respondents. Pressure ulcers was agreed on by 90% of the
respondents, and functional dependency by 80%. It appears that
Asian geriatric societies generally follow the consensus of the
western countries. However, dementia, which Inouye et al. did not
indicate, was agreed on as a geriatric syndrome by all 10
respondents. This addition in thought may be due to the difference
in opinions on whether dementia is a syndrome or a disease.
Inouye et al. may not have indicated dementia as a geriatric
syndrome because it can be categorized as a disease and not just a
condition.
Similarly, although not indicated by Inouye et al., hearing
impairment, visual impairment, sarcopenia, malnutrition, and
frailty were agreed on as geriatric syndromes by all 10 countries/
regions with depression, immobility, and gait disturbances agreed
on by 90%. Further, osteoporosis, failure to thrive, sleep disorder,
and functional dependency were agreed on by 80% of the
respondents. It is not surprising that sarcopenia was agreed to
be a geriatric syndrome as Cruz-Jentoft et al. demonstrated that
sarcopenia is indeed a geriatric syndrome [8].
New listings of geriatric syndromes have been provided by
many authors and expert panels after Inouye’s definition in 2007. A
technical expert panel of academic geriatric physicians, epide-
miologists, and nurses reached consensus on eight geriatric
syndromes that would be recommended for preventive health
services in terms of mortality in older adults. These were multiple
comorbidities, cognitive impairment, frailty, disability, sarcopenia,
malnutrition, impaired homeostasis, and chronic inflammation
[10]. Brown et al. addressed functional impairment, cognitive
impairment, frailty, depression, hearing impairment, visual
impairment, and urinary incontinence as geriatric syndromes
[11]. Lakhan et al. followed Inouye’s definition and considered falls,
pressure ulcers, delirium, functional dependency, cognitive
impairment, and incontinence to be geriatric syndromes [12].
The lists of geriatric syndromes provided by more than 90% of the
Asian-Pacific experts lined up well with the lists of these western
experts.
However, the Asian-Pacific geriatricians suggestions of addi-
tional lists for geriatric syndromes may be reflecting that the term
is sometimes defined in terms of a wider concept, which are
338 C.W. Won et al. / European Geriatric Medicine 4 (2013) 335–338

frequently occurring in geriatric patients. It is obvious that a Please gather accurate answers from your academic society
consensus on the definition of and a corresponding list for members.
geriatric syndromes is needed among the Asian-Pacific geriatric
societies. Yes No Comments
This study has some methodological flaws. Even though we
Dementia
asked the respondents to provide a representative answer after
Inappropriate prescribing of medications
gathering thoughts from the members of their society, we did not
confirm how they reached their final answer. However, as an Incontinence

example, in Korea, we surveyed the geriatric board members of the Depression

Korean Geriatrics Society and got answers from 12 geriatricians. Delirium

Items agreed on by more than six of these geriatricians were added Iatrogenic problems
to the list of geriatric syndromes by the Geriatric Syndrome Falls
Committee under the Korean Geriatrics Society. In Japan, three Osteoporosis
geriatric syndromes experts had a discussion and came up with Hearing impairment
their answers. Visual impairment
In spite of this limitation, I believe that this survey presented an Failure to thrive
overview and a movement toward a consensus of geriatric Immobility
syndromes among the Asian countries. Gait disturbances
Pressure ulcers
5. Conclusions Sleep disorders
Dizziness
We developed a survey containing a list of geriatric Syncope
syndromes and requested its completion by Asian-Pacific Sarcopenia
geriatricians from the following 10 countries/regions: Korea, Self-neglect
Japan, Taiwan, China, Hong Kong, Indonesia, Singapore, Australia,
Functional dependence
the Philippines, and India. Dementia, incontinence, delirium,
Malnutrition
falls, hearing impairment, visual impairment, immobility, gait
Emesis
disturbance, pressure ulcers, sarcopenia, malnutrition, and
Anorexia
frailty were agreed on as geriatric syndromes by at least 90%
Frailty
of the respondents, and seem to be consented to be geriatric
syndromes in Asian-Pacific geriatric societies. These lists were
similar to the lists provided by western experts. However, our 3. Are there other items recognized as geriatric syndrome(s)
respondents suggested additional items as geriatric syndromes. by your geriatric society? Please gather accurate answer from your
This shows that more work is needed among the Asian-Pacific academic society members.
geriatric societies for a consensus on the definition of geriatric
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