Comparison of the Physical Function Trajectories in Three Birth Cohorts of Chinese Older Adults: A 14-Year Longitudinal Study.

OBJECTIVES: It remains uncertain whether the favorable trend of reduction in physical disabilities has become reversed in the recent-born cohorts of older adults. This study aimed to compare the rate of decline with time in self-reported Instrumental Activity of Daily Living (IADL) difficulties, objective measurement of gait speed and grip strength, in three birth cohorts of Chinese older adults. DESIGN: A prospective cohort study. SETTING AND PARTICIPANTS: Four thousand Chinese older adults aged 65 years or above in three birth cohorts (1934-1938, 1929-1933, 1905-1928) were recruited from the community in Hong Kong. MEASUREMENTS: Grip strength, gait speed and IADL difficulties were measured between 2001 to 2017. Joint models were used to examine the trajectories of grip strength, gait speed and IADL difficulties over time, and the interaction effect of age-by-cohort (or also age2-by-cohort) was also examined. RESULTS: The recently born cohort (1934 - 1938) had worse grip strength and more IADL difficulties at the same age than the earlier two cohorts (1929 - 1933; 1905 - 1928). Furthermore, the most recently born cohort also followed a more rapid decline longitudinally with a greater decline observed in gait speed, grip strength and IADL difficulties for women whereas a greater decline in grip strength and IADL difficulties for men. CONCLUSIONS: The continuous improvement of physical limitations in old age may have halted and there appears to be a reversal of this favourable trend in the recent born cohort of older adults living in Hong Kong.

Forehead monitoring of heart rate in neonatal intensive care.

Heart rate is an extremely important physiological parameter to measure in critically unwell infants, as it is the main physiological marker that changes in response to a change in infant condition. Heart rate is routinely measured peripherally on a limb with a pulse oximeter. However, when infants are critically unwell, the blood supply to these peripheries is reduced in preference for central perfusion of vital organs such as the brain and heart. Measurement of heart rate with a reflection mode photoplethysmogram (PPG) sensor on the forehead could help minimise this problem and make it easier for other important medical equipment, such as cannulas, to be placed on the limbs. This study compares heart rates measured with a forehead-based PPG sensor against a wrist-based PPG sensor in 19 critically unwell infants in neonatal intensive care collecting 198 h of data. The two heart rates were compared using positive percentage agreement, Spearman's correlation coefficient and Bland-Altman analysis. The forehead PPG sensor showed good agreement with the wrist-based PPG sensor with limits of agreement of 8.44 bpm, bias of -0.22 bpm; positive percentage agreement of 98.87%; and Spearman's correlation coefficient of 0.9816. The analysis demonstrates that the forehead is a reliable alternative location for measuring vital signs using the PPG.

Vitamins B-12 and C Supplementation Improves Arterial Reactivity and Structure in Passive Smokers: Implication in Prevention of Smoking-Related Atherosclerosis.

BACKGROUND: Atherosclerosis is an important medical problem of modern society. High environmental tobacco smoke in casino is associated with an accelerated atherogenic process. We have previously shown vitamin B12 and C supplementation improves vascular reactivity and may be beneficial in vascular protection. OBJECTIVE: To evaluate the impact of vitamin supplementation on atherosclerosis (brachial artery reactivity FMD and carotid intima-media thickness IMT) in subjects exposed to high environmental tobacco smoke. DESIGN: Double-blind 2x2 factorial design fashion. SETTING: Computer randomization in 4 treatment groups: placebo (n=24), vitamin B12 (n=21), vitamin C (n=23) and vitamin B12+C (n=23) groups. PARTICIPANTS: 91 passive-smoking casino employees (19.2% male, mean age 45.0±8.2 years). INTERVENTION: Subjects were randomized to receive vitamin B12 (500µg daily), vitamin C (200mg daily), vitamin B12+C or image-matched placebo capsules for 1 year. MEASUREMENT: Brachial FMD and carotid IMT (surrogate atherosclerotic markers) were measured by ultrasound at baseline and on completion at 12 months. METHODS: 91 passive smoking casino employees (19.2% male, mean age 45.0±8.2 years) were randomized to receive vitamin B12 (500µg daily), vitamin C (200mg daily), vitamin B12+C or image-matched placebo capsules in double-blind 2 x 2 factorial design fashion for 1 year. Brachial FMD and carotid IMT (surrogate atherosclerotic markers) were measured by ultrasound at baseline and 12 months. RESULTS: Of the 78 (85.7%) passive-smoking employees completed the study, 11.5% had hypertension, 5.1% diabetes mellitus and 15.4% hypercholesterolemia. There were no significant changes in their blood pressures, lipid profiles, glucose and body mass index after supplementation for 1 year, but mild decrease in DBP (p<0.001) and blood creatinine (p<0.01) after combined vitamin B12 and C, and significant increase in blood B12 after vitamin B12 (p<0.01) and vitamin B12+C supplementations (p<0.001). Brachial FMD and cartotid IMT improved after the 3 vitamin supplementations (p<0.001), but not after placebo, being more significant after combined vitamin supplementations (p<0.0001). No adverse effects were reported. CONCLUSION: Vitamin B12 or C supplementation in passive smokers improved vascular reactivity and structures at 1 year, with implication in long term atherosclerosis prevention.

Hip fractures are preventable: a proposal for osteoporosis screening and fall prevention in older people.

Osteoporosis is highly prevalent but underdiagnosed and undertreated in Hong Kong. Fragility fractures associated with osteoporosis often result in loss of independence and increased mortality for home-dwelling patients, imposing a high socio-economic burden on society. This issue requires urgent attention given the rapid growth of the elderly population in Hong Kong by approximately 4.3% each year. To address this situation, a group of experts convened to discuss practical ways to reduce the burden of fractures and formulated three recommendations: first, all men (aged ≥70 years) and women (aged ≥65 years) should receive universal dual-energy X-ray absorptiometry assessment for osteoporosis. Second, all men (aged ≥70 years) and women (aged ≥65 years) with a fracture-risk assessment-derived 10-year risk (hip fracture with bone mineral density) ≥3% should receive ≥3 years of anti-osteoporotic treatment. Third, comprehensive structured assessment (including dual-energy X-ray absorptiometry) should be conducted in older patients with a history of falling. By implementing these recommendations, we estimate that we could prevent 5234 hip fractures in 10 years, an annual incidence reduction of approximately 7%, and save HK$425 million in direct medical costs plus substantial indirect savings. Ample clinical and cost-effectiveness data support these recommendations, and studies in Hong Kong and abroad could serve as models on how to implement them. We are confident that by applying these recommendations rigorously and systematically, a significant reduction in hip fractures in Hong Kong is achievable.

Elderly males with or without existing osteoporotic vertebral fracture have much lower future vertebral fracture risk than elderly females: the MrOS (Hong Kong) year-4 follow-up spine radiograph study.

MrOS (Hong Kong)'s year-4 follow-up shows, for subjects at baseline without vertebral deformity (VD) and endplate or/and cortex fracture (ECF), the VD progression/new VD rate during follow-up in males was half of our paired MsOS (Hong Kong) study's results. For those with VD or ECF, the VD progression/new VD was less than one sixth of females' rate. INTRODUCTION: This study documents MrOS (Hong Kong)'s year-4 follow-up, and the results are compared with the MsOS (Hong Kong) study. Of elderly females with Genant's grade-0, -1, -2, and -3 VD, at year-4 follow-up, 4.6%, 8%, 10.6%, and 28.9% had at least one VD progression or incident VD, respectively. METHODS: Spine radiographs of 1500 Chinese males with baseline (mean age 71.7 years, range 65-91 years) and year-4 follow-up were evaluated according to Genant's VD criteria and ECF (non-existent, ECF0; or existent, ECF1). Grade-2 VDs were divided into mild (VD2m, 25-34% height loss) and severe (VD2s, 34-40% height loss) subgroups. Study subjects were graded into eight categories: VD0/ECF0, VD1/ECF0, VD2m/ECF0, VD0/ECF1, VD1/ECF1, VD2m/ECF1, VD2s/ECF1, and VD3/ECF1. With an existing VD, a further height loss of ≥ 15% was a VD progression. A new VD incident was a change from grade-0 to grade-2/3, or to grade-1 with ≥ 10% height loss. RESULTS: Of subjects with Genant's grade-0, 2.05% (25/1219) developed at least one VD progression or/and new VD, while of subjects with Genant's grade-1, -2, and -3 VD, only 2% (3/149), 3.1% (3/96), and 2.8% (1/36) developed at least one VD progression/new VD, respectively. Among the three ECF0 groups, there was a significant difference in new ECF incidence, with VD0/ECF0 being the lowest and VD2m/ECF0 being the highest. CONCLUSION: VD progression/new VD is much less common in elderly men than in elderly women. Vertebrae with VD had a higher risk of developing ECF.

Osteoporotic vertebral deformity with endplate/cortex fracture is associated with higher further vertebral fracture risk: the Ms. OS (Hong Kong) study results.

Compared with vertebrae without deformity, vertebrae with mild/moderate deformity have a higher risk of endplate or/and cortex fracture (ecf). Compared with subjects without ecf, subjects with ecf are at a higher risk of short-term (4-year period) deformity progression and new incident deformity. INTRODUCTION: The progression and incidence of osteoporotic vertebral deformity/fracture (VD/VF) in elderly Chinese females remain not well documented. METHODS: Spine radiographs of 1533 Chinese females with baseline and year-4 follow-up (mean age 75.7 years) were evaluated according to Genant's VD criteria and endplate/cortex fracture (non-existent: ecf0 or existent: ecf1). Grade-2 VDs were divided into mild (vd2m, 25-34% height loss) and severe (vd2s, 34-40% height loss) subgroups. According to their VD/VF, subjects were graded into seven categories: vd0/ecf0, vd1/ecf0, vd2m/ecf0, vd1/ecf1, vd2m/ecf1, vd2s/ecf1, and vd3/ecf1. With an existing VD, a further height loss of ≥ 15% was a VD progression. A new incident VD was a change from grade-0 to grade-2/3 or to grade-1 with ≥ 10% height loss. RESULTS: Of subjects with Genant's grades 0, - 1, - 2, and - 3 VD, at follow-up, 4.6%, 8%, 10.6%, and 28.9% had at least one VD progression or new incident VD respectively. Among the three ecf0 groups, there was no difference in VD progression or new VD; while there was a significant difference in new ecf incidence, with vd0/ecf0 being lowest and vd2m/ecf0 being highest. Vd1/ecf0 and vd2m/ecf0 vertebrae had a higher risk of turning to ecf1 than vd0/ecf0 vertebrae. If vd1/ecf0 and vd2m/ecf0 subjects were combined together (range 20-34% height loss) to compare with vd1/ecf1 and vd2m/ecf1 subjects, the latter had significantly higher VD progression and new VD rates. CONCLUSION: Vertebrae with grade-1/2 VDs had a higher risk of developing ECF. Subjects with pre-existing ECFs had a higher risk of worsening or new vertebral deformities.

Cost-effectiveness of osteoporosis screening strategies for hip fracture prevention in older Chinese people: a decision tree modeling study in the Mr. OS and Ms. OS cohort in Hong Kong.

Despite the high costs of hip fracture, many governments provide limited support for osteoporosis screening. We demonstrated that osteoporosis screening by dual-energy X-ray absorptiometry (DXA) with or without pre-screening by Fracture Risk Assessment Tool (FRAX) or calcaneal ultrasound are more cost-effective than no screening in Chinese people aged 65 or over in Hong Kong. INTRODUCTION: To examine the cost-effective potential osteoporosis screening strategies for hip fracture prevention in Hong Kong. METHODS: Decision tree models were constructed to evaluate the cost per quality-adjusted life years (QALYs) of the different osteoporosis screening strategies followed by subsequent 5-year treatment with alendronate compared to no screening (but treat if a hip fracture occurs). The multiple osteoporosis screening strategies were composed of alternative tests and initiation age groups were evaluated with a 10-year horizon, and treatment were assigned if central dual-energy X-ray absorptiometry (DXA) T-score (at either the hip or spine) is - 2.5 or less. Strategies included DXA for all people and pre-screening with the Fracture Risk Assessment Tool (FRAX) at specific thresholds or by calcaneal quantitative ultrasonography (QUS) before taking DXA examination. All the model inputs were based on the Mr. OS and Ms. OS Hong Kong cohort; data are obtained from the Social Welfare Department or the published literature. RESULTS: All of the screening strategies, including the universal screening with DXA and the pre-screening with FRAX or QUS before DXA, were consistently more cost-effective than no screening for people aged 65 years old or over. One-way sensitivity analysis with a more optimistic assumption on treatment adherence or inclusion of other major osteoporotic fractures did not change the results materially. Probabilistic sensitivity analyses showed a dominant role of pre-screening with FRAX followed by subsequent osteoporosis drug treatment in people aged 70 years old or over in Hong Kong. CONCLUSIONS: Osteoporosis screening strategies based on DXA with or without pre-screening are more cost-effective compared to no screening for Chinese people aged 65 or over in Hong Kong.

Multicentre prospective observational study of feeding practices in 30-33 weeks preterm infants.

BACKGROUND: Current evidence supports progressive feeding in preterm infants. Due to lower necrotising enterocolitis risk, recent studies suggest starting total enteral feeding from birth in 30-33 weeks preterm infants. The feasibility of this practice is unclear. AIM: Explore feeding practices in 30-33 weeks preterm infants. DESIGN: Prospective, multicentre, observational study recruiting 10 consecutive 30-33 weeks preterm infants from each of the eight UK hospitals. RESULTS: Eighty infants received their first feed at median of 24 hours, achieving total enteral (without intravenous nutrition) and full feeds (≥150 ml/kg/day) at median of 5 and 8 days, respectively. Eleven infants who achieved total enteral feeding within 24 hours after birth achieved full feeds earlier (p=0.02) with shorter hospital stay (p=0.009) but were also of older gestation (p=0.004). CONCLUSION: Current early feeding approaches in 30-33 weeks preterm infants were found to be conservative. Total enteral feeding from birth is possible in these infants but further studies are needed.

A randomized controlled trial of dietetic interventions to prevent cognitive decline in old age hostel residents.

BACKGROUND/OBJECTIVES: To examine whether dietary interventions promote intakes of fruit, vegetable, fish and lower salt intake were effective in preventing cognitive decline in older people. Dietary factors have been associated with cognitive function in older people. SUBJECTS/METHODS: A total of 429 non-demented subjects in 14 old age hostels, with an average age of 83 years, were randomly assigned by hostel to have either regular group dietary counselling and menu changes or advice on hostel menu only. Food and salt intakes were estimated at regular intervals by 24-h recall or food record and fasting urinary sodium, respectively. The primary outcome was cognitive decline as defined by an increase in clinical dementia rating scale score. Secondary clinical outcomes were mini mental state examination, category fluency test, body weight, blood pressures and health-related quality of life. RESULTS: At baseline, the intervention group had more men and lower fish intake. When compared with control group, the intervention group had significantly less decline in intakes of fruit and fish. At month 33%, 22.2% and 27.2% of intervention and control group subjects had cognitive decline, respectively (Unadjusted P=0.285, χ² test). There were no significant group changes in secondary clinical outcomes. On subgroup analysis, fewer cognitively normal subjects in intervention group had cognitive decline at month 24 (adjusted P=0.065). CONCLUSIONS: Dietary interventions in older people were effective in maintaining fruit and fish intake, but this did not lead to a significant reduction in cognitive decline.

An uncommon cause of recurrent falls in an elderly man.

Falls are common among the elderly population. Examinations for the cause of falls are usually mundane, but may be challenging, leading to surprising diagnoses. We report on a previously healthy elderly man who presented with repeated falls and rapidly progressive limitations in mobility, in addition to a stutter. Neuroimaging was particularly helpful for making the diagnosis in this patient.

Correlates for a low ankle-brachial index in elderly Chinese.

This study examines the prevalence of atherosclerosis (using ankle-brachial index (ABI) value <0.9) and associated socioeconomic and lifestyle factors in elderly Chinese, adjusting for presence of cardiovascular diseases and body mass index, in a cross-sectional survey of 1999 men and 1999 women aged 65 years and over living in the community. A questionnaire containing information regarding socioeconomic status, medical history and lifestyle factors was administered. Measurement included height, weight, percentage body fat using dual-energy X-ray absorptiometry and ABI. The Hong Kong population (2000) age adjusted prevalence of ABI <0.9 was 5.3% for men and 11.0% for women. In multivariate analysis, old age, female gender, presence of cardiovascular diseases, cognitive impairment, prolonged 6 m walk, smoking habit and alcohol intake were positively associated with ABI <0.9, while negative associations were observed with Vitamin C intake >100 mg per day, with the lowest OR for the range 141-190 mg (OR 0.4). Physical activity level, and self rated higher social standing in the community, while significant in univariate analysis, were not included as independent significant factors in the multivariate model. Lifestyle factors and the female gender were independent risk factors for atherosclerosis in the elderly Chinese population.

Self-efficacy, health locus of control, and psychological distress in elderly Chinese women with chronic illnesses.

This study examined the associations among self-efficacy, health locus of control, and psychological distress in 159 elderly Chinese women who had chronic physical illnesses. The present findings did not support the dual health control hypothesis that specifies the balance between internal and external health control beliefs is related to a low level of psychological distress. Correlation results showed that internal health locus of control was linked to general self-efficacy. Results from hierarchical regression analysis indicated that health control beliefs did not interact with general self-efficacy; instead, these two variables each exerted their main effects on participants' negative mental health status. It was found that psychological distress was best predicted by a low level of general self-efficacy as well as a high level of external health locus of control. Internal health control beliefs did not contribute to the prediction of distress. Implications and limitations of this study were also discussed.

Relationship of urinary sodium/potassium excretion and calcium intake to blood pressure and prevalence of hypertension among older Chinese vegetarians.

OBJECTIVE: To examine the associations of dietary sodium and potassium, as reflected by the urinary sodium/potassium excretion, and calcium intake with blood pressure and the prevalence of hypertension among older Chinese vegetarians in Hong Kong. DESIGN: Cross-sectional study. SETTING: Research clinic in a teaching hospital in Hong Kong. SUBJECTS: A total of 111 ambulatory vegetarians over the age of 55 were recruited from members of religious organizations or old age hostels. MAIN OUTCOME MEASURES: Hypertension was defined as supine blood pressure >140/90 mmHg or a history of hypertension. Dietary sodium, potassium and calcium intakes were assessed by 24 h recall method or fasting urinary sodium or potassium/creatinine ratios. RESULTS: Seventy-one subjects (64%) were found to have hypertension. Compared with normotensive subjects, hypertensive subjects had lower calcium intake (411+/-s.d. 324 vs 589+/-428 mg, P=0.04), but higher urinary sodium/creatinine ratio (32.6+/-19.3 vs 21.0+/-12.4, P=0.00) and sodium/potassium ratio (4.7+/-2.8 vs 3.4+/-2.3, P=0.02). Among 88 subjects not taking diuretics or antihypertensive drugs, systolic blood pressure was related to calcium intake (r=-0.40), urinary sodium/creatinine ratio (r=0.39), urinary sodium/potassium ratio (r=0.30) and age (r=0.23). Diastolic blood pressure was related to urinary sodium/creatinine (r=0.29). Twenty-three subjects with high urinary sodium/potassium and low calcium intake and 16 subjects with low urinary sodium/potassium ratio and high calcium intake differed markedly with respect to systolic blood pressure (159+/-26 vs 130+/-15 mmHg) and prevalence of hypertension (78% vs 25%). CONCLUSIONS: Older Chinese vegetarians are predisposed to hypertension because of their sodium-rich but calcium-deficient diets.

Chronicity of neurological features in ciguatera fish poisoning.

A 43-year-old woman complained of colicky abdominal pain, followed by numbness, myalgias, and muscle weakness in the four limbs after eating a grouper (Epinepheius spp.). She presented to our hospital 36 hours later with increased myalgias, muscle weakness, and malaise. On examination, the muscle power and sensation in her four limbs appeared to be normal. She was given an intravenous infusion of mannitol 20% (200 ml over 1 hour) and an intramuscular injection of diclofenac (75 mg). Her myalgias then improved and she was discharged. She presented to our hospital again 1 week later with poor appetite, malaise, numbness of the four limbs, and increased muscle weakness. On examination, the muscle weakness was more marked in the lower limbs (4+/5) than in the upper limbs (5-/5) and proximally than distally. She also had some difficulty in getting up from a squatting position. She was given another intravenous infusion of mannitol 20% (200 ml over 1 hour), following which there was subjectively slight improvement in her muscle weakness. Herplasma creatine phosphokinase level was normal. Electromyography performed 4 weeks later revealed no abnormalities. When she was reviewed 45 days after the consumption of the grouper, her muscle weakness and malaise had improved considerably. She could then stand up from a squatting position. However, mild impairment of finger grip was still present. Chronicity of neurological features in other reported cases (e.g., chronic fatigue, relapse of symptoms after exposure to ciguateric fish or alcohol, and peripheral neuropathy) may also indicate a lengthy persistence of ciguatoxins in the body.