Frailty and sarcopenia-from theory to practice.

Frailty and sarcopenia have emerged as important syndromes in geriatrics. Their impact is far reaching and are associated with many poor outcomes in older adults. Assessment of frailty and sarcopenia should form part of the assessment in older adults at all encounters between healthcare staff and older adults, coupled with comprehensive geriatric assessment. Early interventions are warranted based on existing consensus guideline recommendations. Recently, strict lockdown measures to protect at-risk groups during the coronavirus disease 2019 pandemic may have led to worsening of frailty and sarcopenia among older adults, owing to social isolation, reduced access to care, and physical inactivity. Assessment and prevention of frailty and sarcopenia are of particular importance during pandemics. Further study is warranted to find the best strategies for managing frailty and sarcopenia.

Rapid Estimate of Inadequate Health Literacy (REIHL): development and validation of a practitioner-friendly health literacy screening tool for older adults.

INTRODUCTION: This study aimed to develop and validate a brief practitioner-friendly health literacy screening tool, called Rapid Estimate of Inadequate Health Literacy (REIHL), that estimates patients' health literacy inadequacy in demanding clinical settings. METHODS: This is a methodological study of 304 community-dwelling older adults recruited from one community health centre and five district elderly community centres. Logistic regression models were used to identify the coefficients of the REIHL score's significant factors. Receiver operating characteristic (ROC) curve analysis was then used to assess the REIHL's sensitivity and specificity. Path analysis was employed to examine the REIHL's criterion validity with the Chinese Health Literacy Scale for Chronic Care and concurrent validity with self-rated health scale and the Geriatric Depression Scale-15. RESULTS: The REIHL has scores ranging from 0 to 23. It had 76.9% agreement with the Chinese Health Literacy Scale for Chronic Care. The area under the ROC curve for predicting health literacy inadequacy was 0.82 (95% confidence interval=0.78-0.87, P<0.001). The ROC curve of the REIHL showed that scores ≥11 had a sensitivity of 77.8% and specificity of 75.6% for predicting health literacy inadequacy. The path analysis model showed excellent fit (Chi squared [2, 304] 0.16, P=0.92, comparative fit index 1.00, root mean square error of approximation <0.001, 90% confidence interval=0.00-0.04), indicating that the REIHL has good criterion and concurrent validity. CONCLUSION: The newly developed REIHL is a practical tool for estimating older adults' inadequate health literacy in clinical care settings.

Assessment and diagnosis of dementia: a review for primary healthcare professionals.

Dementia is one of the most costly, disabling diseases associated with ageing, yet it remains underdiagnosed in primary care. In this article, we present the comprehensive approach illustrated with a classical case for diagnosing dementia which can be applied by healthcare professionals in primary care. This diagnostic approach includes history taking and physical examination, cognitive testing, informant interviews, neuropsychological testing, neuroimaging, and the utility of cerebrospinal fluid biomarkers. For the differential diagnosis of cognitive impairment, the differences and similarities among normal ageing, mild cognitive impairment, depression, and delirium are highlighted. As primary care physicians are playing an increasingly prominent role in the caring of elderly patients in an ageing population, their role in the diagnosis of dementia should be strengthened in order to provide a quality care for patients with dementia.

Hospital Careful Hand Feeding Program Reduced Feeding Tube Use in Patients with Advanced Dementia.

OBJECTIVES: Tube feeding is prevalent among patients with advanced dementia despite empirical data that suggest its lack of benefit. To provide an alternative to tube feeding for end-of-life patients, a careful hand feeding program was launched in a Hong Kong geriatric convalescent hospital in February 2017. We aim to compare the rates of feeding tube insertion before and after program implementation and determine risk factors for feeding tube insertion. For patients on careful hand feeding, we evaluated their sustainability on oral feeding and the rates of hospital readmissions compared with tube feeding patients over the next 12 months. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Advanced dementia patients ≥60 years with indication for tube feeding due to feeding problems admitted from January 2015-June 2019. METHODS: Data was collected on demographic and clinical variables, initial feeding mode (careful hand feeding vs. tube feeding), subsequent feeding mode changes, and hospital admissions over the next 12 months. Rates of feeding tube insertion, sustainability on oral feeding, and hospital readmissions were compared using Chi-square test. Risk factors for feeding tube insertion were assessed using logistic regression models. RESULTS: Among 616 advanced dementia patients admitted with feeding problems, feeding tube insertion rate declined significantly after careful hand feeding program implementation (72% vs 51% p<.001). Independent risk factors for feeding tube insertion were admission prior to program implementation, presence of dysphagia alone, dysphagia combined with poor intake, and lack of advance care planning. Among patients on careful hand feeding, 91% were sustained on oral feeding over the next twelve months and did not differ significantly before or after careful hand feeding program implementation (p=.67). There was no significant difference in hospital readmission rates between careful hand feeding patients and tube feeding patients before (83% vs 86%, p=.55) and after careful hand feeding program implementation (87% vs 85%, p=.63). CONCLUSIONS AND IMPLICATIONS: A hospital careful hand feeding program significantly reduced the feeding tube insertion rate among advanced dementia patients with feeding problems. The vast majority of patients on careful hand feeding were sustained on oral feeding over the next 12 months but their rate of hospital readmissions remained similarly high after program implementation.

Effectiveness of Partially Hydrolyzed Guar Gum in Reducing Constipation in Long Term Care Facility Residents: A Randomized Single-Blinded Placebo-Controlled Trial.

OBJECTIVES: To assess the effectiveness of partially hydrolyzed guar gum (PHGG) in improving constipation and reducing the use of laxatives among long term care facility (LTCF) residents. DESIGN: A single-center, prospective, randomized, placebo-controlled, single-blinded parallel-group trial from September 2021 to November 2021. SETTING: Four LTCF in Hong Kong. PARTICIPANTS: Fifty-two LTCF residents with chronic constipation (mean age: 83.9±7.6 years, male 38%). INTERVENTION: 5g PHGG mixed with 200ml water per day for 4 weeks was given to intervention group participants. Control group received 200ml water for 4 weeks. Participants continued their usual as-needed laxative (lactulose, senna or dulcolax) on their own initiative. MEASUREMENTS: Baseline measurements included age, gender, Charlson comorbidity index, Roackwood's Clinical Frailty Scale, body mass index and daily dietary fiber intake. Outcome measures were fecal characteristics assessed by Bristol Stool Form Scale, bowel opening frequency and laxative use frequency at baseline, first, second, third and fourth week of trial. Adverse events were measured. The study was registered on ClinicalTrial.gov; identifier: NCT05037565. RESULTS: There was no significant difference in bowel frequency and stool characteristics between the treatment group and control group. However, there was a significantly lower frequency of lactulose, senna, and total laxative use in the treatment group compared with controls in the third and fourth week. There was no significant difference in adverse effects between the two groups. CONCLUSION: This study showed that daily dietary fibre supplementation by using PHGG for 4 weeks in LTCF residents results in significantly less laxative use than placebo. It may be an effective way to reduce laxative dependence among older people living in LTCFs.

Herpetic shoulder paresis in a Chinese elderly patient.

A patient with left shoulder girdle weakness secondary to herpetic myotomal paresis is reported. Needle electromyography revealed denervational discharge from the left supraspinatus, deltoid, and brachioradialis muscles, compatible with a radiculopathy that was relevant to his myotomes affected by zoster infection. The patient was managed with range-of-movement and strengthening exercises as well as pain relief for post-herpetic neuralgia. Further studies are required to determine whether antiviral treatment can limit the extent of motor deficit and hasten recovery. Zoster paresis should be one of the differential diagnoses of girdle muscle weakness.

Total daily energy expenditure in wasted chronic obstructive pulmonary disease patients.

OBJECTIVES: To investigate total daily energy expenditure in chronic obstructive pulmonary disease (COPD) patients during a rehabilitation programme. DESIGN: Observational study involving a case and a control group. SUBJECTS: Ten COPD patients (six with body mass index (BMI) <18.5 kg/m(2) and four with BMI >18.5 kg/m(2)) were evaluated for their energy expenditure profile. Four additional healthy age-matched volunteers were also included for methodology evaluation. INTERVENTIONS: Measurements of total daily energy expenditure (TEE), resting energy expenditure (REE) and diet-induced thermogenesis (DIT) and energy intake were undertaken by indirect calorimetry and bicarbonate-urea methods and dietary records. RESULTS: REE in COPD patients was not significantly different from that predicted by the Harris-Benedict equation. Before the exercise day the mean TEE was 1508 kcal/day and physical activity level (PAL as calculated by TEE/REE) was 1.52. On the exercise day the TEE increased to 1568 kcal/day and PAL was 1.60, but neither of these changes were significant. The energy cost of increased physical activity during rehabilitation exercise was estimated to be 191 kcal/day. No significant change was found in DIT between the two patient groups. However, overall energy balances were found to be negative (-363 kcal/day). CONCLUSION: The rehabilitation programme did not cause a significant energy demand in COPD patients. TEE in COPD patients was not greater than in free-living healthy subjects. Patients, who were underweight, did not have a higher TEE than patients with normal weight. This suggested that malnutrition in COPD patients was not due to an increased energy expenditure. On the other hand, a significant negative energy balance due to insufficient energy intake was found in seven out of 10 patients.

Managing older patients with urinary retention in the Continence Clinic.

OBJECTIVE: To evaluate the effectiveness of the Continence Clinic for managing retention of urine in older patients. DESIGN: Retrospective study. SETTING: Continence Clinic, Fung Yiu King Hospital, Hong Kong. SUBJECTS AND METHODS: Case notes of 58 patients seen at the Fung Yiu King Hospital Continence Clinic from October 1997 to September 2001 were reviewed. The patients had retention of urine with post-void residual volume of more than 200 mL, retention of urine requiring catheterization, or had catheters for unknown reasons. RESULTS: Urodynamic study performed for 22 (38%) patients showed that 12 had detrusor underactivity, six had detrusor hyperactivity with impaired contraction, and four had bladder outlet obstruction. Among the patients who were initially catheterized, the success rate for gradually stopping reliance on urinary catheterization was 84%. The success rate was higher among those who did not undergo urodynamic study than among those who had the study done (95% versus 67%; P=0.03). Reduction in post-void residual volume was observed at the last clinic visits (P<0.0001). Moreover, significant decreases in post-void residual volume were found both for patients who did and did not have urodynamic study. CONCLUSION: Most of the older patients with urinary retention with or without indwelling catheters were treated successfully in the Continence Clinic by appropriate medical therapy. Urodynamic study can be performed for selected patients when managing urinary retention.

Efficacy of dual vaccination of pandemic H1N1 2009 influenza and seasonal influenza on institutionalized elderly: a one-year prospective cohort study.

BACKGROUND: The influenza A (H1N1) 2009 pandemic was declared by the WHO in April 2009. In Hong Kong, the vaccination program began in December 2009 in addition to the annual seasonal trivalent influenza vaccination program. The clinical efficacy of dual vaccination was unknown. METHOD: From December 2009 to November 2010, a prospective 12-month cohort study on institutionalized elderly of nine nursing homes was conducted. Elderly persons who were followed up by the Hong Kong West Community Geriatric Assessment Team and had been vaccinated by the Department of Health were included. Outcome measures included all cause mortality, all cause hospitalization, hospitalization for fever on admission and hospitalization for pneumonia based on ICD-9-CM. RESULTS: 711 elderly persons were included. 274 received both seasonal influenza vaccine and (H1N1) 2009 vaccine (H1N1-TIV), 368 received seasonal influenza vaccine only (TIV alone) and 69 received no vaccination (unvaccinated). Baseline characteristics were well matched between the groups, except there were fewer females in the TIV alone. The 12-month mortality rates of the H1N1-TIV, TIV alone and unvaccinated were 10.6%, 19.8% and 29%, respectively. Multivariate analysis demonstrated that dual vaccination in the institutionalized elderly significantly reduced all cause mortality by 54% (Hazard Ratio [HR] 0.46; 95% confidence interval [CI] 0.29-0.72; p<0.001) and 74% (HR 0.26; CI 0.13-0.49; p<0.001), compared with vaccination of seasonal vaccination alone and no vaccination, respectively. Dual vaccination also reduced all cause hospitalization, hospitalization for fever on admission and hospitalization for pneumonia compared with seasonal vaccination alone and the unvaccinated group. CONCLUSION: Dual vaccination with both H1N1 and seasonal vaccinations provided additional protection to institutionalized elderly in reducing mortality and hospitalization.