Self-perceived upper extremity motor function predicts health-related quality of life in chronic stroke survivors.

PURPOSE: To examine whether the Upper Extremity Functional Index (UEFI) score independently contributes to the Stroke Impact Scale (SIS) score and quantified its relative contribution to SIS scores in chronic stroke survivors. MATERIALS AND METHODS: A cross-sectional study in a university-based rehabilitation centre with people with chronic stroke (N = 95) aged ≥ 50 years. The outcome measures included paretic hand grip strength, Fugl-Meyer Upper Extremity Assessment (FMA-UE), Wolf Motor Function Test (WMFT), UEFI, and SIS. RESULTS: Correlation analysis revealed that paretic hand grip strength, FMA-UE, UEFI, and WMFT scores exhibited a significant moderate positive correlation with SIS scores (r = 0.544-0.687, p < 0.001). The results of a regression model indicated that after adjustment for demographic factors and stroke-related impairments, the UEFI scores remained independently associated with SIS scores, accounting for 18.8% of the variance. The entire model explained 60.3% of the variance in SIS scores. CONCLUSIONS: Self-perceived UE motor function is a crucial component to be included in rehabilitation programmes aimed at enhancing quality of life and participation among chronic stroke survivors.

Observation-based outcome measures, e.g., Fugl­Meyer Assessment for Upper Extremity (FMA-UE), Wolf Motor Function Test (WMFT) could not predict the health-related quality of life (Stroke Impact scale (SIS)) in chronic stroke survivors in our study, which was contradictory with current studies.A self-perceived outcome measure to evaluate upper extremity function (Upper Extremity Functional Index (UEFI)) could independently predict the health-related quality of life (SIS), accounting for 18.8% of the variance.Our study demonstrated that self-perceived UE motor function would be an important component to optimize the rehabilitation programmes aimed at enhancing quality of life and social participation among chronic stroke survivors.

Effects of mirror therapy with electrical stimulation for upper limb recovery in people with stroke: a systematic review and meta-analysis.

PURPOSE: To provide updated evidence about the effects of MT with ES for recovering upper extremities motor function in people with stroke. METHODS: Systematic review and meta-analysis were completed. Methodological quality was assessed using the version 2 of the Cochrane risk-of-bias tool. The GRADE approach was employed to assess the certainty of evidence. RESULTS: A total of 16 trials with 773 participants were included in this review. The results demonstrated that MT with ES was more effective than sham (standardized mean difference [SMD], 1.89 [1.52-2.26]) and ES alone (SMD, 0.42 [0.11-0.73]) with low quality of evidence, or MT alone (SMD, 0.47[0.04-0.89]) with low quality of evidence for improving upper extremity motor control assessed using Fugl-Meyer Assessment. MT with ES had significant improvement of (MD, 6.47 [1.92-11.01]) the upper extremity gross gripping function assessed using the Action Research Arm Test compared with MT alone with low quality of evidence. MT combined with ES was more effective than sham group (SMD, 1.17 [0.42-1.93) for improving the ability to perform activities of daily living with low quality of evidence assessed using Motor Activity Log. CONCLUSION: MT with ES may be effective in improving upper limb motor recovery in people with stroke.

Combining Mirror Therapy (MT) and Electrical Stimulation (ES) modality could improve upper limb motor control, gross gripping function, and performance in ADLs based on ICF for people with stroke.Those individuals with subacute stroke are recommended as the optimal target group for the combined MT and ES.

Clinical Outcomes Following Treatment for COVID-19 With Nirmatrelvir/Ritonavir and Molnupiravir Among Patients Living in Nursing Homes.

Importance: Older patients living in nursing homes are at very high risk of mortality after getting COVID-19. Objective: To evaluate outcomes following oral antiviral treatment for COVID-19 among nonhospitalized older patients living in nursing homes. Design, Setting, and Participants: This is a territory-wide, retrospective cohort study conducted between February 16 and March 31, 2022, with the last follow-up date on April 25, 2022. Participants were patients with COVID-19 living in nursing homes in Hong Kong. Data analysis was performed from May to June 2022. Exposures: Molnupiravir, nirmatrelvir/ritonavir, or no oral antiviral treatment. Main Outcomes and Measures: The primary outcome was hospitalization for COVID-19, and the secondary outcome was risk of inpatient disease progression (ie, admission to intensive care unit, use of invasive mechanical ventilation, and/or death). Results: Of 14 617 patients (mean [SD] age, 84.8 [10.2] years; 8222 women [56.2%]), 8939 (61.2%) did not use oral antivirals, 5195 (35.5%) used molnupiravir, and 483 (3.3%) used nirmatrelvir/ritonavir. Compared with patients who did not use oral antivirals, those who used molnupiravir and nirmatrelvir/ritonavir were more likely to be female and less likely to have comorbid illnesses and hospitalization in the past year. At a median (IQR) follow-up of 30 (30-30) days, 6223 patients (42.6%) were hospitalized and 2307 patients (15.8%) experienced inpatient disease progression. After propensity score weighting, both molnupiravir and nirmatrelvir/ritonavir were associated with a reduced risk of hospitalization (molnupiravir, weighted hazard ratio [wHR], 0.46; 95% CI, 0.37-0.57; P < .001; nirmatrelvir/ritonavir, wHR, 0.46; 95% CI, 0.32-0.65; P < .001) and inpatient disease progression (molnupiravir, wHR, 0.35; 95% CI, 0.23-0.51; P < .001; nirmatrelvir/ritonavir, wHR, 0.17; 95% CI, 0.06-0.44; P < .001). Nirmatrelvir/ritonavir was comparable to molnupiravir in achieving better clinical outcomes (hospitalization, wHR, 1.00; 95% CI, 0.75-1.33; P = .99; inpatient disease progression, wHR, 0.49; 95% CI, 0.20-1.20; P = .12). Conclusions and Relevance: In this retrospective cohort study, the use of oral antivirals to treat COVID-19 was associated with a reduced risk of hospitalization and inpatient disease progression among patients living in nursing homes. The findings of this study of nursing home residents could be reasonably extrapolated to other frail older patients living in the community.

Safety, Feasibility, and Acceptability of Telemedicine for Hypertension in Primary Care: A Proof-of-concept and Pilot Randomized Controlled Trial (SATE-HT).

Hypertension (HT) continues to be a leading cause of cardiovascular death and an enormous burden on the healthcare system. Although telemedicine may provide improved blood pressure (BP) monitoring and control, it remains unclear whether it could replace face-to-face consultations in patients with optimal BP control. We hypothesized that an automatic drug refill coupled with a telemedicine system tailored to patients with optimal BP would lead to non-inferior BP control. In this pilot, multicenter, randomized control trial (RCT), participants receiving anti-HT medications were randomly assigned (1:1) to either the telemedicine or usual care group. Patients in the telemedicine group measured and transmitted their home BP readings to the clinic. The medications were refilled without consultation when optimal control (BP < 135/85 mmHg) was confirmed. The primary outcome of this trial was the feasibility of using the telemedicine app. Office and ambulatory BP readings were compared between the two groups at the study endpoint. Acceptability was assessed through interviews with the telemedicine study participants. Overall, 49 participants were recruited in 6 months and retention rate was 98%. Participants from both groups had similar BP control (daytime systolic BP: 128.2 versus 126.9 mmHg [telemedicine vs. usual care], p = 0.41) and no adverse events. Participants in the telemedicine group had fewer general outpatient clinic attendances (0.8 vs. 2, p < 0.001). Interviewees reported that the system was convenient, timesaving, cost saving, and educational. The system could be safely used. However, the results must be verified in an adequately powered RCT. Trial registration: NCT04542564.

Impact of the Use of Oral Antiviral Agents on the Risk of Hospitalization in Community Coronavirus Disease 2019 Patients (COVID-19).

BACKGROUND: We examined the effectiveness of molnupiravir and nirmatrelvir/ritonavir in reducing hospitalization and deaths in a real-world cohort of nonhospitalized patients with coronavirus disease 2019 (COVID-19). METHODS: This was a territory-wide retrospective cohort study in Hong Kong. Nonhospitalized COVID-19 patients who attended designated outpatient clinics between 16 February and 31 March 2022 were identified. Patients hospitalized on the day of the first clinic appointment or used both oral antivirals were excluded. The primary endpoint was hospitalization. The secondary endpoint was a composite of intensive care unit admission, invasive mechanical ventilation use, and/or death. RESULTS: Of 93 883 patients, 83 154 (88.6%), 5808 (6.2%), and 4921 (5.2%) were oral antiviral nonusers, molnupiravir users, and nirmatrelvir/ritonavir users, respectively. Compared with nonusers, oral antiviral users were older and had more comorbidities, lower complete vaccination rate, and more hospitalizations in the previous year. Molnupiravir users were older and had more comorbidities, lower complete vaccination rate, and more hospitalizations in the previous year than nirmatrelvir/ritonavir users. At a median follow-up of 30 days, 1931 (2.1%) patients were hospitalized and 225 (0.2%) patients developed the secondary endpoint. After propensity score weighting, nirmatrelvir/ritonavir use (weighted hazard ratio 0.79; 95% confidence interval [CI], 0.65-0.95; P = .011) but not molnupiravir use (weighted hazard ratio 1.17; 95% CI, 0.99-1.39; P = .062) was associated with a reduced risk of hospitalization than nonusers. The use of molnupiravir or nirmatrelvir/ritonavir was not associated with a lower risk of the secondary endpoint as compared with nonusers. CONCLUSION: Use of nirmatrelvir/ritonavir but not molnupiravir was associated with a reduced risk of hospitalization in real-world nonhospitalized patients with COVID-19.

Inadequate energy and protein intake, underweight and malnutrition are associated with in-hospital mortality among COVID-19 rehabilitation patients during the omicron outbreak in Hong Kong.

Objective: Malnourished COVID-19 patients were prone to higher mortality and longer length of stay (LOS). This study aims to investigate the malnutrition risk prevalence in the COVID-19 patients and how other nutritional indicators are related to the clinical outcomes in a rehabilitation hospital. Methods: A retrospective cross-sectional study involved 174 COVID-19 patients during the rehabilitation phase. Malnutrition risk, nutritional indicators, mortality, and LOS were compared among different risk groups. Albumin, nutrition intake, and body mass index (BMI) were investigated for their effects on the clinical outcomes. Results: The prevalence of malnutrition risk was 94.9%; those older were higher in malnutrition risk. BMI, energy and protein intakes decreased as the malnutrition risk increased. Albumin, energy and protein intakes were lower in the death group. The high malnutrition risk group and severely underweight patients had 2.7 times and 2.2 times higher in-hospital death, respectively. For subjects ≥75 years old, the odds ratio to death was 6.2 compared to those <75 years old. Conclusion: We observed a high malnutrition risk of 94.9% in COVID-19 patients. Patients with malnutrition risk had a lower BMI, lower nutritional intake, and a higher chance of in-hospital death. These results reinforced the importance of nutrition management in COVID-19 patients.

Effectiveness of a Two-Tier Family-Oriented Intervention in Enhancing the Family Functioning and Care Capacity of the Family Caregivers of Stroke Survivors: Protocol for a Randomized Controlled Trial.

BACKGROUND: Stroke has profound impacts on families. Often, family members, including stroke survivors and the person who takes up the role of the primary caregiver, would encounter demands on finances, rehabilitation arrangement, and even conflicts. Hence, a family-oriented intervention is expected to enable families to rebuild internal and external resources to achieve optimal rehabilitation and community reintegration. OBJECTIVE: This study aims to describe a design of a two-tier family-oriented care management intervention for enhancing the family functioning and care capacity of the caregivers of stroke survivors. METHODS: The two-tier care management intervention was guided by a standardized protocol conducted by trained professional care managers (first tier) with the support of trained volunteers (second tier), which lasted for 8-12 weeks. Participants were recruited through collaborating hospitals according to inclusion and exclusion criteria. In order to examine the effectiveness and cost-effectiveness of the two-tier care management intervention, a two-arm randomization multicenter study was designed, including an active comparison group, which was guided by a standardized protocol conducted by trained volunteers. Dyadic participants, including both stroke survivors and their primary caregivers for both groups, were invited to participate in a questionnaire survey using standardized and purposefully developed measures 3 times: before the intervention, immediately after the intervention, and 2 months after the intervention. The primary outcome was family functioning measured by the Family Role Performance Scale and Family Assessment Device-General Functioning Scale. The secondary outcomes included caregiving burden, depressive symptoms, care management strategies, and the incremental cost-effectiveness ratio. RESULTS: Recruitment began in January 2017 and was completed at the end of April 2019. Data collection was completed at the end of March 2020. As of March 2020, enrollment has been completed (n=264 stroke caregivers). A total of 200 participants completed the baseline questionnaires. We aim to publish the results by mid-2021. CONCLUSIONS: This study successfully developed a two-tier care management protocol that aims to enhance the family functioning of the caregivers of stroke survivors. Guided by a standardized protocol, this family-oriented two-tier intervention protocol was found to be feasible among Chinese families. TRIAL REGISTRATION: ClinicalTrials.gov NCT03034330; https://ichgcp.net/clinical-trials-registry/NCT03034330. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/16703.

Characterising frailty, metrics of continuous glucose monitoring, and mortality hazards in older adults with type 2 diabetes on insulin therapy (HARE): a prospective, observational cohort study.

BACKGROUND: To our knowledge, no previous study has examined the inter-relationship between frailty, dysglycaemia, and mortality in frail older adults with type 2 diabetes who are on insulin therapy. We used continuous glucose monitors (CGMs) to profile this patient population and determine the prognostic value of CGM metrics. We hypothesised that incremental frailty was associated with increased hypoglycaemia or time below range (TBR). METHODS: HARE was a multicentre, prospective, observational cohort study with mortality hazard analysis carried out in four hospitals in Hong Kong. Eligible participants were community-living adults aged 70 years and older; had had type 2 diabetes for 5 years or more; were on insulin therapy; were frail; and were not hospitalised at the time of frailty assessment and CGM recording. Glucose control was characterised according to the Advanced Technologies and Treatments for Diabetes 2019 international consensus clinical targets. Frailty index was computed, and comprehensive frailty assessments and targeted serum metabolic profiling were performed. The Jonckheere-Terpstra test for trend was used to analyse frailty index tertiles and variables. Inter-relationships between CGM metrics and frailty, glycated haemoglobin A1c (HbA1c), and serum albumin were characterised using adjusted regression models. Survival analysis and Cox proportional hazard modelling were performed. FINDINGS: Between July 25, 2018, and Sept 27, 2019, 225 participants were recruited, 222 of whom had CGMs fitted and 215 of whom had analysable CGM data (190 were frail, 25 were not frail). Incremental frailty was associated with older age, greater HbA1c, worse renal function, and history of stroke. Eight of 11 CGM metrics were significantly associated with frailty. Decreased time in range (TIR; glucose concentration 3·9-10·0 mmol/L) and increased time above range (TAR) metrics were strongly correlated with increased frailty and hyperglycaemia, whereas TBR metrics were marginally or not different between frailty levels. Glucose-lowering agents did not significantly affect regression estimates. In patients with HbA1c of 7·5% or more, reduced serum albumin was associated with level 2 TAR (glucose concentration >13·9 mmol/L) and dysglycaemia. During a median follow-up of 28·0 months (IQR 25·3-30·4), increased level 2 TAR was predictive of mortality explainable by frailty in the absence of detectable interaction. Each 1% increment of level 2 TAR was associated with 1·9% increase in mortality hazard. INTERPRETATION: In older adults with type 2 diabetes who are on insulin therapy, incremental frailty was associated with increased dysglycaemia and hyperglycaemia rather than hypoglycaemia. Mortality hazard was increased with severe hyperglycaemia. Future clinical studies and trials targeting actionable CGM metrics highlighted in this study could translate into improved care and outcomes. FUNDING: Health and Medical Research Fund, Food and Health Bureau, The Government of the Hong Kong Special Administrative Region of China.

Randomized trial of a patient empowerment and cognitive training program for older people with diabetes mellitus and cognitive impairment.

AIM: To evaluate the effectiveness of a combined patient empowerment program (PEP) and cognitive training (CT) program on improving glycemic control among older subjects with diabetes and cognitive impairment. METHODS: A prospective single blinded, randomized controlled study was carried out in 139 older patients with diabetes aged ≥65 years with memory complaints and recent glycosylated hemoglobin level of 7-9%. They were randomly assigned to either undergo once-weekly PEP combined with CT for 10 weeks (intervention group, N = 73) or receive no intervention (control group, N = 66). All participants were followed up at months 4 and 12 to examine the immediate and long-term effects on glycemic control, cognition, mood and compliance to drug and diabetes self-management. RESULTS: The intervention did not significantly reduce glycosylated hemoglobin. The intervention group showed significant progressive improvement in memory over 1 year and executive function improved significantly at month 12. There was no significant change in diabetes self-management activities with the intervention. CONCLUSIONS: Combination of PEP and CT did not improve glycemic control or self-care activities in older patients with diabetes and memory complaints but was effective in improving cognitive function in the longer term. Geriatr Gerontol Int 2020; 20: 1164-1170.

Barriers to advance care planning: a qualitative study of seriously ill Chinese patients and their families.

BACKGROUND: Advance care planning (ACP) facilitates identification and documentation of patients' treatment preferences. Its goal aligns with that of palliative care - optimizing quality of life of seriously ill patients. However, concepts of ACP and palliative care remain poorly recognized in Chinese population. This study aims at exploring barriers to ACP from perspective of seriously ill patients and their family caregivers. METHODS: This is a qualitative study conducted in a Palliative Day Care Centre of Hong Kong between October 2016 and July 2017. We carried out focus groups and individual interviews for the seriously ill patients and their family caregivers. A semi-structured interview guide was used to explore participants' experiences and attitudes about ACP. Qualitative content analysis was adopted to analyze both manifest content and latent content. RESULTS: A total of 17 patients and 13 family caregivers participated in our study. The qualitative analysis identified four barriers to ACP: 1) limited patients' participation in autonomous decision making, 2) cognitive and emotional barriers to discussion, 3) lack of readiness and awareness of early discussion, and 4) unprepared healthcare professionals and healthcare system. CONCLUSIONS: Participations of seriously ill patients, family caregivers and healthcare workers in ACP initiation are lacking respectively. A series of interventions are necessary to resolve the barriers.

Pilot study on comparisons between the effectiveness of mobile video-guided and paper-based home exercise programs on improving exercise adherence, self-efficacy for exercise and functional outcomes of patients with stroke with 3-month follow-up: A single-blind randomized controlled trial.

OBJECTIVE: To compare the effectiveness of mobile video-guided home exercise program and standard paper-based home exercise program. METHODS: Eligible participants were randomly assigned to either experimental group with mobile video-guided home exercise program or control group with home exercise program in a standard pamphlet for three months. The primary outcome was exercise adherence. The secondary outcomes were self-efficacy for exercise by Self-Efficacy for Exercise (SEE) Scale; and functional outcomes including mobility level by Modified Functional Ambulatory Category (MFAC) and basic activities of daily living (ADL) by Modified Barthel Index (MBI). All outcomes were captured by phone interviews at 1 day, 1 month and 3 months after the participants were discharged from the hospitals. RESULTS: A total of 56 participants were allocated to the experimental group ( n = 27 ) and control group ( n = 29 ) . There were a significant between-group differences in 3-months exercise adherence (experimental group: 75.6%; control group: 55.2%); significant between-group differences in 1-month SEE (experimental group: 58.4; control group: 43.3) and 3-month SEE (experimental group: 62.2; control group: 45.6). For functional outcomes, there were significant between-group differences in 3-month MFAC gain (experimental group: 1.7; control group: 1.0). There were no between-group differences in MBI gain. CONCLUSION: The use of mobile video-guided home exercise program was superior to standard paper-based home exercise program in exercise adherence, SEE and mobility gain but not basic ADL gain for patients recovering from stroke.

Heart Failure and Frailty in the Community-Living Elderly Population: What the UFO Study Will Tell Us.

Heart failure and frailty are clinical syndromes that present with overlapping phenotypic characteristics. Importantly, their co-presence is associated with increased mortality and morbidity. While mechanical and electrical device therapies for heart failure are vital for select patients with advanced stage disease, the majority of patients and especially those with undiagnosed heart failure would benefit from early disease detection and prompt initiation of guideline-directed medical therapies. In this article, we review the problematic interactions between heart failure and frailty, introduce a focused cardiac screening program for community-living elderly initiated by a mobile communication device app leading to the Undiagnosed heart Failure in frail Older individuals (UFO) study, and discuss how the knowledge of pre-frailty and frailty status could be exploited for the detection of previously undiagnosed heart failure or advanced cardiac disease. The widespread use of mobile devices coupled with increasing availability of novel, effective medical and minimally invasive therapies have incentivized new approaches to heart failure case finding and disease management.

Effects of whole-body vibration on balance and mobility in institutionalized older adults: a randomized controlled trial.

OBJECTIVE: To investigate whether a comprehensive exercise program was effective in improving physical function among institutionalized older adults and whether adding whole-body vibration to the program conferred additional therapeutic benefits. DESIGN: A single-blinded randomized controlled trial was conducted. SETTING: This study was carried out in residential care units. PARTICIPANTS: In total, 73 older adults (40 women, mean age: 82.3 ± 7.3 years) were enrolled into this study. INTERVENTIONS: Participants were randomly allocated to one of the three groups: strength and balance program combined with whole-body vibration, strength and balance program without whole-body vibration, and social and recreational activities consisting of upper limb exercises only. All participants completed three training sessions per week for eight weeks. OUTCOME MEASURES: Assessment of mobility, balance, lower limb strength, walking endurance, and self-perceived balance confidence were conducted at baseline and immediately after the eight-week intervention. Incidences of falls requiring medical attention were recorded for one year after the end of the training period. RESULTS: A significant time × group interaction was found for lower limb strength (five-times-sit-to-stand test; P = 0.048), with the exercise-only group showing improvement (pretest: 35.8 ± 16.1 seconds; posttest: 29.0 ± 9.8 seconds), compared with a decline in strength among controls (pretest: 27.1 ± 10.4 seconds; posttest: 28.7 ± 12.3 seconds; P = 0.030). The exercise with whole-body vibration group had a significantly better outcome in balance confidence (pretest: 39.2 ± 29.0; posttest: 48.4 ± 30.6) than the exercise-only group (pretest: 35.9 ± 24.8; posttest: 38.2 ± 26.5; P = 0.033). CONCLUSION: The exercise program was effective in improving lower limb strength among institutionalized older adults but adding whole-body vibration did not enhance its effect. Whole-body vibration may improve balance confidence without enhancing actual balance performance.

Quality of life and palliative care needs of elderly patients with advanced heart failure.

OBJECTIVE: To examine the quality of life and palliative care needs of elderly patients with advanced heart failure (HF). METHODS: This was a correlation descriptive study conducted at a 650-bed sub-acute hospital. Patients who were aged 65 or over, diagnosed with HF of New York Heart Association Class III or IV symptoms, and mentally sound were eligible to the study. The Edmonton Symptom Assessment Scale, the overall quality of life single item scale, and the McQill Quality of Life Questionnaire (MQoL), were used for measurement. Multiple regression analysis was performed to determine factors for predicting quality of life. RESULTS: A convenience sample of 112 patients was recruited. Their age was 81.5 ± 8.5 years. The three most distressing symptoms reported by the patients were tiredness (5.96 ± 2.78), drowsiness (5.47 ± 2.93), and shortness of breath (5.34 ± 2.96). Their mean overall quality of life single item scale score was 4.72 ± 2.06 out of 10. The mean MQoL physical subscale score was the lowest (4.20 ± 1.767), whereas their mean psychological subscale was the highest (7.14 ± 2.39). However, in a multivariate analysis model, quality of life was significantly associated with existential wellbeing, physical wellbeing, psychological wellbeing and educational level. CONCLUSIONS: The findings highlight that spiritual concerns are significant palliative care needs among elderly patients with advanced HF, in addition to symptom management. This is in line with the argument that palliative care that places great emphasis on holistic care should be integrated to the care of this group of patients.

Symptom clusters and quality of life among patients with advanced heart failure.

OBJECTIVES: To identify symptom clusters among patients with advanced heart failure (HF) and the independent relationships with their quality of life (QoL). METHODS: This is the secondary data analysis of a cross-sectional study which interviewed 119 patients with advanced HF in the geriatric unit of a regional hospital in Hong Kong. The symptom profile and QoL were assessed by using the Edmonton Symptom Assessment Scale (ESAS) and the McGill QoL Questionnaire. Exploratory factor analysis was used to identify the symptom clusters. Hierarchical regression analysis was used to examine the independent relationships with their QoL, after adjusting the effects of age, gender, and comorbidities. RESULTS: The patients were at an advanced age (82.9 ± 6.5 years). Three distinct symptom clusters were identified: they were the distress cluster (including shortness of breath, anxiety, and depression), the decondition cluster (fatigue, drowsiness, nausea, and reduced appetite), and the discomfort cluster (pain, and sense of generalized discomfort). These three symptom clusters accounted for 63.25% of variance of the patients' symptom experience. The small to moderate correlations between these symptom clusters indicated that they were rather independent of one another. After adjusting the age, gender and comorbidities, the distress (ß = -0.635, P < 0.001), the decondition (ß = -0.148, P = 0.01), and the discomfort (ß = -0.258, P < 0.001) symptom clusters independently predicted their QoL. CONCLUSIONS: This study identified the distinctive symptom clusters among patients with advanced HF. The results shed light on the need to develop palliative care interventions for optimizing the symptom control for this life-limiting disease.

Use of a Therapeutic, Socially Assistive Pet Robot (PARO) in Improving Mood and Stimulating Social Interaction and Communication for People With Dementia: Study Protocol for a Randomized Controlled Trial.

BACKGROUND: Socially assistive robotics is a growing area for geriatric research. OBJECTIVE: This single-blind, randomized controlled trial (RCT) aims to investigate the use of PARO, a therapeutic, socially assistive pet robot, in improving mood, and stimulating social interaction and communication for people with dementia in the community. METHODS: For the study, 40 community-dwelling older Chinese adults (≥60 years) with mild to moderate dementia will be recruited and randomly assigned to the PARO therapy group or the psychosocial activities control group. Both treatments consist of six, 30-minute weekly sessions, which will be conducted in a geriatric day hospital. Subjects in both groups will be assessed by a trained research assistant at baseline (pre-), during, and post-treatment. Mood (assessed with a simplified face scale), social interaction, and communication (ie, facial expressions and reactions towards each treatment, assessed with an observation table) will be the primary outcome measures. Secondary outcome measures will include assessments on cognitive function (Mini-Mental State Examination) and depressive symptoms (Cornell Scale for Depression in Dementia), as well as caregiver burden (Zarit Burden Inventory). Subjective impression towards each treatment and qualitative comments from the caregivers, facilitator, and therapists will also be obtained. RESULTS: Recruitment to the pilot study began in 2014 and the last subject is expected to complete their post-treatment assessment in 2015. CONCLUSIONS: This will be the first RCT using PARO to improve mood, and stimulate social interaction and communication in the care of older people with dementia, as well as provide an evidence basis for the use of PARO in dementia care in Hong Kong. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000037606; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12614000037606 (Archived by WebCite at http://www.webcitation.org/6Xi7uXdu9).

A new model for end-of-life care in nursing homes.

OBJECTIVES: This study aimed to promote quality end-of-life (EOL) care for nursing home residents, through the establishment of advance care plan (ACP) and introduction of a new care pathway. This pathway bypassed the emergency room (ER) and acute medical wards by facilitating direct clinical admission to an extended-care facility. DESIGN: An audit on a new clinical initiative that entailed the Community Geriatrics Outreach Service, ER, acute medical wards, and an extended-care facility during winter months in Hong Kong. METHODS: The participants were older nursing home residents enrolled in an EOL program. We monitored the ratio of clinical to emergency admissions, ACP compliance rate, average length of stay (ALOS) in both acute hospital and an extended-care facility, and mortality rates. RESULTS: A total of 76 patients were hospitalized from January to March 2013. Of them, 30 (39%) were directly admitted to the extended-care facility, either through the liaison of Community Geriatrics Outreach Service (group A, 19/76, 25%) or transferred from the ER (group B, 11/76, 14%). The remaining 46 patients (group C, 61%) were admitted via the ER to acute medical wards following the usual pathway, followed by transfer to an extended-care facility if indicated. The ACP compliance rate was nearly 100%. In the extended-care unit, groups A and C had similar ALOS of 11.8 and 11.1 days, respectively, whereas group B had a shorter stay of 7.6 days. The ALOS of group C in acute medical wards was 3.5 days. The in-hospital mortality rates were comparable in groups A and C of 26% and 28%, respectively, whereas group B had a lower mortality rate of 18%. CONCLUSIONS: Nearly 40% of EOL patients could be managed entirely in an extended-care setting without compromising the quality of care and survival. A greater number of patients may benefit from the EOL program by improving the collaboration between community outreach services and ER; and extending hours for direct clinical admission to an extended-care facility.

Obesity can benefit survival-a 9-year prospective study in 1614 Chinese nursing home residents.

OBJECTIVE: Weight loss has been considered predictive of early mortality in nursing home residents. Lower body mass index, irrespective of weight loss, has also been considered detrimental for survival in community-dwelling older persons. We examined which of the 2 is more important for survival in nursing home residents and at what body mass index (BMI) cut-offs survival benefits are gained or lost. DESIGN: Prospective study. SETTING: Nursing homes. PARTICIPANTS: One thousand six-hundred fourteen nursing home residents. MEASUREMENT: Minimum Data Set at baseline and mortality status assessed at 6 months, 1, 2, 4, and 9 years later. Relationship between mortality and significant weight loss (≥5% over 30 days or ≥10% over 180 days), and BMI, was studied by Cox regression with both variables in the same model, adjusted for age, sex, medical conditions (cancer, renal failure, heart disease, dementia, hip fracture, diabetes mellitus), tube-feeding, 25% food left uneaten, swallowing problem, and the activities of daily living hierarchy scale. RESULTS: One thousand six-hundred fourteen residents (69.5% female) with mean age 83.7 ± 8.4 years and mean BMI 21.7 ± 4.8 were studied. Mortality rates were 6.3% (6-month), 14.3% (1-year), 27.1% (2-year), 47.3% (4-year), and 78.1% (9-year). Significant weight loss was not associated with higher mortality at all follow-up durations, whereas higher BMI was significantly protective: mortality reduction per 1 unit increase in BMI were 9% at 6 months, 10% at 1 year, 9% at 2 years, 7% at 4 years, and 5% at 9 years, all at P < .001. Having ≥25% of food left uneaten (51.2% of participants) had no relationship to survival at all follow-up durations. At 9 years, compared with those with BMI < 18.5kg/m(2), the normal weight (BMI 18.5-22.9 kg/m(2), Asia Pacific cut-off), overweight (BMI 23-25 kg/m(2), Asia Pacific cut-off) and obese (BMI > 25 kg/m(2), Asia Pacific cut-off) had significantly lower mortality (hazard ratio 0.65, 0.62, and 0.47, respectively, all P < .001). CONCLUSIONS: Significant weight loss as defined by the Minimum Data Set was not associated with short- or long-term survival in Chinese nursing home residents. BMI, however, is predictive of short- and long-term survival irrespective of weight loss in this population. Low BMI, detectable at a single point of time, may be another readily available alternative trigger point for possible interventions in reducing mortality risk. Obese residents had the lowest mortality compared with those with normal weight.