Development of salient medication reminders to facilitate information transfer during transition from inpatient to primary care: the Delphi process.

OBJECTIVE: Transitional care is important to successful hospital discharge. Providing patients with a clear and concise summary of medication-related information can help improve outcomes, in particular, among older adults. The present study aimed to propose a framework for the development of salient medication reminders (SMR), which include drug-related risks and precautions, using the Delphi process. DESIGN: Identification of potential SMR statements for 80% of medication types used by older adult patients discharged from geriatric medicine departments, followed by a Delphi survey and expert panel discussion. SETTINGS: Medical and geriatric departments of public hospitals in Hong Kong. PARTICIPANTS: A panel of 13 geriatric medical experts. OUTCOME MEASURE: A Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) points, scoring item relevance, importance and clarity. The minimum of 70% consensus was required for each statement to be included. RESULTS: The expert panel achieved consensus through the Delphi process on 80 statements for 44 medication entities. Subsequently, the SMR steering group endorsed the inclusion of these statements in the SMR to be disseminated among older adults at the time of discharge from geriatric medicine departments. CONCLUSIONS: The Delphi process contributed to the development of SMR for older adult patients discharged from public hospitals in Hong Kong. Patient experience with and staff response to the SMR were assessed at four hospitals before implementation at all public hospitals.

Effect of CYP2D6 and CYP3A4 Genotypes on the Efficacy of Cholinesterase Inhibitors in Southern Chinese Patients With Alzheimer's Disease.

Alzheimer's disease (AD) is the most prevalent form of dementia, and age is strongly associated with the incidence of AD. This study aimed to investigate the association between the genotypes of CYP2D6, CYP3A4, and CYP2C9 genes to the clinical efficacy and tolerability of cholinesterase inhibitors (ChEIs) in Chinese patients with AD. One hundred seventy-nine patients with AD with newly prescribed with ChEIs were recruited. The clinical response and tolerability were evaluated at baseline, 3rd-, 6th-, and 12th-month follow-ups and were compared according to their genotypes of CYP2D6, CYP3A4, and CYP2C9. Among patients prescribed with donepezil/galantamine, CYP2D6*10 carriers showed significantly less side effects (P = .009). CYP2D6*10 carriers responded better to ChEIs and resulted in better improvement in Alzheimer's Disease Assessment Scale-Cognitive subscale (P = .027) and Mini-Mental State Examination (P = .012). Further study is required to replicate the finding, and it might be useful for clinicians to decide the medication based on the patients' CYP genotypes.

Effectiveness of a home-based missing incident prevention program for community-dwelling elderly patients with dementia.

ABSTRACTBackground:Getting lost is a recognized complication in patients with dementia. Preventive measures are lacking. This study aims to investigate the effectiveness of a home-based missing incident prevention program (HMIPP) in reducing missing incidents, time of searching, and caregivers' stress. METHODS: The design was a pre- and post-intervention study. Patients were recruited from a hospital-based Geriatric Memory Clinic. Inclusion criteria were as follows: aged 60 years or above, established dementia, and Modified Functional Ambulation Categories score VI or VII. An occupational therapist performed the interventions at the patients's home. These included dementia education, prescription of assistive devices, on-site skills training, environmental modifications, community service referrals, and redesigning of daily life routine tasks. The number of missing incidents and caregivers' stress at three months and one year were compared with baseline data from one year before and the secondary outcome was time for searching of the last incident. RESULTS: A total of 54 patients were recruited. The mean age was 78.8 years and 54% were females. Majority of patients had moderate dementia. The mean number of missing incidents per year was significantly reduced at three months and one year (0.70, 0.22, and 0.14 at 0, 3, and 12 months, respectively; p < 0.001). The time for searching of last missing episode was reduced significantly (6.25, 0.13, and 0.35 hours, respectively; p < 0.001). The caregivers' stress also decreased significantly at three months and one year. CONCLUSION: The HMIPP was effective in reducing the number of missing incidents, searching time, and caregivers' stress at three months and one year.

A comparative study of clinical features and outcomes in young and older adults with severe acute respiratory syndrome.

OBJECTIVES: To determine the clinical presentation, findings, and outcomes of older adults (> 60) with severe acute respiratory syndrome (SARS) and compare these with a control group of younger patients (< or or =60). DESIGN: Retrospective cohort study. SETTING: A community-based, acute hospital in Hong Kong. PARTICIPANTS: All adult inpatients with a clinical diagnosis of SARS. MEASUREMENTS: Clinical presentations, investigations, treatment, and 30- and 150-day mortality. RESULTS: There were 52 young and 25 older patients with a mean age +/- standard deviation of 39.5+/-11.7 and 72.1+/-7.2, respectively. Fever, chills, and diarrhea were more common in younger patients, whereas decrease in appetite and general condition occurred only in older patients. The prevalence of positive reverse-transcriptase polymerase chain reaction for SARS-associated coronavirus (SARS-CoV) in nasopharyngeal secretions and stool samples was similar in the two groups. The prevalence of positive serological tests for SARS-CoV was significantly lower in older patients (42% vs 92%, P<.001). This was largely due to incomplete testing in elderly patients. Older patients were more likely to develop secondary nosocomial infection, be admitted to an intensive care unit, and require mechanical ventilation. The cumulative 30- and 150-day mortality rates were 3.8% and 7.6%, respectively, in young patients with SARS and 56% and 60%, respectively, in older patients (P<.001). CONCLUSION: Older patients with SARS more often presented with nonspecific symptoms, and the prognosis was poor. Reverse-transcriptase polymerase chain reaction was useful in diagnosing SARS in older patients, but the role of serological tests in individual elderly is limited.

Hemorrhagic complications of anticoagulant therapy in Chinese patients.

BACKGROUND: Oral anticoagulants have an expanding role in cardiovascular and thrombotic disorders. Few data are available describing their safety among Chinese patients. We aim to evaluate the incidence of major and minor bleeding complications among Chinese patients receiving long term anti coagulants in community practice. METHODS: A retrospective cohort study was undertaken in a regional hospital. All patients who were initiated on warfarin from January 1, 1998 to December 31, 1998 were enrolled. Out-patient medical charts were reviewed for demographic data, clinical characteristics and adequacy of anticoagulation. Major and minor bleeding complications were documented. RESULTS: A total of 131 patients were identified. The mean age was 67.8 (SD 11.9) years and 52.6% were women. The mean duration of follow-up was 2.2 years (SD 1.1). Major indications for warfarin were: non-valvular atrial fibrillation (60%), venous thrombosis (17%) and rheumatic heart disease (16%). The subjects spent 50% of their total time within target international normalized ratio range. The average annual rates for major and minor bleeding events were 1.8% (95% confidence interval 0.6 to 4.1%) and 18.5% (95% confidence interval 13.9 to 24.2%), respectively. The cumulative incidences of first major and minor bleeding events at 1, 2 and 3 years were 3%, 4%, 5% and 15%, 24% and 37%, respectively. Intensity of anticoagulation was the only predictive factor identified to be associated with bleeding complications. CONCLUSIONS: Among Chinese patients receiving long-term warfarin, major hemorrhage occurred at an acceptable range in clinical practice, while considerable minor bleeding was observed. Utilization of oral anticoagulants in Chinese patients appears safe and should be advocated in situations with appropriate indications.