Reduced Pneumonia Risk in Advanced Dementia Patients on Careful Hand Feeding Compared With Nasogastric Tube Feeding.

OBJECTIVES: To compare survival and pneumonia risk among hospitalized patients with advanced dementia on nasogastric tube feeding (NGF) vs careful hand feeding (CHF) and to examine outcomes by feeding problem type. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Advanced dementia patients aged ≥60 years with indication for tube feeding admitted to 2 geriatric convalescent hospitals between January 1, 2015, and June 30, 2019. METHODS: Comparison on the effect of NGF and CHF on survival and pneumonia risk using Kaplan Meier survival analysis and Cox proportional hazards models. RESULTS: Of the 764 patients (mean age 89 years, 61% female, 74% residential care home residents), 464 (61%) were initiated on NGF and 300 (39%) on CHF. The primary feeding problem types were dysphagia (50%), behavioral feeding problem (33%), or both (17%). There was no difference in 1-year survival rate between NGF and CHF groups (36% vs 37%, P = .71) and survival did not differ by feeding problem type. Nasogastric tube feeding was not a significant predictor for survival (adjusted hazard ratio 1.15, 95% CI 0.94-1.39). Among 577 (76%) patients who survived to discharge, pneumonia rates were lower in the CHF group (48% vs 60%, P = .004). After adjusting for cofounders, NGF was a significant risk factor for pneumonia (adjusted hazard ratio 1.41, 95% CI 1.08-1.85). In subgroup analyses, NGF was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problem (P = .01) but not in patients with behavioral feeding problem alone (P = .24) or dysphagia alone (P = .30). CONCLUSIONS AND IMPLICATIONS: For advanced dementia patients with feeding problems, there is no difference in survival between NGF and CHF. However, NGF is associated with a higher pneumonia risk, particularly for patients with both dysphagia and behavioral feeding problem. Further research on how the feeding problem type impacts pneumonia risk for patients on NGF is needed.

End-of-life care for advanced dementia patients in residential care home-a Hong Kong perspective.

Dementia will become more common as the population ages. Advanced dementia should be considered as a terminal illnesses and end-of-life (EOL) care is very much needed for this disease group. Currently, the EOL services provided to this vulnerable group in Hong Kong, especially those living in residential care homes, is limited. The usual practice of residential care homes is to send older residents with advanced dementia to acute hospitals when they are sick, irrespective of their wish, premorbid status, diagnoses and prognosis. This may not accord with what the patients perceive to be a "good death". There are many barriers for older people to die in place, both at home and at the residential care home. In the community, to enhance EOL care to residential care home for the elderly (RCHE) residents, pilot EOL program had been carried out by some Community Geriatric Assessment Teams. Since 2015, the Hospital Authority funded program "Enhance Community Geriatric Assessment Team Support to End-of-life Patients in Residential Care Homes for the Elderly" has been started. In the program, advance care planning (ACP), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) (non-hospitalized) order will be established and the program will be expected to cover all clusters in Hong Kong by 2018/2019. In hospital setting, EOL clinical plan and EOL ward in geriatric step-down hospitals may be able to improve the quality of death of older patients. In Sep 2015, the Hospital Authority Guidelines on Life-Sustaining Treatment in the Terminally Ill was updated. Amongst other key EOL issues, careful (comfort) hand feeding was mentioned in the guideline. Other new developments include the possible establishment of enduring power of attorney for health care decision and enhancement of careful hand feeding amongst advanced dementia patients in RCHEs.

Dignified Palliative Long-Term Care: An Interpretive Systemic Framework of End-of-Life Integrated Care Pathway for Terminally Ill Chinese Older Adults.

PURPOSE: To critically examine the system dynamics necessary for successfully implementing a novel end-of-life integrated care pathway (EoL-ICP) program in promoting dignity and quality of life among terminally-ill Chinese nursing home residents. METHODS: Thirty stakeholders were recruited to participate in 4 interpretive-systemic focus groups. RESULTS: Framework analysis revealed 10 themes, organized into 3 categories, namely, (1) Regulatory Empowerment (interdisciplinary teamwork, resource allocation, culture building, collaborative policy making), (2) Family-Centered Care (continuity of care, family care conference, partnership in care), and (3) Collective Compassion (devotion in care, empathic understanding, compassionate actions). CONCLUSIONS: These findings highlight the importance of organizational structure, social discourse, and shared meaning in the provision of EoL-ICP in Chinese societies, underscoring the significant triangulation between political, cultural, and spiritual contexts embodied in the experience of dignity.

Effectiveness of a discharge planning and community support programme in preventing readmission of high-risk older patients.

OBJECTIVE: To examine the effectiveness of Integrated Care and Discharge Support for elderly patients in reducing accident and emergency department attendance, acute hospital admissions, and hospital bed days after discharge. Factors that compromise its effectiveness were investigated and cost analysis was performed. DESIGN: Cohort prospective study. SETTING: Integrated Care and Discharge Support for elderly patients in Hong Kong West Cluster. PARTICIPANTS: Home-dwelling patients recruited between April 2012 and March 2013 into Integrated Care and Discharge Support for elderly patients in Hong Kong West Cluster. RESULTS: A total of 1090 older patients were studied. The Integrated Care and Discharge Support for elderly patients programme reduced accident and emergency department attendance by 40% (P<0.001), acute hospital admissions by 47% (P<0.001), and hospital bed days by 31% (P<0.001) at 6 months after implementation. Improvements in Barthel Index 20 (P<0.001) and Modified Functional Ambulation Category scale (P<0.001) were observed. Of the patients, 85 (7.8%) died within 6 months of initiation of the programme. Only 26 (2.4%) older patients required institutionalisation in residential care homes within 6 months after the programme. Increasing age (P=0.025) and high Charlson Comorbidity Index score (P=0.001) were positive predictors for accident and emergency department attendance. A high albumin level (P=0.001) and living alone (P=0.033) were negative predictors for accident and emergency department attendance. Of the patients, 310 (28.4%) had no reduction in bed days after the programme. Increasing age (P=0.025) and number of medications (P=0.003) were positive predictors for no reduction in bed days; while higher haemoglobin level (P=0.034) was a negative predictor. There was a potential annual cost-saving of HK$22.5 million (approximately US$2.9 million). CONCLUSION: The Integrated Care and Discharge Support for elderly patients programme reduced accident and emergency department attendance, acute hospital admissions and hospital bed days, and was potentially cost-saving. Age, Charlson Comorbidity Index, albumin level, and living alone were factors associated with accident and emergency department attendance. Age, number of medications, and haemoglobin level were associated with no reduction in bed days. Further study of the cost-effectiveness of such programme is warranted.

Falls prevention in the elderly: translating evidence into practice.

Falls are a common problem in the elderly. A common error in their management is that injury from the fall is treated, without finding its cause. Thus a proactive approach is important to screen for the likelihood of fall in the elderly. Fall assessment usually includes a focused history and a targeted examination. Timed up-and-go test can be performed quickly and is able to predict the likelihood of fall. Evidence-based fall prevention interventions include multi-component group or home-based exercises, participation in Tai Chi, environmental modifications, medication review, management of foot and footwear problems, vitamin D supplementation, and management of cardiovascular problems. If possible, these are best implemented in the form of multifactorial intervention. Bone health enhancement for residential care home residents and appropriate community patients, and prescription of hip protectors for residential care home residents are also recommended. Multifactorial intervention may also be useful in a hospital and residential care home setting. Use of physical restraints is not recommended for fall prevention.

Preventing aspiration pneumonia in older people: do we have the 'know-how'?

Aspiration pneumonia is common in older people. To reduce the risk of aspiration pneumonia, maintenance of good oral hygiene is important and medications affecting salivary flow or causing sedation are best avoided, if possible. The use of H2 blockers and proton-pump inhibitors should be minimised. Different compensatory and facilitation techniques can be applied during oral feeding. Hand feeding should be tried before consideration of tube feeding. The use of tube feeding is the last resort and is mainly for improving nutrition and hydration. Prevention of aspiration pneumonia and increasing survival rates should not be the rationales for tube feeding. Feeding via both gastrostomy and nasogastric tube has similar risks for aspiration pneumonia, and continuous pump feeding is not better than intermittent feeding. Jejunal feeding might decrease the chance of aspiration pneumonia in selected high-risk patients. If older patients are on angiotensin-converting enzyme inhibitors without intolerable cough, continuing the drug may be beneficial. Folate deficiency, if present, needs to be promptly corrected. Further better-designed studies are warranted to find the best ways for prevention of aspiration pneumonia.

Lateral epicondylalgia: midlife crisis of a tendon.

The pathogenesis and management of lateral epicondylalgia, or tennis elbow, a common ailment affecting middle-aged subjects of both genders continue to provoke controversy. Currently it is thought to be due to local tendon pathology, pain system changes, and motor system impairment. Its diagnosis is usually clinical, based on a classical history, as well as symptoms and signs. In selected cases, additional imaging (X-rays, ultrasound, and magnetic resonance imaging) can help to confirm the diagnosis. Different treatment modalities have been described, including the use of orthotics, non-steroidal anti-inflammatory drugs, steroid injections, topical glyceryl trinitrate, exercise therapy, manual therapy, ultrasound therapy, laser therapy, extracorporeal shockwave therapy, acupuncture, taping, platelet-rich plasma injections, hyaluronan gel injections, botulinum toxin injections, and surgery. Nevertheless, evidence to select the best treatment is lacking and the choice of therapy depends on the experience of the management team, availability of the equipment and expertise, and patient response. This article provides a snapshot of current medical practice for lateral epicondylalgia management.

Community end-of-life care among Chinese older adults living in nursing homes.

AIM: The aim of the present study was to investigate the preference and willingness-to-pay (WTP) of older Chinese adults for community end-of-life care in a nursing home rather than a hospital. METHODS: A total of 1540 older Chinese adults from 140 nursing homes were interviewed. Four hypothetical questions were asked to explore their preferences for end-of-life care. Using a discrete choice approach, specific questions explored acceptable trade-offs between three attributes: availability of doctors onsite, attitude of the care staff and additional cost of care per month. RESULTS: Approximately 35% of respondents preferred end-of-life care in the nursing home, whereas 23% of them would consider it in a better nursing home. A good attitude of staff was the most important attribute of the care site. Respondents were willing to pay an extra cost of US$5 (HK$39) per month for more coverage of doctor's time, and US$49 (HK$379) for a better attitude of staff in the nursing home. The marginal WTP for both more coverage of doctor's time and better attitude of staff amounted to US$54 (HK$418). Respondents on government subsidy valued the cost attribute more highly, as expected, validating the hypothesis that those respondents would be less willing to pay an additional cost for end-of-life care. CONCLUSIONS: Older Chinese adults living in nursing homes are willing to pay an additional fee for community end-of-life care services in nursing homes. Both the availability of the doctor and attitudes of nursing home staff are important, with the most important attribute being the staff attitudes. Geriatr Gerontol Int 2013; 14: 273-284.

Mortality and health services utilisation among older people with advanced cognitive impairment living in residential care homes.

OBJECTIVES: To study the demography, clinical characteristics, service utilisation, mortality, and predictors of mortality in older residential care home residents with advanced cognitive impairment. DESIGN: Cohort longitudinal study. SETTING: Residential care homes for the elderly in Hong Kong West. PARTICIPANTS: Residents of such homes aged 65 years or more with advanced cognitive impairment. RESULTS: In all, 312 such residential care home residents (71 men and 241 women) were studied. Their mean age was 88 (standard deviation, 8) years and their mean Barthel Index 20 score was 1.5 (standard deviation, 2.0). In all, 164 (53%) were receiving enteral feeding. Nearly all of them had urinary and bowel incontinence. Apart from Community Geriatric Assessment Team clinics, 119 (38%) of the residents attended other clinics outside their residential care homes. In all, 107 (34%) died within 1 year; those who died within 1 year used significantly more emergency and hospital services (P<0.001), and utilised more services from community care nurses for wound care (P=0.001), enteral feeding tube care (P=0.018), and urinary catheter care (P<0.001). Independent risk factors for 1-year mortality were active pressure sores (P=0.0037), enteral feeding (P=0.008), having a urinary catheter (P=0.0036), and suffering from chronic obstructive pulmonary disease (P=0.011). A history of pneumococcal vaccination was protective with respect to 1-year mortality (P=0.004). CONCLUSION: Residents of residential care homes for the elderly with advanced cognitive impairment were frail, exhibited multiple co-morbidities and high mortality. They were frequent users of out-patient, emergency, and in-patient services. The development of end-of-life care services in residential care homes for the elderly is an important need for this group of elderly.

Haemophagocytic lymphohistiocytosis: an uncommon clinical presentation of tuberculosis.

Secondary haemophagocytic lymphohistiocytosis is a rare but fatal complication of tuberculosis. We describe two cases, and review the local and international experience on the management of this clinical entity. Prompt treatment with anti-tuberculous drugs forms the cornerstone of therapeutic success.

Rehabilitation in older people: know more, gain more.

Functional decline is common among older patients during or even prior to hospitalisation, in spite of treatment of acute illnesses. An effective rehabilitation programme is vital to improve the motor and functional states of the older patients. Knowing factors affecting rehabilitation of older persons is important for their effective and efficient rehabilitation. This article, with special reference to local studies, examines age, gender, cognitive function, and serum albumin levels as to how they influence rehabilitation in the elderly. The conclusion is that we should not exclude patients of advanced age from rehabilitation programmes, based on poor cognitive function and low serum albumin levels as they can achieve similar gains in motor and functional outcomes. A nutritional programme to improve the albumin level of older persons could speed up the rehabilitation progress, rendering it more efficient. A gender-specific rehabilitation programme is needed to improve functional outcome in men and motor outcome in women. Moreover, knowing the factors influencing residential care home placement affords an opportunity to reduce reliance on institutionalisation after rehabilitation.

Advance directive and end-of-life care preferences among Chinese nursing home residents in Hong Kong.

OBJECTIVES: The objectives of the present study were to describe the knowledge and preferences of Hong Kong Chinese older adults regarding advance directives and end-of-life care decisions, and to investigate the predictors of preferences for advance directive and community end-of-life care in nursing homes. METHODS: This was a cross-sectional survey conducted in 140 nursing homes in Hong Kong. A total of 1600 cognitively normal Chinese older adults were recruited. Information on demographics, social, medical diseases, preferences of end-of-life care decisions, and advance directives were collected by face-to-face questionnaire interviews. RESULTS: The mean age of the participants was 82.4 years; 94.2% of them would prefer to be informed of the diagnosis if they had terminal diseases and 88.0% preferred to have their advance directives regarding medical treatment in the future. Approximately 35% would prefer to die in their nursing homes. The significant independent predictors for the preference of advance directive included asking for relatives' advice, wishing to be informed of their terminal illness diagnoses, absence of stroke, and having no problems in self-care in European Quality of Life-5 Dimensions. For the preference for community end-of-life care and dying in nursing homes, the independent predictors included older age, not having siblings in Hong Kong, Catholic religion, nonbeliever of traditional Chinese religion, not receiving any old age allowance, lower Geriatric Depression Scale score, and being residents of government-subsidized nursing homes. CONCLUSIONS: Most of our cognitively normal Chinese nursing home older adults prefer having an advance directive, and one-third of them would prefer to die in nursing homes.

Lactobacillus rhamnosus hepatic abscess associated with Mirizzi syndrome: a case report and review of the literature.

The clinical significance of Lactobacillus spp. isolated from clinical specimens has often been overlooked due to its low virulence. We report the first case of life-threatening bacteremic liver abscess due to Lactobacillus rhamnosus associated with Mirizzi syndrome in a 74-year-old Chinese man. Literature on sporadic reports of Lactobacillus liver abscess is reviewed.

Financial abuse in a mentally incapacitated old man.

A mentally incapacitated 82-year-old man with no relatives was managed by a geriatrician-led multidisciplinary team when medical staff realised he was at risk of being exploited. They initiated a series of protective measures including an emergency guardianship application. The Guardianship Board appointed the Director of Social Welfare as his public guardian. This case illustrates that hospital staff should be alert to potential elder abuse to ensure timely protection of potential victims.

Does age predict outcome in stroke rehabilitation? A study of 878 Chinese subjects.

BACKGROUND: The predicting value of age on stroke rehabilitation has been controversial. There is a lack of large-scale studies in the Chinese population to examine the effect of age on stroke rehabilitation outcomes. This study examines the predictors of a good outcome after rehabilitation in Chinese stroke patients with special attention to age as a factor. PATIENTS AND METHODS: This retrospective cohort study includes stroke patients receiving a standard inpatient multidisciplinary rehabilitation program in a neuro-rehabilitation ward of a convalescence hospital in Hong Kong from January 2000 to December 2003. Functional independence measure (FIM) >or=90 was used to define a good outcome. Multivariate regression analysis was used to assess the independent predictors of a good outcome. RESULTS: There were important differences in clinical characteristics and complications of stroke among patients of three age groups: <65, >or=65 and <80, and >or=80 years. The total FIM scores both upon admission and at discharge were lower in the older age groups. No significant difference was observed in the changes in FIM scores across these age groups. Age was not an independent predictor for a good outcome. FIM upon admission was an independent predictor for a good outcome (discharge FIM >or=90) in all patients and in individual age groups. Having employment before stroke was a predictor for good outcome in all patients. Living at home prior to stroke was a predictor for the total population and the >or=65 and <80 years group. The length of stay predicted a good outcome in the group >or=80 years. CONCLUSIONS: Admission functional status, employment and living at home before stroke but not age per se are predictors of a good outcome following stroke rehabilitation. As older patients show comparable improvement during rehabilitation, intensive rehabilitation should not be withheld in stroke patients simply because of advanced age.