Ai-Vyrn Chin

Ten year mortality in older patients attending the emergency department after a fall.

To determine the dependency scores, long‐term mortality and factors associated with mortality in older people presenting to the emergency department (ED) with a fall.

Cognitive assessment tools in Asia: a systematic review

BACKGROUND The prevalence of dementia is increasing in Asia than in any other continent. However, the applicability of the existing cognitive assessment tools is limited by differences in educational and cultural factors in this setting. We conducted a systematic review of published studies on cognitive assessments tools in Asia. We aimed to rationalize the results of available studies which evaluated the validity of cognitive tools for the detection of cognitive impairment and to identify the issues surrounding the available cognitive impairment screening tools in Asia. METHODS Five electronic databases (CINAHL, MEDLINE, Embase, Cochrane Library, and Science Direct) were searched using the keywords dementia Or Alzheimer Or cognitive impairment And screen Or measure Or test Or tool Or instrument Or assessment, and 2,381 articles were obtained. RESULTS Thirty-eight articles, evaluating 28 tools in seven Asian languages, were included. Twenty-nine (76%) of the studies had been conducted in East Asia with only four studies conducted in South Asia and no study from northern, western, or central Asia or Indochina. Local language translations of the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were assessed in 15 and six studies respectively. Only three tools (the Korean Dementia Screening Questionnaire, the Picture-based Memory Intelligence Scale, and the revised Hasegawa Dementia Screen) were derived de novo from Asian populations. These tools were assessed in five studies. Highly variable cut-offs were reported for the MMSE (17-29/30) and MoCA (21-26/30), with 13/19 (68%) of studies reporting educational bias. CONCLUSIONS Few cognitive assessment tools have been validated in Asia, with no published validation studies for many Asian nations and languages. In addition, many available tools display educational bias. Future research should include concerted efforts to develop culturally appropriate tools with minimal educational bias.

Normative data for hand grip strength and key pinch strength, stratified by age and gender for a multiethnic Asian population.

INTRODUCTION Hand strength is a good indicator of physical fitness and frailty among the elderly. However, there are no published hand strength references for Malaysians aged > 65 years. This study aimed to establish normative data for hand grip strength (HGS) and key pinch strength (KPS) for Malaysians aged ≥ 60 years, and explore the relationship between hand strength and physical ability. METHODS Healthy participants aged ≥ 60 years with no neurological conditions were recruited from rural and urban locations in Malaysia. HGS and KPS were measured using hand grip and key pinch dynamometers. Basic demographic data, anthropometric measures, modified Barthel Index scores and results of the Functional Reach Test (FRT), Timed Up and Go (TUG) test and Jebsen-Taylor Hand Function Test (JTHFT) were recorded. RESULTS 362 subjects aged 60-93 years were recruited. The men were significantly stronger than the women in both HGS and KPS (p < 0.001). The hand strength of the study cohort was lower than that of elderly Western populations. Significant correlations were observed between hand strength, and residential area (p < 0.001), FRT (r = 0.236, p = 0.028), TUG (r = -0.227, p = 0.009) and JTHFT (r = -0.927, p < 0.001). CONCLUSION This study established reference ranges for the HGS and KPS of rural and urban elderly Malaysian subpopulations. These will aid the use of hand strength as a screening tool for frailty among elderly persons in Malaysia. Future studies are required to determine the modifiable factors for poor hand strength.

A Descriptive Study of Nasogastric Tube Feeding Among Geriatric Inpatients in Malaysia: Utilization, Complications, and Caregiver Opinions

The strong emphasis on feeding in Asian cultures may influence decisions for nasogastric (NG) tube feeding in geriatric inpatients. We evaluated the utility, complications, and opinions of caregivers toward NG tube feeding in an acute geriatric ward in a teaching hospital in Kuala Lumpur. Consecutive patients aged 65 years and older receiving NG tube feeding were included. Sociodemographic, clinical, and laboratory indices were recorded. Opinion on NG tube feeding were evaluated through face-to-face interviews with caregivers, recruited through convenience sampling. Of 432 patients admitted, 96 (22%), age ± standard deviation = 80.8 ± 7.4 years, received NG tube feeding. The complication and mortality rates were 69% and 38%, respectively. Diabetes (odds ratio [95% confidence interval] = 3.34 [1.07, 10.44], aspiration pneumonia (8.15 [2.43, 27.24]), impaired consciousness (3.13 [1.05, 9.36]), and albumin ≤26 g/dl (4.43 [1.46, 13.44]) were independent predictors of mortality. Other relatives were more likely than spouses (23.5 [3.59, 154.2]) and caregivers with tertiary education more likely than those with no formal education (18 [1.23, 262.7]) to agree to NG feeding. Sixty-four percent of caregivers felt NG tube feeding was appropriate at the end of life, mostly due to the fear of starvation. NG tube feeding is widely used in our setting, despite high complication and mortality rates, with likely influences from cultural emphasis on feeding.

How Can We Best Screen for Cognitive Impairment in Malaysia? A Pilot of the IDEA Cognitive Screen and Picture-Based Memory Impairment Scale and Comparison of Criterion Validity with the Mini Mental State Examination

ABSTRACT Objectives: To pilot two new cognitive screening tools for use in an urban Malaysian population and to compare their criterion validity against a gold standard, the well-established Mini-Mental State Examination (MMSE). Methods: The IDEA cognitive screen, Picture-based Memory Impairment Scale (PMIS), and MMSE were administered to a convenience sample of elderly (≥ 65 years) from the community and outpatient clinics at an urban teaching hospital. Consensus diagnosis was performed by two geriatricians blinded to PMIS and IDEA cognitive screen scores using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) clinical criteria. The MMSE performance was used as a reference. Results: The study enrolled 66 participants, with a median age of 78.5 years (interquartile range [IQR], 72.5–83.0) years and 11.0 median years of education (IQR, 9.0–13.0). Forty-three (65.2%) were female, and 32 (48.4%) were Chinese. The area under the receiver operating characteristic (AUROC) curve values were .962 (IDEA cognitive screen), .970 (PMIS), and .935 (MMSE). The optimal cutoff values for sensitivity and specificity were: IDEA cognitive screen: ≤ 11, 90.9% and 89.7%; PMIS: ≤ 6, 97.3% and 69.0%; and MMSE: ≤ 23, 84.6% and 76.0%. Although the sample size was small, multivariable logistic regression modelling suggested that all three screen scores did not appear to be educationally biased. Conclusion: The IDEA and PMIS tools are potentially valid screening tools for dementia in urban Malaysia, and perform at least as well as the MMSE. Further work on larger representative, cohorts is needed to further assess the psychometric properties. Clinical Implications: Study provides alternative screening tools for dementia for both non-specialists and specialists.

Evaluation of Two New Indices of Blood Pressure Variability Using Postural Change in Older Fallers.

AbstractTo evaluate the utility of blood pressure variability (BPV) calculated using previously published and newly introduced indices using the variables falls and age as comparators.While postural hypotension has long been considered a risk factor for falls, there is currently no documented evidence on the relationship between BPV and falls.A case-controlled study involving 25 fallers and 25 nonfallers was conducted. Systolic (SBPV) and diastolic blood pressure variability (DBPV) were assessed using 5 indices: standard deviation (SD), standard deviation of most stable continuous 120 beats (staSD), average real variability (ARV), root mean square of real variability (RMSRV), and standard deviation of real variability (SDRV). Continuous beat-to-beat blood pressure was recorded during 10 minutes’ supine rest and 3 minutes’ standing.Standing SBPV was significantly higher than supine SBPV using 4 indices in both groups. The standing-to-supine-BPV ratio (SSR) was then computed for each subject (staSD, ARV, RMSRV, and SDRV). Standing-to-supine ratio for SBPV was significantly higher among fallers compared to nonfallers using RMSRV and SDRV (P = 0.034 and P = 0.025). Using linear discriminant analysis (LDA), 3 indices (ARV, RMSRV, and SDRV) of SSR SBPV provided accuracies of 61.6%, 61.2%, and 60.0% for the prediction of falls which is comparable with timed-up and go (TUG), 64.4%.This study suggests that SSR SBPV using RMSRV and SDRV is a potential predictor for falls among older patients, and deserves further evaluation in larger prospective studies.

Standing beat-to-beat blood pressure variability is reduced among fallers in the Malaysian Elders Longitudinal Study

Abstract The aim of this study was to determine the relationship between falls and beat-to-beat blood pressure (BP) variability. Continuous noninvasive BP measurement is as accurate as invasive techniques. We evaluated beat-to-beat supine and standing BP variability (BPV) using time and frequency domain analysis from noninvasive continuous BP recordings. A total of 1218 older adults were selected. Continuous BP recordings obtained were analyzed to determine standard deviation (SD) and root mean square of real variability (RMSRV) for time domain BPV and fast-Fourier transform low frequency (LF), high frequency (HF), total power spectral density (PSD), and LF:HF ratio for frequency domain BPV. Comparisons were performed between 256 (21%) individuals with at least 1 fall in the past 12 months and nonfallers. Fallers were significantly older (P = .007), more likely to be female (P = .006), and required a longer time to complete the Timed-Up and Go test (TUG) and frailty walk test (P ⩽ .001). Standing systolic BPV (SBPV) was significantly lower in fallers compared to nonfallers (SBPV-SD, P = .016; SBPV-RMSRV, P = .033; SBPV-LF, P = .003; SBPV-total PSD, P = .012). Nonfallers had significantly higher supine to standing ratio (SSR) for SBPV-SD, SBPV-RMSRV, and SBPV-total PSD (P = .017, P = .013, and P = .009). In multivariate analyses, standing BPV remained significantly lower in fallers compared to nonfallers after adjustment for age, sex, diabetes, frailty walk, and supine systolic BP. The reduction in frequency-domain SSR among fallers was attenuated by supine systolic BP, TUG, and frailty walk. In conclusion, reduced beat-to-beat BPV while standing is independently associated with increased risk of falls. Changes between supine and standing BPV are confounded by supine BP and walking speed.

Individually-tailored multifactorial intervention to reduce falls in the Malaysian Falls Assessment and Intervention Trial (MyFAIT): A randomized controlled trial

Objective To determine the effectiveness of an individually-tailored multifactorial intervention in reducing falls among at risk older adult fallers in a multi-ethnic, middle-income nation in South-East Asia. Design Pragmatic, randomized-controlled trial. Setting Emergency room, medical outpatient and primary care clinic in a teaching hospital in Kuala Lumpur, Malaysia. Participants Individuals aged 65 years and above with two or more falls or one injurious fall in the past 12 months. Intervention Individually-tailored interventions, included a modified Otago exercise programme, HOMEFAST home hazards modification, visual intervention, cardiovascular intervention, medication review and falls education, was compared against a control group involving conventional treatment. Primary and secondary outcome measures The primary outcome was any fall recurrence at 12-month follow-up. Secondary outcomes were rate of fall and time to first fall. Results Two hundred and sixty-eight participants (mean age 75.3 ±7.2 SD years, 67% women) were randomized to multifactorial intervention (n = 134) or convention treatment (n = 134). All participants in the intervention group received medication review and falls education, 92 (68%) were prescribed Otago exercises, 86 (64%) visual intervention, 64 (47%) home hazards modification and 51 (38%) cardiovascular intervention. Fall recurrence did not differ between intervention and control groups at 12-months [Risk Ratio, RR = 1.037 (95% CI 0.613–1.753)]. Rate of fall [RR = 1.155 (95% CI 0.846–1.576], time to first fall [Hazard Ratio, HR = 0.948 (95% CI 0.782–1.522)] and mortality rate [RR = 0.896 (95% CI 0.335–2.400)] did not differ between groups. Conclusion Individually-tailored multifactorial intervention was ineffective as a strategy to reduce falls. Future research efforts are now required to develop culturally-appropriate and affordable methods of addressing this increasingly prominent public health issue in middle-income nations. Trial registration ISRCTN Registry no. ISRCTN11674947

Long-Term Nasogastric Versus Percutaneous Endoscopic Gastrostomy Tube Feeding in Older Asians With Dysphagia: A Pragmatic Study

BACKGROUND A barrier to gastrostomy feeding exists among Asian clinicians and caregivers due to negative perceptions regarding complications. We compared clinical and nutrition outcomes in older dysphagic Asian patients with nasogastric (NG) or gastrostomy tube feeding using a pragmatic study design. METHODS The choice of enteral tube access was determined by managing clinicians and patients/caregivers. Comparisons of tube feeding methods were made during a 4-month period, adjusting statistically for inherent confounders. RESULTS A total of 102 participants (NG: n = 52, gastrostomy: n = 50) were recruited over 2 years from 2013 to 2015. Subjects on long-term NG tube feeding were older (82.67 ± 7.15 years vs 76.88 ± 7.37 years; P < .001) but both groups had similar clinical indications (stroke: 63.5% NG vs 54% gastrostomy; P = .33). After adjustment for confounders, gastrostomy feeding was associated with fewer tube-related complications (adjusted odds ratio [aOR] = 0.19; 95% confidence interval [CI] = 0.06-0.60) and better complication-free survival rate (aOR = 0.32; 95% CI = 0.12-0.89) at 4-month follow-up. Anthropometric and biochemical nutrition parameters improved significantly in both groups at 4 months, but no significant differences were observed at the end of the study. CONCLUSION Gastrostomy feeding is associated with a greater 4-month complication-free survival and lower tube-related complications compared with long-term NG feeding in older Asians with dysphagia. However, no differences in nutrition outcomes were observed between NG and gastrostomy feeding at 4 months.

27PICTURE-BASED MEMORY IMPAIRMENT SCREEN FOR DEMENTIA: INFLUENCE OF ETHNICITY AND EDUCATION LEVEL AMONG THE ELDERLY IN MALAYSIA

Introduction: Differences in linguistic properties, literacy level, and cultural acceptance may cause difficulties and are known as major limitation factors in identifying dementia in developing countries where the greatest increase in prevalence of dementia is expected to be seen. This study aimed to investigate the influence of multi-ethnicity and education level on Picture-based Memory Impairment Screen (PMIS) among elderly in Malaysia. Methods: The PMIS, Identification and Intervention for Dementia in Elderly Africans (IDEA) cognitive screen and Mini Mental State Examination (MMSE) were administered to a convenience sample of elderly individuals (≥60years) from the community and outpatient clinics at the University of Malaya Medical Centre, Kuala Lumpur, Malaysia. Consensus diagnosis was performed by two geriatricians blinded to PMIS scores using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) clinical criteria. Results: A total of 564 participants were recruited with median (interquartile range, IQR) age of 71.5 (67-83) and median years of education 11.0 (9-13). About 317 (55.4%) were female and 255 (44.6%) were male. The majority were Chinese (n=361, 63.1) followed by Indian (n=133, 23.3%) and Malay and Others (n=78,13.6%). Based on DSM-V classification among 75 randomly selected individuals, participants with major neurocognitive disorder (n=33, 64%) (T-test, p<0.05) showed poorer performance in PMIS compared to those with no neurocognitive disorder (n=42, 56%). In univariate analyses, fewer years of education and differences in ethnicity were non-significant (Kruskal-wallis test, p>0.05). After adjustment for DSM-V classification in multivariable logistic regression, fewer years of education and differences in ethnicity remain insignificantly (p>0.05) different in performance of PMIS. Conclusions: PMIS performance showed no influence on ethnicity and education level among our elderly. This study may give options for healthcare providers on available screening tools that consider cultural and educational factors in screening dementia.