James Ka-Hay Luk

Efficacy of Physical Exercise in Preventing Falls in Older Adults With Cognitive Impairment: A Systematic Review and Meta-Analysis

OBJECTIVE Numerous studies have reported the prevention of falls through exercise among cognitively healthy older people. This study aimed to determine whether the current evidence supports that physical exercise is also efficacious in preventing falls in older adults with cognitive impairment. METHODS Two independent reviewers searched MEDLINE; EMBASE; PsycINFO; the Cumulative Index to Nursing & Allied Health Literature; the Cochrane Central Register of Controlled Trials; the Cochrane Bone, Joint, and Muscle Trauma Group Specialized Register; ClinicalTrials.gov; and the UK Clinical Research Network Study Portfolio up to July 2013 without language restriction. We included randomized controlled trials that examined the efficacy of physical exercise in older adults with cognitive impairment. The methodological qualities of the included trials were appraised according to the criteria developed for the Cochrane review of fall prevention trials. The primary outcome measure was the rate ratio of falls. A meta-analysis was performed to estimate the pooled rate ratio and summarize the results of the trials on fall prevention through physical exercise. RESULTS Seven randomized controlled trials involving 781 participants were included, 4 of which examined solely older people with cognitive impairment. Subgroup data on persons with cognitive impairment were obtained from the other 3 trials that targeted older populations in general. The meta-analysis showed that physical exercise had a significant effect in preventing falls in older adults with cognitive impairment, with a pooled estimate of rate ratio of 0.68 (95% confidence interval 0.51-0.91). CONCLUSIONS The present analysis suggests that physical exercise has a positive effect on preventing falls in older adults with cognitive impairment. Further studies will be required to determine the modality and frequency of exercise that are optimal for the prevention of falls in this population.

Prevention of Mortality and Pneumonia Among Nursing Home Older Adults by Dual Pneumococcal and Seasonal Influenza Vaccination During a Pandemic Caused by Novel Pandemic Influenza A (H1N1)

OBJECTIVE To evaluate the efficacy of dual vaccination of seasonal influenza and pneumococcus in nursing home older adults during a novel pandemic of influenza A (H1N1). SETTING Nine nursing homes in Hong Kong. PARTICIPANTS A total of 532 nursing home older adults were included in the study. MEASUREMENTS Efficacy of dual vaccination of seasonal influenza and pneumococcus in nursing home older adults during a novel pandemic influenza A (H1N1). DESIGN A prospective 12-month cohort study was conducted on older residents from December 2009 to November 2010. Participants were divided into 3 groups according to their choice of vaccination: received both seasonal influenza and 23-valent pneumococcal polysaccharide vaccine (PPV-TIV group), received seasonal influenza vaccine alone (TIV group), and those who refused both vaccinations (unvaccinated group). Those who had received vaccination for influenza A (H1N1) were excluded. Outcome measures included mortality from all causes, pneumonia, and vascular causes. RESULTS There were 246 in the PPV-TIV group, 211 in the TIV group, and 75 in the unvaccinated group. Baseline characteristics were similar among the groups. The 12-month mortality rates of the PPV-TIV, TIV alone group, and unvaccinated group were 17.1%, 27.0%, and 37.3% respectively (P < .001). Multivariate analysis demonstrated that, compared with vaccination of seasonal influenza alone, dual vaccination significantly reduced all-cause mortality (hazard ratio [HR] 0.54; 95% confidence interval [CI]: 0.35-0.84; P < .01), mortality from pneumonia (HR 0.60; 95% CI: 0.35-0.99; P < .05), and mortality from vascular causes (HR 0.24; 95% CI: 0.09-0.64; P < .01). CONCLUSIONS During an influenza pandemic or when the circulating influenza strain was not matched by the trivalent seasonal influenza vaccine, dual vaccination of influenza and pneumococcus provided additional protection to nursing home older adults in reducing mortality.

Effectiveness of Influenza Vaccination in Institutionalized Older Adults: A Systematic Review

INTRODUCTION Influenza infection is common among institutionalized older adults. Many nonrandomized observational studies on influenza vaccination suggested that it could reduce influenza-related hospitalizations and mortality in institutionalized older adults. Criticism regarding the effectiveness of influenza vaccine estimated by nonrandomized observational studies include the frailty selection bias and use of nonspecific outcome, such as all-cause mortality. METHODS We conducted a systematic review of studies of influenza vaccination in institutionalized older adults to determine the effects on clinical outcomes. We searched for studies from 3 databases from 1946 to June 2013 assessing effectiveness against influenza infection. We selected studies with good comparability between vaccine group and control group. We expressed vaccine effectiveness (VE) as a proportion, using the formula VE = 1-relative risk or 1-odds ratio. We focused on the following outcomes: influenza-like illness (ILI), laboratory confirmed influenza, hospitalizations due to ILI, or pneumonia and death due to influenza or pneumonia. We did not include all-cause mortality. RESULTS Eleven studies that satisfied the inclusion criteria were identified, representing 11,262 institutionalized older adults. After meta-analysis, we found a significant reduction in pneumonia (VE: 37%, 95% confidence interval [CI]: 18%-53%, P = .001) and death due to pneumonia or influenza (VE: 34%, CI: 10%-53%, P = .01). There was no significant heterogeneity between studies. There was no significant publication bias. CONCLUSION Influenza vaccination in institutionalized older adults could reduce pneumonia and death due to pneumonia or influenza. Influenza vaccination is recommended for institutionalized older adults.

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.

Rehabilitation of Older Chinese Patients With Different Cognitive Functions: How Do They Differ in Outcome?

OBJECTIVE To examine the effect of cognition on functional and motor gain in older Chinese patients undergoing geriatric inpatient rehabilitation. DESIGN A retrospective cohort study. SETTING Geriatric rehabilitation units of 2 convalescence hospitals in Hong Kong. PARTICIPANTS Older Chinese patients (N=778). INTERVENTIONS Comprehensive geriatric assessment and inpatient rehabilitation by a multidisciplinary team. MAIN OUTCOME MEASURES Cognitive status was assessed with the Cantonese version of the Mini-Mental State Examination (C-MMSE). We measured the absolute functional gain and motor gain by using the Barthel Index and Elderly Mobility Scale (EMS) and expressed it as Barthel Index efficacy and EMS efficacy. Relative efficacy was assessed by the Montebello Rehabilitation Factor Score (MRFS). Relative efficiency was deduced by relative efficacy divided by the hospital length of stay (LOS). RESULTS There were significant differences in the total Barthel Index and EMS on admission and at discharge, with lower discharge scores in low C-MMSE groups. The change of Barthel Index (Barthel Index efficacy) and EMS (EMS efficacy) during rehabilitation did not differ among different C-MMSE groups. Significant differences were observed in Barthel Index MRFS efficacy and efficiency as well as EMS MRFS efficacy and efficiency in different cognitive groups; those with better cognitive function had better results. Multivariate analysis showed that LOS (odds ratio [OR]=1.02, P=.002) and diagnosis of musculoskeletal problems (OR=2.24, P=.007) were positive predictors for a Barthel Index MRFS efficacy of .25 or higher. C-MMSE was not an independent predictor for a Barthel Index MRFS efficacy of .25 or higher. LOS (OR=1.02, P=.003), admission C-MMSE (OR=1.04, P=.001), body mass index (OR=1.05, P=.006), and diagnosis of musculoskeletal disorders (OR=1.75, P=.04) were significant positive predictors for an EMS MRFS efficacy of .25 or higher, whereas urinary incontinence was a negative predictor for EMS MRFS efficacy (OR=0.69, P=.04). CONCLUSIONS There was a strong association between admission cognition and relative change in functional and motor efficacy and efficiency. Cognitive function was not associated with absolute functional and motor gain. Cognitive function was an independent predictor for satisfactory mobility outcome but not for functional outcome. Older patients with impaired cognitive function could still benefit from rehabilitation.

Interactive virtual reality Wii in geriatric day hospital: A study to assess its feasibility, acceptability and efficacy

Aim:  Rehabilitation using interactive virtual reality Wii (Wii‐IVR) was shown to be feasible in patients with different medical problems, but there was no study examining its use in a geriatric day hospital (GDH). The aim of the present study was to test the feasibility, acceptability and efficacy of Wii‐IVR in GDH.

Factors affecting institutionalization in older Hong Kong Chinese patients after recovery from acute medical illnesses.

Older patients with medical illnesses are at risk of institutionalization. The purpose of this study is to investigate the factors leading to institutionalization in older patients after recovery from medical illnesses. We studied 535 older patients in two convalescence hospitals in Hong Kong. Of them, 116 patients (21.7%) needed to move to nursing homes upon discharge. Univariate analysis showed that age, single/divorced/widowed status, longer length of stay, pressure sores, urinary incontinence, urinary catheterization, falls, dementia, diabetes mellitus, Barthel index (100), Elderly Mobility Score (EMS), Chinese version of the mini-mental state examination (C-MMSE) and albumin levels were significant factors associated with institutionalization. Multivariate analysis showed that being single/divorced/widowed (odds ratio=OR=2.74, 95% confidence interval=CI=1.36-5.53, p=0.0048), having urinary incontinence on discharge (OR=5.13, CI=2.66-10.6, p<0.001) and admission due to falls (OR=2.4, CI=1.03-5.57, p=0.04) were independent risk factors for nursing home admission. Higher admission EMS (OR=0.91, CI=0.84-0.97, p=0.009), admission C-MMSE (OR=0.93, CI=0.87-0.98, p=0.019), and discharge albumin levels (OR=0.93, CI=0.88-0.99, p=0.02) were independent protecting factors against nursing home admission. Knowledge of these factors can allow us to predict accommodation outcome and develop intervention strategy to reduce institutionalization in the older patients.

Continuous use of antipsychotics and its association with mortality and hospitalization in institutionalized Chinese older adults: an 18-month prospective cohort study.

BACKGROUND Previous meta-analyses have suggested that antipsychotics are associated with increased mortality in dementia patients with behavioral and psychological symptoms (BPSD). Subsequent observational studies, however, have produced conflicting results. In view of this controversy and the lack of any suitable pharmacological alternative for BPSD, this study aimed to investigate the relationship between continuous use of antipsychotics and mortality as well as hospitalizations in Chinese older adults with BPSD residing in nursing homes. METHODS This was a prospective cohort study conducted in nursing homes in the Central & Western and Southern Districts of Hong Kong from July 2009 to December 2010. Older adults were stratified into the exposed group (current users of antipsychotics) and control group (non-users). Demographics, comorbidity according to the Charlson Comorbidity Index (CCI), Barthel Index (BI(20)), Abbreviated Mental Test (AMT), and vaccination status for pandemic Influenza A (H1N1) 2009, seasonal influenza and pneumococcus were collected at baseline. Subjects were followed up at 18 months. All-cause mortality and all-cause hospitalizations were recorded. RESULTS 599 older adults with dementia from nine nursing homes were recruited. The 18-month mortality rate for the exposed group was 24.1% while that for control group was 27.5% (P = 0.38). The exposed group also had a lower median rate of hospitalizations (56 (0-111) per 1000 person-months vs 111 (0-222) per 1000 person-months, median (interquartile range), p<0.001). CONCLUSIONS The continuous use of antipsychotics for BPSD does not increase mortality among Chinese older adults with dementia living in nursing homes. Furthermore, our results show that the use of antipsychotics can lead to decreased hospitalizations.

Functional Status of Older Nursing Home Residents Can Affect the Efficacy of Influenza Vaccination

BACKGROUND The efficacy of influenza vaccination in older nursing home residents is frequently overestimated due to frailty selection bias. Limited data exist to examine this issue. METHODS We conducted a prospective cohort study from December 2009 to November 2010 to evaluate the efficacy of influenza vaccination in old nursing home residents with respect to their functional status. Participants were stratified according to the Barthel Index (BI) into good functioning (GF; BI > 60), intermediate functioning (IF; BI = 5-60), and poor functioning (PF; BI = 0). Participants were vaccinated by monovalent H1N1 2009 and trivalent seasonal influenza vaccinations (H1N1-TIV), TIV alone, or remained unvaccinated by choice. The associations between all-cause mortality, vaccination efficacy, and functional status were examined. RESULTS A total of 711 older nursing home residents were enrolled (GF group: N = 230; IF group: N = 246; PF group: N = 235). At 12 months, H1N1-TIV recipients had the lowest all-cause mortality, whereas unvaccinated residents had the highest all-cause mortality in all three functional status groups. In the comparison between H1N1-TIV recipients and TIV alone recipients, the hazard ratios (HRs) of all-cause mortality were lower in the GF group and higher in the PF group (GF group: HR 0.30 [0.07-0.95], p < .05; IF group: HR 0.40 [0.18-0.86], p < .05; PF group: HR 0.53 [0.28-0.99], p < .05). The same observation was found in comparison between other vaccination statuses (H1N1-TIV vs unvaccinated and TIV alone vs unvaccinated). CONCLUSIONS Influenza vaccination was associated with reduced all-cause mortality in older nursing home residents with different functional statuses. Vaccine efficacy in reducing mortality declined with increasingly impaired functional status.

Chronic Kidney Disease and Its Association With Mortality and Hospitalization in Chinese Nursing Home Older Residents: A 3-Year Prospective Cohort Study

OBJECTIVE To investigate chronic kidney disease (CKD) as a predictor of mortality and hospitalization in Chinese nursing homes older residents. DESIGN A 3-year prospective multicenter cohort study. SETTING Nine nursing homes in Hong Kong. PARTICIPANTS Nursing home older adults (812 total; 271 men and 571 women), mean age 86.0 ± 7.6. MEASUREMENTS Glomerular filtration rate (GFR) was estimated by the Modification of Diet in Renal Disease Study (Chinese-adjusted), and participants were stratified into different severity of renal impairment according to the modified version of Kidney Disease Outcomes Quality Initiative (K/DOQI): stage 1 CKD: GFR > 90 mL/min/1.73 m(2); stage 2 CKD: 60-89 mL/min/1.73 m(2); stage 3A CKD: 45-59 mL/min/1.73 m(2); stage 3B CKD: 30-44 mL/min/1.73 m(2); stage 4/5: <30 mL/min/1.73 m(2). The outcome measures were the all-cause, infection-related, and cardiovascular-related mortality and hospitalizations. RESULTS Older adults with stage 3B and stage 4/5 CKD had higher all-cause, infection-related, and cardiovascular-related mortality than those with earlier stages of CKD. After multivariate analysis, stage 3B and stage 4/5 CKD were independent predictors of all-cause mortality (stage 3B, hazard ratio [HR]: 1.62, 95% CI: 1.12-2.33, P= .01; stage 4/5, HR: 2.00, 95% CI: 1.34-3.00, P= .001) and infection-related mortality (stage 3B, HR: 1.41, 95% CI: 1.08-2.30, P= .019; stage 4/5, HR: 1.91, 95% CI: 1.13-3.23, P= .016), but not cardiovascular-related mortalities. The all-cause, infection-related, and cardiovascular-related hospitalizations were significantly higher in older nursing home adults with stage 3B and stage 4/5 CKD. CONCLUSION In Chinese nursing home older adults, stage 3B and stage 4/5 CKD are independent predictors of all-cause and infection-related mortality. They also predict increased risks of all-cause, infection-related, and cardiovascular-related hospitalizations.