Raymond Lo

Handicap and Its Determinants of Change in Stroke Survivors One-Year Follow-Up Study

Background and Purpose— Stroke, a major health issue affecting the elderly, limits their participation in society. The aim of this study was to investigate changes in stroke survivors handicap levels and to identify their determinants in the subacute phase from 3 months to 1 year. Methods— Data were collected from a prospective cohort of 303 Chinese stroke survivors with the use of questionnaires, including the Lawton Instrumental Activities of Daily Living–Chinese Version (IADL-CV), Barthel Index, Chinese Mini-Mental State Examination, Chinese Geriatric Depression Scale, and the Chinese version of the London Handicap Scale. Results— A total of 297 and 268 patients were successfully followed up at 6 and 12 months, respectively. Whereas IADL remained unchanged throughout, we found an improvement in Barthel Index but a deterioration in the Chinese Geriatric Depression Scale score at 12 months. Multilevel modeling revealed improvements in the mobility and social integration handicap domains and a deterioration in the orientation domain at 12 months. Overall handicap remained unchanged. At 12 months, depression was most significantly and independently associated with poststroke handicap, and advanced old age alone (>80 years) was associated with clinically significant deterioration in handicap. Conclusions— Even though IADL remained static at 1 year, mobility and social integration handicap dimensions can be improved in the early community phase after stroke. Nonphysical factors such as depression were confirmed to be significantly associated with handicap. Rehabilitation should target the high-risk group of very elderly stroke survivors who were 4 times more likely to deteriorate in handicap.

Preliminary Findings of External Counterpulsation for Ischemic Stroke Patient With Large Artery Occlusive Disease

Background and Purpose— We aimed to investigate the feasibility and therapeutic effect of external counterpulsation (ECP) in ischemic stroke. Methods— The trial was a randomized, crossover, assessment-blinded, proof-of-concept trial. ECP treatment consisted of 35 daily 1-hour sessions. Patients were randomized to either early (ECP weeks 1 to 7 and no ECP weeks 8 to 14) or late group (no ECP weeks 1 to 7 and ECP weeks 8 to 14). Primary outcomes were an overall change in National Institutes of Health Stroke Scale (NIHSS) and cerebral blood flow estimated by color velocity imaging quantification. Secondary outcomes were change in NIHSS, color velocity imaging quantification, favorable functional outcome (modified Rankin scale, 0 to 2), and stroke recurrence at weeks 7 and 14, respectively. Results— Fifty patients were recruited. At week 7, there was a significant change in NIHSS (early 3.5 vs late 1.9; P=0.042). After adjusting for treatment sequence, ECP was associated with a favorable trend of change in NIHSS of 2.1 vs 1.3 for non-ECP (P=0.061). Changes of color velocity imaging quantification were not significant but tended to increase with ECP. At week 14, a favorable functional outcome was found in 100% of early group patients compared to 76% in the late group (P=0.022). Conclusion— ECP is feasible for ischemic stroke patients with larger artery disease.

Do pain and disability differ in depressed cancer patients

Seventy consecutively admitted Chinese patients with advanced cancer and pain (mean age 62 years) were evaluated with the Chinese version of the Hospital Anxiety and Depression Scale (HADS), and with the Geriatric Depression Scale (GDS) Short Form (for patients 65 years old or over) in a prospective study. The HADS and GDS had good concordance (kappa = 0.53). By these depression screening tests, the prevalence of probable depression was 41–49%, and the prevalence of definite depression (HADS [.greaterequal] 11) was 29%. There was no difference in age, gender and educational level; no difference in nature and severity of pain; and no difference in the level of disability between depressed (using HADS [.greaterequal] 11) and nondepressed patients with advanced cancer. The study suggests that depression does not correlate with the severity of pain in patients with advanced cancer. It also suggests that impaired activity of daily living (ADL) in these patients is not related to depression.

Evaluation of a continuous quality improvement initiative for end-of-life care for older noncancer patients.

OBJECTIVESnThe burden of suffering among patients with end-stage chronic diseases may be greater than those of cancer patients, as a result of longer duration of illness trajectory and high prevalence of symptoms, yet they may be less likely to receive palliative care services. To improve the quality of care of these patients, we carried out a continuous quality improvement initiative among medical and nursing staff of a convalescent facility.nnnDESIGNnEvaluation of a quality improvement initiative.nnnSETTINGnNonacute institution in Hong Kong SAR, China.nnnPARTICIPANTSnThe participants were patients with advanced chronic diseases not opting for active treatment.nnnINTERVENTIONnThe intervention was a continuous quality improvement process carried out over a 3-month period, consisting of service reengineering, provision of guidelines and educational material, and interactive sessions to achieve culture change among staff. Evaluation before and after the intervention included patient symptoms checklist and quality-of-life measures for patients; quality-of-life and cost-of-care index for family members; quality-of-life and carer burden for staff; and use of various health care services.nnnRESULTSnThere were 80 and 89 participants in the pre- and post-intervention phase. The initiative resulted in shorter duration of stay, fewer investigations, fewer transfers back to the affiliated acute care hospital, and more follow-up by the outreach team, with no significant difference in mortality after adjusting for age and comorbidity. Symptoms of pain and cough were reduced, while there was a trend toward more constipation but less dizziness. Family members satisfaction improved.nnnCONCLUSIONSnIt is possible to improve quality-of-life care for elderly patients with end-stage chronic diseases by staff education, and culture and system change, not only without additional resources, but likely savings were achieved in terms of reduced use of health care resources.

Pain in Chinese cancer patients under palliative care

Over a 4-month period, 218 Chinese patients with advanced cancer were admitted to a palliative care unit in Hong Kong. Ninety-five (44%) of them had pain. Of these 95, 70 (mean age 61.7 years) were evaluated with the visual analogue scale (VAS) and the numerical rating scale (NRS). Forty-two per cent of the 70 patients were illiterate. Eighty-three per cent had metastases. Eighty-seven per cent had pain due to the disease process. Forty-nine per cent had more than one pain, 54% had moderate pain and 20% had severe pain. The most common primary tumour was lung cancer. NRS scores strongly correlated with corresponding VAS scores, suggesting that NRS can routinely be used for pain intensity assessment in the Chinese. The study also showed that 64% of these patients with pain had moderate to severe disabilities in the basic activity of daily living, although there was no correlation between the severity of pain and the severity of disability.

Palliative care in old age

What is palliative medicine? In 1987, the Royal College of Physicians recognized palliative medicine as a specialty,n defining it as ‘the study and management of patients with far-advanced diseasen for whom the prognosis is limited and the focus of care is quality of life’.n In 1990, the World Health Organization added its definition, ‘the active andn total care of a person whose condition is not responsive to curative therapy’.n The aim of palliative medicine is to control pain and other physical symptoms, togethern with integration of psychological, social, spiritual care and support. The ultimaten goal is to help patients to achieve their best quality of life. Palliative medicinen places emphasis on a holistic approach, offering care and support not just for patientsn but also for their families. Palliative medicine hence requires an interdisciplinaryn team approach. With the co-ordinated efforts of all disciplines (such as doctors,n nurses, therapists, social workers, clinical psychologists, dieticians, pastoraln care workers and volunteers), patients can be supported in living their remainingn lives as actively as possible, and families can be assisted in coping with illness,n death and bereavement. Palliative care neither intends to postpone death nor doesn so, but affirms life and regards dying as a normal process. When a patient facesn an incurable illness, it is incumbent on the palliative care team to provide then best treatment and care, adding life to days when days cannot be added to life.

Quality of end-of-life care for non-cancer patients in a non-acute hospital

AIMS AND OBJECTIVESnFew surveys have been carried out documenting the quality of life for non-cancer patients in general district hospitals reaching the final trajectory towards death. We carried out a survey of 80 patients facing the final stages of their chronic illness as well as their carers and hospital staff.nnnBACKGROUNDnWith increasing life expectancy, a large majority of patients are older, where palliative care principles for patients with cancer are equally applicable. Few surveys have been carried out documenting the quality of life for non-cancer patients in general district hospitals reaching the final trajectory towards death in terms of patients and carers perspective, compared with the more extensive literature for patients with cancer.nnnDESIGNnSurvey.nnnMETHODSnAssessment tools include symptom check list, geriatric depression scale, Chinese Death Anxiety Inventory and the McGill Quality of Life Questionnaire for patients; SF-12 and the Chinese cost of care index for informal carers; and the Chinese Maslach Bumout and Death Anxiety Inventories for hospital staff.nnnRESULTSnLower-limb weakness (92·5%), fatigue (86·2%), oedema (85%), dysphagia (58·2%) and pain (48·8%) were the most common symptoms in this group of patients. The mean Chinese Caregiver Stress Index score was 45·93 (SD 6·45) (maximum score = 80). For staff, the mean SF-12 physical component score was lower than the Hong Kong population average.nnnCONCLUSIONnThe findings suggest that there is room for improvement in the quality of end-of-life care. Relevance to clinical practice.u2002 Patients in the final stages of many chronic illnesses have high prevalence of symptoms comparable to those of patients with cancer. Raising awareness and improving training for all health care professionals, formulating guidelines and care pathways and incorporating quality of care as key performance indicators are measures to improve the quality of end-of-life care.

Acute Tubular Necrosis Following Endosulphan Insecticide Poisoning

Endosulphan is a chlorinated hydrocarbon insecticide with potential toxicity for the respiratory and central nervous systems. Renal toxicity has been rarely reported. We describe a man who developed renal failure due to acute tubular necrosis following a suicidal attempt with endosulphan in the absence of significant hypotension or sepsis.

The needs, current knowledge, and attitudes of care staff toward the implementation of palliative care in old age homes.

This study aims to explore in depth the needs, current knowledge, and attitudes of all ranks of old age home staff. A large-scale qualitative study with 13 semistructured focus groups was conducted in Hong Kong. Key themes were extracted by framework analysis. Three major themes were extracted, including role as a service provider, current knowledge, and attitude toward palliative care. There was a marked difference in familiarity with the concept of ‘‘palliative care’’ between different groups of staff, yet both shared the motivation for enhancement. The biggest concerns for the staff were elderly residents’ readiness to accept palliative care, manpower, and resources. Care staff, regardless of rank, seemed to welcome and be ready to adopt a palliative care approach in caring for old age home residents, though not without worries and concerns.

Improving the Quality of End-of-Life Care in Long-Term Care Institutions

PURPOSEnA knowledge transfer program was carried out to improve knowledge in end-of-life care staff at all levels in residential care homes for the elderly, using a model similar to that developed for a non-acute care hospital setting.nnnMETHODSnThe program consisted of a series of seminars and on-site sharing sessions held in the hospital providing outreach support to residential care homes for the elderly (RCHEs), as well as case discussions in the RCHEs. Evaluation was carried out using a knowledge assessment questionnaire before and after the initiative, as well as recording RCHE staff feedback and in-depth interviews with selected residents and their family members.nnnRESULTSnKnowledge gaps among RCHE staff existed in the areas of mortality relating to chronic diseases, pain and use of analgesics, feeding tubes, dysphagia, sputum management, and attitudes towards end-of-life care issues, which improved after the program. From the qualitative study, RCHE staff highlighted knowledge and service gaps, issues relating to use of feeding tubes and refusal to eat, lack of confidence in managing the dying process, application of Advance Care Plan (ACP) in the RCHE setting, and the need for training in these areas. Residents and family members highlighted the preference for death over suffering, planning for death, misconceptions about life-sustaining treatments and the advance directive (AD) document, and service gaps in advance care planning.nnnCONCLUSIONnConsiderable knowledge and service gaps exist among staff and residents of RCHEs, which can be improved by the hospital geriatric team providing services to RCHEs.