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Mandy H Chan,1 Patrick WL Leung,2 Ting-pong Ho,3 Se-fong Hung,4 Chi-chiu Lee,5 Chun-pan Tang,5 Ka-chai Cheung,2 Fung-yee Ching,2 Fefe HK Chan,6 Lu-hua Chen,2 Merce Garcia-Barcelo,7 Pak-chung Sham3 1Department of Clinical Psychology, Kowloon Hospital, Hospital Authority, 2Department of Psychology, The Chinese University of Hong Kong, 3Department of Psychiatry, University of Hong Kong, 4Department of Psychiatry, The Chinese University of Hong Kong, 5Department of Psychiatry, Kwai Chung Hospital, Hospital Authority, 6Department of Clinical Psychology, Alice Ho Mui Ling Nethersole Hospital, Hospital Authority, 7Department of Surgery, University of Hong Kong, Hong Kong, People’s Republic of China Background: Methylphenidate (MPH) has been found to be an effective medication for attention-deficit/hyperactivity disorder (ADHD). However, there are neither consistent nor sufficient findings on whether psychiatric comorbidities and associated cognitive functions of ADHD are related to treatment response to MPH in ADHD children.Objectives: This study investigated whether psychiatric comorbidities, IQ, and neurocognitive deficits are related to treatment response to MPH in ADHD children. In some ways, it is preferable to have a drug that the effectiveness of which to a disorder is not affected by its associated cognitive functions and psychiatric comorbidities. On the other hand, it is likely that the baseline symptom severity of ADHD is associated with the effectiveness of MPH treatment on the symptoms post treatment.Methods: A total of 149 Chinese boys (aged 6–12 years) with ADHD, combined type, and normal IQ participated in this study. Assessment of ADHD symptom severity was conducted pre and post MPH treatment, while assessment of psychiatric comorbidities, IQ, and neurocognitive deficits was performed in a non-medicated condition. Treatment response was defined as the ADHD symptom severity post MPH treatment.Results: Results indicated that MPH treatment was effective, significantly improving the ADHD condition. Yet, comorbid disorders, IQ, and neurocognitive deficits were not related to MPH treatment response on ADHD symptoms. These findings indicated that the effectiveness of MPH was not affected by psychiatric comorbidities and associated cognitive functions of ADHD. Instead, as expected, it was the baseline symptom severity that was mainly related to the treatment response, ie, the milder the baseline condition, the better the treatment response.Conclusion: The current findings positively endorse the widespread clinical use of MPH for treating ADHD. It improves the behavioral symptoms of ADHD regardless of varying psychiatric comorbidities, IQ, and neurocognitive deficits. Keywords: ADHD, psychiatric comorbidities, cognitive functions, treatment response, methylphenidate

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. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: Prior to clinical presentations of Alzheimer's Disease (AD), neuropathological changes, such as amyloid-β and brain atrophy, have accumulated at the earlier stages of the disease. The combination of such biomarkers assessed by multiple modalities commonly improves the likelihood of AD etiology. We aimed to explore the discriminative ability of Aβ PET features and whether combining Aβ PET and structural MRI features can improve the classification performance of the machine learning model in older healthy control (OHC) and mild cognitive impairment (MCI) from AD., Material and Methods: We collected 94 AD patients, 82 MCI patients, and 85 OHC from three different cohorts. 17 global/regional Aβ features in Centiloid, 122 regional volume, and 68 regional cortical thickness were extracted as imaging features. Single or combined modality features were used to train the random forest model on the testing set. The top 10 features were sorted based on the Gini index in each binary classification., Results: The results showed that AUC scores were 0.81/0.86 and 0.69/0.68 using sMRI/Aβ PET features on the testing set in differentiating OHC and MCI from AD. The performance was improved while combining two-modality features with an AUC of 0.89 and an AUC of 0.71 in two classifications. Compared to sMRI features, particular Aβ PET features contributed more to differentiating AD from others., Conclusion: Our study demonstrated the discriminative ability of Aβ PET features in differentiating AD from OHC and MCI. A combination of Aβ PET and structural MRI features can improve the RF model performance., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

We describe a rare and complex case of septic cavernous sinus thrombosis (SCST) in a 70-year-old patient who initially presented with ocular symptoms that rapidly progressed to severe intracranial vascular complications, including subarachnoid hemorrhage (SAH). Despite the use of broad-spectrum antibiotics and anticoagulants, the patient's condition deteriorated. SCST, often caused by sinus infections, presents a significant diagnostic and therapeutic dilemma, with mortality rates exceeding 20%. This report underscores the diversity of clinical presentations, ranging from mild headaches to severe cranial nerve deficits, that complicate diagnosis and treatment. The inability to detect any aneurysms in our patient using magnetic resonance imaging (MRI) and computed tomography angiography (CTA) may indicate an alternative pathogenesis. This could involve venous hypertension and endothelial hyperpermeability. This case illustrates the need for personalized treatment approaches, as recommended by the European Federation of Neurological Societies, and the importance of a multidisciplinary perspective when managing such intricate neurological conditions. Our findings contribute to the understanding of SCST coexisting with SAH.

Background: Subarachnoid-pleural fistula (SPF) is a complex and rare condition characterized by a pathological shunt between the subarachnoid and pleural spaces. It can lead to the accumulation of cerebrospinal fluid (CSF) in the pleural space, pneumocephalus, and the development of central nervous system infection. Trauma or thoracic spinal surgery are common causes of SPF, with symptoms including postural headache, consciousness status changes, and dyspnea. The combination of SPF and subdural hygroma is a severe and rare condition, with little existing literature on its clinical correlation., Case Summary: We report a case of an 83-year-old male patient with traumatic SPF and bilateral frontal subdural hygroma following a fall from height. The patient initially presented with severe lower back and buttock pain. During admission, the patient developed worsening lower limb weakness and pleural effusion. Further investigation revealed the presence of subdural hygromas with mass effect, requiring emergency bilateral subdural drainage. A multidisciplinary approach was undertaken to manage this complex condition, including intervention for hypovolemic CSF status and subdural hygroma management. The pleural effusion eventually resolved and the patient attained a higher level of consciousness after bilateral hygroma drainage surgery. We also reviewed the present literature relating to this rare combination of medical conditions., Conclusion: Traumatic SPF with subsequent subdural hygroma is a rare but serious combination. Although the optimal treatment strategy for this complex condition remains uncertain, our literature review suggested that a multidisciplinary approach, including intervention for hypovolemic CSF and management of the subdural hygroma, is the most beneficial., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Spiritual well-being (SWB) is a key construct in a holistic health model. This study applied a theory-driven mobile health-supported volunteer-assisted self-help (mVS) intervention to enhance SWB for discharged older patients through a medical-social-academia tripartite collaboration. This study followed a quasi-experimental design, conducted from 2017 to 2019. Data were collected from pre- and post-intervention assessment and Clinical Management System under the Hospital Authority in Hong Kong. SWB was assessed by the Spirituality Scale for Chinese Elders with seven domains, a validated scale suitable for the non-religious context. A total of 161 discharged older patients were recruited, 101 received the mVS intervention and 60 received standardized usual volunteer visits. mVS intervention was assisted by volunteers supported by a corresponding mobile application Fu Le Man Xin . The final analysis included 137 older patients living in Hong Kong aged 61 to 94 years. Repeated measures ANOVA showed mVS intervention significantly enhanced two domains of SSCE: meaning of life ( F (1, 64) = 4.029, p  = .049) and relationship with others ( F (1, 57) = 6.428, p  = .014). This study shows that mVS intervention is a feasible medical-social-academia tripartite collaboration that improves two domains of the SWB of discharged older patients: meaning of life and relationship with others.

Background: Patients with type 2 diabetes mellitus (T2DM) and subjective cognitive decline (SCD) have a higher risk to develop Alzheimer's Disease (AD). Resting-state-functional magnetic resonance imaging (rs-fMRI) was used to document neurological involvement in the two groups from the aspect of brain dysfunction. Accumulation of amyloid-β (Aβ) starts decades ago before the onset of clinical symptoms and may already have been associated with brain function in high-risk populations. However, this study aims to compare the patterns of fractional amplitude of low-frequency fluctuations (fALFF) maps between cognitively normal high-risk groups (SCD and T2DM) and healthy elderly and evaluate the association between regional amyloid deposition and local fALFF signals in certain cortical regions., Materials and Methods: A total of 18 T2DM, 11 SCD, and 18 healthy elderlies were included in this study. The differences in the fALFF maps were compared between HC and high-risk groups. Regional amyloid deposition and local fALFF signals were obtained and further correlated in two high-risk groups., Results: Compared to HC, the altered fALFF signals of regions were shown in SCD such as the left posterior cerebellum, left putamen, and cingulate gyrus. The T2DM group illustrated altered neural activity in the superior temporal gyrus, supplementary motor area, and precentral gyrus. The correlation between fALFF signals and amyloid deposition was negative in the left anterior cingulate cortex for both groups. In the T2DM group, a positive correlation was shown in the right occipital lobe and left mesial temporal lobe., Conclusion: The altered fALFF signals were demonstrated in high-risk groups compared to HC. Very early amyloid deposition in SCD and T2DM groups was observed to affect the neural activity mainly involved in the default mode network (DMN)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bao, Shea, Chiu, Kwan, Chan, Chow, Chan and Mak.)

To evaluate the incremental diagnostic value of 18F-Flutemetamol PET following MRI measurements on an unselected prospective cohort collected from a memory clinic. A total of 84 participants was included in this study. A stepwise study design was performed including initial analysis (based on clinical assessments), interim analysis (revision of initial analysis post-MRI) and final analysis (revision of interim analysis post-18F-Flutemetamol PET). At each time of evaluation, every participant was categorized into SCD, MCI or dementia syndromal group and further into AD-related, non-AD related or non-specific type etiological subgroup. Post 18F-Flutemetamol PET, the significant changes were seen in the syndromal MCI group (57%, p < 0.001) involving the following etiological subgroups: AD-related MCI (57%, p < 0.01) and non-specific MCI (100%, p < 0.0001); and syndromal dementia group (61%, p < 0.0001) consisting of non-specific dementia subgroup (100%, p < 0.0001). In the binary regression model, amyloid status significantly influenced the diagnostic results of interim analysis (p < 0.01). 18F-Flutemetamol PET can have incremental value following MRI measurements, particularly reflected in the change of diagnosis of individuals with unclear etiology and AD-related-suspected patients due to the role in complementing AD-related pathological information., (© 2022. The Author(s).)

Introduction: Existing literature on attitudes toward end-of-life care (EoLC) covers the general public but has little information on the frail elderly population. The aim of the current study is to investigate the preferences of Chinese frail elderly home residents with respect to EoLC by conducting cross-sectional surveys., Methods and Analysis: Surveys, including resident and family versions, were developed based on the existing literature and our pilot interviews. The targeted participants were 400 frail elderly home residents (aged ≥65 years old) and 200 family caregivers. Purposive sampling will be used as each elderly home will help to recruit five to 15 elderly participants for the study. Descriptive analysis and modelling will be used to examine preferences on EoLC and related factors, as well as to compare the responses of elderly home residents with those of their family caregivers., Ethics and Dissemination: The cross-sectional survey has obtained approval from the Institutional Review Board. Confidentiality and safety issues will be carefully observed. The results of the study will be disseminated through international conferences, peer-reviewed academic journal publications, and a report in plain language to be shared with elderly residential homes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cognitive impairment (CI) is common among patients on peritoneal dialysis (PD), but it is under-recognized and systematic review on its prevalence and impact across different geographical locations or patient characteristics is lacking., Methods: A search of the literature on CI in PD patients published between 1 Jan 1980 and 25 . April 2019 was conducted. Meta-analysis using a random effects model was performed to determine the pooled estimate of the prevalence of CI. Meta-regression was performed to identify factors contributing to the variance of prevalence rate. A systematic review was also performed to study risk factors of CI and its impact on clinical outcomes., Results: Eight studies were included and the relevant data from 1736 patients were extracted for analysis. Meta-analysis revealed a pooled prevalence of CI at 28.7% (95% CI 15.9-46%). Meta-regression analyses showed that the prevalence of CI was unrelated to patient's age, gender, duration of PD, healthcare policy of dialysis modality, the prospective or retrospective nature of studies, or year of publication. Systematic review of 20 studies showed that older age, female sex and lower education were risk factors for CI. Potential reversible factors for CI include electrolytes disturbances, depression and vitamin D deficiency. Also, CI was associated with a higher risk of hospitalization, mostly due to PD-related peritonitis., Conclusions: CI is common in patients on long-term PD. Screening for CI should be considered in PD patients with increased risk.

Introduction: Cognitive impairment is common among patients on peritoneal dialysis (PD). We hypothesize that cognitive impairment has a negative impact on the outcome of patients on PD, especially with regard to peritonitis., Methods: This was a single-center 2-year prospective cohort study involving 206 patients at 1 PD unit. Cognitive impairment was defined by the latest Hong Kong Montreal Cognitive Assessment Score (HK-MoCA) multiple cut-offs as determined by age and years of education. Eighty percent of patients had come back for interval HK-MoCA. The HK-MoCA was performed at baseline and after 1 year on PD. Potential risk factors for cognitive impairment and peritonitis were studied separately for the first and second year., Results: For cognitive impairment at baseline, multivariate analyses showed that age (odds ratio [OR] 1.003, 95% confidence interval [CI] 1.003 - 1.065, p = 0.03), female sex (OR 3.57, 95% CI 1.60 - 7.97, p = 0.002), peripheral vascular disease (PVD) (OR 3.46, 95% CI 1.33 - 9.01, p = 0.01), and hemoglobin level (OR 0.60, 95% CI 0.43 - 0.84, p = 0.003) were statistically significant factors. For cognitive impairment at 1 year, multivariate analyses showed that age (OR 1.07, 95% CI 1.02 - 1.012, p = 0.007), female sex (OR 5.87, 95% CI 1.86 - 18.5, p = 0.003), and PVD (OR 3.68, 95% CI 1.07 - 12.84, p = 0.04) were statistically significant independent factors for cognitive impairment at 1 year.For self-care PD patients in the second year, patients with cognitive impairment had a higher rate of peritonitis and proportionately more patients suffered from both peritonitis and exit-site infection than non-cognitively impaired patients in the second year (0.50 vs 0.27 episodes per year, p = 0.048; 25% vs 7.2%, p = 0.049). Logistic regression showed that only HK-MoCA-defined cognitive impairment and HK-MoCA scores at 1 year were factors predicting peritonitis (risk ratio [RR] 3.2 [95% CI 1.03 - 9.95], p = 0.04 and RR 0.92 [95% CI 0.86 - 0.995], p = 0.04 respectively)., Conclusions: In summary, increasing age, female sex, anemia, and presence of PVD are risk factors for cognitive impairment in PD patients. Self-care PD with cognitive impairment at 1 year has a higher risk for PD-related peritonitis in the second year. Interval HK-MoCA assessment is recommended to detect cognitive impairment in our local PD patients., (Copyright © 2019 International Society for Peritoneal Dialysis.)

Aim: To study the prevalence and risk factors of delirium and subsyndromal delirium (SSD) in Chinese older adults with acute medical illnesses., Methods: A prospective cohort study was carried out in acute general medical wards in a university-affiliated hospital in Hong Kong. Patients were assessed by the confusion assessment method by geriatricians within 6 h after admission and classified into three mutually exclusive groups, namely delirium, SSD and those without both conditions. Predisposing factors and precipitating factors of delirium and SSD were retrieved from collateral information, clinical charts and electronic clinical records., Results: A total of 575 patients with mean age of 80.8 years were recruited. A total of 73% of the patients did not have delirium, 15.8% of patients had delirium and 11.3% of patients had SSD. On multivariate analysis, patients with delirium or SSD were more likely to be current users of psychotropic medications, had hearing and visual impairment, had a major neurocognitive disorder as defined by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, and with a lower Barthel Index 20 points version than those without both conditions. Significant predisposing and precipitating factors of delirium included psychotropic medications, acute stroke and other causes of organic brain syndromes. Predisposing and precipitating factors of delirium and SSD were almost identical., Conclusions: Delirium and SSD are common among Chinese older adults with acute medical illnesses, with a combined prevalence of delirium and SSD of 27%. Important precipitating and predisposing factors include psychotropic medications, acute ischemic stroke and other causes of organic brain syndromes. Geriatr Gerontol Int 2018; 18: 1625-1628., (© 2018 Japan Geriatrics Society.)

Objective: To create and compare individual and group-based cut-points for wrist accelerometry that correspond to moderate-to-vigorous physical activity (MVPA) in people with spinal cord injury (SCI)., Design: Participants completed a graded treadmill-wheeling test while being assessed for oxygen consumption, wrist-acceleration vector magnitude, and spoke acceleration. Oxygen consumption was converted to SCI metabolic equivalents (METs), and linear regression was applied to determine an individualized vector magnitude cut-point (counts per minute, VM-CPM) corresponding with MVPA (≥3 SCI METs). Multilevel linear regression was applied to determine a group MVPA cut-point. Participants then completed a 6-day monitoring period while wearing the accelerometers., Setting: A local SCI research center., Participants: Manual wheelchair users (N=20; aged 31-64y; injury levels, C5 to L2) with chronic (>1y) SCI., Interventions: Not applicable., Main Outcome Measures: Mean total daily MVPA, wheeled MVPA, and nonwheeled MVPA were calculated using both the individual and group cut-points. Agreement on measures of minutes per day of MVPA between the individual and group mean cut-point method was assessed using Bland-Altman plots., Results: Individual cut-points for MVPA ranged from 6040 to 21,540 VM-CPM, with a group cut-point of 11,652 (95% confidence interval, 7395-15,909). For total daily MVPA, Bland-Altman analysis revealed a bias of .22±33.0 minutes, with 95% limits of agreement from -64.5 to 64.9 minutes, suggesting a large discrepancy between total MVPA calculated from individual and group mean cut-points., Conclusions: Individual calibration of wrist-worn accelerometry is recommended for effective habitual PA monitoring in this population., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Feeding problems are common in older people with advanced dementia. When eating difficulties arise tube feeding is often initiated, unless there is a valid advance directive that refuses enteral feeding. Tube feeding has many pitfalls and complications. To date, no benefits in terms of survival, nutrition, or prevention of aspiration pneumonia have been demonstrated. Careful hand feeding is an alternative to tube feeding with advanced dementia. In Hong Kong, the Hospital Authority has established clear ethical guidelines for careful hand feeding. Notwithstanding, there are many practical issues locally if tube feeding is not used in older patients with advanced dementia. Training of doctors, nurses, and other members of the health care team is vital to the promulgation of careful hand feeding. Support from the government and Hospital Authority policy, health care staff training, public education, and promotion of advance care planning and advance directive are essential to reduce the reliance on tube feeding in advanced dementia.

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., (© The Author(s) 2015.)

Neurovascular coupling reflects the close temporal and regional linkage between neural activity and cerebral blood flow. Although providing mechanistic insight, our understanding of neurovascular coupling is largely limited to non-physiologicalex vivopreparations and non-human models using sedatives/anesthetics with confounding cerebrovascular implications. Herein, with particular focus on humans, we review the present mechanistic understanding of neurovascular coupling and highlight current approaches to assess these responses and the application in health and disease. Moreover, we present new guidelines for standardizing the assessment of neurovascular coupling in humans. To improve the reliability of measurement and related interpretation, the utility of new automated software for neurovascular coupling is demonstrated, which provides the capacity for coalescing repetitive trials and time intervals into single contours and extracting numerous metrics (e.g., conductance and pulsatility, critical closing pressure, etc.) according to patterns of interest (e.g., peak/minimum response, time of response, etc.). This versatile software also permits the normalization of neurovascular coupling metrics to dynamic changes in arterial blood gases, potentially influencing the hyperemic response. It is hoped that these guidelines, combined with the newly developed and openly available software, will help to propel the understanding of neurovascular coupling in humans and also lead to improved clinical management of this critical physiological function., (© The Author(s) 2015.)

An ageing population is posing a great challenge to Hong Kong. Maintaining health and functional independence among older adults is of utmost importance, and requires the collaborative efforts of multiple health care disciplines from both the private and public sectors. The Reference Framework for Preventive Care for Older Adults, developed by the Task Force on Conceptual Model and Preventive Protocols under the auspices of the Working Group on Primary Care, aims to enhance primary care for this population group. The reference framework emphasises a comprehensive, integrated, and collaborative approach that involves providers of primary care from multiple disciplines. In addition to internet-based information, helpful tools in the form of summary charts and Cue Cards are also produced to facilitate incorporation of recommendations by primary care providers into their daily practice. It is anticipated that wide adoption of the reference framework will contribute to improving older adults' health in our community.

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.

Aim: A U-shaped relationship between body mass index (BMI) and all-cause mortality has been reported, but there are few studies examining the association between BMI and cause-specific mortality and hospitalization. We carried out a longitudinal study to examine these associations in Chinese older adults with multiple comorbidities, which could provide a reference for the recommended BMI in this population., Methods: From 2004 to 2013, a retrospective cohort of Chinese older adults was selected from a geriatric day hospital in Hong Kong. They were divided into groups according to their BMI: BMI <16; BMI 16-18; BMI 18.1-20; BMI 20.1-22; BMI 22.1-24; BMI 24.1-26; BMI 26.1-28; BMI 28.1-30 and BMI >30. Other assessments included medical, functional, cognitive, social and nutritional assessment., Results: A total of 1747 older adults (mean age 80.8 ± 7.1 years, 44.1% male, 46.1% living in nursing homes, Charlson Comorbidity Index 2.0 ± 1.6) with a median follow up of 3.5 years were included. Older adults with BMI 24-28 had the lowest all-cause, infection-related and cardiovascular mortality (P < 0.001). Multivariate analysis showed that there was an inverted J-shaped association between BMI and hazard ratio for all-cause and infection-related mortality in both nursing home and community-dwelling older adults. The rate of all-cause hospitalization was lower in older adults with BMI 22-28 (P = 0.002). Multivariate analysis showed that there was an inverted J-shaped association between the odds ratio of recurrent hospitalization and BMI., Conclusion: Chinese older adults with BMI 24-28 had lower all-cause mortality, infection-related mortality, cardiovascular-related mortality and all-cause hospitalization. This study provides a reference for the recommended BMI in this population., (© 2014 Japan Geriatrics Society.)

Background/purpose: The study describes a proactive infection control approach to prevent nosocomial transmission of vancomycin-resistant enterococci (VRE) and tests if this approach is effective for controlling multiple-drug resistant organisms in a nonendemic setting., Methods: In response to the increasing prevalence of VRE in Hong Kong since 2011, we adopted a multifaceted assertive approach in our health care network. This included active surveillance culture, extensive contact tracing, directly observed hand hygiene in conscious patients before they received meals and medications, stringent hand hygiene and environmental cleanliness, and an immediate feedback antimicrobial stewardship program. We report the occurrence of VRE outbreaks in our hospital after institution of these measures and compared with the concurrent occurrence in other public hospitals in Hong Kong., Results: Between July 1, 2011 and November 13, 2013, VRE was identified in 0.32% (50/15,851) of admission episodes by active surveillance culture. The risk of VRE carriage was three times higher in patients with a history of hospitalization outside our hospital networks in the past 3 months (0.56% vs. 0.17%; p = 0.001) compared with those who were not. Extensive contact tracing involving 3277 patient episodes was performed in the investigation for the 25 VRE index patients upon whom implementation of contact precautions was delayed (more than 48 hours of hospitalization). One episode of VRE outbreak was identified in our hospital network, compared with the 77 VRE outbreaks reported in the other hospital networks (controls) without these proactive infection control measures., Conclusion: Our multifaceted assertive proactive infection control approach can minimize the nosocomial transmission and outbreak of VRE in a nonendemic area., (Copyright © 2014. Published by Elsevier B.V.)

Objective: To compare the immunogenicity and safety between full-dose (15 μg) intramuscular (i.m.) and full-dose (15 μg) intradermal (i.d.) immunization of the trivalent influenza vaccine in nursing home older adults., Design: A single-center, randomized, controlled, open-label, parallel group trial from October 2013 to April 2014., Setting: Nine nursing homes in Hong Kong., Participants: Hundred nursing home older adults (mean age: 82.9 ± 7.4 years)., Intervention: Fifty received i.d. (Intanza) and 50 received i.m. (Vaxigrip) vaccination., Measurements: Baseline measurements included demographics, comorbidity, frailty and nutritional status. Day 21 and day 180 immunogenicity (seroconversion rate, seroprotection rate, geometric mean titer [GMT] fold increase in antibody titer) using hemagglutination-inhibition and adverse events were measured. Noninferiority and superiority of i.d. compared with i.m. vaccination in immunogenicity were analyzed. The study was registered on ClinicalTrials.gov; identifier: NCT 01967368., Results: At day 21, noninferiority in immunogenicity of the i.d. vaccination was demonstrated. The seroconversion rate of the H1N1 strain was significantly higher in the i.d. group. At day 180, immunogenicity of both groups fell but the GMT of all strains in i.d. group was higher and the difference was significant for H3N2 strain. The seroconversion rate and GMT fold increase of H3N2 strain was significantly higher in the i.d. group. Local adverse events was significantly more in i.d. group, but they were mild and resolved in 72 hours., Conclusions: I.d. vaccination is noninferior, and even superior in some parts of immunogenicity assessment, to i.m. vaccination without compromising safety in nursing home older adults. I.d. vaccination is a good alternative to i.m. vaccination in this population., (Copyright © 2014 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

A 34-year-old woman presented with a history of persisting headache for years, and a newly developed dizziness, left facial palsy and right hemiparesis two days prior to this admission. Initial computed tomographic angiography of the head demonstrated an area of increased density in the left middle and posterior fossae. Multiple aneurysmally dilated venous ectasias with contrast enhancement at the left pre-pontine cistern causing a massive mass effect to the brainstem were also noted, suggesting a huge vascular abnormality. Digital subtraction angiography revealed an abnormal vascular lesion surrounding the brainstem, which indicated a left direct carotid-cavernous fistula with posterior drainage. As her consciousness deteriorated the next day, a follow-up computed tomography scan was done which revealed a pontine hemorrhage. Subsequently, endovascular closure of the fistula with sacrifice of the left ICA was performed, which successfully eliminated the imaging abnormalities.

Aim: The Charlson Comorbidity Index (CCI) is commonly studied for predicting mortality, but there is no validation study of it in Chinese older adults. The objective of the present study was to validate the use of CCI in Chinese older adults for predicting mortality., Method: We carried out a retrospective cohort study from 2004 to 2013 for patients discharged from a geriatric day hospital in Hong Kong. Comorbidity was quantified using CCI, and patients were divided into six groups according to their score of CCI: CCI-0, CCI-1, CCI-2, CCI-3, CCI-4 and CCI ≥ 5. Other data collected included demographics, and functional, nutritional, cognitive and social assessment. The outcome measure was 1-year mortality., Results: At 1-year follow up, 3.8% (n = 17), 5.9% (n = 37), 9.2% (n = 35), 12.9% (n = 20), 16.9% (n = 23) and 19.3% (n = 60) of CCI-0, CCI-1, CCI-2, CCI-3, CCI-4 and CCI ≥ 5 died, respectively (P < 0.001). Multivariate analysis showed that CCI-1, CCI-2, CCI-3, CCI-4 and CCI ≥ 5 have a hazard ratio (HR) of 1.34 (confidence interval [CI] 1.04-2.12), 2.18 (CI 1.03-4.61), 3.44 (CI 1.52-7.81), 3.74 (CI 1.35-10.39) and 4.63 (CI 2.28-9.43), respectively, compared with CCI-0. The area under the curve of the receiver operating characteristic curves of CCI in predicting 1-year mortality for older adults was 0.68 (CI 0.64-0.72)., Conclusion: There is a significant dose-response relationship in the hazard ratio between CCI and 1-year mortality in Chinese older adults, but involvements of functional, nutritional and social assessments are important for comprehensive quantification of health status in older adults., (© 2013 Japan Geriatrics Society.)

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.

Aim: There is little data regarding the prevalence and associated comorbidities of anemia in Chinese nursing home older adults. The objective of this study was to investigate the prevalence and associated comorbidities of anemia in Chinese nursing home older adults., Methods: We carried out a retrospective cross-sectional study in nine nursing homes in Hong Kong. The hemoglobin (Hb) level, mean corpuscular volume (MCV), serum creatinine and comorbidities data of residents were examined. Older adults were regarded as anemic according to the World Health Organization criteria (Hb <13 g/dL for men and <12 g/dL for women). The glomerular filtration rate (eGFR) was estimated by the Modification of Diet in Renal Disease Study (MDRD [Chinese-adjusted]) equation. Patients with chronic renal impairment were defined as having eGFR <60 mL/min/1.73 m(2) ., Results: A total of 812 residents were included (mean age 86.0 ± 7.6 years). The mean hemoglobin was 12.0 ± 1.8 g/dL in men and 11.4 ± 1.6g/dL in women. The mean eGFR was 75.1 ± 31.7 mL/min/1.73 m(2) . A total of 67.0% of residents had anemia (70.5% in men and 65.2% in women). Anemic older adults were older and had a higher prevalence of renal impairment than non-anemic older adults (P<0.001). There was no significant difference between the two groups regarding the prevalence of other comorbidities. When stratified into different age groups, there were significant correlations between anemia and renal impairment in all subgroups (age ≤ 80 years, P<0.05; age 81-90 years, P<0.01; age >90 years, P<0.05). The same correlation was found between normocytic anemia and renal impairment. Conversely, when stratified according to eGFR (≥ 60 mL/min/1.73 m(2) vs <60 mL/min/1.73 m(2) ), we did not observe a significant correlation between anemia and age group., Conclusion: In conclusion, anemia is prevalent in Chinese nursing home residents and is strongly associated with renal impairment. Further studies of early identification and management of anemia with renal impairment are recommended in this population., (© 2012 Japan Geriatrics Society.)

Background: The relative contribution of long term care facilities (LTCFs) and hospitals in the transmission of methicillin-resistant Staphylococcus aureus (MRSA) is unknown., Methods: Concurrent MRSA screening and spa type analysis was performed in LTCFs and their network hospitals to estimate the rate of MRSA acquisition among residents during their stay in LTCFs and hospitals, by colonization pressure and MRSA transmission calculations., Results: In 40 LTCFs, 436 (21.6%) of 2020 residents were identified as 'MRSA-positive'. The incidence of MRSA transmission per 1000-colonization-days among the residents during their stay in LTCFs and hospitals were 309 and 113 respectively, while the colonization pressure in LTCFs and hospitals were 210 and 185 per 1000-patient-days respectively. MRSA spa type t1081 was the most commonly isolated linage in both LTCF residents (76/121, 62.8%) and hospitalized patients (51/87, 58.6%), while type t4677 was significantly associated with LTCF residents (24/121, 19.8%) compared with hospitalized patients (3/87, 3.4%) (p<0.001). This suggested continuous transmission of MRSA t4677 among LTCF residents. Also, an inverse linear relationship between MRSA prevalence in LTCFs and the average living area per LTCF resident was observed (Pearson correlation -0.443, p=0.004), with the odds of patients acquiring MRSA reduced by a factor of 0.90 for each 10 square feet increase in living area., Conclusions: Our data suggest that MRSA transmission was more serious in LTCFs than in hospitals. Infection control should be focused on LTCFs in order to reduce the burden of MRSA carriers in healthcare settings.

This study aims to develop and test the psychometric properties of the Chinese Health Literacy Scale for Chronic Care (CHLCC). This is a methodological study with a sample of 262 patients 65 years of age and older who had chronic illnesses. Pearson's correlation, independent sample t tests, and analyses of variance were used. The CHLCC showed a significant positive correlation with Chinese literacy levels (r = 0.80; p < .001) but was negatively correlated with age (r =-0.31; p <.001). Respondents who were male (t =4.34; p <.001) and who had reached Grade 12 or higher in school (F = 51.80; p <.001) had higher CHLCC scores than did their counterparts. Individuals with high levels of health literacy had fewer hospitalizations than did their counterparts (β =-0.31; incidence rate ratio = 0.73; p <.05). The CHLCC also displayed good internal reliability (Cronbach'sα =0.91) and good test-retest reliability (intraclass correlation coefficient = 0.77; p <.01). The CHLCC is a valid and reliable measure for assessing health literacy among Chinese patients with chronic illness. The scale could be used by practitioners before implementing health promotion and education.

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., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

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., Methods: It was a clinical trial with matched historic controls. Patients of a GDH were recruited to participate in Wii-IVR by playing "Wii Fit". Participants used a Wii controller to carry out movements involved in an arm ergometer. Each participant received eight sessions of Wii-IVR in addition to conventional GDH rehabilitation. Feasibility was assessed by the total time receiving Wii-IVR, the percentage of maximal heart rate reserve (%MHR) and Borg perceived exertion scale (BS) after participating in Wii-IVR. %MHR and BS were compared with those after carrying out an arm ergometer for the same duration. Acceptability was assessed by an interviewer-administered questionnaire. Efficacy was assessed by comparing improvements in Functional Independence Measure (FIM) between participants and matched historic controls, who received conventional GDH rehabilitations only., Results: A total of 30 patients completed the study. Participants completed a total of 1941 min of event-free Wii-IVR. The mean %MHR was 15.9% ± 9.9% and the mean BS was 7.9 ± 2.3. There was no significant difference in %MHR and BS between participating in Wii-IVR and arm ergometer. Most participants found Wii-IVR similar to the arm ergometer, and would like to continue Wii-IVR if they had Wii at home. Improvements in FIM of participants were significantly more than that of historic controls., Conclusions: Wii-IVR in GDH was feasible and most participants accepted it. Participants had more improvements in FIM., (© 2012 Japan Geriatrics Society.)

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., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

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.

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., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The relationship between cognitive function and geriatric day hospital (GDH) rehabilitation has not been explored. This study investigated this association in 547 older Chinese patients attended GDH. Cognitive status was assessed by Cantonese version of mini-mental state examination (C-MMSE). Functional independence measure (FIM) upon GDH admission and discharge were measured, with FIM gain = FIM discharge-FIM admission while FIM efficiency = FIM gain/by number of GDH visits. FIM discharge ≥ 90 was defined as satisfactory outcome of rehabilitation. Positive correlation was observed between C-MMSE admission and FIM discharge (p < 0.001). There were significant differences in the FIM admission and FIM discharge among the three C-MMSE groups, with lower discharge scores in low C-MMSE groups (p < 0.001). The FIM gain and FIM efficiency during GDH rehabilitation were not different among different C-MMSE groups. C-MMSE admission (p = 0.03) and FIM admission (p < 0.001) were both positive independent predictors for a satisfactory rehabilitation outcomes (FIM discharge ≥90). Cognitive function was not associated with FIM gain and efficiency. This suggested that selected patients with impaired cognition could still benefit from GDH rehabilitation., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

There are increasing expectations on primary care doctors to shoulder a bigger share of care for patients with common geriatric problems in the community. This study aims to examine the outcomes of a postgraduate training course in geriatrics for primary care doctors. A questionnaire developed by the research team was sent to the course graduates (years 2001-2007). Ninety-eight replies were received with a response rate of 52.4% (98/187). Difference in the ratings by the respondents before and after taking the course was analyzed using the nonparametric Wilcoxon signed rank test. Most respondents felt more rewarding and had participated more in geriatric care, and the majority had improvement in their communication skills with elderly patients after taking the course. Moreover, the graduates are more confident in diagnosing and managing common geriatric problems, and deciding to which specialty to refer the elderly patients. Of the referrals, there was a significant increase to private geriatricians and a significant reduction to other specialists. The average number of elderly patients seen per day had also increased. However, little change was observed about making nursing home visits, the frequency of which remained low. Many graduates expressed difficulties in conducting nursing home visits., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)