hong kong reference framework for preventive care … · module on health assessment ... annex 7....

Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings

Module on Health Assessment

in Primary Care Settings


for Preventive Care for Older AdultsHong Kong Reference Framework

for Preventive Care for Older Adultsin Primary Care Settings


Hong Kong Reference Frameworkfor Preventive Care for Older Adults


Hong Kong Reference Frameworkfor Preventive Care for Older Adults



Revised Edition 2017

First published: 2013


Content

1. IMPORTANCE OF HEALTH ASSESSMENT ....................................................................................... 32. DELIVERY OF PREVENTIVE CARE SERVICE: USE EVERY OPPORTUNITY FOR

PREVENTION ........................................................................................................................................................ 43. RECOMMENDATIONS ON SYSTEMATIC HEALTH ASSESSMENT ............................................ 5

3.1. IDENTIFYING THE RIGHT PEOPLE (CASE FINDING) .............................................................. 53.2. BASELINE ASSESSMENT .............................................................................................................. 53.3. FORMULATION OF PERSONALIZED PREVENTIVE CARE PLAN .......................................... 83.4. CARE CO-ORDINATION ................................................................................................................. 83.5. MONITORING AND REVIEW ........................................................................................................ 9

4. HEALTH ASSESSMENT AND PREVENTIVE CARE PLAN FOR DIFFERENT CATEGORIES OFOLDER ADULTS ..................................................................................................................................................114.1. INDEPENDENT WITH NO KNOWN CHRONIC DISEASES ......................................................114.2. INDEPENDENT WITH CHRONIC DISEASES ............................................................................ 134.3. OLDER ADULTS WITH DISABILITIES ....................................................................................... 13

5. ASSESSMENT TOOLS .......................................................................................................................... 166. INFORMATION TO PATIENTS AND CARERS ................................................................................ 21ANNEX

ANNEX 1. ASSESSMENT ON ACTIVITIES OF DAILY LIVING .................................................... 22ANNEX 2. TIMED UP AND GO TEST ............................................................................................... 28ANNEX 3. ONE LEG BALANCE TEST ............................................................................................. 29ANNEX 4. MEASUREMENT OF VISUAL ACUITY (VA) USING A 6-METRES SNELLEN CHART .. 30ANNEX 5. AMSLER GRID TEST ....................................................................................................... 32ANNEX 6. WHISPERED VOICE TEST AND AUDIOSCOPE ........................................................... 33ANNEX 7. GERIATRIC DEPRESSION SCALES ............................................................................... 34ANNEX 8. PATIENT HEALTH QUESTIONNAIRE (PHQ) ............................................................... 39ANNEX 9. ORAL HEALTH ASSESSMENT TOOL ............................................................................ 41ANNEX 10. MALNUTRITION UNIVERSAL SCREENING TOOL FOR HONG KONG CHINESE ...

(HKC-MUST) ..................................................................................................................... 42ANNEX 11. CHINESE NUTRITION SCREENING TOOL (CNS) ....................................................... 43ANNEX 12. MINI-NUTRITIONAL ASSESSMENT (MNA) ................................................................ 46ANNEX 13. ABBREVIATED MENTAL TEST (AMT) ......................................................................... 49ANNEX 14. MINI-COG TEST ............................................................................................................... 50ANNEX 15. GLOSSARY ........................................................................................................................ 53

ACKNOWLEDGMENTS ............................................................................................................................ 55REFERENCES ............................................................................................................................................. 57

2Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings



1. Importance of Health Assessment

The signifi cant increase in the number of older people and the associated age-related disabilities and chronic diseases create challenges to the existing health care system. It has been shown that targeted, proactive and community-based preventive care is more cost-effective than downstream acute care. Therefore, targeted intervention for various health risks at their early stages is of paramount importance not only to the health care system, but also to individual older adult’s active ageing.



2. Delivery of Preventive Care Service: Use EveryOpportunity for Prevention

It has been shown that only 0.5% of clinical encounters in local primary care among the older people are done for physical check-up1. Therefore, more effective measures at primary care settings should be considered to promote healthy ageing and minimise the health risks of older adults. It has been suggested that apart from designated appointments in primary care settings, the health assessment can also be performed opportunistically over time and during multiple visits. Indeed, every clinic visits to primary care providers can be an opportunity for screening of physical, psychological and social problems2,3. In fact, 80% of the population in Hong Kong have consulted primary care providers in one year and with the average of 8 primary care visits per year4. This provides huge opportunities for primary care providers to discuss with their patients on various preventive care services. Moreover, continuity of care as one of the key attributes of family doctor has been shown to improve the consistency with which preventive services are delivered, family doctors can thus take a more proactive role in health promotion and health assessment for older adults. Having good rapport with their patients, family doctors are also in a prime position to motivate their patients to perform various preventive care activities.

Notwithstanding the above, it is worth to note that screening is the testing of people who do not suspect they have a problem. Once a disease is suspected, prompt clinical management should be instituted. Moreover, screening involves a system not just a test and there is always a trade-off between benefi t, harm and affordability. Hence, screening programme if implemented should be occurred at settings where screening service is provided and relevant supporting service is readily accessible.

For details of evidence-based recommendations on preventive care for older adults, please refer to Chapter 5.1 to 5.5 in the Core Document.



3. Recommendations on Systematic Health Assessment

In order to have effective implementation of the evidence-based recommendations, the service delivered should be personalised in accordance with individual’s needs. A structural model should also be put in place to enable family doctors to take the lead in conducting health assessment.

Taking all these into considerations, a baseline assessment can be taken as a foundation for early identifi cation of major problems and designing of subsequent preventive care plans. Task delegation (e.g. database development), patient reminders, call and recall systems to identify needs as well as coordination with other health care professionals and community partners are also essential to ensure consistent delivery of the preventive services. Systematic health assessment is thus recommended as one of the strategies for delivering preventive services to older adults and its core components are:

Identifying the right people (case fi nding) Baseline assessment Formulation of personalized preventive care plan Care co-ordination Monitoring and review

3.1. Identifying the right people (case fi nding)

It has been shown that the distribution of health service utilisation across a population tends to be very uneven, with a small proportion of people who have complex health care needs accounting for a large share of total health care resources. Therefore, in order to ensure that a programme is cost-effective, it is crucial that those individuals at higher risk and who are amenable to preventive care are targeted. Models are now being developed that seek to systematically assess how effective preventive care is likely to be5. If older adults at risk can be identifi ed before they deteriorate, there is more potential to reduce future health care cost.

3.2. Baseline assessment

The baseline assessment aims to systematically review and properly document the level of function and risk profi le of an older adult such that a personalized preventive care plan can be delineated. It should build on existing information about the older person and should include physical, psychological and social factors. Issues that are suggested to be covered in the baseline assessment are summarized in Table 1.



Table 1. Suggested issues to be covered in the baseline assessment

HistoryReview patient’s medical and psycho-social history

√ Past medical history√ Family history of signifi cant illnesses√ Current medications (include over-the-counter medicines

and herbal remedies) and any medications that may cause dry mouth as a side effect

√ Lifestyle behaviour including smoking and drinking habit, diet pattern, physical activities

√ Dental health problems (e.g. diffi culty with chewing or brushing teeth) and dry mouth

√ Vaccination history (especially seasonal infl uenza vaccination and pneumococcal vaccination)

√ Psychological status e.g. mood and emotion status√ Social history such as marital status, home environment,

fi nancial support, family support and social network√ Functional status: current level of mobility e.g. independent,

walk with aids. Current ability and needs in terms of activities of daily living, and any recent deterioration. Any signifi cant change in lifestyle and mood

√ History of fallFocused physical examinationTo perform examination to identify risk factors and common chronic diseases

√ Check height, weight, body mass index and waist circumference

√ Measure blood pressure and check pulse√ Assess patient’s cognitive function if any clinical suspicion

of dementia which based on direct observation, with due consideration of information obtained by way of patient reports and concerns raised by family members, friends, caretakers or others if any

√ Functional status as indicated: hearing, vision, mobility, cognition, mood

√ Obtain other measurements deemed appropriate based on medical and psycho-social history

InvestigationsEarly identifi cation of diabetes mellitus, hyperlipidaemia, cervical and colorectal cancer

√ Check fasting blood glucose√ Check total cholesterol and HDL-cholesterol√ Check cervical smear if indicated (see Chapter 5.4.2a in

Core Document)√ Check faecal occult blood (see Chapter 5.4.2b in Core

Document)



To ensure that all aspects of baseline assessment are considered, a checklist or template can be helpful in daily practice and the chart below is one of the examples for reference.

Baseline Assessment template

Demographics

Social HistoryMarital Status No. of childrenWho are you living with? Smoking: Y/N Quit since:

Duration:Amount:

Drinking: Y/N Duration:________ standard drink(s) per day/ week

Exercise: Y/NType of exercise: _____ minutes per day/ week

Occupation (previous/ current):Retired since:Financial Support:

Mobility status (e.g. unaided, walk with aids): Abilities on self care: □ Independent □ Need assistance □ DependentHistory of fall: ________________Drug History (include OTC medications and herbal remedies)

Drug/ other allergyFamily History□ HT □ DM □ IHD □ Stroke □ Dementia □ Cancer ________________□ Others _________________________________Vaccination HistoryInfl uenza Y/N Last Injection: Pneumococcal Y/N Last injection:Others:Oral Health Any feeling of dry mouth? Y/NAny chewing problem? Y/N Any problem brushing your teeth? Y/NPhysical ExamBP Regular pulse? Y/N Waist circumferenceHeight: Weight: BMIOthers:Investigations:Fasting blood glucose FOBTTotal cholesterol _______ HDL-Cholesterol __________Others: __________Cervical smear Psychological status: depressed mood □ Yes □ No



Common health problems require interventionsSmoking: □ Yes □ NoDrinking: □ Yes □ NoExercise: □ Yes □ NoDiet: □ Yes □ NoHearing impairment: □ Yes □ NoVisual impairment: □ Yes □ NoIncontinence: □ Yes □ NoFall risk: □ Yes □ NoDental problem: □ Yes □ NoDepression: □ Yes □ NoCognitive impairment: □ Yes □ NoSocial isolation: □ Yes □ NoOthers: ____________ □ Yes □ No

Suggested schedule of subsequent assessment: ___________

Referral (if applicable):

3.3. Formulation of personalized preventive care plan

Based on the risk profile and functional capacity obtained from baseline assessment, a personalised preventive care plan can be formulated for different categories of older adults. As older adults tend to have complex health and social care needs, so the preventive care advice and health promotion should be personalized in accordance with the individual’s needs and with due considerations of referral for more comprehensive assessment when required.

The role of carers in maintaining the health and wellbeing of older people should also be acknowledged. Carers (including family members and friends) can often provide valuable knowledge about the older person’s condition, previous illnesses, and behaviour, and, therefore, should be involved in discussions about treatment and care options.

The preventive care plan proposed for different categories of older adults (i.e. independent with no known chronic diseases, independent with chronic diseases, and older adults with disabilities) are described in Chapter 4 of this document.

3.4. Care co-ordination

Once a problem has been identifi ed in the process of preventive care, the family doctors may choose to make the initial intervention themselves or may choose to refer the



patient to other professional discipline or to a community centre from which additional services would be helpful. More often, the care process involves multiple health care workers and care co-ordination is needed in the context of a multidisciplinary team. Fundamental to care co-ordination is the presence of a family doctor who involves in continual communication with patients and their carers to help them to navigate the different levels of health care system, as well as in close liaison with other health care workers to deliver a personalised care.

3.5. Monitoring and review

The implementation of preventive care plan should be monitored to ensure that an individual is receiving an appropriate follow up and package of care. The monitoring process can also allow preventive care plan to be constantly reviewed and changed where necessary. The frequency of such monitoring may vary depending on the individual’s level of need.

The various components of the systematic health assessment are summarized in Figure 1 below. When all the different components are effectively combined into an integrated strategy, it could be considered that a ‘programme approach’ to preventive care has been created. (Those older adults with hypertension or diabetes should have their own pathway of risk assessment as described in the two Hong Kong Reference Frameworks for Hypertension and Diabetes Carea )

If screening programme is to be organised, all activities along the screening pathway should be appropriately planned, coordinated, monitored and evaluated. It is also important that the screening offered is adequately resourced for interventions to address the needs identifi ed.

Older adults offered the screening should be fully informed of the potential individual benefi ts and harms of screening. They should be reminded that health assessment cannot screen out all hidden illnesses and they need to beware of any symptoms despite normal health assessment fi ndings and seek medical advice at once for subsequent management.

a Hong Kong Reference Framework for Hypertension for Adults in Primary Care Settings is available athttp://www.pco.gov.hk/tc_chi/resource/professionals_hypertension_pdf.html and Hong Kong Reference Framework for Diabetes Care for Adults in Primary Care Settings is available at http://www.pco.gov.hk/tc_chi/resource/professionals_diabetes_pdf.html



Figure 1. Different components of the systematic health assessment

Identify target older

adults

• A systematic approach in identifying appropriate target olderadults

BaselineAssessment

• Early identifi cation of common health probiems• Defi ne the level of function and risk profi le

Formulatecare plan

• To formulate a personalised preventive care plan for differentcategories (i.e. independent with no known chronic diseases,independent with chronic diseases, older adult with disabilities)

Care co-ordination

• Family doctor co-ordinates with a team of health care professionalsto deliver a personalised care and help older adult to navigate thedifferent levels of health care system

Monitoringand review

• Monitor and review the implementation of preventivecare plan



4. Health Assessment and Preventive Care Plan forDifferent Categories of Older Adults

4.1. Independent with no known chronic diseases

Considerable geographic variation in the prevalence of major chronic diseases among older people suggests that chronic diseases are not an inevitable part of ageing.

Healthy and active ageing is achievable through lifestyle modifi cation. Therefore, the ideal goal for all older adults is to maintain physical independence and biological reserve as well as enjoy psychosocial well-being through primary prevention and health promotion. Measures that aimed at preventing chronic diseases (such as taking regular physical activities, not smoking, and eating a balanced diet throughout life) are important basic steps towards healthy ageing.

The recommended preventive care activities are summarized in Table 2 below.

Table 2. Recommendations on preventive care for independent older adults with no known chronic diseases

Preventive Care Recommendations (based on Chapter 5.1-5.5 in the Core Document)

Frequency

1. Vaccination - Arrange seasonal infl uenza- Arrange pneumococcal vaccination

AnnuallyAs indicated

2. Promotion ofhealthy lifestyle- Smoking- Drinking- Physical

activity- Diet and

nutrition- Oral health

- Smoking cessation advice- Moderation of alcohol intake- Advise regular physical activities

- Advise healthy eating habit and balanced diet

- Oral hygiene advice.

Every opportunities

3. Screening foroverweight andunderweight

Check BMI +/- waist circumference Monitor body weight and assess risk of malnutrition

Annually



4. Screening for HT Measure blood pressure and check pulse Annually5. Screening for DM Check blood for fasting blood sugar Every 1-3 years6. Screening for

hyperlipidaemiaCheck blood for lipid profi le (total and HDL-cholesterol)

Every 1-3 years

7. Screening forcervical cancer

Check cervical cytology test Every 3 years after two consecutive normal annual cytology tests

8. Screening forcolorectal cancer

Check faecal occult blood test (FOBT) Every 1-2 years

9. Screening forfunctionalimpairment

- Hearing - Vision - Continence - Falls- Dental

- Mood- Cognition- Social

- Screening for hearing impairment - Screening for visual impairment - Screening for incontinence - Screening for risk factors of fall- Screening for dry mouth and difficulty

in chewing and brushing teeth- Screening for depression - Screening for dementia# - Screening for social isolation

Opportunistic or when clinically indicated (please refer to Chapter

5.4.3 to Chapter 5.5 in the Core Document)

# Primary care providers should assess cognitive function whenever cognitive impairment or deterioration is suspected.

For those independent and healthy older adults, the systematic health assessment can be performed regularly (e.g. on annual basis) for review of the risk profile and early identification of chronic diseases. On the other hand, as functional decline can occur at any time after untoward events, so the schedule of systematic health assessment does not preclude family doctors from screening of other important functional domains during other clinical encounters with these older adults. And the strategy of opportunistic screening of various functional domains at each clinic visit would serve as a complementary tool to systematic health assessment. For instance, primary care providers should assess cognitive function whenever cognitive impairment or deterioration is suspected, based on direct observation, patient report, or concerns raised by family members or carers.

The tools used to screen for various functional domains are described in Chapter 5 of this document.



4.2. Independent with chronic diseases

The objectives of preventive services in this group of older adults are to appropriately manage their chronic diseases with reference to both secondary and tertiary prevention, as well as to maintain functional independence.

It is suggested to review the risk profi le and functional level regularly (e.g. on annual basis) for this group of older adults. And as these older adults are at higher risk of functional decline, opportunities during each subsequent clinic visit should be taken to screen for various functional domains (e.g. hearing impairment, visual impairment, incontinence, fall risk, depression and cognitive impairment), such that timely interventions to maximise functional capacity can be arranged.

The number of these functional domains screened depends on the time available, the urgency of the patient’s problems, and the family doctor’s intuitive sense of likelihood of obtaining any additional pertinent information. Some domains that are particular important in those older adults with chronic diseases (i.e. use of medications, depression, social support and network) should be screened more frequently and suggested to be at least annually.

As untoward event can occur at any time, an older adult can therefore move rapidly from the stage of independence to disability. To facilitate progress review of preventive care activities for an individual older adult, the checklist for different stages of an older adult are summarized in Table 3.

4.3. Older adults with disabilities

Older adults with disabilities in this document refer to those complicated with multiple co-morbidities and functional deficits which limit their capacity to perform desired physical, mental and social activities. The objective of preventive care for this group of older adults is to prevent further loss of function and maximise the ability to remain as independent as possible, so as to facilitate their integration in society. More often, a comprehensive assessment which involves extensive evaluation on physical, psychological, social, and functional capabilities is needed, and thus a multidisciplinary approach would be beneficial to this group of older adults. Collaboration with community partners and other health care professionals could be considered when family doctors encounter difficulties in performing comprehensive assessment or interventions at their own clinic setting.

Limitations in ability to carry out ordinary daily physical activities are commonly seen in this group of older adults, so the assessment process can begin with an individual’s ability to perform tasks that are required for living by reviewing the two key divisions of functional ability: Basic Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). The tools used to screen for various functional domains are described in Chapter 5 of this document.



Older adults with disabilities are vulnerable to mental health problems and social deprivation. Improving care for older adults with disabilities and co-morbid mental health problems may therefore require closer working not only between mental and physical health care services, but also with social care and a range of other social support services. The social support services that available to patients and carers are signposted in Annex 3 of the Core Document.

The recommended preventive care activities are summarized in Table 3.

Table 3. Checklist of preventive care activities for an older adult at different stages

Preventive care activities Independent with no known

chronic diseases

Independent with chronic diseases

Older adults with disabilities

Vaccination Infl uenza & pneumococcal vaccinationsPromotion of healthy lifestyle Smoking

DrinkingPhysical activityDiet and nutrition

Oral healthScreening for overweight and underweight

BMI +/- waist circumferenceMonitor body weight and assess risk of malnutrition

Screening for HT Blood pressure and pulseScreening for DM Fasting blood sugarScreening for hyperlipidaemia

Total cholesterol and HDL-cholesterol

Cancer screening:Cervical and colorectal cancer

Cervical cytology test FOBT

Opportunistic screening of functional impairment

HearingVision

IncontinenceFalls

DentalDepressionDementia#

Social isolationRisk assessment of chronic diseases

Annual risk assessment of HT and DM if any



Review use of medications Screen for problems related to medication use and polypharmacy

Assess abilities on self care and daily living

Screen for self care and daily living problems

Assess Basic ADL and Instrumental ADL

Assess social network and carer support

Assess social network

Assess the need of social and carer support

Screen for carer stress

End-of-life care End-of-life planning if deemed necessary

# Primary care providers should assess cognitive function whenever cognitive impairment or deterioration is suspected.



5. Assessment ToolsIn a busy primary care setting, it is difficult to systematically review the comprehensive checklist for every older adult. To identify the common functional disabilities, it is preferable to design a screening tool that is brief, easy to administer and compatible with busy day-to-day practice yet capable of predicting which patients are likely to benefi t from more detailed assessment. A reasonable strategy at busy primary care settings is to first administer a preliminary screening tool to detect the most characteristic sign(s) of functional impairment that warrant for further detail assessment.

Ideally, a screening tool should have good validity and sensitivity. The tool to be used should also be standardised to ensure consistency of performance and have good inter-rater reliability (i.e., it will obtain the same results regardless of who is using it). The tools described in Table 4 are based on literature review and expert recommendations with due considerations on the suitability and applicability at local primary care setting, but by no means exhaustive.

Upon performing the screening and assessment tools, the health care workers should be cautious that:

They should understand the tools well and be competent in performing the assessment. The screening tools are just complementary to and not replacing good professional judgment. To choose which cut-off point depends on striking the balance between sensitivity and specifi city. Patients should have in-depth assessment if there is any clinical suspicion, even though they do not meet the cut off threshold.


They should note that there are copyright issues related to the use of some assessment tools.


Table 4. Recommended strategies for opportunistic screening of various functional disabilities

Functional disabilities

Preliminary screening Further evaluation and corresponding actions

Inabilities on self-care or daily living

Check if the patient:1. need any assistive

devices for walking or2. need assistance for

daily activities of anykinds

- For any positive response, assess Basic ADL and Instrumental ADL (Annex 1).

- Determine underlying causes for the inability if any.

- Explore potential for reversibility in function and institute appropriate medical, social or environmental interventions if necessary.

- Consider the need of rehabilitation and further assessment if low score in Basic ADL and Instrumental ADL.

Fall risk

The module on falls in elderly has been released in February 2015. Please refer to the module for details.

Ask the patient:1. Whether there is history

of two or more fallswithin the last twelvemonths?

2. Whether the patient ispresented with acute fall?

3. Whether there is presenceof clinical conditions (e.g.stroke, Parkinson’sdisease, osteoarthritis)that leads to eitherweakness of the lowerlimb, balance and/or gaitimpairment?

- Any positive answer to the screening questions signifies that the person screened is at a high risk of fall that warrants comprehensive fall assessment and multifactorial intervention.

- Balance and gait should be evaluated in persons with history of fall or fall risk. The Timed Up and Go Test (Annex 2) is a frequently used test of gait or balance.

- The performance of One Leg Balance Test can provide information on the risk of injurious fall (Annex 3).

Impaired vision Ask the patient,

1. ‘Do you have any visualproblems?’ OR

2. ‘Do you have difficultyin reading or doing anyof your daily activitiesbecause of youreyesight?’ (even withwearing glasses)

- If any positive response, check visual acuity (VA) by Snellen Chart (Annex 4) together with pinhole

- If patient complains of seeing line distortion or scotoma, add Amsler Grid Test (Annex 5).

- Obtain detailed history, perform physical examination and investigations where appropriate

- Refer to ophthalmologist if:ocular emergency suspectedcorrected VA worse than 6/12; to confirm cause(s) and offer treatmentsuspects an eye disease that requires their assessment or treatment; or the required treatment cannot be offered by the primary care providers



cataract with VA 6/18 or worse, or daily activities affected: for consideration of surgery

- Referral to optometrists if:refractive errors with corrected VA of 6/12 or better, and without other eye symptoms or signs

Impaired hearing Ask the patient, ‘Do you or your family think that you may have hearing loss?’

- If positive response, can further assess the patient by whispered voice test or using an audioscope (Annex 6)

- If hearing impairment is suspected and affect activities of daily living, further clinical evaluation should be arranged and managed as appropriate

- Patients with chronic otitis media or sudden hearing loss, or who have their daily activities affected by hearing impairment should be referred to an otolaryngologist for further assessment

Incontinence Ask the patient, ‘Did you ever lose your urine or get wet?’

- If positive response, patients should be assessed to determine the diagnostic category as well as underlying aetiology. This can usually be determined on the basis of history 6,7,8,9, physical examination and urinary culture and microscopy

- If surgery is indicated or disabling incontinence which refractory to conservative treatment, referral to specialists should be considered

Depression Ask the patient, ‘Over the past 2 weeks, have you felt down, depressed, or hopeless?’ AND‘Over the past 2 weeks, have you felt little interest or pleasure in doing things?’(Annex 8) Or use GDS-4 (Annex 7)

- For any positive response, proceed to the 15-items Geriatric Depression Scale GDS-15 (Annex 7) or Patient Health Questionnaire (PHQ)-9 (Annex 8)

- Individuals who score 8 or more points in GDS-15 or 5 or more points in PHQ-9 should have full diagnostic interviews that use standard criteria (DSM IV) and further management as appropriate

- Patients with suicidal risk should be managed immediately



Oral health

The module on Dental Health Care for Older Persons has been released in December 2015. Please refer to the module for details.

Ask the patient:1. 'Do you have any oral

discomfort and problemin chewing?'

2. 'Do you have anydifficulty in cleaning yourteeth (and/or dentures)?'

3. 'Do you have any feelingof dry mouth?'

- If positive response, patient should beadvised to consult a dentist as soon as possible

In addition, for institutionalized elderly, consider to use the Oral Health Assessment Tool (OHAT) (Annex 9).

Malnutrition Monitor body weight and ask for any history of weight loss during the past 6 months

- Unintentional weight loss of 5% over the previous 1 month or 10% over the past 6 months should trigger for assessment of malnutrition risk and look for underlying causes.

- Consider malnutrition assessment tools (i.e. C-MUST, CNS or MNA) for institutionalised older adults (Annex 10, 11 and 12).

- Consider a thorough nutritional assessment which includes medical history, medications review, dietary evaluation, oral problems, gastrointestinal disorders, neurological disorders, psychiatric disorders, social aspects, anthropometry, together with initial laboratory work up (e.g. albumin, RFT, LFT, and CBP with lymphocyte count) for those with high risk of malnutrition.

- Management of malnutrition in older adults requires a multidisciplinary approach that treats the underlying causes, improved nutritional status and multi-factorial intervention on co-morbidities.



Table 4.1 Recommended strategies for assessment of cognitive impairment

Initial assessment

Further evaluation and corresponding actions ifcognitive impairment is

present

Primary care providers should assess cognitive function whenever cognitive impairment or deterioration is suspected.

The following is common clinical presentations of cognitive impairment:

1. Impaired ability to acquire and remember newinformation as manifested by symptoms such asrepetitive questioning or conversations,misplacing personal belongings, forgetting eventsor appointments, getting lost on a familiar route.

2. Impaired reasoning and handling of complexfunctional tasks to an extent that it interferes witheveryday activities e.g. inability to managefinances, poor decision-making ability, inabilityto plan complex or sequential activities.

3. Language impairment e.g. having difficultythinking of common words while speaking,hesitations or speech, spelling, and writing errors.

4. Decline in emotional control or motivation e.g.emotional lability, irritability, loss of empathy,loss of drive, social withdrawal, decreased interestin previous activities.

5. Change in personality and behaviour e.g.coarsening of social behaviours.

6. Impaired visuospatial abilities e.g. inability torecognize faces or common objects or to findobjects in direct view despite good visual acuity,inability to operate simple instruments or orientclothing to the body.

- Perform Abbreviated Mental Test (Annex 13), Mini-Cog Test (Annex 14) or Mini-Mental State Examination (MMSE)10 #

- MMSE has additional benefit in assessing the severity of dementia #

- Conduct appropriate investigations to rule out potentially reversible causes

- Referral to neuroimaging and specialist should be arranged according to the results of clinical assessment

# It should be noted that MMSE is under copyright protection; permission for use at a cost would be required.



6. Information to Patients and Carers

Involving the individual and the carer in the care planning process is important, because an engaged patient and carer is more likely to manage various health conditions effectively.

Therefore, alongside all of the steps mentioned in Chapter 3, attention also needs to be given to:

Provide sufficient information to patients and their carers on their health status to facilitate shared decision-making and have open discussions about preventive care options.Empower the patients such that they can have suffi cient confi dence on self-carePsychological support for carers and familiesExplore appropriate social resources for the patients and their carers

Details on practical information related to health care of older adults can be found in Annex 3 of the Core Document.



Annex 1. Assessment on activities of daily living Barthel Index of Independence in Activities of Daily Living (ADL) refers to basic self-care activities that a person performs daily (e.g., eating, dressing, bathing, transferring, using the toilet, controlling bladder and bowel functions). Inability to independently perform even one activity may indicate a need for supporting services (Table 5).

Complex daily tasks are assessed by Instrumental Activities of Daily Living (IADL), and Lawton’s version is commonly used in local setting. Lawton’s Instrumental Activities of Daily Living refers to activities that are needed to live independently (e.g., doing housework, preparing meals, taking medications properly, managing fi nances, using a telephone). IADL are associated with independent living in the community and provide a basis for considering the type of services necessary in maintaining independence. The Chinese Lawton IADL with 3 point scale can be an option for local primary care settings, though the cut-off scores have yet to be established (Table 6).

Defi cits in ADL and IADL11,12 restrict older adults to live independently in the community, and signal the need for more in-depth evaluation of the individual’s socio-environmental circumstances and the need for additional assistance.



Table 5. The Barthel Index of Activities of Daily Living 13, 14, 15

The Barthel IndexBowels0 = incontinent (or needs to be given enemata)1 = occasional accident (once/week)2 = continentPatient’s Score:_______________________

Bladder0 = incontinent, or catheterized and unable to manage1 = occasional accident (max. once per 24 hours)2 = continent (for over 7 days)Patient’s Score:_______________________

Grooming0 = needs help with personal care1 = independent face/hair/teeth/shaving (implements provided)Patient’s Score: _______________________

Toilet use0 = dependent1 = needs some help, but can do something alone2 = independent (on and off, dressing, wiping)Patient’s Score:_______________________

Feeding0 = unable1 = needs help cutting, spreading butter, etc.2 = independent (food provided within reach)Patient’s Score: _______________________

Transfer0 = unable – no sitting balance1 = major help (one or two people, physical), can sit2 = minor help (verbal or physical)3 = independentPatient’s Score:

Mobility0 = immobile1 = wheelchair independent, including corners, etc.2 = walks with help of one person (verbal or physical)3 = independent (but may use any aid, e.g., stick)Patient’s Score:

Dressing0 = dependent1 = needs help, but can do about half unaided2 = independent (including buttons, zips, laces, etc.)Patient’s Score:

Stairs0 = unable1 = needs help (verbal, physical, carrying aid)2 = independent up and downPatient’s Score:

Bathing0 = dependent1 = independent (or in shower)Patient’s Score:

Source: Modifi ed version adapted with permission from Collin et al. (1988)



Instructions: Choose the scoring point for the statement that most closely corresponds to the patient’s current level of ability for each of the 10 items. Information can be obtained from the patient’s self-report, from a separate party who is familiar with the patient’s abilities (such as a relative), or from observation.

Scoring: Sum the patient’s scores for each item. Total possible scores range from 0 – 20, with lower scores indicating increased disability. If used to measure improvement after rehabilitation, changes of more than two points in the total score refl ect a probable genuine change, and change on one item from fully dependent to independent is also likely to be reliable.

Guidelines for the Barthel Index of Activities of Daily LivingGeneral• The Index should be used as a record of what a patient does, NOT as a record of what a

patient could do.• The main aim is to establish degree of independence from any help, physical or verbal,

however minor and for whatever reason.• The need for supervision renders the patient not independent.• A patient’s performance should be established using the best available evidence. Asking

the patient, friends/relatives, and nurses will be the usual source, but direct observationand common sense are also important. However, direct testing is not needed.

• Usually the performance over the preceding 24 – 48 hours is important, but occasionallylonger periods will be relevant.

• Unconscious patients should score ‘0’ throughout, even if not yet incontinent.• Middle categories imply that the patient supplies over 50% of the effort.

Bowels (preceding week)• If needs enema, then ‘incontinent.’• ‘Occasional’ = once a week.

Bladder (preceding week)• ‘Occasional’ = less than once a day.• A catheterized patient who can completely manage the catheter alone is registered as

‘continent.’

Grooming (preceding 24 – 48 hours)• Refers to personal hygiene: doing teeth, fi tting false teeth, doing hair, shaving, washing

face. Implements can be provided by helper.

Toilet use• Should be able to reach toilet/commode, undress sufficiently, clean self, dress, and

leave.• ‘With help’ = can wipe self and do some other of above.



Feeding• Able to eat any normal food (not only soft food). Food cooked and served by others,

but not cut up.• ‘Help’ = food cut up, patient feeds self.

Transfer• From bed to chair and back.• ‘Dependent’ = No sitting balance (unable to sit); two people to lift.• ‘Major help’ = one strong/skilled, or two normal people. Can sit up.• ‘Minor help’ = one person easily, OR needs any supervision for safety.

Mobility• Refers to mobility about house or ward, indoors. May use aid. If in wheelchair, must

negotiate corners/doors unaided.• ‘Help’ = by one untrained person, including supervision/moral support.

Dressing• Should be able to select and put on all clothes, which may be adapted.• ‘Half’ = help with buttons, zips, etc., but can put on some garments alone.

Stairs• Must carry any walking aid used to be independent.

Bathing and Showering• Usually the most diffi cult activity.• Must get in and out unsupervised, and wash self.



Table 6. Chinese Lawton Instrumental Activities of Daily Living Scale (3 point Scale) 16

日常家居及社區活動能力評估

Item Score1 “你能唔能夠自己用電話號碼呢 ?” 包括找電話號碼 , 打及接聽電話

不需要任何幫助需要一些幫忙

完全不能自己做

210

2 “你能唔能夠自己搭車呢 ?” 包括自己上到正確的車 , 俾車錢 / 買車票 , 上 / 落車 ( 假設你必須要搭交通工具去一個遠的地方 , 例如探朋友 / 睇醫生 )



210

3 “你能唔能夠自己買嘢呢 ?” 包括自己揀貨品 , 俾錢及攞番屋企 ( 假設你必須要到附近商店買食物或日用品 )



210

4 “你能唔能夠自己煮食呢 ?” 包括自己諗食乜 , 準備材料 , 煮熟食物及放入碗碟裡 ( 假設你必須要自己準備兩餐 )



210

5 “你能唔能夠自己做家務呢 ?” 包括簡單家務 ( 如抹檯 , 執床 , 洗碗 ) 及較重的家務 ( 如抹地 / 窗 ) ( 假設你必須要自已做家務 )



210

6 “你能唔能夠應付簡單的家居維修呢?” 例如換燈泡 , 維修檯及上緊螺絲等 ( 假設你必須要自已做 )



210



7 “你能唔能夠自己洗衫呢 ?” 包括清洗及曬自己的衫 , 被 , 床單等 ( 假設你必須要洗自己的衫 , 被 , 床單等 )



210

8 “你能唔能夠自己服用藥物呢 ?” 包括能依照指示在正確的時間內服用正確的份量 ( 假設你必須要自已查藥油或食藥等 )



210

9 “你能唔能夠處理自己的財務呢 ?” 包括日常錢銀的找續 , 交租 / 水電費及到銀行提款 ( 假設你必須要買嘢 , 自己交租 / 水電費及有將錢放在銀行 )



210

總分 /18

Source: Chinese version adapted with permission from Tong & Man (2002)



Annex 2. Timed Up and Go Test 17, 18, 19, 20

Instructions:1. Begin the test with the patient sitting correctly in a standard arm chair (approximate

seat height of 46 cm), the patient’s back should rest on the back of the chair. The chair should be stable and positioned such that it will not move when patient moves from sitting to standing.

2. Mark on the fl oor 3 metres away from the chair so that it is easily seen by the patient.3. Ask the patient to perform the following series of manoeuvres:

Rise from the chairWalk at regular pace for 3 metres to the mark on the floor, customary walking aid is allowed Turn around and walk back to the chairSit down in the chair

4. Start timing when patient rise from the chair and stop timing when the patient is seatedagain correctly in the chair.

5. The patient may use any walking aid that is usually used during ambulation, but maynot be assisted by another person.

6. The patient can be given a practice trial that is not timed before testing.

Interpretation:Balance and gait should be evaluated in persons with history of fall or fall risk. The Timed Up and Go Test (TUG) is a frequently used test of gait or balance. The Timed Up and Go Test is to measure the time to rise from the chair, walk at regular pace for 3 metres, turn around and walk back to the chair and finally sit down. Cut off values for fall risk are variable in literatures, which may reflect different subjects characteristics and methodologies. The cut off value of 14 seconds is conventionally adopted to discriminate fallers and non-fallers in healthy, highly functional older people. On the other hand, in frail elderly, a time score of less than 20 seconds identifies elderly people who are independently mobile while more than 30 seconds indicates a need of assistance for mobility task. TUG should be considered together with other relevant factors (e.g. medical and drug history, physical assessment, circumstances of the fall) to identify individuals at high risk of falls.



Annex 3. One Leg Balance Test 21, 22

It has been recognized that balance impairment leads to recurrent falls. One-leg balance is a simple clinical static balance test in which a subject is asked to stand unassisted on one leg. Impaired One Leg Balance Test is defi ned as being unable to stand on one leg for 5 seconds and has been identifi ed as a predictor of injurious falls in community-dwelling older adults.

Procedures: 1) Patient is asked to choose a leg to stand on (whichever the patient feel more

comfortable with)2) Flex the opposite knee allowing the foot to clear the fl oor, and balance on one leg as

long as possible3) The assessor records whether the patient is able to balance for 5 seconds

Older adult who is unable to stand ≥5 seconds would be considered as impaired One Leg Balance.



Annex 4. Measurement of Visual Acuity (VA) using a 6-metres Snellen Chart 23, 24, 25, 26

Equipments: 1. 6 metres (20 feet) visual acuity (VA) chart (e.g. Snellen’s E Chart)2. Pointer3. Occluder4. Pinhole

Procedure:1 Test the patient’s right eye by covering the left eye (always test the right eye fi rst)2 Instruct and encourage the patient to read the VA chart until the smallest line possible 3 If the patient is able to read more than half of the letters on a particular line, instruct him/

her to try reading the next line (with smaller letters) before determining the best VA4 If more than half of all the smallest letters of a line can be read correctly, record the VA

of that particular line, minus the number of letters missed in that line. Examples: If 3 out of 5 of the letters of the 6/6 line can be read correctly, record VA as 6/6-2. If 4 out of 5 of the letters of the 6/7.5 line can be read correctly, record VA as 6/7.5-1

5 If less than half of the all the letters of a line can be read correctly, record the VA of the previous line (with bigger letters)

6 If the patient is unable to achieve an acceptable VA (i.e. 6/12 or better), recheck the VA with a pinhole. If the VA improves with pinhole, record the best VA with pinhole.

Record method: VA (= Visual Acuity) Rt 6/30 Lt 6/60PH (= Pinhole) Rt 6/30 Lt 6/30

7 Repeat the same procedures for left eye by covering the right eye

Points to note: 1 Ensure there is suffi cient illumination on the visual acuity (VA) chart (e.g. use a well-lit

room)2 Ensure the chart is at the same eye level of the patient3 Position the patient at the appropriate distance from the VA chart. If there is limited

space, a mirror should be used with the distance reduced to half4 Pinhole test is a quick way to distinguish between impaired vision due to uncorrected

refractive errors and other ocular pathology. The pinhole focuses light and temporarily removes the effects of refractive errors such as myopia, hyperopia and astigmatism. Refractive error is likely when the VA is improved with pinhole test. However, it should be noted that studies (Rabbetts (2000); and Eagan et al. (1999)) have shown that the pinhole test has some limitations, such as its being affected by imprecise positioning and its being prone to errors due to luminance effects.



5 Record method: 5.1 The numerator is the test distance and the denominator is the distance that a

person with normal vision can see that particular line. Example: 6/30 means a patient can only see the letters of a line at 6 metres whereas a person with normal vision can see the same letters at 30 metres.

5.2 If the patient cannot read one letter from a line, represent it using a minus sign. Example: 6/30-1 means there is a letter cannot be read from that line

5.3 If the patient has refractive error, he/she should wear the glasses for the testing, and ‘with glasses’ should state in the record

5.4 Normal vision: 6/65.5 VA can also be expressed as a decimal that is equal to the numeric value of the

Snellen fraction so 6/6 would become 1.0 and 6/12 would be 0.5.6 Sometimes VA is recorded in other notations e.g. logMAR. LogMAR stands for

Minimum Angle of Resolution which can be converted to a Snellen fraction for comparison.

Table 7. Different VA measurement systems

LogMAR Snellen 20ft Snellen 6m Decimal1.0 20/200 6/60 0.100.9 20/160 6/48 0.1250.8 20/125 6/38 0.160.7 20/100 6/30 0.200.6 20/80 6/24 0.250.5 20/63 6/20 0.320.4 20/50 6/15 0.400.3 20/40 6/12 0.500.2 20/32 6/10 0.630.1 20/25 6/7.5 0.800.0 20/20 6/6 1.00



Annex 5. Amsler Grid Test 27

The Amsler grid is a grid of horizontal and vertical lines with a central dot used to assess a person's central visual field. Amsler Grid Test has been used to screen for age-related macular degeneration (AMD), and although specifi c, it is relatively insensitive in detecting a variety of ocular problems. Studies have shown that the sensitivity of Amsler Grid Test for the detection of AMD varies from 9% in early AMD to 34% in late AMD. Although the Amsler Grid Test has the benefit of being inexpensive and easily used, the high false negative rate means that great care must be taken in interpreting a negative result. Therefore it is suggested to use Amsler Grid Test as a diagnostic tool that aids in the detection of visual disturbances caused by changes in the macula instead of using it as a screening tool.

Instructions: - The patient should wear single vision reading glasses if any- Patient should stand a distance of 30cm from the chart, with one eye covered- Ask the patient to focus on the central dot- Ask if all four corners and all four sides of the chart are seen- Ask if there are any areas of the chart that are missing or distorted in any way and are

any of the lines not straight or unequal in size- Repeat the procedure with another eye

Amsler grid, as seen by a person with normal macula function

Amsler grid, as viewed by a person with age related macular degeneration



Annex 6. Whispered voice test and audioscope 28, 29

The whispered voice test has a sensitivity of 87-96% and a specificity of 70-90% for detecting hearing loss. One systematic reviewed showed that whispered voice test is a simple and accurate test for detecting hearing impairment. However there is some concern regarding the overall reproducibility of the test, particularly in primary care settings. Attempts to standardize the test have been made (e.g., by whispering only after full expiration), but there is no reliable way to control the loudness of the whispers, and robust descriptions of inter-observer variability and test-retest reliability are lacking. Therefore, the results of whispered voice test should be interpreted with caution and should be correlated with patient’s clinical conditions.

Conducting the whispered voice test 1. The examiner stands arm's length (0.6 metre) behind the seated patient and whispers

a combination of numbers or letters (for example, one-two-three) and then asks the patient to repeat the exact sequence

2. The examiner should quietly exhale before whispering to ensure as quiet a voice aspossible

3. If the patient responds incorrectly, the test is repeated using a different combination of numbers or letters

4. The patient is considered to have passed the screening test if they repeat at least threeout of a possible six numbers or letters correctly

5. The examiner should stand behind the patient to prevent lip reading6. Each ear is tested individually, starting with the ear with better hearing, and during

testing the non-test ear is masked by gently occluding the auditory canal with a fi ngerand rubbing the tragus in a circular motion

7. The other ear is assessed similarly with a different combination of numbers or letters

AudioscopeThe audioscope, a hand-held device, is held directly in the external auditory canal with a probe tip sealing the canal. Tones are presented at each frequency (i.e., delivers a 25- to 40-dB pure tone at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz), and the patient is asked to indicate whether he or she can hear the tone. Patients unable to hear a predetermined series of tones may then be referred for formal audiometric assessment.



Annex 7. Geriatric Depression Scales 30, 31, 32, 33

A) Geriatric Depression Scale 15-item Cantonese Version (GDS-15)老人抑鬱短量表 (GDS-15) – 廣東話口語化版本

在施行此短量表時，先說出題目的口語化版本“問 <1>”，若在個別題目中 , 受試者對於問題內容未能掌握清楚，或在評分方面出現問題，則需依次序讀出“問 <2>”。個別較難理解的題目，則設有“問 <3> ”。給受試長者未能掌握“問 <2>”的意思，則需讀出“問 <3> ”。

評分方法：請依照每條題目的評分方法，給予該題目分數。受試者在短量表的總分是１５條題目的分數總和（即最多是１５分）。在個別題目中，如受試者最終未能掌握題目內容，或未能給予確實答案，則不用給予任何分數。為統一填寫短量表總分的格式，可參考下列方法：

受訪者所得分數受訪者最終能回答的題目總數

例一：12/15 即受試者回答所有題目並 15 題 (15)，總分則為 12 分 (12)例二：12/13 即受試者最終只能回答 13 題 (13)，總分則為 12 分 (12) (總分≧ 8 指示有抑鬱的傾向 )

1. 你基本上對自己的生活感到滿意嗎？問 <1>: 喺上個禮拜裏面，你滿唔滿意自己嘅生活呢？

如受試者說“都冇乜滿意唔滿意”或類似的意思，請問 <2>: 咁你係滿意多啲，抑或唔滿意多啲呢？

答案給予分數問 <1> 是 / 滿意 0 分

否 / 不滿意 1 分問 <2> 滿意多啲 0 分

唔滿意多啲 1 分

2. 你是否已放棄了很多以往的活動和嗜好？問 <1>: 喺上個禮拜裡面，你有冇放棄好多以前嘅活動或者嗜好呢？

如受試者未能掌握問題內容，請問 <2>: 喺上個禮拜裡面，好多以前你鍾意做嘅嘢，係咪已經冇做啦？

如受試者說他從來沒有興趣或者嗜好，請問 <3>: 咁喺上個禮拜裡面，你喺朝早或日頭有冇啲嘢做吓？

例如 : 晨運、落街行吓，同人傾吓偈，或者響屋企做吓家務呢 ?

答案給予分數問 <1> 及問 <2> 是 1 分

否 0 分問 <3> 可由受試者自由說出答案，如受試者答案的意思是他仍然有參予

一些活動，不論是多或少，在這條問題上給予”0”分，否則給予 “1”分。



3. 你是否覺得生活空虛？問 <1>: 喺過去呢個禮拜裏面，你係咪覺得生活空虛呢？

如受試者未能掌握問題，請問 <2>: 喺上個禮拜裏面，你係咪覺得做人都幾百無聊賴呢？


否 0 分

4. 你是否常常感到煩悶？問 <1>: 喺上個禮拜裏面，你係咪成日覺得好煩悶呀？

答案給予分數問 <1> 是 1 分

否 0 分

5. 你是否很多時感到心情愉快呢？問 <1>: 你上個禮拜心情係咪成日都咁好呢？

如受試者說“冇乜好唔好”或“都喺咁上下” 之類的說話，請問 <2>: 咁你上個禮拜，係開心嘅時候多啲，定係唔開心嘅時候多啲呢？


否 1 分問 <2> 開心多啲 0 分

唔開心多啲 1 分

6. 你是否害怕將會有不好的事發生在你身上呢？問 <1>: 喺上個禮拜裏面，你有無擔心有啲唔好嘅嘢會發生喺你身上呢？

答案給予分數問 <1> 有 1 分

冇 0 分

7. 你是否大部份時間感到快樂呢？問 <1>: 喺上個禮拜裏面，你係咪成日都覺得開心呀？

如受試者說“都冇乜開心唔開心”或者“一半一半啦”之類的說話，請問 <2>: 咁你喺上個禮拜裏面，係開心多啲，抑或唔開心多啲呢？


否 1 分問 <2> 開心多啲 0 分

唔開心多啲 1 分



8. 你是否常常感到無助？問 <1>: 喺上個禮拜，你有冇覺得無論做乜嘢，都係冇用呢？

如受試者未能掌握問題”，請問 <2>: 喺上個禮拜，你有冇覺得無論做乜嘢，都係無補於事呢？


否 0 分

9. 你是否寧願留在院舍 / 屋企裏，而不出外做些有新意的事情？問 <1>: 喺上個禮拜裏面，你喺咪寧願留低響老人院 / 屋企，都唔想落街做啲有新

意嘅事呢？如受試者未能掌握問題，請

問 <2>: 喺上個禮拜裏面，你喺咪寧願留低響老人院 / 屋企，都唔想落街做啲特別嘅事情呢？如受試者說從來都不喜歡落街或類似的答案，或受試者表示想過但沒有精力，請

問 <3>: 咁你上個禮拜其實想唔想落街行吓，做啲你平時少做嘅嘢呢？


否 0 分問 <3> 想 1 分

唔想 0 分

10. 你是否覺得你比大多數人有多些記憶的問題呢？問 <1>: 喺上個禮拜裏面，你有冇覺得你嘅記性比其他老人家差呢呢？

如受試者說“我點知佢哋啲記性好唔好呢？”或“唔識去同人比較”之類的說話，請

問 <2>: 咁比起兩三個禮拜前，你上個禮拜記性有冇差到呢？

答案給予分數問 <1> 及問 <2> 有 1 分

冇 0 分

11. 你認為現在活著是一件好事嗎？問 <1>: 喺上個禮拜裏面，你有冇覺得做人係一件好事呢？

如受試者未能掌握問題，請問 <2>: 喺上個禮拜裏面，你覺得做人係有意思嘅，係唔係呢？

答案給予分數

問 <1> 及問 <2> 是 / 有 / 係 0 分否 / 冇 / 唔係 1 分



12. 你是否覺得自己現在一無是處呢？問 <1>: 喺上個禮拜裏面，你係咪覺得自己好無用呢？

如受試者說“都無乜所謂啦”或“都唔識分有用同冇用”，請問 <2>: 喺上個禮拜裏面，你有冇覺得自己完全冇用呢？


否 0 分

13. 你是否感到精力充足？問 <1>: 喺上個禮拜，你係咪覺得精力充沛呢？

如受試者未能掌握問題，請問 <2>: 喺上個禮拜，你係咪好夠精力呢？或

喺上個禮拜，你係咪好夠精神呢？


否 1 分

14. 你是否覺得自己的處境無望？問 <1>: 喺上個禮拜裏面，你有無覺得你嘅處境係無晒希望呢？


否 0 分

15. 你覺得大部份的人的境況比自己好嗎？問 <1>: 喺上個禮拜裏面，你係咪覺得大部份人嘅情況都好過你呢？

答案給予分數問 <1> 是 / 係 1 分

否 / 唔係 0 分

Source: Chinese version adapted with permission from Wong et al. (2002)



B) Geriatric Depression Scale 4-item Cantonese Version (GDS–4)

4-items Geriatric Depression Scale (GDS-4) has been shown to be an excellent alternative to GDS 15. With the cut-off point of 2 or more, it has the sensitivity of 76% and specifi city of 65% in the age group 60 to 74. In the group aged 75 years or more, it has the sensitivity of 60% and specifi city of 81%.

The Cantonese version is specially designed for Cantonese-speaking Chinese. For each question, an alternate version <2> is provided in case the respondent finds question <1> diffi cult to understand or answer; <2> is used only when <1> fails to obtain an answer.

Responses scored 1 point are boldfaced and underlined; otherwise, a score of zero is given. Total scores ≥2 are considered elevated (i.e., probably clinically depressed).

以下的問題是人們對一些事物的感受，答案是沒有對與不對。請想一想，在過去一星期內，你是否曾有以下的感受。如有的話，請圈「是」，若無的話，請圈「否」。

問 <1> 你上個禮拜心情係咪成日都咁好呢？是 / 否問 <2> 咁你上個禮拜，係開心時候多啲，定係唔開心時候多呢？ 0/1問 <1> 喺上個禮拜裡面，你喺咪成日行唔安坐唔定？是 / 否問 <2> 喺上個禮拜裡面，你喺咪成日覺得囉囉攣，冇辦法靜落嚟？ 1/0問 <1> 喺上個禮拜裡面，你有無覺得做人係一件好事呢？是 / 否問 <2> 喺上個禮拜裡面，你覺得做人係有意思嘅，係唔係呢？ 0/1問 <1> 喺上個禮拜裡面，你喺咪成日都悶悶不樂？是 / 否問 <2> 喺上個禮拜裡面，你喺咪覺得好似依個世界冇嘢可以令自己 1/0開心咁？

備註：如得分是 2 分或以上，須進一步評估長者的情緒狀況

Geriatric Depression Scale, 4-item Chinese VersionThis is the version before the Cantonese version was developed. This version does not contain an alternate question.

1. 你是否大部份時間都感到心情愉快呢？2. 你是否整天也覺得煩躁和坐立不安？3. 你認為現在活著是一件好事嗎？4. 你感到情緒低落嗎？

Source: Chinese version adapted with permission from Cheng & Chan (2004)



Annex 8. Patient Health Questionnaire (PHQ)34, 35, 36

A) Patient Health Questionnaire (PHQ)-9

The Patient Health Questionnaire (PHQ) was primarily developed for use in primary care setting and has shown good validity with overall accuracy of 85%, sensitivity of 75% and specificity of 90%). The Chinese version of PHQ-9 has been translated using an internationally accepted translation methodology and have been validated locally. The PHQ-9 scoring system can be used for disease severity stratifi cation and monitoring. The change of symptom frequency and severity can be reflected by the change of scores, and thus it can also be used to monitor the change of depressive symptoms with treatments.

在過去兩個星期 , 你有多經常受以下問題困擾 ?

( 請用「√」勾選你的答案 )完全沒有

幾天一半

以上的天數

近乎每天

1. 做任何事都覺得沉悶或者根本不想做任何事 0 1 2 3

2. 情緒低落、抑鬱或絕望 0 1 2 3

3. 難於入睡；半夜會醒或相反地睡覺時間過多 0 1 2 3

4. 覺得疲倦或活力不足 0 1 2 3

5. 胃口極差或進食過量 0 1 2 3

6. 不喜歡自己 - 覺得自己做得不好、對自己失望或有負家人期望

1 2 3

7. 難於集中精神做事，例如看報紙或看電視 0 1

0

2 3

8. 其他人反映你行動或說話遲緩 ; 或者相反地，你比平常活動更多─坐立不安、停不下來

0 1 2 3

9. 想到自己最好去死或者自殘 0 1 2 3

(1-9 題 ) 總分 : _______________________

Scoring

Normal Mild Moderate Moderately severe Severe0 – 4 5 – 9 10 – 14 15 – 19 ≧ 20

Source: Reproduced with permission from Pfi zer Inc. Copyright ©1999 Pfi zer Inc.



B) Patient Health Questionnaire (PHQ)-2

The PHQ-2 includes the fi rst two items of the PHQ-9.

在過去兩個星期 , 你有多經常受以下問題困擾 ?

完全沒有

幾天一半

以上的天數

近乎每天

1. 做任何事都覺得沉悶或者根本不想做任何事 0 1 2 3

2. 情緒低落、抑鬱或絕望 0 1 2 3

The PHQ-2 has the advantage of easy to administer, training time is minimal and subject acceptance is high. The purpose of PHQ-2 is not to establish diagnosis or to defi ne severity, but rather to screen for depression in a “fi rst step” approach. As a screening tool, the PHQ-2 has similar performance to the PHQ-9 in identifying older adults with depression. A PHQ-2 score of 3 or more has a sensitivity of 84% and a specifi city of 90% for a major depression.

Patients with positive screen for PHQ-2 should be further evaluated by PHQ-9 or other validated tools.

Scores for PHQ-2 range from 0-6. A cut-off score of 3 or above is recommended for screening purpose of PHQ-2.

Source : Reproduced with permission from Pfi zer Inc. Copyright © 1999 Pfi zer Inc.



Annex 9. Oral Health Assessment Tool

口腔健康評估入院初次評估

入院後評估

＊如以下有「不清潔」的項目，請通知前線護牙齒 / 口腔狀況及清潔度：

理員加密清潔。

上顎真牙有／沒有 ( 如有 ) : 清潔／不清潔

下顎真牙有／沒有 ( 如有 ) : 清潔／不清潔

上牙托有／沒有 ( 如有 ) : 清潔／不清潔

下牙托有／沒有 ( 如有 ) : 清潔／不清潔

院友姓名：

日期：

日常口腔／牙齒清潔：

可自行清潔

可自行清潔，但需要護理員協助

不能自理，需要護理員幫助清潔

Source: Adapted from Dental Unit, Department of Health

項目 0＝正常 1＝輕微變化 2＝不健康評分跟進

假牙狀況 ‧ 沒有破損‧ 很多時都有戴上

‧ 假牙有標上名字

‧ 假牙只有一個破損部位

‧ 只在進食 / 儀容需要時戴上

‧ 假牙沒有標上名字

‧ 假牙多於一個破損部位

‧ 假牙遺失 / 從不戴上

1＝特別護理2＝轉介

口唇 ‧ 光滑，淺紅色，濕潤

‧ 乾，皺，咀角紅 / 損‧ 有白 / 紅斑，流血或損傷情況少於三星期

‧ 有白 / 紅斑，流血或損傷情況多過三星期

舌頭 ‧ 有正常的紋理，淺紅色，濕潤

‧ 有深紋‧ 有白 / 紅斑，或損傷情況少於三星期

‧ 紅，光滑，有白 /紅斑，或損傷情況多過三星期

口腔唾液 ‧ 組織濕潤，唾液似水般可自由流動

‧ 組織乾涸有黏性 ‧ 組織乾，紅，沒有唾液分泌

牙肉和口腔黏膜

‧ 淺紅色，有輕微紋理，有彈性

‧ 假牙底下的牙肉應該是淺紅色和光滑

‧ 乾，光滑，瘀紅色或腫脹

‧ 有白 / 紅斑，有牙瘡，流血或損傷情況少於三星期

‧ 假牙底下的牙肉有紅色或損傷情況少於三星期

‧ 有白 / 紅斑，有牙瘡，流血或損傷情況多過三星期

‧ 假牙底下的牙肉有紅色或損傷情況多過三星期

牙齒狀況 ‧ 沒有蛀爛的牙齒或牙腳

‧ 1-3 隻蛀爛的牙齒或牙腳

‧ 多過 3 隻蛀爛的牙齒或牙腳

‧ 上，下顎任何一方少於 4 隻牙齒而沒有配帶假牙

1或 2＝轉介

牙齒 / 口腔痛楚

‧ 沒有行為上或語言表達痛楚

‧ 面部沒有異常腫

‧ 有提及牙痛或有行為上表達痛楚，例如拒絕進食

‧ 面部有異常腫脹‧ 加上有提及牙痛或有行為上表達痛楚，例如拒絕進食

總結跟進通知前線護理員進行特別護理轉介牙科醫生

下次評估日期：_________________________負責人姓名：_____________

牙醫記錄 ( 由牙醫填寫 )

牙醫姓名 :

________________

檢查日期 :

________________



Annex 10. Malnutrition Universal Screening Tool for Hong Kong Chinese (HKC-MUST)The Malnutrition Universal Screening Tool aims at detect under nutrition on the basis of knowledge about the association between impaired nutritional status and impaired function37. It was primarily developed for use in the community, where serious confounders of the effect of under nutrition are relatively rare38. It was demonstrated to have high reliability and good concurrent and predictive validity.

Malnutrition Universal Screening Tool for Hong Kong Chinese (HKC-MUST)

The Malnutrition Universal Screening Tool (MUST) is adapted / reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition)Source of reference: BAPEN2003 (http://www.bapen.org.uk) and Hospital Authority Co-ordinating Committee-Grade (Dietetics) 2007 June authentication

*BMI score is set according to Asian data for reference.



Annex 11. Chinese Nutrition Screening Tool (CNS)39

The Chinese Nutrition Screening (CNS) is a useful screening tool to detect the risk of malnutrition for the institutionalised Chinese older adults. It is particularly useful when biochemical and anthropometric data are not available which is common in old aged home settings. It is more likely to identify risk of malnutrition at an early stage since it also includes physical and mental aspects that frequently affect the nutritional status of the elderly40. It was validated locally and by using the cut-off point of 21, it has a sensitivity of 60.9% and specifi city of 72.9% with a negative predictive value of 92.3% and a positive predictive value of 25.8% for malnutrition41.

Chinese Nutrition Screening Tool (CNS)A. In the past three months, has there been any change in food intake?

0 = serious loss of appetite1= appetite decreased, but not seriously2= no change in appetite3 = appetite has improvedAsk the patientIn the past three months, have you eaten more or less than usual?If less, is it a lot less, or only slightly less?

Score

B. In the past three months, has there been a change in body weight?0 = body weight decreased1= no change in body weight2 = body weight increasedAsk the patientIn the past three months, has your body weight increased or decreased?Have your clothes felt tighter or looser?Has your weight kept the same, unchanged?

C. Patient’s activity level0 = can only lie in bed or sit in wheelchair1 = can transfer from bed and sit in wheelchair, but unable to go out2 = can go outAsk the patientCan you transfer from bed and sit in wheelchair?Can you go out?

D. In the past three months, have you suffered from acute illness?0 = yes 1 = noAsk patient, medical or nursing staff, or check medical record



E. Are you happy?0 = very unhappy1 = unhappy2 = reasonably happyAsk patient, medical or nursing staff or check medical recordAsk patient: Do you have relatives or friends who pass away recently?Have you recently moved house or moved into an old age home?

F. Do you live alone?0 = yes 1 = noThis question refers to normal living condition, not the current status when people are staying in hospital or old age home

G. Do you have to take fi ve or more medication a day?0 = yes 1 = no

H. Does the patient have pressure sore, infl amed skin or skin ulcer?0 = yes 1 = noAsk patient, medical or nursing staff or check medical record

I. How many meals do you have in a day?0 = one1 = two2 = three or moreAsk patient, medical or nursing staff, or check medical recordA meal is defi ned to be two or more food items eaten by patient sitting down

J. In the past week, have you taken the following food?1. one portion of milk (or milk powder), cheese, ice cream, yogurt or egg

0 = one portion or less1 = two to three portions2 = four portions or more

2. One portion of bean, bean soup, soya bean curd, soya milk0 = one portion or less1 = two or three portions2 = four portions or more

3. One portion of meat, fi sh or poultry (chicken, duck, geese, pigeon)0 = one portion or less1 = two to three portions2 = four portions or more

One portion of food is equivalent to one glass or 250ml of milk, one piece of cheese, one egg, or half bowlful.



K. In the past week, have you taken the following food?One portion of fresh fruit or fresh fruit juice0 = one portion or less1 = two to three portions2 = four portions or moreOne portion is equivalent to one fresh fruit or 250ml of fruit juice

L. In one day, how much liquid food do you drink (water, fruit juice, soup, congee, soft drink)?0 = three portions or less1 = four to fi ve portions2 = six portions or moreOne portion is equivalent to one glass or 250ml of milk or one bowlful.

M. Patient’s feeding status0 = need assistance1 = can self feed with diffi culty, may need some assistance2 = self feed independently

N. How do you rate your health as compared with people of your age?0 = worse, not too good1 = the same2 = better

If there is suitable equipment and patient is able to stand to have height measured, please answer the following question:O. Patient’s body mass index:

0 = <161 = >16

Total Score (max = 32 points)

Malnutrition Indicator Score≤21: at risk of malnutrition≥22: well nourished

Source: Reproduced with permission from The Journal of Nutrition Health and Aging, 2005, and Woo et al. (2005)



Annex 12. Mini-Nutritional Assessment (MNA)

Mini Nutritional Assessment (MNA) is designed specifi cally to screen for malnutrition in institutionalised older adults. It consists of 18 assessment items divided into four parts: anthropometric, general, dietary, and self-assessment which have shown high predictive value for morbidity and mortality.



Source: Reproduced with permission from Hong Kong East Cluster Nutrition Information Web.



營養調查細則

項目註釋

E 判斷是否患有痴呆症或憂鬱症，一般應以醫生的診斷為依據「嚴重」者指影響基本日常活動

H 至 M 「每日」是指最近兩週的飲食習慣

H 「4 種藥」如 : 醫生開 Daonil , Glucophage 都是醫糖尿，祇算一種藥

J 1( 中號 ) 碗飯 = 相等於五滿湯匙飯1( 中號 ) 碗飯計 250 毫升，一般即 300 毫升碗八分滿

K 1 份水果 = 1 個中型水果，如橙、蘋果、梨等1 份蔬菜 = 3 兩煮熟蔬菜或 1 碗蔬菜

L 1 兩瘦肉 ( 生秤 ) = 1 隻大麻雀牌體積

1 兩肉 ( 煮熟 ) = 直徑 7 公分長之塑膠醬油碟之份量

M 「營養奶或奶粉」需注意開奶所用奶粉份量及使用之盛器容量，再評估長者飲用正確奶量例子 :3 殼加營素開水至 8 安士，祇可換算作營養奶 1/2 杯

P, Q 屬主觀答案，須用心聆聽，以揣摩長者回應

上臂中點圓周測量法‧ 透過量度及監察上手臂的變化，可反映長者的營養狀況‧理想範圍為 20 公分或以上‧若低於 17 公分，則是營養不良的初步指標

定出上手臂中點之位置 ( 見下圖 )1. 指導被測者站直，把其左手手肘彎成 90 度，並使其掌心向下。

若被測者不能直立，患者可以平躺或坐下測定。2. 肩峰頂點與肱骨的肘頭 ( 手肘 ) 頂端，二處各作記號。3. 軟尺的零位置與肩峰位置對齊後，拉長至肘頭號位。4. 量度兩點所成直線之間的距離，取其中點，並在同一直線上做記號



Annex 13. Abbreviated Mental Test (AMT) 42

10-question test to screen for cognitive impairment in geriatrics patientsTest includes short term memory (Q3) and long term memory (Q1,7,8,9), attention (Q10) and orientation (Q2,4,5,6)

1. 請講出你的年齡 ________2. 現在是什麼時間 ________3. 我告訴你一個地址，請你緊記。這地址是 ‘上海街四十二號’ ________4. 今年是甚麼年份 ________5. 這裏是什麼地方 ________6. 你認識這兩位人士嗎 ( 在周圍任何兩位人士 ) ________7. 請講出你的出生日期 ________8. 請講出中秋節的日期 ________9. 請講出香港特首的名字 ________10. 請由二十倒數至一 ________

總得分： ( 答對 = 1 分 ; 答錯 = 0 分 )

Best cut off is 6 (with sensitivity 96% and specifi city 94%)

Source: Reproduced with permission from the Hong Kong Medical Journal, 1995, Hong Kong Academy of Medicine and Chu et al. (1995)



Annex 14. Mini-Cog Test 43

The Mini-Gog test is a 3-minute instrument to screen for cognitive impairment in older adults in the primary care setting. The Mini-Cog uses a three-item recall test for memory and a scored clock-drawing test (CDT). The latter serves as an “informative distracter” helping to clarify scores when the memory recall score is intermediate. The Mini-Cog was as effective as or better than established screening tests in both an epidemiologic survey in a mainstream sample and a multi-ethnic, multilingual population comprising many individuals of low socioeconomic status and education level. In comparative tests, the Mini-Cog was at least twice as fast as the Mini-Mental State Examination. The Mini-Cog is less affected by subject ethnicity, language, and education, and can detect a variety of different dementias. Moreover, the Mini-Cog detects many people with mild cognitive impairment (cognitive impairment too mild to meet diagnostic criteria for dementia).



Source: Mini-CogTM Copyright S.Borson. Reproduced with permission.



Annex 15. Glossary44, 45, 46, 47, 48, 49

ScreeningScreening is the presumptive identification of unrecognized disease or defect by the application of tests, examinations or other procedures which can be applied rapidly. Screening tests sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. Once a disease is suspected, prompt clinical management should be instituted. Moreover, screening involves a system not just a test and there is always a trade-off between benefi t, harm and affordability. Hence, screening programme if implemented should be occurred at settings where screening service is provided and relevant supporting service is readily accessible.

Population-based screeningPopulation-based screening is offered systematically to all individuals in the defi ned target group within a framework of agreed policy, protocols, quality management, monitoring and evaluation by applying a screening test for a disease which is considered important and will produce a net benefi t that is cost effective and that the community considers acceptable.

Opportunistic screeningOpportunistic screening occurs when a test is offered to individuals when they present to a health care practitioner for reasons unrelated to that disease, and particularly for individuals who may be predisposed to that disease, e.g. individuals with particular risk factors or at increased risk, and the disease can be controlled better when detected early in the natural history. The differences between population-based screening and opportunistic screening are described in the table below.

Population-based screening Opportunistic screeningTargets Targeted to general population. Targeted to individuals rather than

general population.Process Adequate staffi ng and facilities for

testing, diagnosis, treatment andprogramme management should beavailable prior to the commencementof the screening programme.

There is proactive invitation of thetarget population.

An organised integrated processwhere all activities along thescreening pathway are planned,coordinated and monitored

The decision to initiate the healthcare encounter is made by theindividual rather than being invited.

The primary care doctor acts onappropriate opportunities duringthe consultation process for diseaseprevention.

The choice of the disease to bescreened depends on circumstancesin the consultation and has to belegitimate and selective.



Example Cervical cancer screeningprogramme.Women aged between 25 and 64 who have ever had sex are invited to have cervical cytology test every 3 years after two consecutive normal annual cytology tests.

Opportunistic screening ofdementia.The primary care doctor is aware of cues pointing to the possibility of dementia during the consultation process, though the patient comes for the condition unrelated to cognitive problem. The primary care doctor then takes the opportunity and performs screening test for dementia.

Primary preventionPrimary prevention aims to reduce the incidence of disease by personal and communal efforts, such as decreasing environmental risks, enhancing nutritional status, immunizing against communicable diseases, or improving water supplies. It is a core task of public health, including health promotion.

Secondary preventionSecondary prevention aims to reduce the prevalence of disease by shortening its duration. If the disease has no cure, it may increase survival and quality of life. It seldom prevents disease occurrence; it does so only when early detection of a precursor lesion leads to complete removal of all such lesions. It is a set of measures available to individuals and communities for the early detection and prompt intervention to control disease and minimise disability; e.g., by the use of screening programs.

Tertiary preventionTertiary prevention consists of measures aimed at softening the impact of long term disease and disability by eliminating or reducing impairment, disability, and handicap; minimising suffering; and maximizing potential years or useful life.



AcknowledgmentsThis Module on Health Assessment was developed with the active support and invaluable contribution of the Members of the Sub-group on Health Assessment.

Members of the Sub-group on Health Assessment (2013)

ConvenorDr Felix CHAN Hon-wai Hong Kong West Cluster Service Director

(Primary and Community Health Care);Chief of Service, Department of Medicine, Tung Wah Group of Hospitals Fung Yiu King Hospital;Consultant Physician (Geriatrics)

MembersDr Mark CHAN Suen-ho Private General PractitionerDr Eunice CHAN Yin-chiu Specialist in Family Medicine,

United Christian Nethersole Community Health ServiceDr Rudolph CHOW Wai-man Private General Practitioner;

Honorary Clinical Assistant Professor,Department of Family Medicine and Primary Care,The University of Hong Kong

Dr Henry KONG Wing-ming Fellow of Hong Kong College of Community MedicineProf Timothy KWOK Chi-yui Professor, Division of Geriatrics,

Department of Medicine and Therapeutics,The Chinese University of Hong Kong

Prof Claudia LAI Kam-yuk Professor, School of Nursing, The Hong Kong Polytechnic University

Prof Lam Tai-pong Professor and Chief of Postgraduate Education, Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong

Dr LAU Ho-lim Vice-President (General Affairs), The Hong Kong College of Family Physicians

Dr Christina MAW Kit-chee Senior Manager (Elderly and Community Care), Hospital Authority

Dr Francis MOK Chun-keung Chairman, Specialty Board in Geriatric Medicine, Hong Kong College of Physicians



Mr Bobby NG Representative of Hong Kong Occupational Therapy Association; Senior Occupational Therapist, Occupational TherapyDepartment, Kowloon Hospital, Hospital Authority

Dr WONG Man-shun Council Member, Association of Licentiates of Medical Council of Hong Kong

Dr Nelson WONG Chi-Kit Head of Corporate Medical Scheme Service,Dr Vio & Partners

Prof Thomas WONG President, Tung Wah CollegeKwok-shingDr YEUNG Chiu-fat President, Hong Kong Doctors UnionThe following service units of the Department of Health:

Dental ServiceElderly Health ServiceProfessional Development and Quality Assurance



References

1 Patient morbidity and management patterns of community-based primary health care services in Hong Kong. Hong Kong Med J 2011. 17(Suppl 3): p. S33-7.

2 Canadian Task Force on the Periodic Health Examination. The Periodic Health Examination 1984. A Report of the Periodic Health Examination Task Force. Ottawa, Ontario: Health Services Directorate, Health Services and Promotion Branch, Department of National Health and Welfare: 1984; 15.

3 US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore, Md: Williams & Wilkins. 1996.

4 Lam CLK, Leung GM, Mercer SW, Fong DYT, Lee A, Lam TP, Lo YYC. Utilization patterns of primary health care services in Hong Kong: does having a family doctor make any difference? HKMJ. 2011; 1(suppl): S28-S32.

5 Lewis GH (2010). Predictive Modelling in Action: How ‘virtual wards’ help high-risk patients receive hospital care at home. Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2010/Aug/Predictive-Modeling-in-Action.aspx . Accessed on 18 Nov 2011

6 The Royal Australian College of General Practitioners. Guidelines for Preventive Activities in General Practice. 8th Edition. [Internet]. South Melbourne (Australia): The Royal Australian College of General Practitioners; c2013. Available at: http://www.racgp.org.au/your-practice/guidelines/redbook/. Accessed on 8 Aug 2013

7 Continence Foundation of Australia. Promoting bladder and bowel health, 2008.

8 O'Neil B, Gilmour D. Approach to urinary incontinence in women. Diagnosis and management by family physicians. Can Fam Physician. 2003; 49: 611-8.

9 Shamliyan, T., Prevention of fecal and urinary incontinence in adults. Evidence report/technology assessment No. 161. Rockville: Agency for Healthcare Research and Quality. 2007.

10 Chiu H, Lee HC, Chung WS, Kwong PK. Reliability and validity of the Cantonese Version of Mini-Mental State Examination – a Preliminary Study. J Hong Kong Coll Psychiatr. (1994) 4 , SP2, p25-28. Available at: http://easap.asia/journal_file/9402_ V4N2_p25.pdf. Accessed on 18 Nov 2011

11 University of Iowa Geriatric Education Library -Geriatric Assessment tools. [Internet]. Available at: http://www.healthcare.uiowa.edu/igec/tools/ . Accessed on 18 Nov 2011


http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2010/Aug/Predictive-Modeling-in-Action.aspx

http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2010/Aug/Predictive-Modeling-in-Action.aspx


12 University of Michigan Medical School - Geriatric Functional Assessment 2003. [Internet]. Available at: http://www.med.umich.edu/lrc/coursepages/M1/HGD/GeriatricFunctionalAssess.pdf . Accessed on 18 Nov 2011

13 Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988;10(2):61-63.

14 Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65.

15 Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud. 1988;10(2):64-67.

16 Tong YC, Man WK. The Validation of the Hong Kong Chinese Version of the Lawton Instrumental Activities of Daily Living Scale for Institutionalized Elderly Persons. Occupational Therapy Journal of Research: Occupation, Participation and Health 2002;22(4): 132- 142.

17 Podsiadlo D, Richardson S. The Time “Up & Go”: A Test of Basic Functional Mobility for Frail Elderly Persons. Journal of the American Geriatrics Society 1991; 39(2): 142-148.

18 Shumway- Cock A, Brauer S, Woollacott M. Predicting the Probability for Falls in Community-Dwelling Older Adults Using the Timed Up & Go Test. Physical Therapy 2000; 80(9): 896-903.

19 Schoene D, Wu SM, Mikolaizak AS, Menant JC, Smith ST, Delbaere K, Lord SR. Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc. 2013 Feb;61(2):202-8.

20 Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatrics 2014;14:14.

21 Vellas B.J., Wayne S.J., Romero L et al. One-leg balance is an important predictor of injurious falls in older person. J Am Geriatr Soc 1997; 45: 735-738.

22 Jonsson E, Seiger A, Hirschfeld H. One-leg stance in healthy young and elderly adults: a measure of postural steadiness? Clinical Biomechanics. Aug 2004. 19(7):688-94.

23 Diabetic Complication Screening Manual (2006). Professional Services and Medical Development Division, HA, the Diabetes Educators Group and the Hong Kong Society of Endocrinology, Metabolism and Reproduction.


http://www.med.umich.edu/lrc/coursepages/M1/HGD/GeriatricFunctionalAssess.pdf

http://www.med.umich.edu/lrc/coursepages/M1/HGD/GeriatricFunctionalAssess.pdf


24 Rabbetts, R. B. (2000) Bennett & Rabbetts’ Clinical Visual Optics. Butterworth, Oxford. p.45.

25 Eagan, S. M. , Jacobs, R. J. and Demers-Turco, P. L. (1999) Study of luminance effects on pinhole test results for visually impaired patients. Optom. Vis. Sci. 76, p.50-58.

26 Visual Acuity Measurement Standard (1984). International Council of Ophthalmology (ICO) (http://www.icoph.org/dynamic/attachments/resources/icovisualacuity1984.pdf )

27 Loewenstein A, Malach R, Goldstein M, et al. Replacing the Amsler grid - a new method for monitoring patients with age-related macular degeneration. Ophthalmology 2003;110:966–970.

28 Screening and Management of Adult Hearing Loss in Primary Care: Clinical Applications. JAMA. 2003; 289(15): 1986-1990.

29 Whispered voice test for screening for hearing impairment in adults and children: systematic review. BMJ. 2003 October 25; 327(7421): 967.

30 Lee HB, Chiu HFK, Kwok WK, CM Leung, Kwong PK, Chung DWS. Chinese elderly and the GDS short form. Clinical Gerontologist 1993; 14(2), 37 – 42.

31 Lee, HCB, Chiu, HFK, & Kwong, PPK (Jan & July 1994). Cross-validation of the Geriatric Depression Scale Short Form in the Hong Kong Elderly. Bulletin of the Hong Kong Psychological Society, 32/33, 72-77.

32 Wong MTP, et al. Development and inter-rater reliability of a standardized verbal instruction manual for the Chinese Geriatric Depression Scale-short form. Int J Geriatr Psychiatry 2002; 17, 459-463.

33 Cheng ST, Chan ACM. A brief version of the Geriatric depression scale for the Chinese. Psychological Assessment 2004, Vol 16, No 2, 182-186.

34 Teddy M Chen, Frederick Y Huang, Christine Chang, Henry Chung. Using the PHQ-9 for depression screening and treatment monitoring for Chinese Americans in Primary Care. Psychiatric Services. July 2006, 57: 976-981.

35 Lowe B, Unutzer J, et al. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Medical Care 2004;1194-1201.

36 Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care 2003, (41) 1284-1294.

37 Malnutrition Advisory Group (MAG). MAG guidelines for Detection and Management of Malnutrition. British Association for Parental and Enteral Nutrition, 2000, Redditch, UK.



38 Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN Guidelines for Nutrition Screening 2002. Clinical Nutrition 2003, 22(4): 415-421.

39 K. Lok, J. Woo, E. Hui, T. Kwok, Usefulness of the Chinese Nutrition Screening (CNS) tool in predicting 12 month mortality in elderly Hong Kong Chinese living in Institution. The Journal of Nutrition, Health & Aging, Vol 13, Number 2, 2009.

40 Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN Guidelines for Nutrition Screening 2002. Clinical Nutrition 2003, 22(4): 415-421.

41 Lok K, Woo J, Hui E, Kwok T. Usefulness of the Chinese Nutrition Screening (CNS) Tool in Predicting 12 month Mortality in Elderly Hong Kong Chinese Living in Institutions. The Journal of Nutrition, Health and Aging 2009; 13(2): 96-101.

42 L W Chu, et al. Validation of Abbreviated Mental Test (Hong Kong version) in the elderly medical patients. HKMJ 1995;1: 207-211.

43 Borson, S., et al., The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 2000. 15(11): 1021-7.

44 Miquel Porta. A Dictionary of Epidemiology. 5th ed. Oxford University Press; 2008.

45 Wald N. Opportunistic screening. Journal of Medical Screening. 1994;1:208.

46 The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice 8th edition [Internet]. c2013 [cited 8 Aug 2013]. Available from: http://www.racgp.org.au/download/Documents/Guidelines/Redbook8/redbook8.pdf

47 Australian Health Ministers’ Advisory Council. Population Based Screening Framework [Internet]. c2008 [cited 5 Jun 2012]. Available from: http://www.cancerscreening. gov.au/internet/screening/publishing.nsf/Content/pop-based-screening-fwork/$File/screening-framework.pdf

48 National Health Committee. Screening to Improve Health in New Zealand: Criteria to assess screening programmes [Internet]. c2003 [cited 5 Jun 2012]. Available from: http://nhc.health. govt.nz/publications/nhc-publications-pre-2011/screening-improve-health-new-zealand

49 Oxford Handbook of Public Health Practice. 2nd ed. Oxford University Press. 2006; Part 3: Sect. 3.6, Assuring screening programmes.


http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/pop-based-screening-fwork/$File/screening-framework.pdf



http://nhc.health.govt.nz/publications/nhc-publications-pre-2011/screening-improve-health-new-zealand

http://nhc.health.govt.nz/publications/nhc-publications-pre-2011/screening-improve-health-new-zealand