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The Health ofthe Elderly
in Hong Kong
The Health ofthe Elderly
in Hong Kong
The Health ofthe Elderly
in Hong Kong
The Health ofthe Elderly
in Hong Kong
Edited by Shiu-kum Lam
iv
Contents
Printed in Hong Kong by ColorPrint Production Ltd.
Hong Kong University Press
The University of Hong Kong
Pokfulam Road, Hong Kong
© Hong Kong University Press 1997
ISBN 962 209 431 7
All rights reserved. No portion of this publication may be
reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopy, recording,
or any information storage or retrieval system, without
permission in writing from the publisher.
This volume comes with a booklet of summaries in
Chinese. Acknowledgement is due to Medcom Limited
for supplying the Chinese translation of the summaries
free of charge.
v
Contents
14Con ten t s
Shiu-kum LAM
Contributors ix
Foreword by the Governor of Hong Kong xi
Foreword by Rotary Club of Hong Kong Northwest xiii
Preface xvii
Chapter 1 1
Geriatric Medicine in Hong Kong — An Overview
Leung-wing CHU, Shiu-kum LAM
Chapter 2 21
Background and Methods of the Study
Mona Bo-nar LO
Chapter 3 43
Social and Health Status of Elderly People in Hong Kong
Edward Man-fuk LEUNG, Mona Bo-nar LO
Chapter 4 63
Helicobacter Pylori Infection — Epidemiology and Clinical
Significance Among the Elderly in Hong Kong
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
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Contents
Chapter 5 75
Upper Gastrointestinal Abnormalities in the Elderly Helicobacter
Pylori Carriers
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
Chapter 6 87
Prevalence of Palpitations, Cardiac Arrhythmias and Their
Associated Risk Factors in Ambulant Elderly
Ngai-sang LOK, Chu-pak LAU
Chapter 7 99
Prevalence of Coronary Heart Disease and Associated Risk
Factors in Ambulant Elderly
Chu-pak LAU, Ngai-sang LOK
Chapter 8 111
Lipids, Lipoproteins and Other Biochemical and Haematological
Parameters in Elderly Ambulant Hong Kong Subjects
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
Chapter 9 129
Reference Height-weight Tables for Hong Kong Elderly Men
and Women
Leung-wing CHU, Shiu-kum LAM, Edward Denis JANUS,
Annie Wai-chee KUNG, Chu-pak LAU, Edward Man-fuk
LEUNG, Mona Bo-nar LO
Chapter 10 139
Thyroid Dysfunction in Ambulatory Chinese Subjects Over the
Age of Sixty
Annie Wai-chee KUNG, Edward Denis JANUS
Chapter 11 147
The Prevalence of Diabetes Mellitus in Elderly Subjects in Hong
Kong
Annie Wai-chee KUNG, Edward Denis JANUS
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Contents
Chapter 12 161
The Prevalence and Risk Factors of Fractures in Hong Kong
Annie Wai-chee KUNG
Chapter 13 173
Ageing in Hong Kong
Nelson Wing-sun CHOW, Iris CHI
Chapter 14 193
Summing Up: The Economics of Ageing in Hong Kong
Shiu-kum LAM
Index 201
viii
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ix
Contents
14Contr ibutors
Vincent TO
Editor:
Shiu-kum LAM, MD, FRCP, FRCP(E), FRCP(G), FACP, FACG,
FRACP, FHKAM(Med), FHKCP
Division of Gastroenterology & Hepatology, Department of Medicine,
The University of Hong Kong, Queen Mary Hospital, Hong Kong.
Contributors:
Shing-shun CHEUNG, B.Sc.
Medical Laboratory Technician, Department of Clinical Biochemistry,
Queen Mary Hospital, Hong Kong.
Iris CHI, B.Sc.(CUHK), M.SW, D.SW(Calif)
Department of Social Work and Social Administration, The University
of Hong Kong, Hong Kong.
Chi-kong CHING, MD, MRCP(UK), FHKCP(HK), FHKAM(Med)
Division of Gastroenterology & Hepatology, Department of Medicine,
The University of Hong Kong, Queen Mary Hospital, Hong Kong.
Nelson Wing-sun CHOW, Dip.Soc.St., BA, MA Econ(Manch), PhD,
MBE, JP
Department of Social Work and Social Administration, The University
of Hong Kong, Hong Kong.
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ContentsContributors
Leung-wing CHU, MRCP(UK), FHKCP, FHKAM(Med)
Division of Geriatrics, Department of Medicine, The University of
Hong Kong, Queen Mary Hospital, Hong Kong.
Edward Denis JANUS, MD(Otago), PhD(Lond), FRACP
Department of Clinical Biochemistry, Queen Mary Hospital, Hong
Kong.
Annie Wai-chee KUNG, MD, FRCP(E), FHKCP, FHKAM(Med)
Division of Endocrinology, Department of Medicine, The University
of Hong Kong, Queen Mary Hospital, Hong Kong.
Chu-pak LAU, MD, FRCP, FRCP(E), FHKCP, FHKAM(Med)
Division of Cardiology, Department of Medicine, The University of
Hong Kong, Queen Mary Hospital, Hong Kong.
Man-chun LEE, AIBMS
Senior Medical Technologist, Department of Clinical Biochemistry,
Queen Mary Hospital, Hong Kong.
Edward Man-fuk LEUNG, MRCP(UK), FRCP(E), MPA(HK), FHKCP,
FHKAM(Med)
Department of Medicine, United Christian Hospital, Kowloon, Hong
Kong.
Mona Bo-nar LO, M.Sc.(Lond)
Board of Directors, The Hong Kong Society for the Aged, Hong Kong.
Ngai-sang LOK, MBBS, M.Phil
Division of Cardiology, Department of Medicine, The University of
Hong Kong, Queen Mary Hospital, Hong Kong.
Benjamin Chun-yu WONG, MRCP(UK)
Division of Gastroenterology & Hepatology, Department of Medicine,
The University of Hong Kong, Queen Mary Hospital, Hong Kong.
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Contents
14Foreword by the Governor of Hong Kong
Vincent TO
Much has been written about Hong Kong’s remarkable success as a
community, but less about the extent to which that success has been
due to the courage, determination and hard work of those who are
now enjoying the benefits — and facing the challenge — of old age.
We owe them a great debt of gratitude.
We can go some way to discharging that debt by ensuring that the
elderly in our community can live in dignity, with help and
encouragement to maintain their health and to continue to participate
fully in the life of the community. I am delighted, therefore, to see the
publication of a book dedicated to pursuing that aim.
It should perhaps come as little surprise, given what they have
achieved and the qualities they have demonstrated, that people in
Hong Kong live longer than their counterparts almost anywhere else
in the world. Life expectancy at birth was 75.4 years for men in 1994,
up from 67.7 years in 1972, whilst that for women increased from
75.4 years to 81 years over the same period.
Increasing life expectancy, together with a dramatic decline in the
birth rate, has brought great changes to the population distribution in
Hong Kong. The proportion of persons aged 65 and above in the total
population increased from 3.2% in 1961 to 8.8% in 1991. It is expected
to reach 12.3% by the year 2001.
This book comes at an opportune time to help us to address the
emerging needs of an ageing population. It will be a valuable source of
reference for specialists, researchers, health care providers and for all
those involved in the planning and provision of services for the elderly.
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Contents
It combines principles and practical experience and sets out new models
to deal with the many challenges lying ahead.
I congratulate the editors, contributors and all involved for their
success in putting together this valuable publication.
Christopher Patten
Governor of Hong Kong
1996
Foreword by the Governor of Hong Kong
xiii
Contents
14Foreword by Rotary Club of
Hong Kong Northwest
Rotary Club of Hong Kong Northwest
We are proud to have made a mountain out of a molehill.
One of the four avenues of service of every Rotary Club is community
service. So when the directors of the Rotary Club of Hong Kong
Northwest (the Club) took office at the start of the Rotary year on 1 July
1993 under the presidency of John M.K. Lei, they invited members of the
Club to sponsor projects that would benefit the community.
At that time, health awareness was gaining popularity and
importance. One proposal was for the Club to finance the cost of a
general health check up for up to 500 underprivileged elderly persons.
John Cheng, one of the past presidents of the Club, had access to
the services of a local laboratory, so it was proposed that the number
of elderly persons be increased to 900.
Initially, blood samples would be taken and analyzed for a complete
blood picture — liver and renal function, lipid profile, and fasting
glucose count. However, one director of the Club, Dr. Steve Cheung,
felt that an opportunity existed for further analysis as similar data is
lacking. At the suggestion of Ng Wing Hong, the director responsible
for community service, who is also a director of the Hong Kong
Society for the Aged (SAGE), Professor Shiu-kum Lam of the
Department of Medicine of Hong Kong University was approached to
undertake further analysis of data.
As things developed, what started as a general health check-up
project grew into a study of the health condition of the aged in Hong
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Contents
Kong with the objective of prevention of illnesses and improvement of
health care.
An opening ceremony to mark the commencement of the project
was held on 8 January 1994 and was officiated by the Chairman of
SAGE and member of the Executive Council Professor the Hon. Edward
Kwan-yiu Chan, District Governor of Rotary International District
3450 and member of the Legislative Council the Hon. Moses Mo-chi
Cheng, Director of Medical and Health Department Dr. S.H. Lee, and
President John M.K. Lei.
A seminar on health care followed the ceremony with Professor
Shiu-kam Lam moderating. The speakers were practising cardiologist
Rotarian Dr. Ping-ching Fong, and Deputy Director of Hong Kong
Red Cross Blood Transfusion Centre Dr. Chi-kit Lin. About 400 elderly
persons were in attendance.
With the assistance and co-operation of SAGE, blood samples
were taken from 1912 elderly persons over a period of eight days in
seven centres strategically located in different areas. This exercise was
huge not only in terms of the number of elderly persons participating,
but also the number of support persons involved. There were technicians
from the laboratory and Red Cross, nurses and volunteers, distributors
of refreshment, and members and spouses of both the Club and Rotary
Club of Midlevels who worked to a roster in attending at the centres
to help the elderly persons feel at ease. Every centre was attended by
one or more volunteer doctors. One centre was attended by Rotary
Past District Governors Peter Hall and Dr. Raymond Wong.
The first stage of the project was completed and reports were
distributed in March and April to the elderly persons at seven centres,
when talks on health care were also conducted.
To obtain the necessary data for the study, the University of Hong
Kong suggested that the elderly persons should complete a questionnaire
regarding their diet, life style, illnesses, living condition, etc. A trip to
the University of Hong Kong unit at Queen Mary Hospital for the
almost 2000 elderly persons over eight weekends was organized.
Medical students from the University were on hand to discuss with
each person the contents of his or her questionnaire during the months
of April and May 1994, and volunteer nurses from Queen Mary
Hospital performed ECG examination on them.
A selected group of 200 elderly persons with deranged thyroid
function then underwent further tests.
The ultimate objective of the project was the publication of a book
to document the findings and research materials with a view to
Foreword by Rotary Club of Hong Kong Northwest
xv
ContentsForeword by Rotary Club of Hong Kong Northwest
betterment of health care of the aged. Work towards achieving the
objective continued under the Rotary presidency of Peter Wing-leung
Lai in 1994/1995, and Ng Wing Hong in 1995/1996.
We would like to congratulate and thank everyone involved in the
project, starting with the 2000 elderly persons whose co-operation
was vital, the staff and students of the University of Hong Kong, the
staff of SAGE, the Geriatric Society, the Red Cross, the nurses from
Queen Mary Hospital, all volunteers, Rotarians and their spouses of
the Club as well as the Rotary Club of Midlevels led by Past Presidents
Leon Lai and current President Raymond Ng. The have all made this
project possible.
In addition to the Club’s sponsorship to undertake this project, the
University of Hong Kong also made substantial financial sacrifice by
levying a nominal charge for the many services it provided.
Rotary Club of Hong Kong Northwest
1996
xvi
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xvii
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14Pre f ace
Vincent TO
Hong Kong, one of the four Asian dragons (the others being Korea,
Taiwan and Singapore), has a GDP per capita second only to Japan in
Asia. Its way of life is becoming more sophisticated, its people want to
enjoy better health, and its population is ageing. It is a typical, emerging
city in Asia. Understanding it should help us understand the other
developing Asian cities.
The population of Hone Kong has always been thought to be
young. In 1980, 40% were below the age of 20, and the median age of
the population was 25. Most of the social programmes had naturally
and rightly been directed to the young. For instance, we have been
proud to have one of the lowest infant mortality rates in the world.
Today, in 1996, it is still young by most standards, However, Hong
Kong is ageing and the life expectancy of its people is longer. The
proportion of those aged 65 and above has more than doubled from
4% in 1980 to 9% today, and will be 18% by 2020. Our females are
now expected to live till 79 and males till 72 — among the world’s top
longevities. The rapidity of ageing and the life expectancy in Hong
Kong is second only to Japan in Asia. By 2020, the number of over-
80s in all OECD countries will have doubled.
There has been very little information on the health and way of
life of the elderly in Hong Kong. How often do they have chronic
illness such as diabetes, hypertension, coronary heart diseases, and
dyspeptic problems? What proportion of the elderly population have
disabilities? How good is their nutrition? What is their dietary pattern
like? Do they have normal blood counts? How normal is their
xviii
ContentsPreface
cholesterol? What is their kidney, thyroid and liver function like?
How strong are their bones and how many will need hip replacement,
which appears to be routine in developed countries? What is their
daily activity? What is their quality of life?
These questions have obvious bearings on the future socio-economic
planning and strategies in relation to the increasing elderly population
in Hong Kong. For example, how can we keep intact the apparently
disintegrating Chinese culture of looking after the elders in the family
setting so that they can ‘age in place’? How many nursing homes does
Hong Kong need as more and more people survive to the age when
they need nursing care? How can we keep the extra life expectancy
gained free from disability, and what provision is needed for those
whose extra time gained is spent in poor health? Is the health of the
elderly good enough to warrant extension of their working life — this
matters to politicians since this is one way to ease the financial problem
of an ageing population.
I was, therefore, overwhelmed with delight when a Rotarian
approached me two years ago on the possibility for the Department of
Medicine, University of Hong Kong to work with the Rotary Club of
Hong Kong Northwest and the Hong Kong Society for the Aged on a
health project on the Hong Kong elderly. It has been most gratifying
to see the project evolving from a simple and noble idea of doing a
health check for a cohort of senior citizens to a piece of ambitious and
meaningful research on a representative sample of the elderly population
in Hong Kong. It should be noted that while the accomplishment of
this project is no doubt the result of a substantial donation, much
more importantly it represents the hard work of a large number of
volunteers with diverse backgrounds who share a common interest in
life and who are driven by the common dedication to make Hong
Kong a better place to live in.
Shiu-kum Lam
Professor and Head
Department of Medicine
University of Hong Kong
Queen Mary Hospital
Hong Kong
1997
1
Geriatric Medicine in Hong Kong — An Overview
1Geriatric Medicine in Hong Kong —
An Overview
Leung-wing CHU, Shiu-kum LAM
INTRODUCTION
‘It is not enough for a great nation to have added new
years to life. Our objective must be to add new life to
those years.’
John F. Kennedy (1917–1963)
Population ageing is an important issue both globally and locally. In
1991, the world’s elderly population (aged 65 and over) was 320
million. By the year 2000, it will increase by 28% to 410 million1. In
1996, the Hong Kong elderly population (aged 65 and over) was
629 555. By the year 2006, it will be 761 900, a net increase of 21%.
In the same period (1996–2006), the increase in the old-old group
(aged 75 and over) is 56%. Decrease in birth rate coupled with increase
in average life expectancy are the main reasons behind this demographic
change (Table 1.1). The improvement in public health measures, food
availability and medical treatment for diseases in recent years have
made the elders in Hong Kong today live significantly longer than
their forefathers. For example in 1996, the average life expectancy
was 75.9 years for men and 81.5 years for women in Hong Kong
(Table 1.2)2,3. However, the biggest challenge now is not only to make
2
Leung-wing CHU, Shiu-kum LAM
our elders live longer but to make them live better — a better functional
state and a better quality of life. Compression of morbidity and
successful ageing is our desired goal, yet to be achieved4,5.
HISTORY OF GERIATRIC MEDICINE
Geriatric medicine has been defined as the branch of general medicine
which deals with the clinical, rehabilitative (remedial), psychosocial
Table 1.1 Crude birth rate and crude death rate of Hong Kong(per 1000 population)
Year Crude birth rate Crude death rate
1 9 4 6 2 0 . 1 1 0 . 7
1 9 5 6 3 7 . 0 7 . 4
1 9 6 6 2 5 . 5 5 . 2
1 9 7 6 1 6 . 9 5 . 1
1 9 8 6 1 3 . 1 4 . 7
1 9 9 2 1 2 . 1 5 . 3
1 9 9 5 1 1 . 2 5 . 1
Table 1.2 Average life expectancy (at birth) of Hong Kong people(1972–2011)
Year Men (years) Women (years)
1 9 7 2 (actual) 6 7 . 7 7 5 . 4
1 9 7 7 (actual) 7 0 . 1 7 6 . 7
1 9 8 2 (actual) 7 2 . 6 7 8 . 4
1 9 8 7 (actual) 7 4 . 2 7 9 . 7
1 9 9 1 (actual) 7 4 . 9 8 0 . 5
1 9 9 6 (projected) 7 5 . 9 8 1 . 5
1 9 9 7 (projected) 7 6 . 1 8 1 . 6
2 0 0 2 (projected) 7 6 . 8 8 2 . 2
2 0 0 7 (projected) 7 7 . 3 8 2 . 7
2 0 1 1 (projected) 7 7 . 7 8 3 . 0
3
Geriatric Medicine in Hong Kong — An Overview
and preventive aspects of illness in elderly people6. The term ‘geriatrics’
was first coined by an American physician Dr Nascher (1863–1944) in
1907. Subsequently, he published his textbook Geriatrics in 1914.
However, the pioneer of geriatric medicine was Dr Marjory Warren
from the United Kingdom. In the year 1935, while Dr Warren was a
Medical Officer at West Middlesex Hospital, she was appointed to
look after over 700 old people in a neighbouring infirmary which the
hospital had taken over. She started her ‘geriatric’ practice of detailed
assessment and rehabilitation of the 714 ‘incurable’ patients in the
‘chronic sick’ ward. Amazingly, she uncovered a significant number of
misplacement and misdiagnoses in those elderly patients. Over one-
third of the patients were discharged subsequently. She stated in her
report that ‘the creation of a specialty of geriatrics would stimulate
better work and initiate research’7,8,9. Over the past 50 years, geriatric
services and departments were established nationwide in the United
Kingdom. Geriatric medicine is now a recognized specialty in the United
Kingdom, Canada, the Netherlands, the Irish Republic, Spain, New
Zealand, Australia and Hong Kong. In the United States, geriatrics is
an area of ‘added competence’10.
DEVELOPMENT OF GERIATRIC MEDICINE IN HONGKONG..................................................................
Based on the British model, Hong Kong established its first geriatric unit
in 1975. In this respect, Hong Kong was ahead of the rest of Asia. In
the initial ten years, the development of geriatric services was slow.
However in recent years, the importance of geriatric service to the
elderly community has been gradually recognized. At present, there is
at least one geriatric service per hospital cluster (Table 1.3)11. The future
development now depends on both the demand as well as policies of
the Hong Kong Government and the health authorities. Obviously, with
the very rapid increase in the very elderly population, corresponding
geriatric service development should be planned well ahead to avoid any
crisis or mishap. The commitments published in the ‘Report of the
working group on the care for the elderly’12 in 1994 were very positive.
In general, the service structure of geriatric medicine is moving
towards a fairly uniform format. At present, a typical cluster-based
geriatric service in Hong Kong includes in-patient and out-patient, a
day hospital and a community outreach service13,14,15,16. These service
4
Leung-wing CHU, Shiu-kum LAM
Table 1.3 History of geriatric services in Hong Kong
Year Hospital Unit
1 9 7 4 United Christian Hospital Geriatric ward
1 9 7 5 Princess Margaret Hospital First formal Geriatric Department in Hong Kong
1 9 7 8 Caritas Medical Centre Geriatric Department
1 9 8 2 Kwong Wah Hospital Geriatric Department
1 9 8 5 Prince of Wales Hospital Geriatric Team (fully integrated model)and Shatin Hospital (1991)
1 9 9 0 Tuen Mun Hospital Geriatric Department
1 9 9 0 Ruttonjee Hospital Geriatric Department
1 9 9 1 Haven of Hope Hospital Geriatric Assessment and Rehabilitation Unit
1 9 9 3 Queen Elizabeth Hospital Geriatric Team (fully integrated model)
1 9 9 4 Queen Mary Hospital and Geriatric Division (fully integrated model)Fung Yiu King Hospital
1 9 9 4 Yan Chai Hospital Medical Rehabilitation and Geriatric Unit
1 9 9 5 Pamela Youde Nethersole Geriatric Division (fully integrated model)Eastern Hospital
1 9 9 5 Wong Chuk Hang Complex Geriatric Departmentfor the Elderly
1 9 9 5 St. John Hospital Geriatric Department
1 9 9 5 Wong Tai Sin Hospital Geriatric Division
1 9 9 6 Our Lady of Maryknoll Hospital Geriatric Department
set-ups greatly facilitate the practice of progressive patient care for
elderly patients. To date, nearly every hospital cluster in Hong Kong
possesses a full range of geriatric services. As an illustration, the geriatric
service set-up in the Hong Kong West Hospital Cluster (the authors’
service area) is summarized in Table 1.4 17,18.
Elderly people have multiple needs, which include social,
psychological, physical health and functional status aspects. These needs
are inter-related and in fact often intertwined. Health, functional,
psychological and socio-economic status are all important considerations
in the care of elderly people. As geriatric patients are typically frail, a
multi-dimensional19 and multi-disciplinary team approach is the
cornerstone of success in any geriatric service programme. Figure 1.1
summarizes the key dimensions to assess and manage in elderly patients
while Figure 1.2 describes the core members and supporting members
of the multi-disciplinary geriatric team20.
5
Geriatric Medicine in Hong Kong — An Overview
Table 1.4 Geriatric services in the Hong Kong West hospital cluster
1 . Acute geriatric beds in Queen Mary Hospital (12 beds)
2 . Convalescence hospital beds in Fung Yiu King Hospital (80 beds)
3 . Geriatric rehabilitation beds in Fung Yiu King Hospital (24 beds)
4 . Infirmary (long-stay or continuing care) beds in Fung Yiu King Hospital (80 beds)
5 . Geriatric day hospital in Fung Yiu King Hospital (22 places)
6 . Discharge planning programmes for the elderly, both Queen Mary Hospital andFung Yiu King Hospital
7 . Geriatric out-patient clinics(a) Geriatric clinic in Sai Ying Poon Polyclinics (new case assessment and follow-up)(b) Falls clinic in Queen Mary Hospital(c) Memory clinic in Queen Mary Hospital(d) Geriatric nutrition clinic in Queen Mary Hospital(e) Continence clinic in Fung Yiu King Hospital
8 . Hong Kong West Community Geriatric Assessment Service(a) Outreach medical and rehabilitation service to care and attention homes, day-
care centres and multi-service centres(b) Pre-admission assessment of elderly people prior to admission to subvented
residential homes(c) Assessment service for Central Infirmary Waiting List clients to determine need for
infirmary placement(d) Domiciliary visit — medical, nursing, physiotherapy, occupational therapy service(e) Education and training programme to carers and community elders.
Venues — in multi-service centres, day-care centres, care and attention homes,and in Fung Yiu King Hospitals
(f) Health education, screening and health promotion programme to communityelderly people (in collaboration with district boards, hospitals in the Hong KongWest cluster, Hong Kong College of General Practitioners, social centres andmulti-service centres for the elderly)
Figure 1.1 Multi-dimensional assessment of the frail elderly patient
Physical health/disease status
Functional status The frailPsychological
(e.g. activities elderlyhealth status
of daily living) patient
Socioeconomic andenvironmental status
6
Leung-wing CHU, Shiu-kum LAM
Core members:Geriatrician Core membersNurseSocial worker Geriatrician SocialOccupational therapist workerPhysiotherapist Nurse
Elderly patientSupporting members:DietitianPodiatrist Occupational PhysiotherapistSpeech therapist therapistProsthetic and orthotic specialistPsychogeriatricianClinical psychologistVolunteerPastoral care
By consultation:All subspecialties of medicineOther specialties
Figure 1.2 The multi-disciplinary geriatric team
ELDERLY SERVICES RELATED TO GERIATRICS
Residential homes (subvented) for elderly people
A full range of residential facilities for the elderly will be available in the
near future. The old self-care hostel will be phased out gradually. Seven
new nursing homes providing 1400 places for elderly people is anticipated
to commence service in 1997. The objective is to provide service for
elderly people whose needs are intermediate between those of the
infirmary and subvented care and attention homes. The future continuum
will then be homes for the aged, care and attention homes, nursing homes,
and infirmaries12 (Figure 1.3). To achieve a smooth operation and to
avoid unnecessary duplication, a single waiting list should be maintained.
Assessment should be carried out by a team of multi-disciplinary staff,
preferably by the existing community geriatric assessment team. The
present services provided by the Hospital Authority, the Department of
Health, the Social Welfare Department and non-government
organizations require very good co-ordination. Partnership between the
public, subvented and private institutions is very important. In the process
of implementation, the establishment of a regional co-ordination body
to overlook all elderly services in each region ensures seamless care
provision for the elderly people in need of different services.
7
Geriatric Medicine in Hong Kong — An Overview
Figure 1.3 Future continuum of residential care for elderly people in Hong Kong
Long Central Infirmary Waiting List
Prior to the launch of Community Geriatric Assessment Service for the
Central Infirmary Waiting List clients in 1994, there were over 5000
people on the list. After initial assessment, about 30% of the names
were removed from the list — the majority of them were dead at the
time of contact. In October 1996, there were still 5514 people waiting
for an infirmary bed [source: Hospital Authority of Hong Kong,
monthly statistics on central waiting list for general infirmary service].
Approximately 90% of the infirmary waiting list clients were elderly18.
To cope with the large demand, more infirmary beds are required
when building future hospitals. As it takes years to build a hospital,
more infirmary beds should be designated in hospitals which still have
spare capacity. The latter may arise as a result of a decline in paediatric
and young patient population in hospitals. The opening of an infirmary
ward under the existing geriatric service in Pamela Youde Nethersole
Eastern Hospital has set an example of maximizing resource utilization
in a general hospital as well as providing a continuum of geriatric
hospital care in the same setting.
Elderly health centres
Seven elderly health centres have been planned12. Six centres have
already been opened. The present objectives of providing basic health
screening and education to the centres’ members do not seem to obtain
the desired response. Charging a fee of $220 could be a discourageing
>Deterioration in health conditions
Homes for Subvented care and Nursing homes Infirmariesthe aged attention homes
Infirmary units insubvented care and
attention homes(will be phasedout gradually)
8
Leung-wing CHU, Shiu-kum LAM
factor. Another problem is the lack of geriatric input and support.
Perhaps closer liaison should be developed with existing geriatric service
on a regional basis.
Private nursing homes
In February 1995, the number of private nursing homes for the elderly
was 435. Altogether, they provided about 19 141 places [Ref. (27) in
HA752/10/3/3II]. Different standards of nursing, nutrition and
psychological care for the elderly residents have been noted in private
nursing homes. The majority of the private nursing homes (over 97%)
have poor standards21. Elderly patients with very poor nutritional states,
aspiration pneumonia, development or deterioration of pressure sores,
and limb contractures are often encountered in our daily geriatric
practice. These simply reflect the poor nursing and caring standards.
Additional fees are often charged by the private nursing home for
escorting the elderly patient to attend clinic for follow-up. This
additional financial burden may result in subsequent loss of clinic
follow-up and unnecessary hospital admissions.
The implementation of the ‘Residential Care Homes (Elderly
Persons) Ordinance’22 in June 1996 should lead to an improvement of
standards in the private nursing homes. Staffing by trained health
workers (trained by the College of Nursing and the Social Welfare
Department) and compliance to a set of medical, nursing and safety
standards are required by the Ordinance23. As the majority of private
nursing homes may not be able to meet the required standards, a grace
period of three years is available for these homes to make improvement.
The main worry is massive closing down of private nursing homes at
the end of the grace period. The elderly residents may then be sent
back to their own homes or re-admitted into the already congested
hospital system.
Community Geriatric Assessment Service — the need forfurther development
Elderly people who are living alone
This was an area which struck the headline in February 1996 when
nearly 30 elderly died during the cold spell24,25,26. Geriatric outreach
9
Geriatric Medicine in Hong Kong — An Overview
service should be extended to these needy elderly people. A pro-active
approach should be adopted. A strategy of active domiciliary case
finding by trained geriatric nurse should be practised. A programme of
in-home geriatric assessment can postpone the development of disability
and reduce institutionalization amongst elderly people living at home27.
‘Hospital in the home’, a domiciliary geriatric service model first
developed in Australia, is being experimented by some geriatric services
in Hong Kong (e.g. project by Haven of Hope Hospital28). It can be
part of the Community Geriatric Assessment Service.
Apart from services provided by professional carers, informal carers
(i.e. family members, friends, volunteers, etc.) should be mobilized
(through education and training in care-giving) and supported by the
professional geriatric staff12.
Health promotion and preventive geriatrics
There are presently many community health promotional events in
Hong Kong. Current health promotional activities only focus on the
detection of common medical illnesses and education in common
medical diseases12. Looking ahead, a comprehensive preventive strategy
should be devised. More should be done on the preventive aspects of
care including life-style modifications (e.g. exercise, nutrition) in the
old age. Psychological health should also be promoted. Collaboration
with the elderly health centre should be practised at the regional level.
Extension of geriatric support to private nursing homes
Knowing the poor standards of the private nursing homes in Hong
Kong, these homes are in need of professional geriatric advice. If co-
operation of the staff in these homes can be obtained, visiting medical
and rehabilitative services should be offered to these homes by the
community geriatric assessment team.
Migration of elderly people back to China — either after retirement orwhen they became chronically sick
Many of our Hong Kong elders came to Hong Kong from Mainland
China when they were young. Some of them still have family members
in the Mainland. The cost of living is lower in China compared to
Hong Kong. Therefore, we may assume that some of them may prefer
to return and live in China after retirement. The result of a local
10
Leung-wing CHU, Shiu-kum LAM
survey found that only 3.3% of the elderly would go back to China
for their retirement29.
However, for the sick or disabled elderly patients, problems of
care-giving arise. A small number of our patients migrated back to
China because of the lower cost of living or the availability of care-
givers there. Unfortunately, the continuity of medical care was
jeopardized. The lack of proper follow-up medical care would
sometimes lead to disastrous though preventable medical complications,
e.g. diabetic hypoglycaemic or hyperglycaemic coma. Furthermore,
geriatric rehabilitation is not practised in most part of China.
AGEING RESEARCH AND GERIATRIC CARE
Ageing, diseases and disuse
Physical frailty and/or mental frailty are important concerns in geriatric
care. Frailty is a condition in which deteriorating physical and/or mental
function places the elderly person at increased risk of poor outcomes,
e.g. mortality, hospitalization, institutionalization. Poor physical
functional status and mental functional status have been shown to be
powerful predictors of poor outcomes30. Normal ageing, age-related
diseases and undesirable life-style factors (e.g. disuse) all contribute to
physical or mental frailty. The delineation of reversible factors on top
of ageing can lead to major improvement in the function and quality
of life in the old age. For example, disuse (or de-conditioning) constitutes
a large portion of the age-related decline in function31. The following
account highlights, from a personal point of view, the important areas
in recent geriatric research.
Age-related changes (mainly decline in morphological, physiological
and psychological functions) have been well described32,33,34. Cross-
sectional studies have provided some clues to what might be the changes
due to ageing. Longitudinal studies, on the other hand, have pointed
out the dangers of trying to derive general conclusions from cross-
sectional studies alone. For example, the generally accepted age-related
linear decline in organ functions has been proven to have large
individual variation, both among the organ systems within a given
individual and across individuals for a given organ34,35. On the issue of
the mechanism of ageing, it is a subject of a lot of researches. Studies
with the fruit fly Drosophilia and the nematode Caenorhabditis elegans
11
Geriatric Medicine in Hong Kong — An Overview
help to define the genetic basis of ageing. These studies have suggested
that derepression of a gene (age-1) may lead to the production of a
‘death compound’. On the issue of life prolongation with dietary
restriction in rodents, it has been found that dietary restriction has
produced many of the hormonal changes associated with ageing. The
other area is the resurgence of the free radical theory of ageing and the
role ofmitochondrial DNA mutations with ageing. They open new
ideas for research in therapeutic interventions30,36,37.
The prevention, treatment and rehabilitation of age-related diseases
are important areas in clinical geriatrics. Researches into age-related
diseases can help to improve outcome and quality of life in the elderly
people. They can also help to separate the effect of diseases from
ageing. The prevention of disability is as important as the reduction of
mortality. Stroke, dementia, hip fracture and Parkinson’s disease are
responsible for the majority of severe disabilities in Hong Kong18.
Treatment of both systolic and diastolic hypertension are very effective
in lowering stroke and cardiovascular events. [EWPHE38, STOP-
hypertension39, MRC trial40, SHEP41.]
In Hong Kong, the incidence of hip fractures has increased about
three-fold over the past 20 years42. The main determinants for hip
fractures in the elderly are osteoporotic bone (low bone mass) and falls43.
Preventive measures for osteoporosis and falls are effective in reducing
osteoporotic fracture. Adequate calcium intake44,45, adequate Vitamin D
intake46, exercise45, hormonal replacement in post-menopausal female30,
and probably thiazide diuretic treatment47,48 are preventive measures
for osteoporosis. The low average calcium intake (400mg or less)49 has
been shown to be a risk factor for hip fracture among elderly people
in Hong Kong. Calcium supplementation and exercise have been found
to be effective treatments in increasing bone density45. Falls in the elderly
is a very hot topic in geriatric literature. The risk of falls is related to
the presence of risk factors which include decreased vision, decreased
balance, hip weakness sedative drug and the need for more than four
medications50,51. Moreover, the risk of falls is directly proportional to
the number of risk factors52. In management, a multi-factorial
intervention programme for falls has been shown to be effective in
reducing falls53. Recently, falls prevention and intervention research in
various settings (hospitals, nursing homes and in the community) has
been started in several geriatric units in Hong Kong.
Another factor causing physical frailty is prolonged disuse or de-
conditioning. A long period of reduced physical activity can lead to
sarcopenia31 which may result in significant decline in functional status
12
Leung-wing CHU, Shiu-kum LAM
in the old age54. Hormonal decline contributes too to the occurrence
of sarcopenia. These observations thus open up possible channels for
intervention in the old age.
Exercise, particularly resistance exercise, has been shown to increase
remarkably the muscle bulk, muscle strength, walking ability and
functional status in the frail nonagenarian living in nursing homes55,56.
Exercise is useful in retarding the age-associated changes in body
composition, aerobic capacity and strength57. In an eight-year
longitundinal study of runners versus control (subjects in each group
were at least 50 years old), runners were reported to have better
functional state (as measured by disability score)58 than control. In the
Chinese culture, tai chi chuan is a fairly well accepted type of exercise.
Previous studies in elderly tai chi chuan practitioners have shown an
encourageing trend towards slowing down the decline in
cardiorespiratory functions59,60. It can also reduce the occurrence of falls61.
Future studies can investigate its long term effects in both mortality and
functional status, and compare its efficacy with other types of exercise.
However, the main difficulty in any exercise research is the problem of
compliance. Interest, motivation, fun, and social interaction should be
incorporated into exercise programmes to improve the compliance.
Several hormones have been noted to decline with advancing age.
In addition to the dramatic decline in estrogen at menopause, growth
hormone, testosterone and dehydroepiandrosterone (DHEA) all show
an age-related decline. Hormonal replacement therapy (HRT) in
postmenopausal women has been shown to have beneficial
cardiovascular and bone effects30. The acceptance of HRT among Hong
Kong women, however, is low49. Growth hormone replacement could
partially reverse the age-related body composition change.
Unfortunately, it also causes troublesome side effects, particularly carpal
tunnel syndrome. Other researches with growth hormone or growth
hormone releasing hormone with or without exercise are still under
investigation62. Age-related decline in DHEA and its sulfate has been
found to be correlated with lower performance in basic activities of
daily living63. Replacement of DHEA has been found to improve
memory function64 and decrease bone loss65. More results are needed
before replacement therapy can be considered for widespread use.
High prevalence of undernutrition among the elderly people
contributes to high mortality66 and frequent hospital admission67.
Nutritional supplementation can decrease mortality68. Vitamin
supplementation is effective in decreasing bed-days due to infection.
Pyridoxine supplementation can improve cognitive function while
13
Geriatric Medicine in Hong Kong — An Overview
thiamine supplementation can improve general well-being in selected
elderly subjects69,70. Future studies are required in these areas.
Cholesterol levels in the elderly are less predictive of cardiovascular
disease and total mortality. The practice of avoiding cholesterol-lowering
drugs in elderly people is further supported by a recent meta-analysis
which failed to show a decrease in mortality even in middle-aged
patients. There is evidence which suggests that low cholesterol levels
are predictive of future cognitive function30.
Mental frailty is another important problem in geriatrics. Cognitive
impairment and depressive symptoms are common among elderly people
in Hong Kong71,72. Screening for cognitive impairment and depression
in local elderly people is now facilitated by the availability of validated
local brief assessment tools73,74,75. Early recognition of depression is
important. Over 30% of the suicide deaths in Hong Kong were elderly
aged 60 or above76. Dementia is a devastating disorder. To people
with Alzheimer’s disease, the development of Special Care Units77 in
the United States, the launching of tacrine (tetra-aminoacridine)78,
donezepil79 and estrogen replacement80 treatments represent new though
controversial management approach. Further research is required in
the local community on this approach. The greatest advance is in the
understanding of the pathogenesis of Alzheimer’s disease (AD). The
characteristic lesions of AD are the b-amyloid deposits (plaques) and
abnormally phosphorylated tau proteins, resulting in the accumulation
of insoluble paired helical filaments (neurofibrillary tangles). b-amyloid
protein is derived from an amyloid precursor protein that is regulated
by a gene on chromosome-21. In mice model, b-amyloid protein has
been shown to produce memory loss for recent events but not previously
learned events. Continuing studies show that a number of small peptides
can inhibit the amnestic effects of the b-amyloid protein. b-amyloid
protein probably produces its amnestic effect through interacting with
gamma-amino-butyric acid receptor30. The presence of the genotype
APOE-ε4 has also been shown to be an important genetic determinant
of susceptibility to AD81. Another finding is the slowing of cognitive
decline by indomethacin, probably through inhibition of complement
activation82. Further research in these areas may allow more rational
drug design for Alzheimer’s disease.
Health services research in geriatrics
Health services research is a very important area in geriatric care.
14
Leung-wing CHU, Shiu-kum LAM
Elderly patients are the major consumer of health care resources in
Hong Kong. In 1995, 40% of hospital in-patients under the Hospital
Authority of Hong Kong were elderly people aged 65 and over (point
prevalence at 30 March 1995)83. In any evaluation or research, clinical
outcomes should include an assessment of functional performance and
quality of life. Health services utilization outcome measures should
include an assessment of optimal use or unnecessary use. Over the
past two decades, the role of geriatric assessment and management
units in the management of the frail elderly patient have been studied
in many randomized clinical trials. A recent meta-analysis published in
the Lancet confirmed the usefulness of geriatric programmes in
improving mortality, placement, physical and cognitive function, and
decreasing hospital admission84. Locally, the problems encountered by
elderly patients discharged from hospitals in Hong Kong have been
studied. Various problems have been found — unsatisfactory follow-
up procedure, medication compliance problems, lack of community
support and an increase in functional disabilities85. The provision of
an elderly discharge programme, in many hospitals in the last two
years is a step forward to improve the large variety of caring issues
after hospital discharge. Another recent development in Hong Kong is
the networking of geriatric and community welfare services for the
elderly at every regional level. Preliminary data on Community Geriatric
Assessment Service in Hong Kong has demonstrated its effectiveness in
decreasing unplanned hospital admissions, decreasing visits to the
Accident and Emergency Department as well as decreasing the staff
escort time for the subvented care and attention home86. However,
longer term studies of larger scale are required to document its
effectiveness versus cost. In the future, provision of new services should
be integrated with health services research to enable evaluations. Many
other areas such as frequent hospital readmission87,88,89, polypharmacy90,
the use of restraint91,92, resusitation policy93,94,95 concerning the elderly
have been researched in overseas countries. However, local data is
inadequate. Differences in cultural, societal and health care systems
limit the direct applicability of overseas research results in Hong Kong.
Controlled studies are therefore needed while translating overseas
research findings into our daily geriatric practice in Hong Kong.
15
Geriatric Medicine in Hong Kong — An Overview
CONCLUSION
Over the past 20 years, geriatric services have developed from one
formal geriatric service for the whole of Hong Kong to at least one
geriatric service in each hospital cluster in this city. Geriatric medicine
aims at managing the complex disease-related health care, rehabilitation
and social needs of elderly patients, with a co-ordinated multi-
disciplinary approach. Future advances in the treatment of age-related
diseases, ageing research and health services research may hopefully
lead to further improvement of functional status, quality of life as well
as longevity of our elderly population.
NOTES
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environment in a large academic nursing facility. J Am Geriatr Soc,
1995, 43:914–8.
92. Sundel M, Garrett, Horn RD. Restraint reduction in a nursing home and
its impact on employee attitudes. J Am Geriatr Soc, 1994, 42:381–7.
93. Gulati RS, Bhan GL, Horan MA. Cardiopulmonary resusitation of old
people. Lancet, 1983, 2:267–9.
94. Williams R. The ‘do not resusitate’ decision: guidelines for policy in the
adult. J Royal Coll Phy Lon, 1993, 27:139– 40.
95. Lee MA, Cassel CK. The ethical and legal framework for the decision
not to resusitate. West J Med, 1984, 140:117–22.
21
Background and Methods of the Study
2Background and Methods of the Study
Mona Bo-nar LO
INTRODUCTION
The present study was a joint effort of a university, a social club and
an elderly welfare agency. Started as a usual health promotion
programme by the elderly welfare agency, a community service project
of the Rotary, with the participation of a university, the project was
then transformed into the beginning of a databank on elderly health in
Hong Kong, opening up many possibilities of intervention programme
evaluation, new hypotheses and in-depth studies. This fully illustrates
the value of inter-sectoral co-operation and the vital role a university
can play in primary health care.
The origin
This project was initiated in mid-November 1993 as a community
health service project by the Hong Kong Society for the Aged (SAGE),
with the primary objective of advocating the importance of preventive
health care among the elderly. The Rotary Club of Hong Kong
Northwest agreed to organize the project jointly. The original intention
was to offer free health check-up and some health talks to about 1200
people over the age of 60.
After some discussion, it was decided that besides taking blood
pressure, weight and height, only blood screening should be done.
22
Mona Bo-nar LO
Later, with the generosity of the Rotarians, the target number of
elderly was expanded to 2000. A private medical laboratory, the Safe
Test Medical Laboratory Centre Ltd., was invited by the Rotary Club
to provide the blood tests at a concessionary rate. A programme
timetable was prepared for implementation and the official launching
cum educational seminar was scheduled for 8 January 1994. Had it
not been for the involvement of the university, this would remain just
another service programme in the community.
From community service project to an integrated study
The turning point came when in the process of planning, it suddenly
drew on the members that the findings of the check-up should be
documented. After all, much resources would be involved — human,
financial and material. They should be put to the best use. It was
decided that the Department of Medicine of the University of Hong
Kong and the Hong Kong Geriatric Society be invited to consider such
a possibility, and also to see if a research component could be integrated
into the community health project planned. Through a Rotarian, Prof.
SK Lam was approached.
The outcome of the negotiation was the submission of a proposal
from the Department of Medicine by a team of researchers from
different medical specialties who were interested in working together
on the project. In January 1994, a study team was set up to examine
the feasibility, with representatives from the university, the Rotary
Club and SAGE.
The university investigators proposed to examine five areas: peptic
ulceration, heart health, endocrine status, activity for daily living and
quality of life, and the remaining areas of the screening tests. The
investigators would be responsible for the research design, data analysis
and the publication of the results.
SAGE agreed to join the team on the conditions that the study
included aspects that were of use towards future planning and service
improvement, that follow-up be done for the screening results with the
assistance of the university, and that relationship be established with
the university for ongoing support. In return, SAGE would be
responsible for the recruitment of the elderly, organizing the blood
screening programme and the follow-up services, opening a number of
elderly centres for data collection, together with providing the necessary
staff and volunteer support.
23
Background and Methods of the Study
The Rotary Club of Hong Kong Northwest agreed to raise the
funds required for the whole project, and render technical support
where appropriate.
With agreement of all parties concerned, the study team or the
Working Group on the Elderly Health Study began meeting regularly
to steer the project and the study. In the process, it had become
increasingly evident that it was a very productive experience of sharing
between the university medical experts and the community in identifying
health needs, educating the community, and in collecting the data
required, through both objective and subjective means — an opportunity
so rare and yet so vital for effective planning for ‘adding life to years’.
Definition of elderly
According to the Report of the United Nations Secretary-General for
1980, ‘elderly’ was defined as 60 years of age and over 1. In Hong
Kong, in the context of welfare services, the elderly is also defined as
persons aged 60 and over 2. Our study also adopted the same definition
for elderly. However, we need to remind ourselves that ‘ageing’ is a
more appropriate term, since it suggests continuing development and
change during the later stages of the life span rather than a static
situation. In the study, we attempted to understand then what the
health and social needs of people were and how they change as people
become older.
The situation of the elderly
The Hong Kong population is ageing rapidly. It was estimated that
people aged 60 and over would rise from 748 700 in 1990 to 974 500
by the year 2000 [source: White Paper: Social welfare into the 1990s
and beyond ]. In the same paper, it stated that with the increase in life
expectancy, the age group of 75 and above would also increase — a
group likely to have greater need for services such as long-term health
and residential care. The number of elderly living alone was anticipated
to increase as well3.
In industrialized counties in the European region, it was reported
that about half of the total health care budget was allocated to the
medical care of the elderly. In the United Kingdom, it has been estimated
that the expenditure per head on health services among those 75 and
24
Mona Bo-nar LO
over was almost six times that of those aged 16–64 4. It was also
found that nearly two-thirds of those with appreciable handicap
(needing some support) and with severe handicap (needing considerable
support) were over the age of 75. Of those aged 65 and over who
were disabled, 30% lived alone5.
If these were the findings for Europe, they may be true for Hong
Kong. Hong Kong would have to take heed for quality of life and for
the health, social and economic implications that imply. With a total
population of some 6.2 million in Hong Kong and almost 17% of the
population age 60 years and over by the year 2000, no wonder the
elderly has become an area of public concern.
The objectives of the study
Little had been done on the health, social conditions, needs and
problems of the elderly in Hong Kong. Even less had been done on
correlating social survey data with clinical examination and laboratory
analysis in one study with a large number of subjects. According to
the World Health Organization, by combining knowledge about the
biological, psychological, social and medical aspects of ageing, it is
possible to increase the understanding of the problems of the elderly
and to develop adequate services to meet their need and prevent
premature dependence and unnecessary institutionalization. The aims
of this study were:
• To provide a comprehensive health profile and the functional ability
of the elderly, and their use of health and social services.
It was recognized that the use of health services depended not
only on the level of health of the people but also on the social
support available.
• To provide the information needed for planning health and social
services for the elderly in future years.
This study could be used to generate hypotheses about the
level of health, the process of ageing and the need for services. It
was hoped that they would provide a basis for research action
aiming at preventing premature disability and enhancing the health
and well being of the elderly.
Old age does not necessarily mean disease and disability. Many
problems are preventable with early detection and prompt action.
Information, however, is required for effective intervention to be carried
25
Background and Methods of the Study
out. It was our hope that this study could contribute to some gaps in
the knowledge required.
Areas of study
The following areas were examined in the study:
1. peptic ulceration: chronic gastritis test and questionnaire
2. heart health: questionnaire on angina, palpitation and fat intake,
ECG and fasting blood for sugar, cholesterol, triglyceride, HDL
and LDL/total cholesterol
3. endocrine status: questionnaire on iodine and calcium intake, blood
for thyroid function test (TSH) and urine sample for iodine
4. activity of daily living and quality of life of elderly subjects:
questionnaire
5. other screening tests: complete blood count, renal and liver function
The number and type of subjects planned was up to a total of
2000 active elderly (>60 years), who would voluntarily present
themselves at the seven screening centres during the eight days of
blood collection6.
SURVEY METHODS AND SAMPLE
The cross-sectional survey of the active elderly Chinese in Hong Kong
was made up of three major components: the blood tests, the ECG
examination and the questionnaire interviews. The collection of data
was divided into two phases. The first phase concentrated on collecting
the blood samples, taking weight and height, blood pressure and
completion of a few questions on identification, medical history and
health habits at the seven social and multi-service centres for elderly of
SAGE in different locations of Hong Kong Island, Kowloon and New
Territories (see Appendix 2.1 for a list of locations and other details).
The second phase was essentially for the ECG examination and the
administration of the questionnaire interviews.
26
Mona Bo-nar LO
Study subjects
This study was a cross-sectional survey of the active elderly Chinese
living in Hong Kong. The subjects were recruited through open
recruitment from seven elderly centres of SAGE located in Chai Wan,
North Point, Shatin, Kwun Tong, Tseung Kwan O and Tsuen Wan.
The studied subjects were self-selected to enrol in the health checking
programme. Therefore, the study subjects represented more of a group
of active elderly people attending elderly centres.
PHASE I
Data collection and analyses
The first phase was performed in seven elderly centres of SAGE
distributed throughout Hong Kong. A total of 2035 elderly persons
aged 60 years and over had registered for the first phase of study;
1912 of them actually turned up for the study. The first phase was
conducted between 17–27 January 1994. The laboratory test results
were distributed to participants through another health education
seminar organized by SAGE.
The following tests were performed:
• complete blood picture
• kidney function tests
• liver function tests
• blood sugar
• lipid profile: cholesterol
– triglycerides
– LDL cholesterol
– HDL cholesterol
– LDL/total cholesterol
• thyroid function tests
• chronic gastritis tests
• urine specimen: iodine
• ECG
27
Background and Methods of the Study
Organization and personnel
The co-ordinator and staff members of SAGE at the survey centres were
responsible for the overall organization of the blood collection and the
other screening tests in the eight days. That included preparation of
consent forms (already drafted by a Rotarian lawyer) for the elderly
participants, other logistics, and necessary arrangements for the
volunteers. The actual procedure of blood collection itself was carried out
by professionals and Red Cross volunteers with the assistance of a
representative of the private laboratory. Five doctors also helped to
supervise the screening centres, with some doctors on duty for more than
one day (see list of doctors on duty in Appendix 2.2). Altogether, 116 staff
members of SAGE and 163 volunteers helped in the blood collection days.
Analysis of the blood samples
With the university involvement, it was decided that all blood tests,
except for the complete blood count, be analyzed at the Department of
Clinical Biochemistry, Queen Mary Hospital, as soon as sampling for
that day was completed. The complete blood count was sent to the
private laboratory for analysis partly because that had to be done by
another department of the university, and partly as compensation for
not engaging the private laboratory to do the major analyses (see
Appendix 2.3 for details on the amount of blood collected for each
purpose and the tubes used).
The elderly participants were asked to come to the centres in a
fasting state (no food after 12 midnight, water allowed), and a total of
about 15 ml of venous blood was taken. The venesection was performed
by trained registered nurses and medical technicians.
Follow-up
The participants were informed that the screening results would be
given to them on a day when they could also come to hear an
educational talk by a doctor on the health problems identified. They
were informed too that for those with thyroid problems, they would
be followed up at the university specialist clinic at Queen Mary Hospital
to ensure proper management. For those who were infected with
Helicobacter Pylori, they would be invited for further investigation.
28
Mona Bo-nar LO
Other tests and measurements
During the blood taking session, blood pressure, weight and height
were taken. A few questions on smoking, drinking and medical history
were asked. The participants were also asked to give a 10ml urine
specimen on the day of blood sampling.
PHASE II
This was performed at the Queen Mary Hospital.
The ECG examination
Organization
The ECG examination was performed at the Department of Medicine,
Queen Mary Hospital between 15 March and 19 April 1994, over 24
three-hour sessions on Saturday afternoons and whole day on Sundays.
Fifty-four registered nurses (volunteers) with training in ECG and the
procedure were responsible for the examinations. The procedure was
supervised by the Cardiology Division of the Department of Medicine,
University of Hong Kong. The elderly who had taken the blood tests
in Phase I and volunteered to take the ECG were organized by the
staff members of SAGE and taken to Queen Mary Hospital by coach.
There were two sessions per afternoon, with 40 elderly for each session.
The elderly were advised to wear simple attire which was quick to
undress. (See Appendix 2.5 for details of participation.)
The examination and analysis
A resting 12-lead ECG and a 30s rhythm strip (leads I–III) were
performed. People with chest pains were further evaluated with the
Rose Questionnaire for angina pectoris. ECG abnormalities were
classified basing on the Minnesota Code criteria. The data analysis
was done first at the Cardiology Division, and then integrated into the
data for biochemistry and questionnaire for computer data processing.
29
Background and Methods of the Study
Follow-up
The elderly were informed that the results would be reported back and
distributed to them individually through SAGE. Those who needed
follow-up would be invited to return for further examination.
The questionnaire interview
Organization
The questionnaire interview was conducted in the same afternoons as the
ECG examinations while the elderly were waiting for their turn for the
examination. The interviews were done by 150 volunteer medical students
of the University of Hong Kong. The students were trained and supervised
by the Senior Lecturer in Medicine who was a member of the Working
Group. She also helped to co-ordinate the design of the questionnaire and
the arrangement of the questionnaire interview. Both medical students and
nurses of ECG were paid a token fee for their transportation expenses.
The questionnaire
The Questionnaire was made up of 12 sections. It covered background
information on demographic and socio-economic characteristics, health
habits (such as smoking, alcoholic drinking, physical exercise),
pregnancy, illness and family history, fractures, use of drugs and
vitamins, activity of daily living, use of medical and social services,
subjective feeling of health status, mental health assessment and dietary
practices. The Rose Questionnaire was included here. The interview
lasted from half an hour to 45 minutes each, depending on how
articulated the elderly person was.
The analysis
Altogether 1480 questionnaires were completed for data processing.
The data was initially processed by outside data consultants. They
were then analysed by the individual researchers who were responsible
for developing that section of the questionnaire in relation to the
clinical examinations and the laboratory investigations.
30
Mona Bo-nar LO
The sample
As mentioned in the background of the study, the elderly had already
been recruited for the blood tests of the community health service
programme planned by SAGE and the Rotary before the university
participated. For that reason, the sample for the elderly study was of a
self-selected nature. It was more representative of the active elderly
Chinese population, who joined social centres and volunteered for
such programmes. The recruitment of the elderly by SAGE was an
open one. The blood screening was announced through Radio V, and
specifically designed posters were prepared for general circulation.
Primarily, it was through the social service and multi-service centres of
SAGE and related organizations that the event was publicized.
A total of 2035 elderly applied to join the blood tests, but only
1912 turned up for the tests. Not all the elderly who took part in the
blood tests wanted to carry on with the ECG and questionnaire
interviews. The actual number who joined the Phase II data collection
was 1595, but only 1480 elderly completed the interviews (Table 2.1).
Table 2.1 Response rate of the survey of elderly participants(Both sexes combined)
Data Number Number of Percentcollection enrolled participants response
Blood tests 2 0 3 5 1 9 1 2 9 4 . 0
ECG examination 1 7 7 0 1 5 9 5 9 0 . 1
Questionnaire interview 1 5 9 5 1 4 8 0 9 2 . 8
Note: The figures on response rates were based on the information provided by the ServiceCo-ordinator of SAGE and the actual number of questionnaires received for data processing.
31
Background and Methods of the Study
APPENDIX 2.2
List of doctors on duty at the survey centres
Date Centre Doctor on duty
January 1994
17–18 Chai Wan Multi-service Centre Dr. Chun-por WongChai Wan Ruttonjee Sanitorium
1 9 Eastern District Multi-service Centre Dr. Chun-por WongNorth Point Ruttonjee Sanitorium
2 0 Tsuen Wan Multi-service Centre Dr. Ngai-shing NgTsuen Wan Princess Margaret Hospital
2 1 Hin Keng Social Centre Dr. Ka-hang AllKwai Chung Prince of Wales Hospital
2 2 Kai Yip Social Centre Dr. Man-fuk LeungKwun Tong United Christian Hospital
2 5 Tsui Lam Social Centre Dr. Man-fuk LeungJunk Bay United Christian Hospital
2 7 Kwai Chung Multi-service Centre Dr. Tak-kwan AllTsuen Wan Princess Margaret Hospital
APPENDIX 2.1
The seven survey centres
Date Centre
January 1994
17–18 Chai Wan Multi-service Centre, Chai Wan
1 9 Eastern District Multi-service Centre, North Point
2 0 Tsuen Wan Multi-service Centre, Tsuen Wan
2 1 Hin Keng Social Centre, Kwai Chung
2 2 Kai Yip Social Centre, Kwun Tong
2 5 Tsui Lam Social Centre, Junk Bay
2 7 Kwai Chung Multi-service Centre, Tsuen Wan
32
Mona Bo-nar LO
APPENDIX 2.3
Blood collection and tube used
Tubes Volume (ml) Priorities(if not enough specimen)
EDTA 1 4
Heparinized bottle 6 1
Clotted bottle 5 3
Fluoride 1 2
Citrate bottle 2 5
APPENDIX 2.4
Responsible personnel and participants of the blood collection atthe seven survey centres
Date No. of No. of No. of SAGE No. of SAGEenrolment participants staff volunteers
January 1994
1 7 2 5 0 2 4 2 1 5 3 7
1 8 2 5 0 2 3 4 1 5 3 7
1 9 2 5 0 2 3 1 1 6 8
2 0 2 5 0 2 2 8 1 9 2
2 1 2 7 0 2 6 5 9 2 3
2 2 2 5 5 2 3 9 9 4 4
2 5 2 6 1 2 4 7 1 6 7
2 7 2 4 9 2 2 6 1 7 5
Total 2 0 3 5 1 9 1 2 1 1 6 1 6 3
43
Social and Health Status of Elderly People in Hong Kong
3Social and Health Status of Elderly People
in Hong Kong
Edward Man-fuk LEUNG, Mona Bo-nar LO
ABSTRACT
This chapter examines the characteristics of the elderly respondents
who participated in the survey carried out by the Hong Kong Society
for the Aged in 1994. Though the majority of the respondents were
living with their family or their spouse, over half of them were single
or widowed. This group of elderly had a heavy reliance on the family
or the government for financial support. Only 3.4% of them were still
working, and the majority were financially dependent after retirement.
Their life-styles were, in general, active and their health habit good.
Only 18.8% of the respondents were smokers and 10.5% had drinking
habit. Their self perceived health status were similar to other peers.
Hearing and visual impairments were common among the respondents
while the common chronic illnesses included rheumatism, hypertension,
fractures, peptic ulcer and diabetes mellitus. The main functional
limitation was identified as the ability to perform heavy household
work. It was also found that the life satisfaction of the elderly had a
direct correlation with the presence of illnesses and functional
impairment.
44
Edward Man-fuk LEUNG, Mona Bo-nar LO
INTRODUCTION
Hong Kong is an ageing society. Even in 1986, there were already more
than 8% of the population who were aged 65 and over. The percentage
was further increased to 8.7% in 19911. As the elderly group has a heavy
reliance on medical and social services, acquiring essential knowledge on
the factors affecting the elderly’s well-being is important for the future
planning of elderly services. With this in mind, the present chapter tries
to examine the socio-demographic pattern, the health habits and its
correlation with the health status of the elderly in Hong Kong. The analysis
is based on the study carried out by Hong Kong Society for the Aged in
1994. Through observation and analysis, it is hoped that some
enlightenment on the promotion of health for the elderly could be made.
SOCIO-DEMOGRAPHIC PATTERN
One thousand four hundred and eighty elderly with a mean age of
70.6 (SD 6.26) were interviewd (Table 3.1). Though the marital status
of the majority of the respondents (50.6%) were married, 42.4% of
them were widowed (Table 3.2). 65.9% of them were living with their
family, 13.4% living only with their spouse and 11% living alone
(Table 3.3). Only 3.4% of the respondents were still working (Table
3.4). The majority of them (64.3%) depended on their family to support
their living (Table 3.5), while 26% of them rely on government subsidy.
One hundred and thirty-six (9.2%) of the respondents were receivers
of the Comprehensive Social Security Allowance Scheme (Table 3.6).
Table 3.1 Age distribution
Age group Number Percentage
< 6 0 1 3 0 . 960–64 2 3 6 1 5 . 965–69 4 2 5 2 8 . 770–74 4 0 6 2 7 . 475–79 2 4 1 1 6 . 380–84 1 0 5 7 . 185–89 2 2 1 . 5
9 0 + 6 0 . 4No data 2 6 1 . 8
45
Social and Health Status of Elderly People in Hong Kong
Table 3.2 Marital status
Status Number Percentage
Single 7 3 4 . 9Married 7 4 9 5 0 . 6Widowed 6 2 8 4 2 . 4Separated 1 4 0 . 9No data 1 6 1 . 1
Table 3.6 Types of government subsidy
Type Number Percentage
Old age allowance 7 5 1 5 0 . 7Disability allowance 1 6 1 . 1Public assistance 1 3 6 9 . 2Not on government subsidy 5 7 7 3 9 . 0
Table 3.5 Major source of income
Income Number Percentage
Salary 4 4 3 . 0Government 3 8 5 2 6 . 0Family 9 5 2 6 4 . 3Savings 7 2 4 . 9Others 2 7 1 . 8
Table 3.4 Working status
Type Number Percentage
Working 5 0 3 . 4Retired 8 0 0 5 4 . 1Housewife 6 0 5 4 0 . 9No data 2 5 1 . 7
Table 3.3 Living arrangement
Type Number Percentage
Living alone 1 6 3 1 1 . 0With spouse 1 9 9 1 3 . 4With family 9 7 6 6 5 . 9With others 1 4 2 9 . 6
46
Edward Man-fuk LEUNG, Mona Bo-nar LO
HEALTH HABITS
Having regular exercises and the avoidance of smoking and drinking
are some of the positive health habits. The surveyed group demonstrated
a group of elderly who were more inclined to positive health habits.
18.8% of them had smoking habits and 10.5% drank. In fact, a high
percentage of the respondents did various types of exercises. The more
commonly practised exercises included walking, doing household work,
tai chi and jogging (Table 3.7). In general, most of the respondents
had an active life style. 82.5% of them took part in outdoor walking
activities (Table 3.8). Over half of the interviewees expressed that they
would seek medical advice when they became sick (Table 3.11).
Table 3.8 Activities
Types Number Percentage
Outdoor walking 1 2 1 7 8 2 . 5Climb stairs 9 0 8 6 1 . 6Climb slopes 8 5 9 5 8 . 3Walking with heavy load 3 4 5 2 3 . 5
Table 3.7 Exercise frequency
Exercise Frequency per week
Walking 5 . 3Medium household work 4 . 3Light household work 4 . 1Tai chi 1 . 8Aerobic exercise 0 . 8Jogging 0 . 8Heavy household work 0 . 6
Table 3.9 Smoking habits
Number Percentage
Smoker 2 7 8 1 8 . 8Non-smoker 1 1 7 6 7 9 . 5No data 2 6 1 . 8
47
Social and Health Status of Elderly People in Hong Kong
Table 3.10 Drinking habits
Number Percentage
Drinker 1 5 6 1 0 . 5Non-smoker 1 2 9 4 8 7 . 4No data 3 0 2 . 0
Table 3.13 Self-perceived health compared with others
Health condition Number Percentage
Worse 2 1 3 1 4 . 4Same 7 4 1 5 0 . 1Better 5 1 5 3 4 . 8No data 1 1 0 . 7
Table 3.11 Health seeking behaviour when sick
Number Percentage
Self 1 4 4 9 . 7Relatives or neighbour 2 4 8 1 6 . 8Herbalist 5 1 3 . 4Doctors 9 9 2 6 7 . 0Others 2 6 1 . 8No data 1 9 1 . 3
Table 3.12 Self-perceived health
Health condition Number Percentage
Very poor 8 0 . 5Poor 2 2 6 1 5 . 3Average 7 6 5 5 1 . 7G o o d 4 2 9 2 9 . 0Very good 4 2 2 . 8No data 1 0 0 . 7
HEALTH STATUS
The health status is important in determining the elderly’s dependency
on health services. Only 31.8% of the interviewees considered
themselves had good physical health (Table 3.12), while the majority
48
Edward Man-fuk LEUNG, Mona Bo-nar LO
(51.7%) considered themselves had average health. Among them, over
42.3% considered their health deteriorating when compared with the
past year (Table 3.14).
Prevalence of chronic illness
As chronic illnesses are common among the elderly, a study on the
presence and occurrence of chronic illnesses was carried out
Table 3.14 Self-perceived health compared with last year
Health condition Number Percentage
Worse 6 2 6 4 2 . 3Same 6 8 0 4 5 . 9Better 1 6 2 1 0 . 9No data 1 2 0 . 8
Hearing and eye-sight
The study revealed that a significant number of elderly had hearing and
sight difficulties. Only around 31.2% of them had good hearing, while only
12.1% of the them considered themselves had good vision (Table 3.15).
Table 3.15 Hearing and vision
Number Percentage
Hearing:Cannot hear 1 0 . 1Poor 3 9 2 2 6 . 5Average 6 1 4 4 1 . 5G o o d 4 1 5 2 8 . 0Very good 4 7 3 . 2No data 1 1 0 . 7
Vision:Blind 1 0 . 1Light perception only 3 7 2 . 5Read newspaper 3 7 9 2 5 . 6Poor 3 9 8 2 6 . 9Average 4 7 6 3 2 . 2G o o d 1 7 9 1 2 . 1No data 1 0 0 . 7
49
Social and Health Status of Elderly People in Hong Kong
(Table 3.16). The five most common chronic illnesses affecting this
group of elderly were rheumatism (34.2%), hypertension (32.2%),
fracture (17.1%), peptic ulcer (13.5%) and diabetes mellitus (10.7%).
4.9% of the elderly respondents had been suffering from some sort of
urinary incontinence and 3.8% of them also had history of stroke.
Table 3.16 Prevalence of chronic illnesses
Illness Number Percentage
Rheumatism 5 0 4 3 4 . 2Hypertension 4 7 4 3 2 . 2Fracture 2 0 5 1 7 . 1Peptic ulcer 1 9 8 1 3 . 5Diabetes mellitus 1 5 8 1 0 . 7Chronic bronchitis 1 2 0 8 . 2Coronary heart disease 1 0 0 6 . 8Hyperthyroidism 8 9 6 . 1Urinary incontinence 7 2 4 . 9Stroke 5 5 3 . 8Faecal incontinence 4 3 2 . 9Hyperparathyroidism 2 1 1 . 4
Table 3.17 Difficulties in activities of daily living
Activities of daily living Number Percentage
Heavy housework 5 5 1 3 7 . 2Stairs 2 4 8 1 6 . 8Taking Public Transport 1 1 2 7 . 6Getting up/down (bed/chair) 9 5 6 . 4Visiting friends 9 1 6 . 1Buying food 8 5 5 . 7Going out 8 3 5 . 6No difficulty 2 1 5 1 4 . 5
Functional ability and disability
As impairment of functional ability means inability of self care, the
assessment on the elderly’s functional ability is important in finding
out the real need of the society for community support services and
institutionalization. The study had surveyed on the ‘instrumental
activities of daily living and activities of daily living’ (Table 3.17). This
sample showed that heavy housework (37.2%), climbing stairs (16.8%),
50
Edward Man-fuk LEUNG, Mona Bo-nar LO
taking public transport (7.6%), getting up/down from bed/chair (6.4%)
and visiting friends (6.1%) were the five most commonly impaired
activities of daily living. 20.7% of the interviewees showed impairment
in two or more of the activities (Table 3.18), yet 19 (1.3%) respondents
had impairment in all 15 items of the activities of daily living.
DIETARY PATTERN
Place for meals
Most of the interviewed elderly had meals at home: breakfast (67.7%),
lunch (91.8%), and dinner (97.2%). If they went out, they would eat
in restaurants rather than fast food stores. It was breakfast that the
elderly ate out more often than any other meals. For those who ate
outside, 37.7% indicated that they had their breakfast in restaurants
regularly, and 19.7% occasionally. For lunch, 4.9% ate regularly in
restaurants, and 16.3% ate there occasionally. Only 2.2% ate regularly
at fast food stores, and 7.5% ate there occasionally. For dinner, just
1% ate regularly in restaurants, and 14% occasionally Even fewer
(0.6%) had their dinner at fast food stores (Figures 3.1–3.3).
Table 3.18 Number of impairment in activities of daily living
Number of impairment Number of respondents Percentage
0 7 9 5 5 3 . 71 3 7 7 2 5 . 52 1 2 3 8 . 33 6 5 4 . 44 3 9 2 . 65 2 2 1 . 56 1 2 0 . 87 7 0 . 58 5 0 . 39 2 0 . 1
1 0 4 0 . 31 1 2 0 . 11 2 2 0 . 11 3 2 0 . 11 4 4 0 . 31 5 1 9 1 . 3
51
Social and Health Status of Elderly People in Hong Kong
N = 1480
Figure 3.1 Breakfast habits of the elderly
N = 1480
Figure 3.2 Lunch habits of the elderly
52
Edward Man-fuk LEUNG, Mona Bo-nar LO
N = 1480
Figure 3.3 Dinner habits of the elderly
Types of food
The elderly took high fat food regularly. For example, one in five
(19.7%) had bone soup, cream soup and other fatty soup regularly,
and 21.6% occasionally. These elderly also liked to eat desserts (cakes,
ice-cream, sweetened buns), with 13.5% of them eating regularly and
35.5% occasionally. For deep fried food, 12.2% ate regularly and
27% occasionally. Canned food was eaten by 3.1% regularly and
24.7% occasionally (Table 3.19).
Cooking methods and oil used
Most elderly (82.9%) preferred steaming their food regularly and 11.6%
occasionally. About one-third (34.4%) of them regularly cooked food
by immersing in boiling water, and 26.5% doing so occasionally.
However, 51.7% regularly and 22.9% occasionally used the method
of shuffling their food with oil. Also 27.3% regularly and 34.4%
occasionally cooked their food by putting on a hot oil layer (Table 3.20).
Most elderly (62.5%) used peanut oil regularly for cooking and 45.5%
regularly used corn oil. The percentage of regular use of butter and
margarine was very small, just 1.0% and 5.3 % respectively.
53
Social and Health Status of Elderly People in Hong Kong
Table 3.19 Percentage of high fat and cholesterol food taken
Types of food Never Seldom Occasional Regular Total N oeaten (%) (%) (%) number of answer
(%) respondents
Bone soup, cream soup,other fatty soup 2 3 . 8 3 4 . 9 2 1 . 6 1 9 . 7 1 4 6 4 1 6
Chinese and WesternDesserts (egg cakes,cream cakes, ice cream,sweetened buns) 1 2 . 5 3 8 . 5 3 5 . 5 1 3 . 5 1 4 6 6 1 4
Deep fried food(e.g. chicken wing, fish,sweet and sour pork,spring roll) 1 4 . 9 4 6 . 0 2 7 . 0 1 2 . 2 1 4 6 5 1 5
Nut (peanut, cashew nut,etc.) 1 8 . 0 4 1 . 9 2 9 . 5 1 0 . 6 1 4 6 7 1 3
Fat meat (e.g. preservedmeat, pork with fat,spare rib, beef flank,roast pork etc.) 3 9 . 0 4 6 . 7 1 0 . 4 3 . 9 1 4 6 7 1 3
Squid, cuttlefish, shrimpand crab fat 4 1 . 9 4 2 . 1 1 2 . 7 3 . 3 1 4 6 6 1 4
Canned food (luncheonmeat, salted beef,meat sausage,oil immersed in oil) 2 3 . 8 4 8 . 4 2 4 . 7 3 . 1 1 4 6 6 1 4
Internal organs (liver, brain,heart, lung, kidney,intestine) 5 2 . 1 3 8 . 2 8 . 1 1 . 7 1 4 6 5 1 5
Table 3.20 Methods of cooking used
Types of food Never Seldom Occasional Regular Total N oeaten (%) (%) (%) number of answer
(%) respondents
Fry 2 0 . 8 5 5 . 7 1 8 . 3 5 . 1 1 4 4 5 3 5
Shuffle with oil 4 . 3 2 1 . 1 2 2 . 9 5 1 . 7 1 4 5 0 3 0
Put on a hot oil layer 5 . 4 3 2 . 8 3 4 . 4 2 7 . 3 1 4 5 0 3 0
Immerse in boiling water 8 . 4 3 0 . 8 2 6 . 5 3 4 . 4 1 4 4 0 4 0
Cook with hot water 1 2 . 2 3 7 . 7 2 5 . 0 2 5 . 0 1 4 3 0 5 0
Hotpot style 6 . 9 3 5 . 1 3 5 . 3 2 2 . 8 1 4 4 6 3 4
Steam 1 . 2 4 . 3 1 1 . 6 8 2 . 9 1 4 4 9 3 1
54
Edward Man-fuk LEUNG, Mona Bo-nar LO
Everyday food
For milk products, the elderly preferred milk powder (32.2%) to
drinking fresh milk (9.7%) and skimmed milk (17.2%). They obviously
ate plenty of fish, with 84% of them eating fish regularly (every day)
and 10.7% occasionally. Only 1.6% never ate any fish. For pork, beef
and lamb meat, 49.8% ate them regularly and 29.6% occasionally.
For poultry, 38.6% ate regularly and 40.1% occasionally. Our elderly
liked fruit and vegetables too, with 86.2% eating fruit regularly, and
over 90% regularly had vegetables for both lunch and dinner (91.3%
and 94.1% respectively). Only 0.5% of them never ate fruit and
vegetables for lunch (Table 3.21). On average the elderly ate about
one bowl of rice or noodle, or a piece of bread per meal.
LIFE SATISFACTION
The feeling of life satisfaction is an essential measure on the well-being
of the elderly. The present study included 17 questions on life
satisfaction basing on the Philadelphia Morale Scale. The Philadelphia
Morale Scale, which had been widely used in the United States and
Table 3.21 Food being taken daily
Types of food Never Seldom Occasional Regular Total N oeaten (%) (%) (%) number of answer
(%) respondents
Milk productsFresh milk 5 1 . 4 2 8 . 2 1 0 . 0 9 . 7 1 3 9 5 8 5Skimmed milk 5 3 . 1 2 1 . 6 8 . 0 1 7 . 2 1 3 8 6 9 4Milk powder 4 0 . 4 1 6 . 0 1 1 . 3 3 2 . 2 1 4 2 7 5 3
Meat ProductsFish 1 . 6 3 . 7 1 0 . 7 8 4 . 0 1 4 6 7 1 3Beef, pork, lamb, meat 4 . 7 1 5 . 9 2 9 . 6 4 9 . 8 1 4 6 9 1 1Poultry (chicken, ducks,
geese) 4 . 0 1 7 . 4 4 0 . 1 3 8 . 6 1 4 6 7 1 3
Fruit 0 . 5 3 . 9 9 . 3 8 6 . 2 1 4 6 6 1 4
VegetableLunch 0 . 5 1 . 8 6 . 4 9 1 . 3 1 4 6 8 1 2Dinner 0 1 . 1 4 . 8 9 4 . 1 1 4 6 8 1 2
55
Social and Health Status of Elderly People in Hong Kong
United Kingdom, had never been tested in Hong Kong. The adoption
of this scale aimed at testing whether it was applicable to Chinese
elderly in Hong Kong.
In conducting this survey, one score was awarded to a favourable
answer to each question, with the maximum being 17. Table 3.22
shows the distribution of score among the respondents who had
answered all 17 questions. In general, the life satisfaction among them
was satisfactory. Over half of them scored more than 10 out of 17.
ASSISTANCE
When ill, the majority (67.9%) would seek for help first from a doctor
of western medicine, and only 3.5% would go to a practitioner of
Chinese medicine. 16.2% said they would go to their relatives and
friends first. One in ten would try to manage by themselves first, and
a mere 0.8% would consider seeking help from their neighbours first.
Due to time constraint, this first report could only describe very
generally certain aspects of the way of life among the elderly. With
more in-depth analyses later, it might be possible to correlate the way
of life, health, use of services and other objective investigations.
Table 3.22 Philadelphia Morale Scale
Score Number Percent
1 8 0 . 62 1 6 1 . 13 3 2 2 . 24 5 7 4 . 05 7 3 5 . 16 7 7 5 . 47 8 6 6 . 08 9 6 6 . 79 1 2 1 8 . 5
1 0 1 2 5 8 . 81 1 1 6 3 1 1 . 41 2 1 6 9 1 1 . 81 3 1 6 7 1 1 . 71 4 1 4 4 1 0 . 11 5 7 0 4 . 91 6 2 3 1 . 61 7 1 0 . 1
56
Edward Man-fuk LEUNG, Mona Bo-nar LO
USE OF SERVICES
There is increasing consideration that services provided for old people
should not only satisfy their everyday basic needs, but should also
create the factors necessary for the maintenance of their integration in
the community, and in spite of ageing and mental and physical
constraints, their independence and self-fulfilment. Different services
may contribute to the preservation of old people’s personal way of
life.
The past few years have shown that old people in Europe have
used social and health service three to four times more than would be
expected from their proportion in the total population. Research work
analyzing old people’s use of services is therefore of vital importance.
The use of service too assumes that the elderly are aware of the
services available and that the needed services are there when people
need them. That may not be the case in the developing world with all
the limitations of general knowledge and provisions affordable.
Here let us look at what the findings in the use of services tell us
about our sample of elderly. The service used most by the elderly was
the out-patient clinics of the government which charged less and hence
generally affordable. The average number of visits by the elderly was
8.1 times in the previous year. They also paid about six visits to their
own doctors in that year. One in ten elderly was hospitalized in the
previous year and 5.1% of them had surgical operation. 77.6% of
them had blood test, which meant that on average each elderly had
1.1 blood test. 31.9% of them had X-ray. For preventive programme
such as dentistry, only about a quarter (24.5%) had visited a dentist in
the past year. For social service such as meals on wheels and home
help, few had used them. It might be that our respondents were in
general the more active elderly. Also quite a few of the elderly had
ECG (36.8%) and only 7.9% had physiotherapy (Table 3.23).
IMPLICATIONS ON SOCIAL SERVICES
In view that the elderly was an important target group of social services
in Hong Kong, the present study hoped to draw some implications on
the planning of future services for them.
When an elderly becomes sick, the spouse would usually take up
57
Social and Health Status of Elderly People in Hong Kong
Table 3.23 Use of health and social services in the past year
Service type Number of Average Percent Total N orespondents times used of number answer
that used last year respondents ofthe service respondents
Visit a doctor 1 2 1 1 6 . 0 8 2 . 4 1 4 7 0 1 0X-ray 467 0 . 6 3 1 . 9 1 4 6 5 1 5Blood test 1 1 3 8 1 . 1 7 7 . 6 1 4 6 7 1 3E C G 540 0 . 5 3 6 . 8 1 4 6 7 1 3Visit a dentist 3 6 0 0 . 5 2 4 . 5 1 4 6 8 1 2Visited by nurse/health worker 2 3 0 . 7 1 . 6 1 4 6 3 1 7Visit government out-patient clinic 1 4 6 7 8 . 1 1 0 0 . 0 1 4 6 7 1 3Hospitalization 1 5 7 – 1 0 . 7 1 4 6 7 1 3Surgical operation 7 4 – 5 . 1 1 4 6 0 2 0Physiotherapy 1 1 5 – 7 . 9 1 4 6 1 1 9Occupational therapy 1 6 – 1 . 1 1 4 5 9 2 1Meals and wheels 1 5 – 1 . 0 1 4 6 6 1 4Home help 1 4 – 1 . 0 1 4 6 6 1 4Social work counselling 3 8 – 2 . 6 1 4 6 2 1 8
the carer’s role. However, the present study revealed that the majority
of the elderly were single or widowed elderly. This meant that there
would be a strong demand for substitute to the usual carer’s role. In
this situation, the provision of social support services became essential.
The government should, therefore, try to establish a caring environment
through the provision of different types of social support services for
the elderly who had difficulties in daily activities.
The finding that over half of the elderly were living with their
family confirmed that the family unit was still the major supporting
network for the elderly. However, since most of the Hong Kong families
are busy either at work or at school during the daytime, the caring
capacity of the Hong Kong family unit still remains a question to be
further examined. So, it is time for the government to evaluate on its
existing provision of supporting services. Undoubtedly, services such
as day-care centre for elderly, outreaching services, community nursing
service and home help services are on the soaring demand. The
government should immediately take a closer look at what kind of
support services could best be provided for those families which have
to look after disabled elderly.
The fact that the elderly in Hong Kong were financially heavily
dependent was also note-worthy. According to the present study, 64.3%
58
Edward Man-fuk LEUNG, Mona Bo-nar LO
of the elderly depended on their families for financial support, and
26% depended on government subsidy. The figure of less than 10% of
them were self-reliant demonstrated that the elderly in Hong Kong
were, in general, highly dependent for their daily living expenses.
Though there were intense debates in the past two years on the
establishment of Retirement Protection Scheme for the elderly in Hong
Kong, nothing positive has come out of it yet. Therefore, further
development on financial support for the elderly was required if a
stable society was desired.
The present study showed that a significant number of elderly had
difficulty in coping with heavy housework (37.2%). Besides, quite a
lot of them had difficulty in performing daily activities such as climbing
up stairs, taking public transportation, getting up or down from bed
or chair, and visiting friends. The impairments of these activities would
seriously affect the elderly’s social life. As social and recreational life
was important in maintaining the well-being of the elderly, there was
need for the social service sectors to develop services which could help
the elderly to maintain adequate social activities during old age.
Volunteers, visiting services and neighbourhood support should be
developed to enhance the social network of the elderly. The provision
of adequate home help services to relieve the elderly from their heavy
housework task was also important.
Among the interviewees, about 5.4% of them had difficulties in
five or more items of the activities of daily living. This group of elderly
required personal care support services in community or residential
settings either in the form of day care, home care or residential places.
However, then, there were only 11 care-and-attention places per 1000
elderly over the age of 60. This number was definitely far below the
real need. Further investigation into the need of this group of elderly
and improvement measures for them are urgently required.
THE RELATIONSHIP BETWEEN LIFE SATISFACTION AND
CHRONIC ILLNESSES
The study compared the Philadelphia Morale Scale mean score of
those elderly respondents with and those without chronic illnesses. It
was found that the low scoring in the Philadelphia Morale Scale had a
significant correlation with the occurrence of chronic illnesses and
59
Social and Health Status of Elderly People in Hong Kong
Table 3.24 Philadelphia Morale Score for elderly with and without chronic illnesses
Chronic illness PMS score PMS score P(positive history) (negative history)
Faecal incontinence 8 . 5 8 1 0 . 0 9 <0.01Urinary incontinence 8 . 1 8 1 0 . 1 5 <0.01Coronary heart disease 9 . 1 6 1 0 . 1 3 <0.01Stroke 9 . 0 1 0 . 1 <0.05Peptic ulcer 9 . 2 5 1 0 . 1 <0.01Rheumatic disorders 9 . 2 2 1 0 . 4 8 <0.01Fractures 9 . 5 3 1 0 . 1 1 <0.05
impairment in ADL activities in elderly. Tables 3.24 and 3.25 below
show the correlation.
The mean score for the Philadelphia Morale Scale in the group
with chronic illness and functional impairment was significantly lower
than that of the normal group. Those respondents who were suffering
from urinary or faecal incontinence had the lowest scores. This
demonstrates that these two illnesses affect the elderly most.
Correlation study also showed that the Philadelphia Morale Score
had a positive correlation with the self-perceived health status of the
elderly respondents. Therefore, it can be concluded that the Philadelphia
Morale Score is a good instrument to measure the life satisfaction
among the elderly in Hong Kong.
Table 3.25 Philadelphia score vs ADL impairments
Activities of daily living Impaired Normal P
Bathing 8 . 2 5 1 0 . 1 1 <0.01Washing clothes 8 . 6 4 1 0 . 0 8 <0.05Feeding 8 . 7 4 1 0 . 0 8 <0.02Getting up bed/chair 8 . 2 7 1 0 . 1 6 <0.01Stairs 8 . 8 1 1 0 . 2 9 <0.01Toiletting 8 . 8 5 1 0 . 1 0 <0.01Cooking 8 . 0 5 1 0 . 1 2 <0.01Washing 7 . 6 9 1 0 . 1 8 <0.01Heavy housework 9 . 1 9 1 0 . 5 5 <0.01Buying food 7 . 9 1 1 0 . 1 7 <0.01Going out 8 . 0 2 1 0 . 1 6 <0.01Taking public transport 8 . 0 1 0 . 2 <0.01Visiting friends 8 . 0 5 1 0 . 1 6 <0.01Managing personal finance 8 . 6 5 1 0 . 1 8 <0.01
60
Edward Man-fuk LEUNG, Mona Bo-nar LO
IMPLICATIONS ON HEALTH SERVICES
Most of the elderly interviewed maintain a good health habit. They
practised various types of exercises such as walking, doing household
work and jogging. However, conventional exercises like tai chi or
aerobic exercises were practised less frequently than expected. This
phenomenon was likely due to the lack of educational opportunity for
the elderly. In addition, as many of the elderly considered doing
household chores as part of their daily exercises, they might neither see
the need nor find the time to perform their exercise routine. Therefore,
elderly centres should devote more time to develop exercise programme
for their members. Increasing the scope of elderly exercise training
would be beneficial for them both for fitness and recreational purposes.
Smoking has been proven to be hazardous to health. Yet 18.8% of
our elderly respondents had smoking habit. Stronger strategy such as
enhancement of educational activities on smoking and health, and
supporting group for quitting smoking for elderly people should be
developed to reduce smoking habit among the elderly.
It was found in our study that the Hong Kong elderly had a high
prevalence of chronic illnesses. Illnesses such as rheumatic complaints,
hypertension, fractures, peptic ulcer and diabetes seriously affected
their well-being. Among these illnesses, the effects brought about by
hypertension, diabetes and fractures were more serious. They brought
about long term complications such as stroke, renal involvement, heart
and vascular complications and immobility. Therefore, early detection
of common illnesses among the elderly was important. Early
intervention could easily be conducted by primary care physicians
through routine health checks. Besides, the high prevalence of fractures
also indicated the seriousness of osteoporosis among the elderly . Public
health measures should be developed to reduce the possibility of fracture
in elderly and the detection and prevention of osteoporosis in the
female population should also be a priority in health promotion.
Hearing and visual ability were two important concerns for elderly
to have a quality life. The impairment of either of them might seriously
affect the well-being of the elderly. Yet our study showed that a great
proportion of the elderly (around 30%) had either hearing or visual
loss. To enable the elderly to live a healthy old age, adequate resources
for detection and proper treatment of common disabling conditions in
elderly should be provided. The provision of proper hearing aid and
the availability of eye service will certainly be helpful.
61
Social and Health Status of Elderly People in Hong Kong
REFERENCES
1. Census and Statistics Department. Hong Kong 1991 Population Census,
Hong Kong Government, 1991.
63
Helicobacter Pylori Infection — Epidemiology and Clinical Significance Among the Elderly
4Helicobacter Pylori Infection —
Epidemiology and Clinical SignificanceAmong the Elderly in Hong Kong
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
ABSTRACT
This cross sectional study described the prevalence of Helicobacter pylori
infection as detected by a serological blood test in 1698 elderly subjects
in Hong Kong ageing from 56 to 95. Questionnaires were used to correlate
the seroprevalence with demographic data and diet. The overall prevalence
of Helicobacter pylori infection was 72.2%. The males had a significantly
higher carrier rate than the females in this age group. There were no
correlation between seroprevalence and physical parameters. Those with
low albumin had a significantly higher carrier rate. More frequent nut
consumption was associated with lower Helicobacter pylori carrier rate.
Other dietary and cooking habits showed no correlation. All elderly
subjects tested specifically for anti-CagA antibody (n=52) were negative.
Metronidazole resistant Helicobacter pylori strains were found in 84%
of the patients with antral biopsies done. We concluded that there was a
high prevalence of Helicobacter pylori infection among the elderly in Hong
Kong. High albumin and frequent nut consumption were associated with
less seropositivity. The role of cytotoxin producing and metronidazole
resistant strains of Helicobacter pylori required further examination.
64
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
INTRODUCTION
The dictum ‘no acid — no ulcer’ first proclaimed by Schwarz in 19101
and subsequently quoted by many has never been challenged as fiercely
as it has been over the last decade after the description of an organism
called Helicobacter pylori2. It is a gram negative microaerophilic
organism that colonizes gastric epithelial tissues. It has been shown to
be highly associated with chronic atrophic (type B) gastritis2,3, peptic
ulcer disease4,5 and gastric cancer6–10. Furthermore, it has been
demonstrated that the risk of developing peptic ulcer in subjects with
Helicobacter pylori antral gastritis has increased by 5–14 folds over a
period between 10–18 years11,12. The risk of developing gastric cancer
in Helicobacter pylori carriers has also been estimated to be between
2.8–6 times over a mean period of 12 years (range 4 months to 24
years)6–8. These facts serve to underscore the importance of this organism
in the aetio-pathogenesis of gastroduodenal pathologies.
It has been demonstrated that approximately 10% of the adults
develop peptic ulcer disease during their lifetime13. Thus, a significant
amount of work time and finance is lost because of the illness. Although
gastric cancer is not as prevalent as peptic ulcer disease, its annual
mortality rate in Hong Kong is approaching 10/100 000 population.
The majority of our patients with peptic ulcer disease or gastric cancer
has been demonstrated to be Helicobacter pylori positive14–16.
Approximately half of the world’s population is infected by
Helicobacter pylori, being higher in developing countries than in
developed ones17. The prevalence of infection is known to increase
with age, to differ between ethnic groups and to be similar between
men and women. Low socio-economic status, low education standard
and crowded living condition in childhood are important risk factors
for contracting infection according to previous reports17,18. Our previous
study on sero-epidemiology among healthy blood donors in Hong
Kong showed that 56.6% of the subjects were positive for Helicobacter
pylori19. The prevalence increased with age. For those below 20, the
prevalence was around 17%. For those between 21 and 40, the
prevalence was around 45%. For those above 41, the prevalence was
around 65%. There was no difference between males and females in
the overall prevalence or prevalence in each age group. The data pattern
observed was in accordance with the rest of the world17. Our prevalence
lay between that of the developing countries and that of developed
ones. In the children group our prevalence was around 17%. In the
65
Helicobacter Pylori Infection — Epidemiology and Clinical Significance Among the Elderly
USA, 5–15% of children in the 3–5 year age group were infected. In
India 60% of children aged 3–10 years were infected. The improvement
in socio-economic standard and living conditions in general in our
society in the past 20 years may account for the low prevalence in
those below age 20.
As far as the prevalence of Helicobacter pylori infection rate in the
elderly group is concerned, most studies report figures between 65–85%17.
However most of the studies only included a very small sample size in the
elderly age group making interpretation of these studies difficult. The
number of subjects in the previous Hong Kong study was also small
probably reflecting the reluctance in this age group to give blood.
There are a small number of reports on the effect of diet on the
prevalence of Helicobacter pylori infection. The impact of cooking
habits on the Helicobacter pylori infection rate to the best of our
knowledge has not been studied so far. This study was designed to
evaluate the effect of diet and cooking habits on the Helicobacter
pylori infection rate in addition to documentation of the overall
prevalence of Helicobacter pylori infection among the elderly Chinese
in Hong Kong. We have also prospectively examined a group of these
volunteers to evaluate the accuracy of the commercially available kit
for the diagnosis of Helicobacter pylori infection, the nature of
gastroduodenal pathology, the subtypes, particularly the cytotoxin
producing ability and the resistance to metronidazole, of Helicobacter
pylori strains in these subjects since these properties are related to
ulcerogenesis/carcinogenesis20–22 and efficacy of conventional eradication
therapy respectively.
METHODS
Study population
The study population consisted of healthy subjects between the ages of
56 and 95 years. It formed part of the health check-up programme
organized jointly by the Society for the Aged and Rotary Club. Members
of community centres in nine districts were invited to join the health
check-up programme on a voluntary basis. The whole programme
consisted of measurements of body height, weight and blood pressure,
blood taking and electrocardiogram in the hospital setting and
questionnaire completed with the help of voluntary workers.
66
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
Questionnaire
The questionnaire was designed to obtain demographic data such as
date and place of birth, gender, marital status, occupation, income,
smoking and alcohol consumption. Presence of underlying medical
illnesses including coronary heart disease, hypertension, diabetes
mellitus, peptic ulcer, operation in gastrointestinal tract were asked.
History of taking antibiotics in the past three months and painkiller in
the past month were noted. Detail diet history were obtained such as
the place of having breakfast, lunch and dinner, frequency of taking
fried food, fat meat, cream and fatty soup, squid and cattle fish,
animal organs, canned meat and fish, nuts, and desserts. Cooking
styles were asked on the following categories: fry, shuffle with oil,
immerse in boiling water, cook with hot water, hotpot, or steam. The
types of oil used were asked such as peanut oil, maize oil, margarine,
butter or pork oil. Consumption of fresh milk, skimmed milk, milk
powder, fish, red meat, poultry, fruits and vegetables were asked.
Daily starch intake and preference of rice, rice noodles, noodles and
bread were asked. The questionnaire also included other questions in
relation to other study areas and details are listed in Appendix 2.6 in
Chapter 2.
Blood sampling
Participants were gathered at the laboratory in Queen Mary Hospital
for blood taking. Tests included complete blood count, liver and renal
function test, and thyroid function test; cholesterol and triglyceride
profiles were done as mentioned in the other reports.
Anti-Helicobacter pylori antibody assay (GAP IgG ELISA)
Sera were also tested for IgG antibody against Helicobacter pylori
using the GAP IgG ELISA (BIORAD) according to the manufacturer’s
instructions. Internal standards were included as reference. Antibody
titre >20 units/ml was considered positive. This assay was found in a
pilot study by using 13C-urea breath test as the gold standard to have
a sensitivity of 100% and a specificity of 87.5%.
67
Helicobacter Pylori Infection — Epidemiology and Clinical Significance Among the Elderly
Anti-CagA antibody assay
CagA 17/12 (recombinant fragment) fusion protein was produced as
described before23,24. The assay has been demonstrated to have a
sensitivity of 96.2% and specificity of 96.6%23. Pooled sera from four
strong CagA antibody positive duodenal ulcer patients were used as
internal standards. Results of the tested sera were expressed with
reference to the standard curve derived from these internal standards.
Statistical methods
Chi-square test were used to examine the association between
Helicobacter pylori infection and the subject’s characteristics.
RESULTS
A total of 1698 participants were studied. The overall prevalence of
Helicobacter pylori was 72.2% (Table 4.1). We analysed the age-
specific prevalence according to four age range: 56–65, 66–75, 76–85
and 86–95. The number of participants in each group were 414, 882,
367 and 35 respectively. 73.9% (n=306) of subjects in the first group
were seropositive. Similarly 71.4% (n=630), 71.7% (n=263) and 77.1%
(n=27) of the subjects in the second, third and fourth group were
seropositive respectively. There was no significant increase in
Helicobacter pylori carrier rates with advancing age in the range 56–
95.
Seroprevalence of Helicobacter pylori in relation to sex was analysed
(Table 4.1). Overall there were 306 males and 1392 females in the
study. 78.1% (n=239) of the males were Helicobacter pylori positive
while 70.9% (n=987) of the females were Helicobacter pylori positive
(p<0.01). Hence the males had a significantly higher Helicobacter pylori
carrier rate than the females among the elderly. The percentage
prevalence of Helicobacter pylori in males in the four age groups were
81.2%, 76.6%, 78.7% and 80% respectively, while those in the females
were 72.5%, 70.2%, 70.3% and 76.7% respectively. There was no
significant increase in seroprevalence with increasing age in either sex,
and there was no significant difference in prevalence in between the
two sex in each age group.
68
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
Table 4.1 Seroprevalence of Helicobacter pylori in relation to age and sex
Age group Male (%)* Female (%)* Total (%)*
56–65 6 9 (81.2) 3 4 5 (72.5) 4 1 4 (73.9)
66–75 1 7 1 (76.6) 7 1 1 (70.2) 8 8 2 (71.4)
76–85 6 1 (78.7) 3 0 6 (70.3) 3 6 7 (71.7)
86–95 5 (80.0) 3 0 (76.7) 3 5 (77.1)
Total 3 0 6 (78.1) 1 3 9 2 (70.9) 1 6 9 8 (72.2)
*Percentage of Helicobacter pylori positivity
Helicobacter pylori prevalence were correlated with living pattern,
smoking habit and alcohol consumption. It was found that living with
family did not have significant difference in Helicobacter pylori
prevalence than living alone (p=0.57). Smoking and drinking did not
have any influence on Helicobacter pylori prevalence as well.
We analysed the effect of medical illness on Helicobacter pylori
prevalence. Presence of coronary heart disease, hypertension, diabetes
mellitus, history of gastrointestinal surgery had no correlation with
Helicobacter pylori prevalence.
Physical parameters were analysed with Helicobacter pylori
seropositivity. Measurements in body height were divided into three
groups: less than 152cm, 152–177cm and greater than 177cm.
Measurements in body weight were divided into those less than 45kg,
45–75kg and greater than 75kg. Measurements in diastolic blood
pressure were divided into those less than 80mmHg, 80–95mmHg,
and greater than 95mmHg. Those in systolic blood pressure were
divided into groups of less than 120mmHg, 120–170mmHg and greater
than 170mmHg. In the above groups there were no correlation with
Helicobacter pylori seropositivity.
Biochemical parameters were also correlated with Helicobacter
pylori serology results. Albumin level were divided into those greater
than or less than 40g/L. Triglyceride were divided into those greater
than or less than 2mmol/L. Total cholesterol were divided into those
greater than or less than 5.5mmol/L. LDL-cholesterol were divided
into those greater than or less than 3.5. HDL-cholesterol were divided
into three groups, those less than 0.8mmol/L, 0.8–2.2mmol/L and
those greater than 2.2mmol/L.
In the analysis of correlation between albumin and Helicobacter
pylori seroprevalence, we found that 100% (n=11) of those with
69
Helicobacter Pylori Infection — Epidemiology and Clinical Significance Among the Elderly
albumin less than 40 were Helicobacter pylori positive while 72.3% of
those with albumin greater than 40 were Helicobacter pylori positive
(p<0.05) (Table 4.2). It was statistically significant that those with low
albumin had a higher Helicobacter pylori carrier rate. The analysis in
other biochemical parameters did not show any statistical significance.
We asked the usual place of having breakfast, lunch and dinner,
whether in a restaurant, fast food store or at home. There was no
association of Helicobacter pylori carrier rate with the place of eating.
Cooking styles were questioned by the frequency of using the following
methods: fry, shuffle with oil, immerse in boiling water, cook with hot
water, hotpot or steam. We analysed individually the frequency of
each cooking style with Helicobacter pylori carrier rate and found no
correlation. Diet consumption frequency were asked. The following
items were included: fried food, fat meat, cream and fatty soup, squid
and cattle fish, animal organs, canned meat and fish, nuts, desserts,
fresh milk, skimmed milk, milk powder, fish, red meat, poultry, fruits
and vegetables. There was no correlation in the Helicobacter pylori
prevalence with the frequency of individual item consumption except
for nuts. We divided nut consumption into three groups: frequent,
occasional and no consumption. 59.4% of those taking nuts frequently
were Helicobacter pylori positive, while 72.8% of those not taking
nuts were Helicobacter pylori positive. Hence taking nuts more
frequently was associated with a smaller Helicobacter pylori carrier
Table 4.2 Prevalence rate of Helicobacter pylori infection in relationto albumin level and nut consumption
Total (%)* P value
Albumin level
≤ 40g/L 1 1 (100)> 40g/L 1 6 7 6 (72.3) 0 . 0 4
Total 1 6 8 7 (72.5)
Nuts intake
N o 2 1 7 (72.8)Occasional 8 8 0 (73.9)Frequent 1 3 3 (59.4) 0 . 0 0 2
Total 1 2 3 0 (72.1)
* Percentage of Helicobacter pylori positivity
70
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
rate (p<0.005) (Table 4.2). There was no association in Helicobacter
pylori prevalence with daily starch intake and preference of rice, rice
noodles, noodles and bread.
Anti-CagA antibody assay
Fifty-two subjects were selected at random to have CagA antibody
assay performed. None of them showed a positive result, indicating
that these elderly did not harbour the cytotoxin-producing Helicobacter
pylori strain.
Metronidazole resistant strains
Metronidazole resistant Helicobacter pylori strains were found in 84%
(87.5% of the females and 75% of the males) in the group of elderly
patients who had culture and sensitivity of the antral biopsies done.
DISCUSSION
We performed a cohort study on the Helicobacter pylori infection in
elderly Chinese in Hong Kong. 72.2% of the people aged above 56 in
Hong Kong were infected with Helicobacter pylori. The figure lay
between those of developed countries and developing countries. In the
developing countries, around 80–90% of the population in this age
group were infected. In the developed countries, around 55–65% of
the same age population were infected. Hence it supported the evidence
so far that socio-economic standard, living condition and hygiene were
important etiological factors in Helicobacter prevalence. The people in
our study group were born in 1900–40. Most of them were born in
China and came to Hong Kong in around 1935–55. Poor socio-
economic standard and living environment in those days, both in China
and in Hong Kong, could account for the high prevalence in the
people in this age range.
We subdivided the study group into four age range, 56–65, 66–75,
76–85 and 86–95. Previous reports showed a decreasing Helicobacter
pylori carrier rate in the extreme elderly. Those studies usually included
relatively few sample subjects in the extreme age, hence the results were
71
Helicobacter Pylori Infection — Epidemiology and Clinical Significance Among the Elderly
questionable. In this study we were able to include 367 subjects in the
age range of 76–85 and 35 subjects in the age range 86–95. It was
shown that there was no significant change in the seroprevalence in
individual age group with increasing age. In fact the seroprevalence
showed a plateau effect at around 72% throughout the whole age range.
We have demonstrated in a previous study in Hong Kong and
together with other data in the world that Helicobacter pylori carrier
rate increased with increasing age in those age less than 50. This did
not hold true for the age group above 56 in the present study. From
our data, we could not find any cause for the relatively constant
prevalence with increasing age. If we assumed that the new infection
rate in the community remained constant regardless of age, then we
should expect the prevalence to increase in the elderly also. The level
off effect observed would be attributed to host factor. Further study in
the elderly is needed to answer this question.
Physical parameters such as body weight and height, diastolic and
systolic blood pressure and also alcohol consumption and smoking did
not correlate with Helicobacter pylori prevalence. This was consistent
with other studies in other parts of the world. The presence of other
medical illness also had no correlation with Helicobacter pylori status.
Since most of the infection of Helicobacter pylori occurred in young
age, it would be unlikely that the physical built of the elderly would
have significant correlation with infection rate.
These data suggested that poor hygiene and water supply was
associated with increased infection. We tried to identify sources of
infection by determining the chance of acquiring infection in different
places of meals. Failure to identify the association between eating
place and infection rate might be accounted by the heterogeneous
eating habit in Hong Kong Chinese. The actual eating habit was so
diversified in our population that the questions asked might be
inadequate to reflect the actual situation.
We try to correlate the cooking style with Helicobacter pylori
prevalence. The negative association in all categories might be due to
the vast variation in everyday cooking style among Hong Kong families.
Families usually had three to four dishes in each meal and even within
one meal, various cooking methods were employed. Hence even if one
single cooking method was associated with increase infection, it would
be difficult to stand out in view of the usual cooking habit in the
society.
We found that frequent intake of nuts was associated with less
Helicobacter pylori infection in the elderly. Analysis on other food
72
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
substances did not show similar association. The reason for such
association was not evident in the present study. We postulated that
there might be some substance in the nuts which might inhibit the
colonization of Helicobacter pylori in the stomach mucosa. Further
study need to be carried out to clarify the fact.
Helicobacter pylori infection was highly associated with peptic
ulcer disease. It has been shown that more than 80% of gastric ulcer
and more than 95% of duodenal ulcer disease patients had harboured
this organism in their stomach4. However, Helicobacter pylori carriers
might be entirely asymptomatic or simply suffer from non-ulcer
dyspepsia. The role of Helicobacter pylori infection was still unclear
and controversial in the latter condition. There were evidence from
longitudinal study that Helicobacter pylori carriers were both at risk
of subsequent peptic ulcer disease (8–14 times over 10–15 years period),
as well as gastric cancer (2.8–6 fold over a mean period of 12 years)6–8.
Recently, there were evidence supporting certain pathogenic strain of
Helicobacter pylori, the cytotoxin-producing type, being the culprit
for the ulcerogenesis and carcinogenesis. Our recent study in a younger
population of Hong Kong revealed that approximately 30% of the
general population and 80% of the peptic ulcer disease patients were
positive for cytotoxin-producing Helicobacter pylori strain24. These
results might explain the preponderance of overall peptic ulcer disease
in our population. How could we reconcile the absence of cytotoxin-
producing Helicobacter pylori carriers in the elderly population that
we studied? It was speculated that the lack of this pathogenic strain
was either by chance or by natural selection because if they had had
cytotoxin-producing Helicobacter pylori infection they might have
presented earlier to clinician with peptic ulcer disease. Whether these
elderly subjects would develop gastroduodenal pathology remained to
be seen by further follow-up study.
The high prevalence of metronidazole resistant Helicobacter pylori
strain both in the males and the females in this sub-group of elderly
patients was highly suggestive of age effect. The higher prevalence in
females than in males was also noteworthy. It was speculated that the
older age group subjects probably had significantly higher chance to
exposure to the use of imidazole. Similarly, females were more likely
to consume this drug because of higher incidence of genitourinary
infection that required such a therapeutic agent for treatment.
This study showed that there was a high prevalence of Helicobacter
pylori infection among the elderly in Hong Kong. However, they
appeared to harbour the non-pathogenic strain which might explain
73
Helicobacter Pylori Infection — Epidemiology and Clinical Significance Among the Elderly
why they did not have any gastroduodenal pathology. The high
metronidazole resistant prevalence in these organisms suggested that
the elderly, particularly females, had previous exposure to this drug.
We identified that hypoalbuminemia and low intake of nuts were
associated with higher Helicobacter pylori positive rates. The impact
of high seroprevalence of Helicobacter pylori to the general health of
the elderly was still unclear but likely to be insignificant because of the
low pathogenicity of the strain they carry. Long term follow-up of
these subjects would no doubt be helpful in delineating whether the
bacteria were truly non-pathogenic and should be left alone.
NOTES
1. Schwarz K. Ueber penetrierende Magen-und Jejunalgesch wure. Beitrage
zur Klinische Chirurgie, 1910, 67:95.
2. Warren JR, Marshall BJ. Unidentified curved bacilli on gastric epithelium
in active chronic gastritis. Lancet, 1983, I:1273–5.
3. Tytgat GNJ, Lee A, Graham DY, Dixon MF, Rokkas T. The role of
infectious agents in peptic ulcer disease. Gastroenterol Int, 1993, 6:76–89.
4. Graham DY. Treatment of peptic ulcers caused by Helicobacter pylori.
N Engl J Med, 1993, 328:349–50.
5. Davies GR, Crabtree JE. Helicobacter pylori: trick or treat? J Roy Soc
Med, 1994, 87:436–9.
6. Forman D, Newell DG, Fullerton F, et al. Association between infection
with Helicobacter pylori and risk of gastric cancer: evidence from a
prospective investigation. Br Med J, 1991, 302:1302–5.
7. Parsonnet J, Friedman GD, Vandersteen DP, et al. Helicobacter pylori
infection and the risk of gastric carcinoma. N Engl J Med, 1991,
325:1127–35.
8. Nomura A, Stemmermann GN, Chyou PH, et al. Helicobacter pylori
infection and gastric carcinoma among Japanese Americans in Hawaii.
N Engl J Med, 1991, 325:1132–6.
9. The Eurogast Study Group. An international association between
Helicobacter pylori infection and gastric cancer. Lancet, 1993, 341:1359–
62.
10. Hansson LE, Engstrand L, Nyren O, et al. Helicobacter pylori infection:
independent risk indicator of gastric adenocarcinoma. Gastroenterol,
1993, 105:1098–103.
11. Cullen DJE, Collins BJ, Christiansen KJ, Epis J, Warren JR, Cullen KJ.
Long term risk of peptic ulcer disease in people with Helicobacter pylori
infection: a community based study. Gastroenterol, 1993, 104:A60.
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Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
12. Sipponen P, Varis K, Fraki O, et al. Cumulative ten-year risk of
symptomatic duodenal and gastric ulcer in patients with or without
chronic gastritis: a clinical follow-up study of 454 outpatients. Scand J
Gastroenterol, 1990, 25:966–73.
13. Lam SK, Hui WM, Ching CK. Peptic ulcer disease: epidemiology,
pathogenesis, and etiology. In W.S. Haubrich, F. Schaffner, J.E. Berk
eds., Bockus Gastroenterology, 5th edition, 1994, 700–48.
14. Hui WM, Lam SK, Chau PY, et al. Persistence of Campylobacter pylori
with healing of duodenal ulcer and improvement of accompanying
duodenitis and gastritis. Dig Dis Sci, 1987, 32:1255–60.
15. Hui WM, Lam SK, Chau PY, et al. Pathogenetic role of Campylobacter
in gastric ulcer. J Gastroenterol Hepatol, 1987, 2:309–16.
16. Yuen ST, Luk ISC, Cheng WS, et al. Helicobacter pylori and gastric
carcinoma in Hong Kong. Int J Surg, 1994, 1:201.
17. Megraud F. Epidemiology of Helicobacter pylori infection. Gastroenterol
Clin N Am, 1993, 22:73–88.
18. Riccardi VM, Rotter JI. Familial Helicobacter pylori infection — Societal
factors, human genetics, and bacterial genetics. Ann Intern Med, 1994,
120:1043–4.
19. Ching CK, Yuen ST, Luk ISC, Ho J, Lam SK. The prevalence of
Helicobacter pylori carrier rates among the healthy blood donors in
Hong Kong. J H K Med Assoc, 1994, 46:295–8.
20. Crabtree JE, Taylor JD, Wyatt JI, et al. Mucosal IgA recognition of
Helicobacter pylori 120 kDa protein, peptic ulceration and gastric
pathology. Lancet, 1991, 338:332–5.
21. Covacci A, Censini S, Bugnoli M, et al. Molecular characterisation of the
128-kDa immunodominant antigen of Helicobacter pylori associated with
cytotoxicity and duodenal ulcer. Proc Natl Acad Sci (USA), 1993,
90:5791–5.
22. Crabtree JE, Wyatt JI, Sobala GM, et al. Systemic and mucosal humoral
responses to Helicobacter pylori in gastric cancer. Gut, 1993, 34:1339–
43.
23. Xiang Z, Bugnoli M, Ponzetto A, et al. Detection in an enzyme
immunoassay of an immune response to a recombinant fragment of the
128 kilodalton protein (CagA) of Helicobacter pylori. Eur J Clin Microbiol
Infect Dis, 1993, 12:739–45.
24. Ching CK, Wong BCY, Lam SK, et al. Prevalence of cytotoxin-producing
Helicobacter pylori (Helicobacter pylori) strains detected by the anti-
CagA assay (ACAA) among patients with peptic ulcer disease and controls
(abstract). Gastroenterol, 1995, 108:No.4 SS,pA 70.
25. Goodwin CS, Marshall BJ, Blincow ED, et al. Prevention of nitroimidazole
resistance in Campylobacter pylori by co-administration of colloidal
bismuth subcitrate: clinical and in vitro studies. J Clin Pathol, 1988,
41:207–10.
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Upper Gastrointestinal Abnormalities in the Elderly Helicobacter Pylori Carriers
5Upper Gastrointestinal Abnormalities inthe Elderly Helicobacter Pylori Carriers
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
INTRODUCTION
Helicobacter pylori infection has been demonstrated to be strongly
associated with chronic atrophic (type B) gastritis, peptic ulcer disease
and gastric cancer1,2. The risk of developing peptic ulcer in a
Helicobacter pylori carrier is about 5–14 times that of a non-carrier
over a period of 10–18 years3,4. Similarly, chronic Helicobacter pylori
infection also predisposes carriers to a significant increased risk of
gastric cancer when compared with the non-carriers; the risk is
approximately between 3–6 times higher5. However, there has been
very little evidence that these apply to the Chinese populations.
It is now widely accepted that therapy aiming at eliminating
Helicobacter pylori infection should be the first line treatment for cases
of Helicobacter pylori positive peptic ulcer disease because successful
eradication therapy significantly reduces peptic ulcer recurrence6–9. This
approach has been strongly endorsed by the recent National Institute
of Health consensus panel10. It is believed that dual therapy (one ulcer
healing agent plus one anti-microbial agent) is in general inferior to
triple therapy (one ulcer healing agent plus two anti-microbial agents)
in terms of achieving Helicobacter pylori eradication. However, the
evidence is very limited. Furthermore, the compliance and the side
effect profile are in direct proportion to the number of agents used.
76
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
There is preliminary evidence suggesting that one-week anti-Helicobacter
pylori therapy is as effective as two weeks therapy in eradicating the
organism11 which hopefully would improve the compliance rate. Thus,
there is still a lack of unanimous agreement on the combination therapy
regimen for this purpose. The two most important factors that determine
successful eradication of Helicobacter pylori are patient compliance
and bacterial resistance against metronidazole12,13. We are interested in
the efficacy of different anti-microbial cocktails in eliminating
Helicobacter pylori. The subjects who came for upper gastrointestinal
endoscopy examination on the voluntary basis were therefore entered
into this therapeutic study with their consent. A long term follow-up
at six-monthly intervals was also organized to assess the Helicobacter
pylori re-infection rate by the non-invasive 13C-urea breath test in those
who had successful eradication. Furthermore, we were interested in
the ultimate differential peptic ulcer and/or gastric cancer rates between
those who remained Helicobacter pylori free and those who became
infected by Helicobacter pylori.
METHODS
Study demography
The study population consisted of healthy subjects between the ages of
56 and 95 years. It formed part of the health check-up programme
organized jointly by the Society for the Aged and Rotary Club Hong
Kong Northwest. Members of community centres in nine districts were
invited to join the health check-up programme on a voluntary basis. The
whole programme consisted of measurement of body weight , height and
blood pressure, blood taking and electrocardiogram in the hospital
setting and questionnaire completed with the help of voluntary workers.
Blood sampling
Participants were arranged to come to the laboratory in Queen Mary
Hospital for venesection with their consent. Among the various tests,
antibody level against Helicobacter pylori was also determined by
using the GAP IgG ELISA (BIORAD) test kit according to the
manufacturer’s instruction. Internal standards were included as
77
Upper Gastrointestinal Abnormalities in the Elderly Helicobacter Pylori Carriers
reference. Antibody titre >20 units/ml was considered positive. This
assay was found in a pilot study by using 13C-urea breath test as the
gold standard to have a sensitivity of 100% and a specificity of 87.5%.
Interview
Subjects with a positive serum antibody test against Helicobacter pylori
were informed by the Society for the Aged through the community
centres. A standard letter with recommendations were issued to these
individuals. One of the options was individual consultation at Queen
Mary Hospital with a gastroenterologist. Those who wished to attend
the specially organized Helicobacter pylori clinic made their individual
arrangements. During the interview, questions were asked on upper
gastrointestinal symptoms, previous upper gastrointestinal investigations
and treatments if appropriate, consumption of non-steroidal anti-
inflammatory drugs (NSAID). Upper gastrointestinal symptoms were
broadly classified into two groups, those with epigastric pain suggestive
of ulcer and those suggestive of dysmotility (dyspepsia, bloating,
belching) or gastro-oesophageal reflux (acid regurgitation, heartburn,
odynophagia and/or dysphagia). All subjects who had attended the
interview were offered the service of a diagnostic upper endoscopy
examination on a voluntary basis.
Endoscopy examination
Written consents were obtained before the endoscopy. A diagnostic
upper endoscopic examination was carried out and biopsies were taken
from the duodenum (x2), the gastric antrum (x6) and corpus (x2).
They were all sent for histological examination except for four antral
biopsies which were used for a bedside urease test as well as for
culture and sensitivity testing for Helicobacter pylori infection. Subjects
were informed of the endoscopic finding afterwards by the endoscopist.
Treatment
Subjects with endoscopic lesions such as ulcers, severe erosions and
tumours were excluded from the long term follow-up study and treated
individually accordingly. Subjects with normal findings or gastritis
78
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
and/or duodenitis were randomized to receive either eradication therapy
or no treatment. There were six different eradication regimens used in
this study. All drugs were given for two weeks. Group 1 (AT) consisted
of amoxycillin 500 mg and tetracycline 500 mg four times a day. Group
2 (LCM) consisted of omeprazole (Losec) 20 mg twice daily, and
clarithromycin 250 mg and metronidazole 300 mg four times a day.
Group 3 (SCM) consisted of sucralfate 1gm, clarithromycin 250 mg
and metronidazole 300 mg four times a day. Group 4 (ACM) consisted
of augmentin 750 mg three times a day, and clarithromycin 250 mg
and metronidazole 300 mg four times a day. Group 5 (AC) consisted
of augmentin 750 mg three times a day and clarithromycin 250 mg
four times a day. Group 6 (ATM) consisted of amoxycillin 500 mg,
clarithromycin 250 mg and metronidazole 300 mg four times a day.
Subjects in no treatment group were given antacid tablets to be used
as required.
Subjects in the active treatment group were given an information
sheet in Chinese regarding the possible side effects and they were
advised to contact the endoscopy unit whenever significant adverse
reactions occur. Repeat endoscopy was performed four to six weeks
after completion of the treatment to document eradication of
Helicobacter pylori infection in the actively treated group. Their
compliance and the side effects were recorded. They were then followed
up at regular intervals, six-monthly, on a long term basis to check for
(a) re-infection by Helicobacter pylori and (b) the development of
peptic ulcer disease or gastric cancer. The no treatment group was
similarly followed up to detect the development of the latter.
RESULTS
Patient demography and upper gastrointestinal symptoms
Among the 1698 subjects tested for antibody against Helicobacter
pylori, 1226 (72.2%) had a positive result. There were 239 males and
987 females. The male to female ratio was approximately 1:4. All the
1226 Helicobacter pylori positive subjects were invited to attend the
Helicobacter pylori clinic for further advice. Up to April of 1995, a total
of 302 (24.6%) subjects had been interviewed. The service was still
available and on-going but late comers were not included in the present
analysis. Among the 302 subjects included in this analysis, 44 (14.6%)
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Upper Gastrointestinal Abnormalities in the Elderly Helicobacter Pylori Carriers
were male and 258 (85.4%) were female, giving rise to a male-to-female
ratio of approximately 1:6. Their ages ranged from 57 to 89.
One hundred and sixty-eight subjects (55.6%) reported a history
of having a variety of upper gastrointestinal symptoms. One hundred
and eight subjects had epigastric pain as the only symptom. One
hundred and eleven subjects had dyspepsia and related symptoms.
Fifty-eight subjects had both epigastric pain and dyspepsia. Only 14
subjects reported to have past history of epigastric pain which was no
longer present and four subjects reported to have dyspepsia in the past
only. The age of onset is shown in Table 5.1.
Among the 108 subjects having epigastric pain, the majority (65.8%)
had onset of pain at the age of 51–70; 42 subjects (38.9%) had onset
between 61–70, and 29 subjects (26.9%) had onset between 51–60.
Among the 111 subjects with dyspepsia, the majority (63.1%) had onset
of dyspepsia in the age of 51–70. Forty-eight subjects (43.2%) had onset
between 61–70, and 22 (19.8%) subjects had onset between 51–60.
Complications of peptic ulcer included acute upper gastrointestinal
haemorrhage and perforation. Twelve subjects (4%) had history of
ulcer bleeding. All were female and the mean age of the first attack of
ulcer bleeding was 58.6 (range 34 to 71) years old. In two of these
subjects, there was a history of regular non steroidal anti-inflammatory
drugs (NSAID) consumption. Three subjects had multiple episodes of
ulcer bleeding (mean 3, range 2–4). Eight subjects had investigations
done for the bleeding including two barium meal examination and six
upper endoscopy examinations. One of these three subjects had partial
gastrectomy after the first attack of ulcer bleed in 1970. The subsequent
recurrent ulcer bleed was managed conservatively by anti-ulcer therapy.
The other two patients only received periodic anti-ulcer medications
for their upper gastrointestinal bleeds. The rest were treated empirically
without any specific investigation performed. Only one subject (0.3%)
had a history of perforated peptic ulcer and had operation more than
ten years ago.
Table 5.1 Age of onset of epigastric pain and/or dyspepsia
21–30 31–40 41–50 51–60 61–70 71–80 > 8 0 Uncertain Total
Pain 3 7 1 9 2 9 4 2 1 1 1 1 6 1 0 8
Dyspepsia 2 1 1 5 2 2 4 8 1 2 1 1 0 1 1 1
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Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
Forty-seven subjects have been taking NSAIDs periodically
predominantly for minor arthralgia and/or arthritis. Approximately
60% (28/47) had upper epigastric pain and/or dyspepsia. Twenty-
three subjects had epigastric pain and 17 subjects had dyspepsia. Three
subjects gave a history of gastric ulcer but none had a history of
duodenal ulcer. Two subjects had a history of ulcer bleeding. While
eight subjects had been investigated before, only half of these subjects
had upper endoscopy examination; the other half had barium meal
examination ordered by their private practitioners.
Among the 168 symptomatic subjects, 72 subjects (42.9%) gave a
history of being investigated sometime ago elsewhere: 44 subjects had
barium meal examination, and 32 subjects had upper endoscopy
examination. Four subjects had both barium meal and endoscopy to
identify underlying upper gastrointestinal abnormality. There were ten
subjects who had multiple barium meal and/or endoscopy examinations.
Upper endoscopy examination
One hundred and seventy-five subjects had undergone upper endoscopy
examination in this study so far. The majority (62%, 108/175) were
symptomatic. Endoscopic findings among these subjects included
gastritis (n=72), duodenitis (n=15), gastric erosion (n=8), duodenal
erosion (n=8), gastric ulcer (n=5), duodenal ulcer (n=7), gastric ulcer
scar (n=2), duodenal ulcer scar (n=6), deformed duodenal bulb (n=12),
gastric polyp (n=4), gastric xanthoma (n=1) and normal findings in 84
subjects (Table 5.2). Among the five subjects with gastric ulcer, two
(40%) were completely asymptotic and two had a history of NSAID
ingestion. All the seven subjects with duodenal ulcer were symptomatic
and only one had a history of taking NSAID. Among the eight subjects
with gastric erosions, three were totally asymptomatic and two had a
history of consuming NSAID. Only 50% of the eight subjects with
duodenal erosions were symptomatic and two gave a history of taking
NSAID.
Among the 47 subjects taking NSAID, 32 had upper endoscopy
done. Findings included gastritis (n=15), gastric erosion (n=2), duodenal
erosion (n=2), gastric ulcer (n=2), duodenal ulcer (n=1), gastric ulcer
scar (n=1), duodenal ulcer scar (n=1), gastric polyp (n=1) and normal
examination in 11 subjects (Table 5.2). Thus, significant gastroduodenal
pathologies, ulcer and erosions were observed in about one-fifth (22%)
of these subjects who gave a history of regular or periodic NSAID
81
Upper Gastrointestinal Abnormalities in the Elderly Helicobacter Pylori Carriers
Table 5.2 Endoscopic findings
Whole group On NSAID
Gastritis 7 2 1 5Duodenitis 1 5 0Gastric erosions 8 2Duodenal erosions 8 2Gastric ulcers 5 2Duodenal ulcers 7 1Gastric ulcer scars 2 1Duodenal ulcer scars 6 1Deformed duodenal bulb 1 2 0Gastric polyps 4 0Gastric xanthoma 1 0Normal 8 4 1 1
Total 1 7 5 3 2
consumption. One subject with gastric ulcer was entirely asymptomatic.
The only subject with duodenal ulcer had recurrent epigastric pain for
over ten years.
Treatment efficacy, compliance and side effect profiles
The overall medication compliance, adverse effect and Helicobacter
pylori eradication rates were 56% (45/80), 68% (54/80) and 75%
(41/55) respectively (Table 5.3). The compliance rate was not dependent
on the number of drugs taken since 64% (18/28) and 52% (27/52) of
those taking dual and triple therapy respectively completed the course
of treatment as suggested (p>0.05). There were similarly no difference
in the prevalence of adverse effect events between the dual and triple
therapy treated groups (p>0.05). However, the overall Helicobacter
pylori eradication rate was significantly better in the triple therapy
group than the dual therapy one (86% vs 50%, p<0.025).
Side effects were very common which occurred in the majority
(68%) of all the elderly who took the medications. However, only
approximately 38% found them unbearable and the remaining 33%
only noticed very mild adverse effects. When we analysed according to
treatment groups, unbearable side effects occurred in 46%, 17%, 36%,
55%, 29% and 50% in groups AT, LCM, SCM, ACM, AC and ATM
82
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
respectively. The most prominent side effects were nausea, diarrhoea
and vomiting which did not seem to bear any relationship to the
number of drugs received (Table 5.4). Metronidazole containing
Table 5.4 Side effects of the anti-Helicobacter pylori treatment regimens
AT LCM S C M A C M A C ATM TOTAL
Nausea 5 2 3 4 1 4 1 9Diarrhoea 2 2 2 3 5 5 1 9Vomit 3 1 1 5 3 1 1 4Malaise 3 0 3 2 1 1 1 0dizziness 2 1 3 2 0 2 1 0Epigastric pain 1 0 3 1 4 1 1 0Poor appetite 4 1 1 0 0 3 9Epigastric discomfort 1 2 3 1 0 1 8Bitter taste 0 3 1 1 1 2 8Loose stool 2 1 1 1 0 1 6Hunger 2 0 0 0 0 0 2Sore throat 0 2 0 0 0 0 2Rash 1 0 0 0 1 0 2Palpitation 0 1 1 0 0 0 2Dyspepsia 0 1 1 0 0 0 2Headache 0 0 1 0 1 0 2
The side effects that occurred once were not listed (constipation, decrease urine output, sweating, legcramp, dry mouth, insomnia, bone pain, flatus).
Table 5.3 Results of eradication treatment
No. of subjects AT LCM S C M A C M A C ATM TOTAL
On treatment 1 3 1 3 1 5 1 1 1 5 1 3 8 0
Good compliance 7 1 0 8 3 1 1 6 4 5
Poor compliance 6 3 7 8 4 7 3 5
Side effect:Nil 2 5 5 0 6 4 2 2Mild 5 5 4 5 4 2 2 5Unbearable 6 2 5 6 4 6 2 9
Second Endoscopy 8 1 0 1 0 8 1 0 9 5 5
Default rate (%) 3 8 9 2 3 2 7 2 9 1 8 2 5
No. HP –ve 3 9 9 6 6 8 4 1
Eradication rate (%) 3 7 9 0 9 0 7 5 6 0 8 9 7 5
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Upper Gastrointestinal Abnormalities in the Elderly Helicobacter Pylori Carriers
regimens were no more likely than the non-metronidazole containing
regimens to give rise to nausea or any other symptoms. One subject
(1.3%) had acute colitis probably related to the treatment and two
subjects had skin rash which subsided after stopping the medications.
There was no treatment related hospitalization or mortality.
DISCUSSION
It has been well recognized that there is an increasing prevalence of
Helicobacter pylori infection in most communities because of the cohort
effect14. Hong Kong is no exception. We have re-confirmed our previous
findings15 of increasing Helicobacter pylori prevalence with age in this
study. In our previous healthy blood donor study, there was a lack of
elderly volunteers because on the whole very few elderly people were
willing to donate blood. The prevalence of upper gastrointestinal tract
symptoms in Helicobacter pylori carriers is extremely variable, with
reporting figures between 43–87% Helicobacter pylori positive rates
in the non-ulcer disease sufferers16. High prevalence of Helicobacter
pylori infection of 78% has been reported in elderly subjects with
non-ulcer dyspepsia17. In our current study of the elderly subjects, we
noticed 55% of the responders, all Helicobacter pylori positive, to be
symptomatic. This, however, might not represent the true prevalence
since the response rate to the questionnaire was only 25%. It might
have overestimated the prevalence. We suspected there was a self-
selection because those with symptoms would be more likely to respond
to the invitation.
It was interesting to note that approximately 16% of the subjects
that we interviewed consumed regular NSAID. The majority of these
subjects had little indications for NSAID treatment. The promiscuous
use of NSAID in the elderly age group was well known and was once
again confirmed in this study. Furthermore, 22% of the NSAID takers
were found to have gastroduodenal ulceration or erosions, and almost
another 50% of the subjects had evidence of NSAID related gastritis.
The alarmingly high percentage of upper gastrointestinal tract symptoms
as well as endoscopic abnormalities associated with NSAID ingestion
in the elderly means that we should be more careful in prescription
and consider prophylactic anti-ulcer therapy accordingly.
In this small series of endoscopic screening, we discovered 29
subjects (16%) with active or inactive gastroduodenal ulceration. This
84
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
was in line with previous observation of approximately 20%
asymptomatic peptic ulceration in necropsy series18,19. Our findings
were very similar to that observed in the Norwegian population20.
It is well known that the life time peptic ulcer disease is
approximately 10%21. Subjects with Helicobacter pylori infection has
been shown to have a significantly increased risk of developing peptic
ulcer disease, being 5–14 folds over a period of 10–18 years3,4. The
aim of our effort in setting up a randomized controlled study in these
elderly subjects was to examine if eradication therapy would
significantly reduce such a risk. Elderly subjects with complicated peptic
ulcer disease, for example bleeding peptic ulcer, are usually at
significantly higher risk of developing morbidity and mortality when
comparing to their younger counterparts. The potential benefit of such
an intervention would only be appreciated in due course.
It was noticed in this study that the compliance to the antibiotic
therapy was rather poor. Over one third (44%) of the subjects failed
to complete the course of antibiotics prescribed. This was attributed to
the side effects of the medications which occurred in about 68% of
those who were randomized to receive active medications. The overall
efficacy of these antibiotic cocktails was rather high (75%) with triple
therapies showing significantly superior eradication rates to the dual
therapies. The encouraging fact was that the side effect profiles were
not dependent on the number of drugs given in each cocktail, nor did
it bear any relationships with the type of antibiotics given.
It was concluded that asymptomatic peptic ulcer disease occurred
in the elderly population of Hong Kong. Inappropriate NSAID
prescription led to significant gastroduodenal inflammation and/or
ulcerations in a high proportion of NSAID takers. Clinicians should
be warned against the promiscuous use of such a hazardous drug. The
commonly used antibiotics against Helicobacter pylori were not very
well tolerated by the elderly. Thus, it affected the compliance and
ultimately the eradication rate. Future designs in the combination anti-
Helicobacter pylori therapy should take into consideration of these
unfavourable parameter. Until the ultimate modality of intervention,
that is vaccination, is available, we still strive to develop the ideal
cocktail for eliminating this organism from the stomach by further
therapeutic trials.
85
Upper Gastrointestinal Abnormalities in the Elderly Helicobacter Pylori Carriers
SUMMARY
We interviewed 302 elderly Helicobacter pylori carriers in Hong Kong.
Over half of them reported a history of having upper gastrointestinal
symptoms. Upper endoscopy examination was performed for 175
subjects and 52% of them had abnormal findings varying from
inflammation, old ulcer scars to erosions and ulcerations. Sixteen percent
of the subjects we interviewed consumed regular NSAID and a high
percentage of them had upper gastrointestinal symptoms and endoscopic
abnormalities. A low compliance rate of 56% in those receiving
eradication therapy can be attributed to the high adverse effect of the
prescribed medication (68%) on elderly subjects. The overall eradication
rate was 75%. Triple therapies showed significantly superior eradication
rates to the dual therapies. The study will continue to address the
issues of recurrence of Helicobacter pylori infection and the beneficial
effect of eradication therapy on ulcer and cancer prevention.
NOTES
1. Marshall BJ. Helicobacter pylori. Am J Gastoentorol, 1994, 89:S116–
28.
2. Fennerty MB. Helicobacter pylori. Arch Intern Med, 1994, 154:721–7.
3. Cullen DJE, Collins BJ, Christiansen KJ, Epis J, Warren JR, Cullen KJ.
Long term risk of peptic ulcer disease in people with Helicobacter pylori
infection — a community based study. Gastroenterol, 1993, 104:A60.
4. Sipponen P, Varies K, Fraki O, et al. Cumulative 10-year risk of
symptomatic duodenal and gastric ulcer in patients with or without
chronic gastritis: a clinical follow-up study of 454 outpatients. Scand J
Gastroenterol, 1990, 25:966–73.
5. Ching CK, Lam SK. Helicobacter pylori as an aetiological factor in
gastric cancer? Asian Cancer Bulletin, 1994, Vol.1 No.2, pp. 1&6.
6. Hosking SW, Ling TKW, Chung SCS, et al. Duodenal ulcer healing by
eradication Helicobacter pylori without anti-acid treatment: randomised
controlled trial. Lancet, 1994, 343:508–10.
7. Graham DY, Lew GM, Klein PD, et al. Effects of treatment of
Helicobacter pylori infection on the long-term recurrence of gastric or
duodenal ulcer. Ann Intern Med, 1992, 116:605–8.
8. Labenz J, Borsch G. Evidence for the essential role of Helicobacter pylori
in gastric ulcer disease. Gut, 1994, 35:19–22.
9. Sung JJY, Chung SSC, Ling TKW, et al. Antibacterial treatment of gastric
86
Benjamin Chun-yu WONG, Chi-kong CHING, Shiu-kum LAM
ulcers associated with Helicobacter pylori. N Engl J Med, 1995, 332:139–
42.
10. NIH Consensus. Helicobacter pylori in peptic ulcer disease. JAMA, 1994,
272:65–9.
11. Marshall BJ. Treatment strategies for Helicobacter pylori infection.
Gastroenterol Clin N Am, 1993, 22:183–98.
12. Graham DY, Lew GM, Malaty HM, et al. Factors influencing the
eradication of Helicobacter pylori with triple therapy. Gastroenterol,
1992, 102:493–6.
13. Rautelin H, Seppala K, Renkonen O, et al. Role of metronidazole
resistance in therapy of Helicobacter pylori infections. Antimicrob Agents
Chemother, 1992, 36:163–6.
14. Megraud F. Epidemiology of Helicobacter pylori infection. Gastroenterol
Clin N Am, 1993, 22:73–88.
15. Ching CK, Yuen ST, Luk ISC, Ho J, Lam SK. The prevalence of
Helicobacter pylori carrier rates among the healthy blood donors in
Hong Kong. J Hong Kong Med Assoc, 1994, 46:295–8.
16. Lambert JR. The role of Helicobacter pylori in non-ulcer dyspepsia. A
debate-For. Gastroenterol Clin N Am, 1993, 22:141–51.
17. O’Riordan TG, Tobin A, O’Morain C. Helicobacter pylori infection in
elderly dyspeptic patients. Age Ageing, 1991, 20:189.
18. Watkinson G. The incidence of chronic peptic ulcer found at necropsy.
Gut, 1960, 1:14–31.
19. Lindstrom CG. Gastric and duodenal ulcer disease in a well-defined
population. Scand J Gastroenterol, 1978, 13:139–43.
20. Bernersen B, Johnsen R, Straume B, Burhol PG, Jenssen TG, Stakkevold
PA. Towards a true prevalence of peptic ulcer: the Sorreisa gastrointestinal
disorder study. Gut, 1990, 31:989–92.
21. Lam SK, Hui WM, Ching CK. Peptic ulcer diseases — epidemiology,
pathogenesis, and aetiology. In: Bockus Gastroenterology (eds.
W.S.Haubrich, F. Schaffner, J.E. Berk), 5th edition 1994, 700–48.
87
Palpitations, Cardiac Arrhythmias and Their Associated Risk Factors in Ambulant Elderly
6Prevalence of Palpitations, Cardiac
Arrhythmias and Their Associated RiskFactors in Ambulant Elderly
Ngai-sang LOK, Chu-pak LAU
ABSTRACT
To determine the prevalence of palpitations, cardiac arrhythmias and
associated cardiovascular risk factors in an ambulatory elderly
population, 1454 ambulatory elderly people (219 males and 1235
females, age range 60–94 years) were assessed in a territory-wide health
survey including anthropometric measurements, biochemical blood tests,
questionnaire interview and resting surface ECG examination.
Prevalence of palpitations and ECG abnormalities were determined
and correlated with coronary risk factors and biochemical blood tests.
Palpitations were present in 364 subjects (23.6%) and cardiac
arrhythmias were found in 183 subjects (12.6%). Conduction
abnormalities and sinus bradycardia were the commonest findings
(9.8%). Premature beats (atrial 2.3%, ventricular 1%) were the next
most frequent arrhythmia. Atrial fibrillation was the commonest
sustained arrhythmia and was present in 19 subjects (1.3%). Compared
to those without arrhythmia on ECG, people with arrhythmias were
predominantly males and were older (72±8 years vs 70±6 years, p<0.05),
had a higher prevalence of smoking (12.9% vs 5%, p<0.05) and
coronary heart disease (30.7% vs 11.4%, p<0.05). The prevalence of
88
Ngai-sang LOK, Chu-pak LAU
palpitations between subjects with documented arrhythmias (excluding
conduction disturbance) and those without arrhythmias on surface
ECG was similar (9% vs 7.7%, p=NS). We concluded that cardiac
arrhythmias were common in the elderly and were often asymptomatic.
Subjects with ECG documented arrhythmias were more common in
males, and were associated with smoking and ischaemic heart disease.
Palpitation was a frequent complaint in the ambulatory elderly with
no bearing on arrhythmias recorded on resting ECG.
INTRODUCTION
Cardiac arrhythmias had been found to be common in apparently
healthy elderly people1,2. Apart from symptomatology, cardiac
arrhythmias had prognostic significance. Besides the adverse impact of
ventricular ectopics on survival in patients with prior myocardial
infarction3, atrial fibrillation in the elderly carried an increase risk of
cerebrovascular events4. Most previous studies assessed the prevalence
of cardiac arrhythmias in a limited number of subjects and were usually
based on the recordings of ambulatory ECG. On the other hand, the
prevalence of cardiac arrhythmias on the resting ECG, the most
commonly used cardiac investigation, had rarely been evaluated. In
addition, there was no data on the risk factor profile for the
development of cardiac arrhythmias, nor the prevalence of palpitations
in the general population. The prevalence of ECG abnormalities and
associated risk factors of cardiac arrhythmias in an ambulatory elderly
population were studied and described in this chapter.
SUBJECTS AND METHODOLOGY
Subject recruitment and the relevant demographic data have been
mentioned in the foregoing chapter. A total 1912 subjects responded
to the recruitment in the elderly centres where blood tests and other
anthropometric measurements were performed. They were then invited
to participate in the ECG examination and questionnaire interview
which were conducted in a regional hospital (Queen Mary Hospital) on
another occasion. Free bus services were provided from each of these
centres to the hospital, and 1454 subjects attended the second session.
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Palpitations, Cardiac Arrhythmias and Their Associated Risk Factors in Ambulant Elderly
Blood tests, anthropometric and blood pressuremeasurements
In the first session, the subjects attended the elderly centres after
overnight fasting for anthropometric, blood pressure measurements
and blood collection. These were performed by nurses and trained
medical technicians. Using a standing scale with a height attachment,
height and weight were measured with the subjects in light clothing
without shoes. Sitting blood pressure in duplicates were taken with a
sphygmomanometer after resting for at least 10 minutes. A total of 15
ml venous blood was then taken for the following tests: complete
blood picture, renal and liver functions, thyroid stimulation hormone
(TSH), free thyroxine (FT4) level, fasting glucose level and fasting
lipid profile. All the blood samples were processed within 2 hours and
subsequently analysed by the Department of Clinical Biochemistry,
Queen Mary Hospital, University of Hong Kong. Fasting glucose level
was determined by a hexokinase method (Hitachi 747, Boehringer
Mannheim, Germany). Total cholesterol was measured with an
enzymatical method (Hitachi 717 analyser).
Questionnaire study
Questionnaire interview was performed by trained third-year medical
students. The questionnaire consisted of questions on demographic
information, past and current smoking and drinking habits, history of
hypertension, coronary heart disease, diabetes mellitus and stroke, the
prevalence of these diseases in first degree relatives, use of medications
and dietary habit. The questions specifically relevant to the present
study included:
Palpitations
For subjects who claimed to have a history of palpitations, a custom-
designed questionnaire was used for further assessment (Table 6.1).
Palpitations were considered to be related to an abnormal rhythm if
its onset was sudden, and the rhythm was about one and a half time
faster than the usual rate. Other indications of pathological rhythms
were irregular beating and skipped beats.
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Ngai-sang LOK, Chu-pak LAU
Coronary heart disease
For subjects with chest discomfort or chest pain, the Rose questionnaire
for angina pectoris5 (Appendix 6.1) was used for further assessment.
Coronary heart disease was defined as a history of chest discomfort that
satisfied Rose criteria for angina pectoris: chest discomfort provoked
by exertion and relieved by resting. History of myocardial infarction
was suggested by severe chest pain for more than half an hour. In
addition, subjects with known history of coronary heart disease on
regular medications were also considered to have coronary heart disease.
Risk factors
Hypertension was defined as a history of treatment for hypertension
or a systolic blood pressure >160 mmHg and/or diastolic blood pressure
>95 mmHg. Diabetes mellitus was present if fasting blood sugar >7.8
mmol/L or if there was a known history. Smoking was defined as
current smoker smoking ≥6 cigarettes per day. Alcohol drinking was
Table 6.1 Questionnaire for evaluation of palpitations and the responses
No. (%) of positive answer
1 . Did you feel abnormal heartbeat? 3 6 4 (23.6%)If no, skip the following questions.
2 . Was your abnormal heartbeat related to:(a) exercise or manual labour 1 9 6 (13.4%)(b) psychological stress 2 6 1 (17.9%)(c) lying on the left side 4 9 (3.4%)
3 . When you felt abnormal heartbeat, is the rhythm:(a) regular 2 4 8 (17.1%)(b) irregular 1 1 6 (7.9%)
4 . The onset of abnormal heartbeat is:(a) sudden and immediately fast 2 6 7 (18.3%)(b) gradually from slow to fast 9 0 (6.2%)
5 . Did you feel ‘missed’ beat? 5 1 (3.5%)
6 . When you felt abnormal heartbeat, the heart rate is:(a) ≥150% of usual heart rate 1 2 1 (8.3%)(b) <150% of usual heart rate 1 6 4 (11.3%)(c) same as usual but stronger 7 7 (5.3%)
* Palpitations were considered to be pathological if the rhythm was irregular, the onset was sudden,or the heart rate was ≥150% of usual rate which was unrelated to exercise and psychologicalstress.
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Palpitations, Cardiac Arrhythmias and Their Associated Risk Factors in Ambulant Elderly
considered significant when the subject had over 1/2 catty of white
wine (about 60g alcohol) every day.
ECG examination
A resting 12-lead surface ECG was recorded using a standardization
of 1 mV=10 mm and a paper speed of 25 mm/sec. In addition to a 12-
lead strip of 4 cardiac cycles per lead, a 30 sec tracing of lead I, II and
III was also recorded. All ECG recordings were processed by recorders
with automatic analysis (Cardiofax V, Nihon Kohden, Japan) and
then reviewed by two separate doctors. Abnormal ECG findings were
classified according to the Minnesota Code criteria6. Arrhythmias were
categorized as premature atrial, nodal, or ventricular beats (code 8.1),
ventricular tachycardia (code 8.2), atrial fibrillation or flutter (code
8.3), supraventricular tachycardia (code 8.4), first degree heart block
(code 6.3), left bundle branch block (code 7.1), and right bundle
branch block (code 7.2).
DATA AND STATISTICAL ANALYSIS
To evaluate the relationship between thyroid function and lipid profile
and the prevalence of documented arrhythmias, the results of ECG
examination and questionnaire interview were correlated to the total
cholesterol and thyroxine level. Coronary risk factors in people with
and without arrhythmias were assessed by chi-square test. One way
analysis of variance was used to reveal the frequency of age, thyroid
function and cholesterol level between subjects with atrial fibrillation
and other arrhythmias. Clinical and biochemical characteristics of
subjects with arrhythmia and those with normal ECG were compared
by unpaired t test. All results were expressed as mean ± 1 SD. The
difference was considered to be statistically significant when p value
was less than 0.05.
RESULTS
Three hundred and sixty-four subjects claimed to have palpitations.
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Palpitations, Cardiac Arrhythmias and Their Associated Risk Factors in Ambulant Elderly
Table 6.2 Cardiac arrhythmias detected by resting ECG in 183 elderly subjects
Arrhythmias No. (percentage)
Conduction disturbance:
Sinus bradycardia 3 3 (18.0%)
First degree heart block 5 1 (27.9%)
Wenckebach AV block 1 (0.5%)
Right bundle branch block 5 1 (27.9%)
Left bundle branch block 9 (4.9%)
Atrial premature beats 3 3 (18.0%)
Ventricular premature beats 1 6 (8.7%)
Atrial fibrillation 1 9 (10.4%)
Atrial tachycardia 2 (1.0%)
The prevalence of palpitations in subjects with documented
arrhythmias and those without documentation was similar (Figure 6.2).
The prevalence of palpitations was not affected even after exclusion of
subjects with conduction disturbances which were considered unlikely
to cause symptoms. Subjects with atrial fibrillation were older than
Table 6.3 Prevalence of risk factors in subjects with documented arrhythmiasand subjects without arrhythmia documented on surface ECG
Arrhythmias Arrhythmia P value(documented) (not documented)
No. of subjects 1 8 3 1 2 7 1 —
Age (years) 7 2± 8 7 0± 6 <0.05
Sex : male/female 4 9 / 1 3 4 1 7 0 / 1 1 0 1 <0.05
Smoking 12.9% 5% <0.05
Drinking 1.1% 0.6% N S
Hypertension 37.1% 33.8% N S
C H D 30.7% 11.4% <0.005
Diabetes mellitus 19.4% 13.7% N S
C V A 4.3% 3.4% N S
Cholesterol (mmol/L) 6.2± 1.1 6.1± 1.1 N S
FT4 (pmol/L) 0.8± 0.3 0.4± 0.1 N S
CHD = coronary heart disease; CVA = cerebrovascular accident; FT4 = free thyroxine level.
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Palpitations, Cardiac Arrhythmias and Their Associated Risk Factors in Ambulant Elderly
ambulatory ECG. Another study reported a high incidence of sinus
bradycardia (89%) but only 2 subjects (2%) had marked sinus
bradycardia (<40 beats per minute)2. Using ambulatory ECG recording,
this high incidence was related to the recording of resting and sleeping
period of the day. We observed a lower incidence of sinus bradycardia
and a similar incidence of conduction disturbance on the resting ECG
which was taken in the alert period of the day. Atrial premature beats
have been shown to be fairly common (5–15%) in elderly people1,9.
Similarly, atrial tachycardia was rare in most studies1,2,6. A lower
incidence of ventricular premature beats were observed in the present
study compared with the results of ambulatory ECG study (12–17%)2,9.
Since 24-hour ECG was more effective in detecting non-sustained
arrhythmias, the true prevalence of arrhythmias might be higher than
what we found. In this health survey, only resting ECG was performed
due to limited resource. Nevertheless resting ECG was still the most
commonly used method in routine cardiac investigation.
Our finding that 1.2% of subjects had atrial fibrillation was
comparable with the result of an earlier study showing atrial fibrillation
in 1.1% of the subjects aged more than 60 on resting ECG. A higher
incidence (3–10%) was reported with ambulatory ECG monitoring
which included patients with paroxysmal atrial fibrillation1,7. In the
Framingham study10, chronic atrial fibrillation was found to be related
to diabetes mellitus and hypertension. Similar associations were not
detected in this study based on ambulant subjects, but such associations
were found in patients admitted with atrial fibrillation in an in-hospital
study in the same locality11. This may suggest the presence of
hypertension and diabetes mellitus might predispose to more severe
symptoms or complaint in patients with atrial fibrillation. On the
other hand, a higher prevalence of stroke was present in patients with
documented atrial fibrillation compared with those with other
arrhythmias.
Previous studies seldom addressed the associated coronary risk
factors of cardiac arrhythmias, especially in an active elderly population.
However, the relation between ventricular arrhythmia and coronary
risk factors have been studied in younger subjects between 35 to 57
years12, ventricular premature beats have been shown to be strongly
associated with the level of systolic blood pressure and increasing age,
but not related to smoking and serum cholesterol level. We have
documented that in the elderly subjects, arrhythmias occurred more
often in males, smokers and those with the presence of coronary heart
disease.
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Ngai-sang LOK, Chu-pak LAU
Prevalence of palpitations and its relationship to arrhythmia have
not been systematically studied in population survey in elderly. Among
98 subjects aged 60–65 years receiving Holter monitoring, only four
subjects complained of palpitations and a correlating arrhythmia was
revealed in two of them2. In another study, it was found that sustained
asymptomatic atrial fibrillation occurred far more frequently than
symptomatic atrial fibrillation13. None of these studies used well defined
criteria for palpitations which might be a non-specific complaint. We
found that palpitations occurred in a substantial proportion of the
elderly (364/1454, 23.6%), and could be considered pathological in
121/1454 subjects (8.3%). Even then, the frequency of palpitations
considered pathological in subjects with documented arrhythmias were
similar to those without. This confirmed that a large percentage of
arrhythmias were asymptomatic, and resting ECG documentation of
arrhythmias abnormalities had little bearing on the prevalence of
palpitations. Other methods of documentation such as event recordings
might be better tools for elucidation of a potential arrhythmic cause of
palpitations compared to either Holter or ECG recordings.
CONCLUSION
Cardiac arrhythmia was a common finding in the active elderly. The
incidence of arrhythmia and atrial fibrillation increased with advancing
age. Palpitation was a common complaint in active, independent elderly
people (23.6%), although only one-third of them was considered to
have a likely arrhythmic cause from the history. Documented cardiac
arrhythmias on a 12 lead ECG was present in 12.6%, and including
conduction disturbance, sinus bradycardia and atrial premature beats,
the commonest sustained arrhythmia was atrial fibrillation. The male
sex, advancing age, smoking and ischaemic heart disease were risk
factors for arrhythmia. Arrhythmias on the resting ECG had little
bearings on the cause of palpitations.
NOTES
1. Camm AJ, Evans KE, Ward DE, Martin A. The rhythm of the heart in
active elderly subjects. Am Heart J, 1980, 99:598–603.
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Palpitations, Cardiac Arrhythmias and Their Associated Risk Factors in Ambulant Elderly
2. Fleg JL, Kennedy HL. Cardiac arrhythmias in a healthy elderly population.
Detection by 24 hour ambulatory electrocardiography. Chest, 1982,
81:302–7.
3. Kostis JB, Byington R, Friedman LM, Goldstein S, Furberg C. Prognostic
significance of ventricular ectopic activity in survivors of acute myocardial
infarction. J Am Coll Cardiol, 1987, 10:231–42.
4. Kalman JM, Tonkin AM. Atrial fibrillation: epidemiology and the risk
and the prevention of stroke. PACE, 1992, 15:1332–46.
5. Rose GA. The diagnosis of ischaemic heart pain and intermittent
claudication in field surveys. Bull World Health Organization, 1962,
27:645–58.
6. Blackburn H, Keys A, Simonson E, Rautaharju P, Punsar S. The
electrocardiogram in population studies. A classification system.
Circulation, 1960, 111:1160–76.
7. Manolid TA, Furberg MCD, Rautaharju PM, Siscovick D, Newman AB,
Borhani NO, et al. Cardiac arrhythmias on 24–h ambulatory
electrocardiography in older women and men: the cardiovascular health
study. J Am Coll Cardiol, 1994, 23:916–25.
8. Bjerregaard P, Ingerslev J. Prevalence and prognostic significance of cardiac
arrhythmias detected by ambulatory electrocardiography in subjects 85
years of age. Eur Heart J, 1986, 7:570–5.
9. Kennedy HL, Whitlock MPH, Sprague MK, Kennedy LJ, Buckingham
TA, Goldberg RJ. Long-term follow-up of asymptomatic healthy subjects
with frequent and complex ventricular ectopic. N Engl J Med, 1985,
312:193–7.
10. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiological
features of chronic atrial fibrillation: the Framingham study. N Engl J
Med, 1982, 306:1018–22.
11. Lok NS, Lau CP. Presentation and management of patients admitted
with atrial fibrillation: a review of 291 cases in a regional hospital. Int J
Cardiol, 1995, 48:271–8.
12. Crow RS, Prineas RJ, Dias V, Taglor HL, Jacobs D, Blackburn H.
Ventricular premature beats in a population sample. Frequency and
associations with coronary risk characteristics. Circulation, 1975, 51:211–
6.
13. Page RL, Wilkinson WE, Clair WK, McCarthy EA, Pritchett ELC.
Asymptomatic arrhythmias in patients with symptomatic paroxysmal
atrial fibrillation and paroxysmal supraventricular tachycardia.
Circulation, 1994, 89:224–7.
9 9
Prevalence of Coronary Heart Disease and Associated Risk Factors in Ambulant Elderly
7Prevalence of Coronary Heart Disease and
Associated Risk Factors in AmbulantE l d e r l y
Chu-pak LAU, Ngai-sang LOK
ABSTRACT
Background
Coronary heart disease (CHD) is the commonest cardiovascular disease
and is associated with substantial mortality and morbidity. In Hong
Kong, it has emerged as the top killer in recent years. However, the
existing epidemiological information of CHD is mainly based on in-
hospital statistics. The aim of this study was to evaluate the prevalence
of CHD, associated risk factors, lipid profile and ischaemic
electrocardiographic changes related to ischaemia in active elderly. In
addition, the relationship between dietary habit, lipid profile and
prevalence of CHD was also addressed.
Methods and results
A total of 1480 elderly people from seven elderly centres were
interviewed for CHD which was defined as positive results in Rose
questionnaire for angina, known history of CHD, or regular use of
1 0 0
Chu-pak LAU, Ngai-sang LOK
relevant medications. Biochemical blood tests including renal, liver
and thyroid functions, fasting blood sugar level and lipid profile and a
12 lead surface electrocardiogram (ECG) were performed. The
questionnaire interview included questions about family and personal
health history, use of medications, smoking, dietary habit and quality
of life. Among the 1454 elderly people with complete data, CHD was
diagnosed in 208 subjects (14.3%) and 100 subjects had symptom of
angina. According to the Minnesota code criteria, ischaemic change
on resting ECG was revealed in 11% of the subjects with CHD and
5.8% of subjects without CHD respectively. Associated risk factors
included smoking, diabetes mellitus and family history of CHD. Stroke
was found to be significantly related to CHD. There was no significant
difference in the age, body weight, and lipid profile (triglyceride, total
cholesterol, HDL- and LDL-cholesterol level) of subjects with CHD
compared to those without CHD. The triglyceride level was higher in
the elderly who had a dietary habit of regular high fat and cholesterol
intake than those who did not have that dietary habit (1.75±3.5 mmol/L
vs 1.49±0.8 mmol/L, p<0.05), while the cholesterol level and the
prevalence of CHD were similar in both groups (18.1% and 15.7%
respectively). Different cooking methods did not have any effect on
lipid level and the prevalence of CHD.
Conclusion
CHD was a common disease in active elderly. Associated risk factors
for CHD included smoking, diabetes mellitus and family history of
CHD while stroke was the significantly associated disease. In people
over the age of 60 years old, the prevalence of CHD was independent
of age, body weight, hypertension and cholesterol level. Ischaemic
ECG change by definition was more common in subjects with CHD.
Regular intake of high fat and cholesterol food resulted in higher
triglyceride level.
INTRODUCTION
CHD is a world-wide leading cardiovascular disease due to
atherosclerosis of the coronary arteries. It draws a lot of concern not
only because of the increasing incidence, but also because reason that
1 0 1
Prevalence of Coronary Heart Disease and Associated Risk Factors in Ambulant Elderly
patients with CHD may have the potential risk of sudden death. In
Hong Kong, cardiovascular disease has been reported to be the second
commonest cause of death next to cancer since the 1960s and the
mortality of CHD has nearly doubled in the last two decades. When
diseases are courted as a single entity, CHD is now the first killer
disease in Hong Kong1.
CHD increases with age. According to the census in 1991, the
proportion of elderly people was increasing over the last ten years,
reaching 8.7% in 19912. Unfortunately, up to now, most data about
CHD available have been derived from hospitalization and mortality
rate, while little is known about its prevalence in the elderly population
at large, especially among the active elderly. The major risk factors for
CHD has been well described for a long time but whether they are
applicable for local elderly people has not been assessed. In this study,
we also attempted to find out whether dietary habit might have an
influence on lipid profile, and the prevalence of CHD.
SUBJECTS AND METHODS
Subject recruitment and the demographic data were discussed in
Chapter 1. In brief, subjects turned up in the recruitment centres for
fasting blood analysis, anthropological and blood pressure
measurements. Most of them participated in a detailed questionnaire
and ECG examination in the Queen Mary Hospital, University of
Hong Kong within three months of the first visit.
Fasting blood samples
Fasting lipid profile (triglyceride, total cholesterol, HDL- and LDL-
cholesterol level) and fasting blood sugar were checked in the
biochemical blood tests.
Anthropological measurement
During the blood taking session, blood pressure was measured in
duplicates after the participants had settled down for at least five
minutes. In addition, body weight and height were recorded.
1 0 2
Chu-pak LAU, Ngai-sang LOK
ECG examination
Resting ECG examination included both a 12 lead strip and a 30s
tracing of lead I, II and III. All were recorded at a paper speed of 25
mm/sec with a standardization of 1 mV=10 mm. After manual revision,
the tracings were categorized by the Minnesota code system3 and
subjects with a Q wave suggesting myocardial infarction (code 1.1–
1.2), ST depression (code 4.1–4.3) or negative T wave (code 5.1–5.3)
were classified as having ischaemic ECG changes.
Questionnaire
Questionnaire interview was performed by trained volunteers who
were third-year medical students. Questions relevant to CHD and the
risk factors included: (1) past history of hypertension, CHD, diabetes
mellitus and stroke, and the prevalence of these diseases in first degree
relatives; (2) Rose questionnaire for evaluating subjects with chest
discomfort (Appendix 7.1). Angina pectoris angina was considered if
chest discomfort was provoked by exertion, relieved by resting, and
the site included either the sternum or the anterior chest and the left
arm4. History of myocardial infarction was suggested by serious chest
pain lasting for 30 minutes or longer. In addition, dietary habits which
were considered to indicate a high fat intake such as: place where food
was taken (restaurant, fast food shop and at home), preference of high
fat and cholesterol food (e.g. animal fat, meat and offal), and the
nature of cooking methods (frying, steaming and boiling) were enquired
with a questionnaire designed by the Dietetic Department, Queen Mary
Hospital.
DEFINITIONS OF TERMS
CHD was diagnosed by the result of questionnaire interview, including
angina pectoris as defined by Rose questionnaire, known history of
CHD or long-term use of anti-anginal medications. Hypertension was
presented by history of treatment for hypertension or a systolic blood
pressure ≥160 mmHg and diastolic blood pressure ≥95 mmHg
respectively. Diabetes mellitus was present if there was a history of
treatment or fasting blood sugar >7.8 mmol/L. Stroke was defined by
1 0 3
Prevalence of Coronary Heart Disease and Associated Risk Factors in Ambulant Elderly
known history. Whether the subject was current smoker or had history
of CHD in first degree relative was asked in the different parts of the
questionnaire. High cholesterol intake was considered if the subject
regularly took (more than once weekly) high fat and cholesterol food.
STATISTICAL ANALYSIS
An unpaired t test was used to compare the age, body mass index,
blood pressure and lipid profile of subjects with and without CHD,
and to compare the lipid profile and the prevalence of CHD in subjects
who had a higher cholesterol intake with others. The relation between
smoking, hypertension, diabetes mellitus, history of CHD in first degree
relatives and CHD, and the association of ischaemic ECG changes and
CHD were assessed by chi-square analysis. All results were expressed
as mean ± SD and a p value less than 0.05 was considered to be
statistically different.
RESULTS
Prevalence of CHD and associated risk factors
A total of 1912 elderly people attended the centres for blood taking
and anthropological measurements. Of these subjects, 1480 people
attended the second session for questionnaire and 1595 subjects had
ECG examination. A total of 1451 persons (98%) had complete data
(blood tests, questionnaire, and ECG) for analysis. The population
sample had 255 men and 1225 women with a mean age of 70.9 years
in men and 70.6 years in women. CHD was found in 208 subjects (32
males and 176 females). Their mean age was similar to those without
CHD (70.2±6.7 years vs 70.8±6.2 years, p=NS). Figure 7.1 shows the
percentage of subjects with CHD in different age groups. Ischaemic
changes on resting ECG was present in 11% of the subjects with CHD
and in 5.8% of the subjects without. Among those with CHD, 100
subjects had symptom of angina. Compared with subjects without
evidence of CHD, subjects with CHD so diagnosed showed a higher
frequency of smoking, diabetes mellitus, family history of CHD and
stroke, while no effect of body weight and hypertension on CHD had
1 0 5
Prevalence of Coronary Heart Disease and Associated Risk Factors in Ambulant Elderly
Dietary habit, lipid profile and CHD
The dietary pattern of elderly people were shown in Table 7.3. Most of
the elderly people had their meals at home. A high intake of high fat and
cholesterol was present in 31% of the subjects. This resulted in a higher
triglyceride level compared with that of those who less commonly had
that kind of food. However, the cholesterol level was unchanged
(Table 7.4) and the prevalence of CHD was similar in both groups
(18.1% and 15.7%, p=NS). Some cooking methods such as frying or
shuffle with oil were considered to have a risk of increasing fat and
cholesterol intake. The result turned out that the frequency of using
these methods had no effect on lipid profile and the prevalence of CHD.
DISCUSSION
Main findings
This study with a population predominantly consisting of elderly female
documented that CHD was associated with smoking, diabetes mellitus,
Table 7.3 The dietary pattern of elderly people —usual place where food is taken
Restaurant Fast food shop At home
Breakfast 30.9% 1.6% 67.5%
Lunch 5.0% 2.4% 92.6%
Dinner 2.0% 0.6% 97.4%
Table 7.4 The effect of dietary habit on lipid profile in elderly people
Regular high Seldom/occasional P valuecholesterol intake high cholesterol intake
TG (mmol/L) 1 .75± 3.5 1.49± 0.8 <0.05
Chol (mmol/L) 6 .21± 1.0 6.17± 1.2 N S
HDL-Chol (mmol/L) 1 .39± 0.3 1.41± 0.4 N S
LDL-Chol (mmol/L) 4 .37± 4.3 4.10± 1.0 N S
* TG = triglyceride; Chol = cholesterol
1 0 6
Chu-pak LAU, Ngai-sang LOK
family history of CHD and stroke, but was not significantly related to
body mass, hypertension and lipid level. The level of cholesterol was
comparable to the level of the general population. Significant fat
consumption occurred in the elderly resulting in a high triglyceride
level, although the relationship to CHD was unclear.
Prevalence of CHD
Since the prevalence of CHD in local ambulatory elderly had rarely
been assessed, it was difficult to compare the local prevalence (14.3%)
with previous data. The exact sex ratio of CHD was not revealed in
this study due to the predominance of female participants. It was well
known that the incidence of CHD increased with advancing age.
However, in our population, the prevalence of CHD was not affected
by age. This result probably should be separated from the in-hospital
data that included more serious cases. In addition, due to the voluntary
recruitment nature of this study, the sickly individual may not be able
to attend.
Risk factor for CHD
Our study showed that body weight was not related to CHD. The
result may be that the body mass index of most subjects was within
normal range (20–25) and obesity (body mass index >30) was only
present in 2% of males and 6% of females. After excluding the ex-
smokers, smoking was still significantly associated with CHD. This
finding was compatible with the result of another study in which the
incidence of CHD was reduced by smoking cessation5. However, there
was no correlation between number of cigarette smoked and CHD.
Different studies6,7 has demonstrated that hypertension increased
the mortality rate of CHD. In the Framingham study, risk of developing
CHD increased with the severity of hypertension, irrespective of age
or sex8. In this study, we found that the prevalence of hypertension in
subjects with and without CHD was not statistically different, although
there was a trend toward a higher prevalence in people with CHD.
Whether this reflects a methodological or ethnically related problem
remained to be classified.
Apart from smoking, diabetes mellitus and family of CHD have
been shown to be the risk factors for CHD. In a similar community-
1 0 7
Prevalence of Coronary Heart Disease and Associated Risk Factors in Ambulant Elderly
based study for people aged 65 years and above, people with history
of diabetes mellitus were found to have an increased CHD mortality9.
Family history of CHD might indicate the subjects could be affected
by similar risk factors, but whether it had any other implications (for
example, genetic determinant) needed further investigation. On the
other hand, our finding that significant association between CHD and
stroke has not been evaluated in other studies.
Although several studies have shown that serum cholesterol is
positively associated with the risk of CHD in the elderly10,11, similar
relationship between lipid profile and CHD did not appear in this
study. In addition, the mean total cholesterol level in the subjects with
and without CHD was unexpectedly high when compared with the
age-adjusted mean serum cholesterol of 5.0–5.7 mmol/L in previous
surveys carried out in Hong Kong12,13, although in those reports the
population of the elderly was very limited.
Dietary habit and its relation to lipid level and CHD
Serum lipid level is associated with a high dietary cholesterol intake,
and diet control is the first line of treatment for lipid lowering. On the
other hand, influence of local Chinese dietary patterns in the risk for
CHD is unknown. The only positive result in our study on diet and
CHD was that regularly taking high fat and cholesterol food resulted
in a comparative higher triglyceride level. A more scientific method
assessing the intake of cholesterol such as detailed food analysis is
required before a conclusion can be drawn. But the lack of association
with high cholesterol and CHD probably preclude a relationship
between CHD and diet. However, in another survey, it has been found
that people with a higher prevalence of CHD purchased more high
cholesterol food than others14. The last finding that no significant
association between different cooking methods and lipid profile might
be related to the fact that most subjects prepared food with peanut oil
or vegetable oil rather than animal oil.
There were two limitations in this study. First, since the participants
were mainly the elderly who actively joined social programmes, self-
selected bias was unavoidable. Second, the interpretation of the data
might be affected by the imbalance of male and female ratio.
1 0 8
Chu-pak LAU, Ngai-sang LOK
CONCLUSION
In active elderly, CHD was a common disease and the risk factors
included smoking, diabetes mellitus, family history of CHD and stroke.
There was no significant association between CHD and age, body
weight, hypertension and lipid profile. The mean cholesterol level in
subjects with and without CHD was above normal reference. Ischaemic
change on resting ECG was a common finding in subjects with CHD.
Serum cholesterol level and prevalence of CHD were not affected by
regular high cholesterol intake, although this might result in a higher
triglyceride level. Preparing food by frying, boiling or steaming resulted
in no significant difference in lipid profile.
NOTES
1. Public health report 1994. Chapter 2: Coronary heart disease in Hong
Kong. Hong Kong: Department of Health, 14–32.
2. Hong Kong 1992: A review of 1991. In: Chapter 23, Population and
immigration, 364–71.
3. Blackburn H, Keys A, Simonson E, Rautaharju P, Punsar S. The
electrocardiogram in population studies. A classification system.
Circulation, 1960, 111:1160–76.
4. Rose GA. The diagnosis of ischaemic heart pain and intermittent
claudication in field surveys. Bull World Health Organisation, 1962,
27:645–58.
5. Tosteson AN, Weinstein MC, Williams LW, et al. Long-term impact of
smoking cessation on the incidence of coronary heart disease. Am J
Public Health, 1990, 80:1481–6.
6. Fletcher A, Bulpitt C. Epidemiology of hypertension in the elderly. J
Hypertens Suppl, 1994, 12:S3–5.
7. Higgins M, Thom T. Trends in CHD in the United States. International
J of Epidemiology, 1989, 18:S58–66.
8. Kannel WB. Office assessment of coronary candidates and risk factor
insights from the Framingham study. J Hypertens Suppl, 1991, 9:13–9.
9. Seeman T, Mendes de Leon C, Berkman L, et al. Risk factors for coronary
heart disease among older man and women: a prospective study of
community-dwelling elderly. Am J Epidemiol 1993, 138:1037–49.
10. Sorkin JD, Andres R, Muller DC, et al. Cholesterol as a risk factor for
coronary heart disease in elderly men. The Baltimore Longitudinal Study
of Aging. Ann Epidemiol, 1992, 2:59–67.
1 0 9
Prevalence of Coronary Heart Disease and Associated Risk Factors in Ambulant Elderly
11. Fletcher AE, Bulpitt CJ. Epidemiological aspects of cardiovascular disease
in the elderly. J Hypertens Suppl, 1992, 10:51–8.
12. Woo J, Ho SC, Lau J, Yuen YK, Chan SG, Masari J. Cardiovascular
disease, electrocardiogram abnormalities and associated risk factors in
an elderly Chinese population. Int J Cardiol, 1993, 42:249–55.
13. Fong PC, Tam S, Tai YT, Lau CP, Lee J, Sha YY. Epidemiologic studies
of the serum lipids and apolipoproteins in Hong Kong Chinese:
demographic characteristics and serum lipid and apolipoprotein
distributions. Journal of Epidem and Community Medicine, 1994, 48:356–
61.
14. Lip GYH, Malik I, Luscombe C, McCarry M, Beevers G. Dietary fat
purchasing habits in whites, blacks and Asian peoples in England —
implications for heart disease prevention. Int J Cardiol, 1995, 48:287–
93.
1 1 1
Lipids, Lipoproteins and Other Biochemical and Haematological Parameters in Elderly
8Lipids, Lipoproteins and Other Biochemicaland Haematological Parameters in Elderly
Ambulant Hong Kong Subjects
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
ABSTRACT
Blood samples taken from 1992 elderly Hong Kong subjects, aged 60–
93 years, were analyzed for the common automated biochemical and
haematological parameters. Reference ranges were determined for both
males and females and for each sex decade in both sexes. The major
findings from the 1525 women and 362 men for whom adequate data
was available were: (1) biologically and statistically significant sex
differences for creatinine, phosphate, alkaline phosphatase, gamma
glutamyl transferase and urate; (2) increases in creatinine with age in
both sexes and also of urea and urate (statistically significant in females);
(3) significant male/female differences in body mass index (BMI) and
HDL cholesterol; (4) an age related decrease in BMI in women; (5)
mean cholesterols of 5.9 and 6.2 mmol/L respectively, similar to levels
found in the USA in 1976–80 surveys; (6) male/female differences in
red cell and white cell count, haemoglobin, haematocrit, mean
corpuscular volume and mean corpuscular haemoglobin, as occur in
younger individuals, but no age effects. These findings indicated the
need for using sex and/or age related reference ranges for at least a
number of these parameters in clinical practice.
1 1 2
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
SUBJECTS
All 1992 subjects aged 60–93 years had a blood sample taken after an
overnight fast of 12 hours. Not all assays were performed on all
subjects. Subjects attended one of seven centres and blood was taken
at any one centre on a specific day and processed on the same day
(and evening) at the laboratory of the Department of Clinical
Biochemistry, Queen Mary Hospital. Thus there were seven different
sessions of blood taking and seven corresponding sessions for
biochemical analysis. The duration of tourniquet application was not
specified and might have been prolonged in some cases due to difficulties
in obtaining an adequate volume of blood. This might affect the final
results, particularly for calcium which be might elevated if there was
prolonged venous stasis.
METHODS
Blood samples were drawn into lithium heparin, thixotropic gel tubes
for measurements of TSH, urate, and for electrolyte, renal and liver
function test profiles; into fluoride oxalate tubes (1 mg/ml) for fasting
glucose assays; into EDTA tubes (1 mg/ml) for cholesterol, triglyceride
and HDL cholesterol estimations, and into EDTA tubes for
haematological tests.
Blood samples were centrifuged on the same day for 10 minutes at
1500 g prior to aliquoting and analysis. Measurements of urate,
electrolytes, renal and liver function tests were made on the plasma
supernatant on the red cells under the thixotropic gel using primary
sample tubes on a Hitachi 747 random access analyzer (Boehringer
Mannheim, Germany). The methods used (Table 8.1) were those in
daily use in the Department of Clinical Biochemistry, Queen Mary
Hospital, the 1300-bed main teaching hospital of the University of
Hong Kong. The laboratory participates in the Murex External Quality
Control programme as well as having its own internal quality control
programmes. Glucose was measured on fluoride oxalate plasma on
the same Hitachi 747 analyzer, using the hexokinase method.
Cholesterol and triglycerides were measured on a Hitachi 717 analyzer
(Boehringer Mannheim, Germany) using the cholesterol oxidase and
lipase/glycerol kinase methods. HDL cholesterol was measured by the
1 1 3
Lipids, Lipoproteins and Other Biochemical and Haematological Parameters in Elderly
same cholesterol oxidase method after precipitation of the
apolipoprotein B containing lipoproteins (VLDL and LDL) with
polyethylene glycol (PEG 6000). LDL-cholesterol was calculated
according to the Friedewald equation. The laboratory participates in
the RCPA/AACB quality programmes for lipids and lipoproteins. TSH
was measured by a sensitive TSH assay (microparticle capture
immunoassay) using the Abbott ACS 180 random assess analyzer. The
laboratory participates in the Murex Quality assurance programmes
for TSH.
Table 8.1 Methods used
Analyte Instrument Method
Sodium 7 4 7 Ion selective electrode
Potassium 7 4 7 Ion selective electrode
Calcium 7 4 7 Cresolphthalein complexone
Chloride 7 4 7 Ion selective electrode
Urea 7 4 7 Urease/kinetic
Creatinine 7 4 7 Alkaline picrate
Phosphate 7 4 7 Phosphomolybdate reduction
Total bilirubin 7 4 7 Sulphanilic acid
Direct bilirubin 7 4 7 Sulphanilic acid
Total protein 7 4 7 Biuret
Albumin 7 4 7 Bromocrescol green
Globulin Calculated
Alkaline phosphatase 7 4 7 p-Nitrophenolphosphate
Aspartate amino transferase (AST) 7 4 7 Kinetic
Alanine amino transferase (ALT) 7 4 7 Kinetic
Gammaglutamyl transpeptidase (GGT) 7 4 7 γ-Glutamyl-3 carboxy-4-nitroanilide substrate
Urate 7 4 7 Urease/Peroxidase colorimetric
Glucose 7 4 7 Hexokinase
Cholesterol 7 1 7 Cholesterol oxidase
HDL cholesterol 7 1 7 PEG 6000/Cholesterol oxidase
LDL cholesterol Calculated
Triglycerides 7 1 4 Lipase/Glycerol kinase
TSH ACS 180 Luminescence immunoassay
Haematology Automated Cell Counter
1 1 4
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
Blood samples for haematological parameters were measured at
the Safe Test Medical Laboratory. Only the main parameters will be
reported here.
STATISTICAL METHODS
Statistical analysis was performed using the Statistical Package for the
Social Sciences. Reference ranges were shown as mean ± 2 SD or 2.5
to 97.5 percentiles as indicated in the text, figures and tables.
Comparisons between groups (males vs females or age decade groups
within each sex) were performed using analysis of variance (ANOVAR).
RESULTS
In Table 8.2 are listed the observed reference ranges (mean ± 2SD) for
commonly performed biochemical tests in elderly men (n=362) and
women (n=1525). There were biologically and statistically significant
male/female differences for creatinine (p<0.001), phosphate (p<0.01),
alkaline phosphatase (p<0.001), GGT (p<0.001) and urate (p<0.001).
Table 8.3 shows those parameters for which there were biologically
and statistically significant different reference ranges for the three age
decades. Creatinine increased with age in both sexes. Urea and urate
increased with age in females, and in males a similar trend was evident
but did not reach statistical significance (probably because of lower
statistical power due to smaller numbers). Similarly albumin decreased
with age in females (statistically significant) while a similar trend was
evident in males. These age changes reflected the opposing effects of
deteriorating renal function and reduced tissue bulk (especially muscle)
with increasing age. In the case of creatinine the absolute changes
might be sufficiently large to warrant the use of age decade related
reference ranges in clinical practice.
The results of BMI, fasting glucose, TSH, total cholesterol,
triglycerides, LDL cholesterol (calculated) and HDL cholesterol are
shown in Table 8.4. The distributions of the cholesterol, triglyceride,
LDL cholesterol and HDL cholesterol levels are shown in Figures 8.1–
8.4. There were biologically and statistically significant male/female
differences for BMI (p<0.01) and HDL cholesterol (p<0.001) warranting
1 1 5
Lipids, Lipoproteins and Other Biochemical and Haematological Parameters in Elderly
Tab
le 8
.2R
efer
ence
ran
ges
for
com
monly
per
form
ed t
ests
(pla
sma)
exp
ress
ed a
s m
ean ±
2 S
D
Anal
yte
Units
Men
(60
– 9
0)W
omen
(60
– 9
3)
Ran
geM
ean
Med
ian
No
.R
ange
Mea
nM
edia
nN
o.
Sodi
umm
mol
/L1
40
–1
52
14
61
46
36
21
41
–1
52
14
61
46
15
25
Pota
ssiu
mm
mol
/L3
.7–
5.9
4.8
5.0
36
23
.7–
5.7
4.7
4.7
15
25
Chlo
ride
mm
ol/L
96
–1
10
10
31
03
36
29
7–
11
01
04
10
41
52
5
Ure
a*
mm
ol/L
2.9
–1
0.1
6.5
6.0
36
22
.6–
9.9
6.3
6.0
15
25
Crea
tin
ine*
µm
ol/L
68
–1
49
10
81
05
36
25
3–
11
98
58
21
52
5
Calc
ium
mm
ol/L
2.2
–2
.62
.42
.43
62
2.2
–2
.62
.42
.41
52
5
Ph
osph
ate*
mm
ol/L
0.8
2–
1.3
41
.08
1.1
03
62
0.9
5–
1.4
71
.21
1.2
11
52
5
Bilir
ubin
(tot
al)
µm
ol/L
3–
21
12
12
35
83
–1
71
09
15
11
Bilir
ubin
(dir
ect)
µm
ol/L
0–
83
33
58
0–
63
31
51
1
Tota
l pro
tein
g/ L
69
–8
77
87
83
58
69
–8
77
87
81
51
1
Albu
min
*g
/ L4
3–
55
49
49
35
84
3–
54
48
48
15
11
Glob
ulin
(ca
lc)
g/ L
21
–3
72
92
93
58
22
–3
83
03
01
51
1
Alka
line
phos
phat
ase*
U/L
58
–1
12
85
81
35
83
4–
14
89
18
61
51
1
AS
TU
/L8
–4
22
52
33
58
4–
43
23
21
15
11
ALT
U/L
0–
44
21
19
35
80
–4
91
91
61
51
1
GG
T*
U/ L
0–
10
43
42
43
58
0–
80
25
19
15
11
Ura
te*
mm
ol/L
0.2
2–
0.5
80
.40
0.3
93
58
0.1
6–
0.5
20
.34
0.3
31
51
1
*Age
and
/or
sex
diff
eren
ces
foun
d (s
ee T
able
8.3
and
tex
t).
1 1 6
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
Table 8.3 Reference ranges for commonly performed tests —age effects (mean ± 2SD)
Analyte Units Sex A g e Range Mean Median N o .
Creatinine µmol/L M 60–69 72–137 1 0 5 1 0 3 1 6 8(ANOVA, p<0.01) M 70–79 70–150 1 1 0 1 0 6 1 6 1
M 80–90 58–183 1 2 1 1 1 1 3 3
Creatinine µmol/L F 60–69 56–107 8 1 7 9 7 2 2(ANOVA, p<0.001) F 70–79 50–123 8 7 8 4 6 3 8
F 80–93 51–139 9 5 8 9 1 6 5
Urea mmol/L F 60–69 3.0–8.8 5 . 9 5 . 8 7 2 2(ANOVA, p<0.001) F 70–79 2.6–10.4 6 . 5 6 . 1 6 3 8
F 80–93 2.2–11.6 6 . 9 6 . 5 1 6 5
Urate mmol/L F 60–69 0.17–0.49 0 . 3 3 0 . 3 3 7 1 9(ANOVA, p<0.05) F 70–79 0.17–0.53 0 . 3 5 0 . 3 4 6 2 9
F 80–93 0.18–0.54 0 . 3 6 0 . 3 6 1 6 3
Albumin g / L F 60–69 43–55 4 9 4 9 7 1 9(ANOVA, p<0.001) F 70–79 42–54 4 8 4 8 6 2 9
F 80–93 41–53 4 7 4 7 1 6 3
sex related reference ranges. At this age cholesterol, LDL cholesterol
and triglyceride levels in both sexes were similar and the expected
higher total and LDL cholesterols in females were not evident.
Table 8.5 shows the reference ranges for the three age decades for
BMI, cholesterol, triglycerides, LDL and HDL cholesterol. BMI
decreased significantly with age in women. In men the very old (over
80, n=29) showed lower BMI values but these did not attain statistical
significance. Cholesterol, triglycerides and LDL cholesterol levels showed
a decreasing trend with age in men, and HDL a rising trend, but these
differences were not statistically significant. Women aged over 80
showed a trend (NS) towards lower total and LDL cholesterol, and
higher HDL cholesterol levels than women aged 60–79 years. The
observed changes were consistent with the effects of BMI and sex
hormones in younger age groups (see discussion). In this case it was
postulated that reductions in BMI in the elderly, especially the very
old, would reduce total cholesterol, LDL cholesterol and triglycerides,
and raise HDL cholesterol. Reductions in testosterone secretion with
age might attenuate the HDL cholesterol lowering effects present in
males from puberty into middle age.
The results of the fasting glucose and TSH findings are discussed
in more details in other chapters of this report. Results of the common
1 1 7
Lipids, Lipoproteins and Other Biochemical and Haematological Parameters in Elderly
Tab
le 8
.4 R
efer
ence
ran
ges
for
BM
I, g
luco
se (
fast
ing)
, TSH
, lip
ids
and li
pop
rote
ins
(mea
n ±
2SD
)
Para
met
erUn
itsM
en (
60 –
90)
Wom
en (
60 –
93)
Ran
geM
ean
Med
ian
No
.R
ange
Mea
nM
edia
nN
o.
BM
I*k
g/m
21
6.3
3–
30
.65
23
.49
23
.00
32
21
6.4
9–
31
.93
24
.21
24
.00
13
95
Fast
ing
gluc
ose
mm
ol/L
3.3
–8
.25
.75
.03
54
2.7
–8
.85
.85
.01
50
8
TSH
mIU
/L0
–3
.60
1.5
81
.40
36
00
–5
.58
1.5
81
.30
15
11
Chol
este
rol
mm
ol/L
3.7
–8
.15
.95
.93
60
4.0
–8
.46
.26
.21
52
4
Trig
lyce
ride
sm
mol
/L0
–3
.92
1.5
81
.28
36
10
–3
.52
1.5
01
.32
15
24
LDL-
Chol
(Ca
lc)
mm
ol/L
1.9
–5
.93
.93
.93
50
2.1
–6
.14
.14
.01
50
1
HD
L -Ch
ol*
mm
ol/L
0.5
2–
2.0
81
.30
1.2
53
59
0. 6
6–
2.2
21
.44
1.3
81
51
6
*Age
and
/or
sex
rela
ted
diff
eren
ces
foun
d (s
ee T
able
8.5
and
tex
t).
1 2 2
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
Table 8.5 Reference ranges for BMI, lipids and lipoproteins, age effects(mean ± 2SD)
Parameter Units Sex A g e Range Mean Median N o .
BMI kg/m 2 M 60–69 17.79–29.90 2 3 . 8 2 2 3 . 6 0 1 5 1(ANOVA, p<0.001, F) M 70–79 15.46–31.42 2 3 . 4 4 2 3 . 3 5 1 4 2(NS, M) M 80–89 14.48–29.64 2 2 . 0 6 2 0 . 7 6 2 9
F 60–69 17.45–31.85 2 4 . 6 5 2 4 . 4 8 6 7 0F 70–79 15.73–32.33 2 4 . 0 3 2 3 . 0 9 5 7 3F 80–93 15.84–30.08 2 2 . 9 6 2 2 . 9 1 1 5 2
Cholesterol mmol/L M 60–69 3.9–8.3 6 . 1 6 . 1 1 6 8M 70–79 3.7–8.1 5 . 9 5 . 9 1 5 9M 80–89 3.6–7.6 5 . 6 5 . 4 3 3F 60–69 4.0–8.4 6 . 2 6 . 2 7 2 2F 70–79 4.1–8.5 6 . 3 6 . 2 6 3 8F 80–93 3.7–8.3 6 . 1 6 . 0 1 6 4
Triglycerides mmol/L M 60–69 0–4.38 1 . 6 8 1 . 3 7 1 6 8M 70–79 0–3.60 1 . 5 2 1 . 2 6 1 6 0M 80–89 0.12–2.56 1 . 3 4 1 . 1 4 3 3F 60–69 0–2.97 1 . 4 9 1 . 3 3 7 2 2F 70–79 0–3.96 1 . 5 2 1 . 3 4 6 3 8F 80–93 0–3.64 1 . 4 6 1 . 1 9 1 6 4
LDL-chol mmol/L M 60–69 2.0–6.0 4 . 0 4 . 0 1 6 4(calc) M 70–79 1.9–5.9 3 . 9 3 . 9 1 5 3
M 80–89 1.6–5.6 3 . 6 3 . 5 3 3F 60–69 2.2–6.2 4 . 2 4 . 1 7 1 0F 70–79 2.1–6.1 4 . 1 4 . 1 6 3 0F 80–93 1.7–6.1 3 . 9 3 . 8 1 6 1
HDL-chol mmol/L M 60–69 0.58–1.98 1 . 2 8 1 . 2 5 1 6 8M 70–79 0.47–2.15 1 . 3 1 1 . 2 5 1 5 8M 80–89 0.54–3.18 1 . 3 6 1 . 3 5 3 3F 60–69 0.63–2.19 1 . 4 1 1 . 3 4 7 1 9F 70–79 0.66–2.22 1 . 4 4 1 . 3 9 6 3 4F 80–93 0.74–2.34 1 . 5 4 1 . 5 0 1 6 3
automated haematological parameters are shown in Table 8.6. There
were significant male/female differences in red cell count (p<0.001),
white cell count (p<0.01), haemoglobin (p<0.001), haematocrit
(p<0.001), mean corpuscular volume (p<0.05) and mean corpuscular
haemoglobin (p<0.05). There were no significant age effects observed
in either sex.
1 2 3
Lipids, Lipoproteins and Other Biochemical and Haematological Parameters in Elderly
Tab
le 8
.6 R
efer
ence
ran
ges
for
com
monly
per
form
ed h
aem
atolo
gica
l tes
ts (
mea
n ±
2 S
D)
Para
met
erUn
itsM
en (
60 –
90)
Wom
en (
60 –
93)
Ran
geM
ean
Med
ian
No
.R
ange
Mea
nM
edia
nN
o.
RB
C Co
un
t***
X1
06/m
m3
4.9
8–
6.3
85
.18
5.0
81
91
3.5
8–
6.0
54
.81
4.7
51
46
9
WB
C Co
un
t**
X1
09/L
3.6
1–
10
.75
7.1
86
.80
19
13
.36
–1
0.3
36
.84
6.6
01
47
0
Plat
elet
Cou
ntX
10
9/L
10
5–
30
72
06
20
41
91
10
2–
33
42
18
21
31
46
9
Ha
emo
glo
bin
***
g/d
L1
2.8
–1
8.0
15
.41
5.3
19
11
1.1
–1
7.1
14
.11
4.1
14
69
Hae
mat
ocri
t (P
CV) *
**%
38
.5–
53
.14
5.8
46
.11
91
33
.8–
50
.44
2.1
41
.91
46
9
Mea
n Co
rpus
cula
r Vo
l(M
CV
)*fl
76
.0–
92
.28
9.1
90
.01
91
80
.8–
95
.48
8.1
89
.01
46
8
Mea
n Co
rpus
cula
rH
aem
oglo
bin
(M
CH)*
pg /
c ell
24
.1–
35
.93
0.0
30
.41
91
22
. 4–
36
.82
9.6
30
.21
46
9
Mea
n Co
rpus
cula
rH
aem
oglo
bin
Con
c( M
CH
C)
g/d
l3
0.4
–3
6.8
33
.63
3.7
19
12
9. 7
–3
7.1
33
.43
3.5
14
69
Sign
ific
ant
mal
e/fe
mal
e di
ffer
ence
s*
p<
0.0
5*
*p
<0
.01
**
*p
<0
.00
1
1 2 4
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
DISCUSSION
Until recently reference ranges for many laboratory tests have only
been established in young and middle aged individuals and it has often
been assumed that these are applicable to the elderly. World wide the
proportion of the elderly in the population is increasing. In particular
a greater proportion of the population are living to 75 years or older.
In the USA persons aged 65 years and older make up over 60% of
patient in general hospitals, a far greater proportion than paediatric
patients (15%) for whom reference values are already available. In
Hong Kong life expectancy at birth had increased to 80.3 years for
women and 75.1 years for men by 1993 and the population of elderly
people has been expanding rapidly. The proportion of the population
aged 65 and above increased from 3.3% in 1963 to 9.2% in 1993,
and it was projected to reach 11.3% by 20031. This is also reflected in
hospital admissions.
In 1993 Willard R. Faulkner and Samuel Meites published the first
comprehensive up to date reference book on laboratory reference data
in the elderly: Geriatric Clinical Chemistry — Reference Values2. They
collated a large volume of data, mainly supplied by colleagues in North
America and Europe. Some data was also contributed from the Beijing
Institute of Geriatrics and from Japan. In total 31 sets of data covering
134 analytes were available from 275 000 subjects in 15 countries.
Some sets of data were very large and well documented with one
including 92 individuals aged from 90 to over 100 years of whom 72
appeared completely free of overt disease3. The authors aimed for at
least 120 subjects for each age category (ideally 200) and preferred
percentiles because many parameters did not follow Gaussian
distributions. This means that the 2.5 percentile and 97.5 percentile
were used as the lower and upper limits of their reference ranges (often
referred to as the normal ranges) rather than the mean ± 2 SD. However,
in our study, we have used mean ± 2 SD as our reference ranges instead
of using the percentiles which gave very similar ranges. Figure 8.1
(cholesterol, Gaussian distribution) and Figure 8.2 (triglyceride, non
Gaussian distribution) illustrate these points.
In Hong Kong relatively little published data is available for
individuals aged over 65 years. Data on the commonly measured
analytes is especially lacking. Woo and Lam in 1990 published lipid
and lipoprotein data on 314 Hong Kong Chinese of whom 257 were
aged from 60 to over 80 years4. There is also some data on BMI,
1 2 5
Lipids, Lipoproteins and Other Biochemical and Haematological Parameters in Elderly
diabetes, lipids and lipoproteins of individuals aged 60–64 years who
were studied as part of surveys of predominantly young and middle
aged adults5,6,7. The Hong Kong Cardiovascular Risk Factor Prevalence
Study of 3000 healthy individuals currently underway (coordinator
E.D. Janus) includes a substantial number of randomly selected
individuals aged 60–74 years.
Factors which may effect laboratory test results include analytical
and biological variables. Analytical variability has been markedly
reduced with modern automated analysis, use of standards and the use
of Internal (in-house) and External Quality Control. Thus the precision
(reproducibility) and accuracy (closeness of the result to the true value)
are now excellent. Biological variation within and between individuals
and problems in the collection and transport of samples are now often
responsible for a greater proportion of the observed inter and intra-
individual variation.
Many factors, reviewed by Donald S. Young8, contribute to pre-
analytical variability in the elderly. These include body composition
(partly nutrition related), genetic factors including race, gender,
menopausal status, obesity, diet, environmental factors, smoking,
posture or venous occlusion during the test, recent food intake, alcohol,
drugs and exercise.
In our local study a number of analytes warranted further specific
comment.
Sodium levels were higher (mean 146 mmol/L) than in most other
studies (mean 140 mmol/L)3. The reason for this was not clear. The
mean for healthy younger adults in our laboratory was 142 mmol/L.
Calcium increases slightly in the elderly3 and our observations
were consistent with others3.
The higher levels of phosphate in elderly females than males was
also consistent with others3.
Alkaline phosphatase levels rose after menopause in females. Before
menopause women had lower levels than men. By age 60 they caught
up and after that, as in our study, levels in women exceeded those in
men3. The reason for this was not clear.
Urea rose with age mainly because of decreases in glomerular
function and our observations were consistent with this.
Creatinine rose significantly with age in both sexes in our study
whereas in other studies quoted by Tietz3 the increases in levels were not
statistically significant until after age 90. The opposing effects of reduced
muscle mass (less creatinine produced) and reduced glomerular function
(less creatinine excreted) were thought to account for these observations.
1 2 6
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
Urate showed a male-female difference and a rise with age in
females3, and our observations also showed this.
Albumin in both our studies and those reported by Tietz3 decreased
with age but only to a small extent.
For Haematological Parameters gender differences persisted in the
elderly. Very little literature data is available on age effects. In the 60
to 90-year-olds we found no significant age effects. Tietz noted some
reduction in red cell and white cell counts and in haemoglobin and
haematocrit after age 90 years3.
Of particular interest were the lipid and lipoprotein parameters. It
is well known that after menopause, total and LDL cholesterol levels
rise in women as LDL-receptor function drops off in parallel with
estrogen decreases. Thus in women, levels rise to those of men and
may exceed them9,10,11. In our study, levels of total and LDL cholesterol
in women were indeed slightly (but not significantly) higher than those
of men. The mean cholesterol levels of 5.9 and 6.2 mmol/L in men
and women respectively were similar to those found in this age group
in the USA in the 1976–80 surveys12 and this was a cause for concern.
The levels observed were about 10% higher than those found by Woo
and Lam in 1990 in their rather smaller survey which also recruited
subjects from a social centre for the elderly. This could be due to the
small sample size, their use of only one centre in a lower socio-economic
area and perhaps due to further changes in diet in the population over
this five-year period. Tietz commented on lower levels of cholesterol in
the very old men (over 90 years) and we noticed a similar trend in
those aged over 80 years.
HDL tended to increase with age in both our study and those
reviewed by Tietz3 although these changes did not attain statistical
significance. Although we showed some tendency to decreasing
triglyceride levels with age, there was no consistent age related trend
in the literature, and many factors such as genes, diet, obesity and
alcohol confound the issue of triglycerides.
BMI values in the male sexagenarians in our study were similar to
those found locally in an earlier study with smaller numbers of
individuals aged 55–64 years5 (mean 23.8 (ours) vs 24.0 kg/m2). In
women in contrast we showed a significant BMI decrease with age
and noted that in those aged 55–64 the mean was 25.4 kg/m2 compared
with 24.65 kg/m2 in those women aged 60–69 years in our study.
In conclusion we provided for the first time good reference range
data of the elderly in Hong Kong, in some cases with sufficient
differences in gender or age decade reference ranges for these to be put
1 2 7
Lipids, Lipoproteins and Other Biochemical and Haematological Parameters in Elderly
in place in clinical laboratories. We noted with some concern the
apparently high levels of total and LDL cholesterol and (as discussed
elsewhere in this volume) the high prevalence of diabetes in the elderly.
ACKNOWLEDGEMENTS
The authors are grateful to the many individuals who have contributed
to this project. Laboratory recording and analysis was carried out by
Ms. S.K. Au, Mrs. A.B.K. Cheung, Mr. D. Cheung (haematology tests),
Mr. K.K. Chung, Ms. S.W. Ng, Mr. S.M. Ong and Mr. F.Y.K. Wong;
statistical analysis in part by Dr. C. Leung, Dr. T.F. Chan and
Mr. S.T.S. Siu; data input assistance was provided by Miss Camila Li
and Ms. Mona Lo provided the extensive liaison which made the entire
project possible.
NOTES
1. Yeung S, Ho YY. Health of the community. Public Health and
Epidemiology Bulletin, Hong Kong, August 1994, 17–21.
2. Faulkner WR, Meites S, eds. Geriatric clinical chemistry: reference values.
AACC Press, Washington DC, USA, 1994.
3. Tietz NW, Shuey DF, Wekstein DR. Laboratory values in fit aging
individuals — sexagenarians through centenarians. Clin Chem, 1992,
38:1167–85.
4. Woo J, Lam CWK. Serum lipid profile in an elderly Chinese population.
Arteriosclerosis, 1990, 10:1097–101.
5. Lau E, Woo J, Cockram S, et al. Serum lipid profile and its association
with some cardiovascular risk factors in an urban Chinese population.
Pathology, 1993, 28:344–50.
6. Cockram CS, Woo J, Lau E, et al. The prevalence of diabetes mellitus
and impaired glucose tolerance among Hong Kong Chinese adults of
working age. Diabetes Research and Clinical Practice, 1993, 21:67–73.
7. Fong PC, Tam SCF, Tai YT, Lau CP, Lee JSK, Sha YY. Epidemiologic
studies of the serum lipids and apolipoproteins in Hong Kong Chinese.
Demographic characteristics and serum lipid and apolipoprotein
distributions. J Epidemiol Comm Health, 1994, 48:355–9.
8. Young DS. Preanalytical variability in the elderly. In: Geriatric clinical
chemistry: reference values (Faulkner WR, Meites S, eds.) AACC Press,
Washington DC, USA, 19–47.
1 2 8
Edward Denis JANUS, Man-chun LEE, Shing-shun CHEUNG
9. Lipid Research Clinics Program. Population studies data book, volume 1:
the prevalence study. NIH Publication, No. 80–1527. National Heart,
Lung and Blood Institute, Bethesda, MD, 1980.
10. Grundy SM. Multifactorial etiology of hypercholesterolaemia. Implications
for prevention of coronary heart disease. Arteriosclerosis and Thrombosis,
1991, 11:1619–35.
11. Bush TL, Fried LP, Barrett-Connor E. Cholesterol, lipoproteins and
coronary heart disease in women. Clin Chem, 1988, 34:B60–70.
12. Carroll M, Sempos C, Briefel R, et al. Serum lipids in adults 20–74
years, United States, 1976–80. National Centre for Health Statistics.
Vital Health Stat, 1993, 11(242).
1 2 9
Reference Height-weight Tables for Hong Kong Elderly Men and Women
9Reference Height-weight Tables for
Hong Kong Elderly Men and Women
Leung-wing CHU, Shiu-kum LAM, Edward Denis JANUS,Annie Wai-chee KUNG, Chu-pak LAU, Edward Man-fuk LEUNG,
Mona Bo-nar LO
ABSTRACT
The present study is a report on reference tables of height-weight of
our local Hong Kong elderly population. Body height and weight were
measured in 1305 active ambulatory Hong Kong Chinese elderly
persons in 1994. Two hundred and twenty-six were men and 1079
were women. The age ranged from 60 to 94 years old. Height-weight
reference tables, with and without adjustment for age, were constructed
according to the data. Overall, men were heavier than women. The
overall mean weight was 63.0±9.5 kg for men and 55.4±8.8 kg for
women. For both men and women, the mean weight increased with
increase in height. For women, the body weight (adjusted for height)
showed a significant age-related decline. For men, there was no
significant age-related decline in weight. Future study may improve
the tables by having a greater number of very old men and women
(aged 80 years and over). A long-term prospective follow-up study to
test the ‘age-specific desirable height-weight hypothesis’ is needed in
Hong Kong.
1 3 0
Leung-wing CHU et al.
INTRODUCTION
Body weight and height are simple, easy to measure and commonly
used parameters in clinical observations. Overseas reports on body
weight or height-weight tables for Caucasians have been published for
many years. The most commonly used table is the Metropolitan height-
weight table for American adults (25–59 years old)1,2. The effect of
advancing age on body height and weight has also been studied and
described. In Caucasian population, there is an age-related change in
body weight and height. Body height decreases significantly after
maturity. On average, the decline is 1.2 cm per 20 years. Body weight
reaches a plateau between the age of 65 and 74 and then falls after the
age of 74. Because of these age-related changes, the Metropolitan
height-weight table may not be applicable to the elderly population.
For the elderly American, two other tables are available for
reference4,5. In the United Kingdom and Europe, weight standards for
the elderly age group have also been published6,7.
In Hong Kong, however, there is no published report of body
weight by height and sex. The main objective of the present study is to
report on reference tables of height-weight of our local Hong Kong
elderly population.
METHOD
In 1994, a health screening programme for the elderly was conducted
in seven social and multi-service centres for the elderly in Hong Kong.
The study was a joint project involving the Department of Medicine
and Clinical Biochemistry of the University of Hong Kong, the Society
for the Aged, and the Rotary Club of Hong Kong (Northwest). Study
subjects were active ambulatory elderly Hong Kong Chinese who lived
in different areas of Hong Kong. They were all voluntary participants.
In the programme, assessment included body weight, height,
questionnaires on health status, and blood taking (for blood glucose,
lipids etc). Some of the results have already been published8 . For the
present height and weight study, only individuals whose age were 60
and over were included. Body weight was measured (in their usual
indoor clothes) to the nearest 0.1 kg, with a mechanical weight scale.
Height, without shoes, was recorded to the nearest 1 cm.
1 3 1
Reference Height-weight Tables for Hong Kong Elderly Men and Women
The height and weight data for men and women were analyzed with
the software SPSS for Windows (ver. 6.1). The overall mean weight
and percentiles of weight for each sex were analysed first. The mean
weight for different height-groups (for each sex) was then analysed.
Weights for different combinations of height-groups and age-groups
were then analysed. Finally, the effect of height on body weight was
analysed with one-way ANOVA, while the effect of age, adjusted for
height, on body weight was analysed with simple factorial ANOVA.
RESULTS
A total of 1912 elderly subjects participated in the screening programme.
Subjects who had their body weight and height measured and were of
age 60 and over were included. Eleven subjects were under 60 years
old. Subjects with incomplete data were also excluded. The final sample
size was 1305 (response rate = 69%). Two hundred and twenty-six
were men and 1079 were women. The distributions of body weight
and height in each sex were approximately normal. Table 9.1 shows
the mean, the standard deviation (SD), the 5th, 10th, 50th and 90th
percentiles of body weight of different height groups for women. It is
obvious that the number of subjects for extremes of height-groups is
small. In men, three groups (the shortest and the two tallest groups)
contained less than five subjects per group (Table 9.1). In women, two
groups (the shortest and the tallest groups) contained less than five
subjects per group (Table 9.2).
Table 9.3 shows the mean, the standard deviation, and the 10th
percentile of body weights of different height and age groups for men.
Table 9.4 shows the mean, the standard deviation, and the 10th
percentile of body weights of different height and age groups for
women. It should also be noted that the number of subjects for extremes
of height and age groups was small too. In men, three groups contained
less than five subjects per group (Table 9.3). In women, five groups
contained less than five subjects per group (Table 9.4).
The overall mean weight was 63.0±9.5 kg for men and 55.4±8.8
kg for women. The mean weight of men was statistically greater than
that of women (unpaired t test, p<0.001).
For both men and women, the mean weight showed a statistically
significant increase with increasing height (p<0.0001, one-way ANOVA)
(Tables 9.1 and 9.2).
1 3 2
Leung-wing CHU et al.
Table 9.1 Height-weight table for Hong Kong elderly men (60–94 years old)
Height (cm)* N Mean 5th 10th 50th 90thweight percentile percentile percentile percentile
± 1 SD (kg) (kg) (kg) (kg) (kg)
143 – 150 3 52.0 ± 8.5 4 4 . 0 4 4 . 0 5 1 . 0 –
151 – 155 1 5 56.8 ± 7.0 4 7 . 5 4 8 . 7 5 5 . 0 6 8 . 4
156 – 160 4 8 60.2 ± 7.9 4 6 . 8 4 9 . 9 6 1 . 8 7 0 . 0
161 – 165 7 1 61.2 ± 8.9 4 7 . 0 5 0 . 0 6 1 . 0 7 3 . 8
166 – 170 6 3 66.0 ± 9.3 4 6 . 6 5 4 . 4 6 6 . 0 7 7 . 2
171 – 175 1 8 69.6 ± 9.9 5 6 . 0 5 6 . 9 7 0 . 3 8 2 . 4
176 – 180 4 70.4 ± 12.0 5 5 . 0 5 5 . 0 7 1 . 4 –
181 – 185 4 73.0 ± 1.5 7 1 . 0 7 1 . 0 7 3 . 2 –
Overall 2 2 6 63.0 ± 9.5 4 7 . 5 5 0 . 0 6 3 . 0 7 5 . 5
* Mean weight for different height groups, p<0.0001 (one-way ANOVA)
Table 9.2 Height-weight table for Hong Kong elderly women(60–94 years old)
Height (cm)* N Mean 5th 10th 50th 90thweight percentile percentile percentile percentile
± 1 SD (kg) (kg) (kg) (kg) (kg)
131 – 135 4 47.0 ± 4.4 4 2 . 0 4 2 . 0 4 7 . 0 –
136 – 140 2 7 48.3 ± 6.4 3 8 . 3 4 1 . 3 4 8 . 0 5 8 . 0
141 – 145 1 5 1 50.0 ± 8.8 3 5 . 4 3 9 . 2 5 1 . 0 6 0 . 9
146 – 150 3 2 2 53.4 ± 8.1 4 1 . 0 4 3 . 1 5 3 . 5 6 3 . 5
151 – 155 3 2 2 56.8 ± 8.0 4 4 . 0 4 7 . 2 5 6 . 4 6 6 . 7
156 – 160 1 9 1 59.1 ± 8.7 4 2 . 6 4 8 . 0 5 9 . 0 7 0 . 7
161 – 165 4 6 61.8 ± 7.2 5 1 . 7 5 2 . 4 6 1 . 8 7 2 . 0
166 – 170 1 3 58.8 ± 9.9 4 5 . 5 4 6 . 7 5 9 . 0 7 7 . 0
171 – 175 3 60.3 ± 14.1 4 8 . 5 4 8 . 5 5 8 . 5 –
Overall 1 0 7 9 55.4 ± 8.8 4 1 . 5 4 4 . 0 5 5 . 0 6 6 . 5
* Mean weight for different height groups, p<0.0001 (one-way ANOVA)
For women, the body weight (adjusted for height) showed a
statistically significant decline with increasing age (p<0.0001)
(Table 9.3). However, for men, there was no statistically significant
decrease in weight with increasing age (Table 9.4).
1 3 3
Reference Height-weight Tables for Hong Kong Elderly Men and Women
Table
9.3
Ave
rage
hei
ght-
wei
ght
table
by
age
group f
or
Hong
Kong
elder
ly w
om
en (
age
60–9
4)
Hei
ght
(cm
)**
Mea
n w
eigh
t ±
1 S
D (
10th
per
cen
tile
) in
kg
Age
gro
up
*
60
–6
97
0–
79
80
–8
99
0–
94
13
6–
14
051
.1±
5.9
(43.
5)47
.8±
6.6
(40.
4)43
.9±
4.6
(38.
0)—
(n=9
)(n
=14
)(n
=4)
14
1–
14
553
.8±
8.2
(45.
9)50
.9±
8.6
(38.
8)46
.1±
7.9
(34.
1)39
.3±
8.8
(33)
(n=
53)
(n=
71)
(n=
25)
(n=2
)
14
6–
15
054
.3±
7.6
(44.
6)53
.0±
8.5
(42.
8)50
.6±
7.9
(40.
0)—
(n=
150)
(n=
145)
(n=
26)
15
1–
15
557
.2±
8.2
(47.
0)56
.8±
8.0
(47.
5)53
.3±
5.9
(45.
5)—
(n=
164)
(n=
139)
(n=
19)
15
6–
16
060
.3±
8.7
(50.
0)57
.6±
8.8
(43.
0)57
.6±
7.8
(44.
5)—
(n=
107)
(n=
75)
(n=9
)
16
1–
16
561
.8±
7.3
(52.
8)62
.5±
6.4
(52.
8)59
.0±
10.7
(48
.5)
—(n
=25
)(n
=17
)(n
=4)
16
6–
17
060
.8±
12.2
(48
.5)
59.0
±7.
3 (4
8.5)
51.5
±2.
1 (5
0.0)
—(n
=7)
(n=4
)(n
=2)
Mea
n w
eigh
ts f
or d
iffe
rent
hei
ght
grou
ps,
** p
<0.
001
(ANO
VA);
mea
n w
eigh
ts f
or d
iffe
rent
age
gro
ups
, *
p<
0.00
1 (A
NOVA
).
1 3 4
Leung-wing CHU et al.
Table
9.4
Ave
rage
hei
ght-
wei
ght
table
by
age
group f
or
Hong
Kong
elder
ly m
en (
age
60–9
4)
Hei
ght
(cm
)**
Mea
n w
eigh
t ±
1 S
D (
10th
per
cen
tile
) in
kg
Age
gro
up
*
60
–6
97
0–
79
80
–8
99
0–
94
15
1–
15
558
.1±
9.8
(49.
5)57
.9±
5.8
(51.
0)—
—(n
=4)
(n=9
)
15
6–
16
061
.3±
7.7
(50.
0)59
.1±
8.1
(49.
0)61
.1±
10.8
(49
.0)
—(n
=22
)(n
=23
)(n
=3)
16
1–
16
562
.4±
8.1
(51.
0)61
.4±
9.3
(47.
0)55
.7±
9.2
(48.
0)59
.4±
12.9
(50
.2)
(n=
28)
(n=
35)
(n=6
)(n
=2)
16
6–
17
065
.2±
9.9
(48.
8)65
.9±
9.0
(55.
3)70
.0±
8.4
(58.
0)—
(n=
25)
(n=
32)
(n=6
)
17
1–
17
567
.0±
7.5
(57.
4)73
.7±
11.4
(56
.0)
——
(n=
11)
(n=8
)
Mea
n w
eigh
ts f
or d
iffe
rent
hei
ght
grou
ps,
** p
< 0
.001
(AN
OVA
); m
ean
wei
ghts
for
dif
fere
nt a
ge g
roup
s ,
p =
N.S
. (A
NOVA
)
1 3 5
Reference Height-weight Tables for Hong Kong Elderly Men and Women
DISCUSSION
Although foreign height-weight tables are available for immediate
reference, they are not suitable for use on our Chinese elderly population
in Hong Kong. Genetic differences in the pattern of fat distribution
suggest that weights associated with minimal mortality will show
significant racial differences9. Lowest-risk weights differ for different
populations10. Thus, the weight tables developed from Caucasians
cannot be used as reference tables in Hong Kong.
The present study is the first published report of reference height-
weight values of elderly people in Hong Kong. Our study subjects
were active ambulatory elderly Chinese attending seven social and
multi-service centres for the elderly, and living in different areas in
Hong Kong. Therefore, they were quite representative of our active
elderly Chinese population in Hong Kong. Their height-weight values
might thus serve as a reasonable reference standard for our elderly
population.
The relative excess of females to males in our sample was due to
the following observed facts. Firstly, there were more women than
men in the elderly age group in the Hong Kong population. In 1994,
the ratio of females to males (aged 60 and over) was about 2 to 111.
This was due to longer life expectancy in women. The average life
expectancy at birth (in 1994) was 81.0 years for women and 75.4
years for men11. Secondly, more elderly women than men in Hong
Kong joined social centres for the elderly as members. In a report
published by the Hong Kong Council of Social Service, the female to
male ratio in social centres for the elderly was 5.1 to 1 (for members
aged 65 and over)13. This ratio was very similar to the sex ratio
(female to male ratio of 4.8 to 1) in our present sample.
It is common knowledge that tall individuals weigh heavier than
short individuals, and men weigh heavier than women. In Hong Kong,
do these general facts remain true when one grows old? According to
the present study, the answer was yes. The mean weight (for either
sex) increased with increasing height and the mean weight of men was
statistically greater than that of women.
How about ageing? Will our body weights change? In our study,
there was a significant effect of age on body weight (adjusted for
height) in women but not in men. An age-related decrease in weight
was clearly seen in women. For example, the mean weight of the 80–
89 years and 146–150 cm subgroup was 3.7 kg lighter than that of the
1 3 6
Leung-wing CHU et al.
60–69 years and 146–150 cm subgroup (i.e. of equal height but different
age). In men, there was no significant age-related decline or change in
height-adjusted weight. This was inconsistent with findings reported
by Master et al.5 There were two possibilities: firstly, the body weight
of Hong Kong elderly men genuinely did not decrease with ageing;
secondly, the male group (n=226) in our study was smaller in size than
the female group (n=1079), and the subgrouping by age and height
had resulted in very small number of cases (n<5) in the very old
subgroups (80–89 and over 90 subgroups) in males. Therefore, even if
there was an age-related decline in weight in the male, the present
study might not have sufficient power to detect the decrease. To resolve
this issue, future studies should include more male subjects above the
age of 80 years old.
The concept of a ‘desirable’ body weight was first advocated by
the Metropolitan life insurance company. The company published its
first height-weight tables for American men and women in 19591. In
1983, a revised table was published. The ‘desirable’ body weight,
adjusted for sex and height, was derived from an analysis of mortality
data of the company’s insured persons. The ‘desirable’ weight was
found to be associated with the lowest mortality in the corresponding
height subgroup. However, the data of the Metropolitan Life Insurance
tables were derived from the Caucasian adult population aged 25 to
59 years only2. The applicability of the same tables to the old population
is uncertain. For Americans aged 65 to 94, Master et al. reported a
height-weight table with age adjustment by subgrouping5. Frisancho et
al., using data from the First and Second National Health and Nutrition
Examination Surveys, has also presented the body weights (in
percentiles) for Americans aged 25 to 54 (adult) and 55 to 74 (young
elderly)4. In the 1983 Metropolitan table and the Frisancho’s table, an
objective assessment of body frame sizes (by measurement of elbow
breadth) was adopted. However, it must be emphasized that age is a
more important factor than sex and body frame in the construction of
height-weight tables. The ‘desirable’ body weight actually changes with
advancing age. Minimal mortality occurs at progressively increasing
body weight as age advances (20–29, through 60–69). In any ‘desirable’
height-weight research, it is necessary to adjust weight standards for
age9.
In Hong Kong, the hypothesis of a ‘desirable’ body weight has not
been evaluated in any clinical study. Another expression of relative
weight, the body mass index, has been reported to be associated with
mortality at both 20 and 40 months of follow-up of a group of Hong
1 3 7
Reference Height-weight Tables for Hong Kong Elderly Men and Women
Kong elderly aged 70 and above14. It seems reasonable to believe that
an age-specific ‘desirable’ height-weight for our elderly population in
Hong Kong is probably true. To validate or refute this hypothesis, a
long-term (over 10 years) prospective follow-up study is needed.
Potential confounding variables, particularly smoking and co-morbid
diseases, should be adjusted. Mortality, disability measures, health
services utilization and quality of life assessment can be employed as
outcome measures. Adequate number of very old (age 80 to 100 years)
but active and ambulatory individuals should be included in the study
sample. In addition, male subjects should be recruited in adequate
number.
CONCLUSIONS
The present study has provided the first reference height-weight table
of our Hong Kong elderly population. After adjustment for height, an
age-related decrease in body weight was observed in women but not in
men. For the very old group (aged 90 years and over for women and
aged 80 years and over for men), the number of subjects is small.
Future study is needed to improve this area. A long-term prospective
follow-up study to test the age-specific ‘desirable’ height-weight
hypothesis is also needed in Hong Kong.
NOTES
1. Metropolitan height and weight tables. Stat Bull Metrop Life Found,
1959, vol. 40.
2. Metropolitan height and weight tables. Stat Bull Metrop Life Found,
1983, 64(1):3–9.
3. Isadore Rossman. The anatomy of ageing. In: Isadore Rossman, ed.,
Clinical geriatrics. Philadelphia: JB Lippincott Co., 1986, 3–22.
4. Frisancho AR. New standards of weight and body composition by frame
size and height for assessment of nutritional status of adults and the
elderly. Am J Clin Nutr, 1984, 40(4):808–19.
5. Master AM, Lasser R. Tables of weights and heights of American aged
65–94 years. J Am Med Assoc, 1960, 172:658–62.
6. Lehman AB, Bassey EJ, Morgan K, Dallosso HM. Normal values for
weight, skeletal size and body mass indices in 890 men and women aged
over 65 years. Clin Nutr, 1991, 10:18–22.
1 3 8
Leung-wing CHU et al.
7. Euronut SENECA investigators. Nutritional status: anthropometry. Eur
J Clin Nutr, 1991, 45 (Suppl. 3):31–42.
8. Kung AWC, Janus ED, Lau CP. The prevalence of diabetes and its
effects in elderly subjects in Hong Kong. HKMJ, 1996, 2(1):26–33.
9. Andres R, Elahi D, Tobin JD, Muller DC, Brant L. Impact of age on
weight goals. Ann Intern Med, 985, 103(6(pt 2)):1030–3.
10. Harrison GG. Height-weight tables. Ann Intern Med, 1985, 103(6(pt
2)):989–94.
11. Demographic Statistics Section, Census and Statistics Department. Hong
Kong population projection 1992–2011. Census and Statistics
Department. Hong Kong Government Printer, 1992.
12. Census and Statistics Department. Vital statistics (Appendix 32). In:
Renu Daryanani, ed., Hong Kong 1995 — a review of 1994. Hong
Kong: Government Printing Department of Hong Kong, 1995, 504.
13. Elderly Service Department and Research Department, Hong Kong
Council of Social Services. Service model of social centres for the elderly:
an evaluation study (report written in Chinese). Hong Kong Council of
Social Services, Hong Kong. 1994, 23–7.
14. Ho SC. Health and social predictors of mortality in an elderly Chinese
cohort. Am J Epidemiol, 1991, 133:907–21.
1 3 9
Thyroid Dysfunction in Ambulatory Chinese Subjects Over the Age of Sixty
10Thyroid Dysfunction in Ambulatory
Chinese Subjects Over the Age of Sixty
Annie Wai-chee KUNG, Edward Denis JANUS
INTRODUCTION
Disorders of the thyroid gland as well as abnormalities of thyroid
function are very common in the elderly. Elderly patients with thyroid
disease may often be undiagnosed because of atypical presentation or
because of the masking effect of coexisting systemic illnesses.
Furthermore, patients with mild or subclinical hypothyroidism usually
have vague or no symptoms and the diagnosis is often made by screening
serum thyroid hormones or thyrotropin (TSH) levels. In contrast, many
elderly patients with non-thyroidal illnesses may have abnormal thyroid
function tests results, which may be misleading to the physicians and
may result in inappropriate management. Physiological changes of
thyroid function tests have been well documented in the elderly. In
essence, there are abnormal alterations in the neuronal control of TSH
secretion as well as a reduction in both secretion and degradation of
thyroid hormones1. Thus, this reduced pituitary-thyroid function
appears to be a natural consequence of ageing, but this should not be
regarded as hypothyroidism.
In Western populations, thyroid dysfunction affects 10% of the
elderly, and the prevalence varies tremendously between ethnics groups.
It has been reported that the prevalence of hypothyroidism varied from
0.9% to 17.5%, and that for hyperthyroidism was 3.9% to 11.8%1–6.
1 4 0
Annie Wai-chee KUNG, Edward Denis JANUS
However, as abnormal thyroid function tests results may also be due
to non-thyroidal illnesses, data gathered in hospital populations or
elderly homes may not reflect the true prevalence of thyroid dysfunction
in the population. According to a study performed in the US, the
prevalence varied with ethnic groups, and the whites had higher
prevalences of thyroid disorders than the blacks6. The cause for thyroid
dysfunction in the elderly has been attributed mainly to autoimmume
thyroiditis. About 67% of those subjects with elevated TSH values had
positive results for thyroid autoantibodies. Furthermore, the prevalence
of autoimmune thyroiditis is dependent to a certain extent on the dietary
iodine content of the population studied. It was observed that a much
higher incidence of subclinical hypothyroidism was found in areas with
high dietary iodine intake compared to regions with iodine deficiency1.
The second most frequent cause for hypothyroidism is previous
radioactive iodine or surgery for the treatment of thyrotoxicosis or
thyroid tumour. As for subclinical hyperthyroidism, the most common
cause is excessive thyroid hormone therapy, and endogenous Graves’
disease or autonomous thyroid nodules.
So far no data was available for Chinese populations. The aim of
this study was to determine the prevalence of thyroid dysfunction in
healthy ambulatory elderly in southern Chinese in Hong Kong and to
determine the causes for their abnormalities.
SUBJECTS
The subjects were voluntary ambulatory participants of a health
screening project. They were recruited from seven different community
day centres distributed all over Hong Kong. The subjects were over 60
years and the mean age was 71.6±6.8 years (range 60–93). The medical
history, including the use of drugs, was obtained by a questionnaire.
The subjects did not have knowledge of the availability of thyroid
screening at enrolment.
METHOD
Screening of thyroid function was carried out using the primary TSH
screening method. Serum TSH had been confirmed to remain relatively
1 4 1
Thyroid Dysfunction in Ambulatory Chinese Subjects Over the Age of Sixty
stable in adult life up to 90 years of age. Although both decrease and
increase in serum TSH had been reported in apparently healthy elderly
subjects, these changes occurred within the normal range for young
adults1. TSH was determined by a sensitive TSH assay (microparticle
capture enzyme immunoassay, Abbott Laboratory, Chicago, IL, USA)
and the normal range for young healthy adults was 0.35–5.5 mIU/L.
We defined elevation of TSH values as greater than 6.0 mIU/L and
suppressed TSH values as less than 0.1 mIU/L. The sensitivity of the
TSH assay was 0.03 mIU/L. The interassay and intraassay coefficient
of variations were 4.8% and 3.6% respectively. If the TSH value was
abnormal, further thyroid function tests were performed to determine
the type of thyroid abnormality. Serum free T4 was determined by
fluorescent polarization immunoassay (Abbott Laboratory) and total
T3 by RIA (Amersham, Buckinghamshire, UK). The normal range for
FT4 was 10–19 pmol/L and for total T3 was 0.8–2.0 ng/ml. Antibodies
to thyroglobulin (TGA) and thyroid microsomal antigens (TMA) were
estimated by particle gel agglutination (Serodia, Fujirebio, Japan).
Patients with elevated TSH and subnormal FT4 and/or T3 were
considered as hypothyroid; those with elevated TSH but normal FT4
and T3 were considered as subclinically hypothyroid. In contrast, those
with suppressed TSH <0.1 mIU/L and raised FT4 and/or T3 were
diagnosed as hyperthyroid; whereas those with suppressed TSH but
normal FT4 and T3 were considered as subclinically hyperthyroid.
Those subjects with abnormal TSH results were recalled and thyroid
function tests were repeated after an interval period of six months in
order to document whether the abnormal TSH value was only a
transient phenomenon.
RESULTS
A total of 1520 female and 360 male subjects received TSH screening.
The frequency distribution of the TSH values is shown in Table 10.1.
Elevated TSH was observed in 19 subjects (18 females, 1 male).
Suppressed TSH value of <0.1 mIU/L was found in 28 subjects (24
females, 4 males). Subnormal TSH values (0.1 to 0.35 mIU/L) were
detected in 54 subjects (49 females, 5 males).
Frequency distribution curves showed that the median value for
TSH decreased with age in the females: 60–69 years, 1.3 mIU/L; 70–
79 years, 1.25 mIU/L; ≥80 years, 1.05 mIU/L (p=0.02). However, this
1 4 2
Annie Wai-chee KUNG, Edward Denis JANUS
Table 10.1 Frequency distribution of TSH values
TSH (mIU/L) Number of Subjects
< 0.1 2 8 (1.5%)
0.1 – 0.34 5 4 (2.9%)
0.35 – 5.9 1 7 7 9 (94.6%)
6.0 – 9.9 1 0 (0.5%)
≥ 10.0 9 (0.5%)
Table 10.2 Sex and age distribution of abnormal TSH results
Age (years)
60 – 69 70 – 79 ≥ 80
No. of male subjects 1 6 8 1 5 9 0 3 3No. of female subjects 7 2 0 6 3 6 1 6 4
Suppressed TSH (< 0.1 mIU/L)Male 2 (1.19%) 2 (1.25%) 0 (0%)Female 12 (1.66%) 10 (1.58%) 2 (1.22%)
Elevated TSH (≥ 6 mIU/L)Male 1 (0.59%) 0 (0%) 0 (0%)Female 10 (1.38%) 7 (1.11%) 1 (0.61%)
Subnormal TSH (0.1 – 0.34 mIU/L)Male 2 (1.19%) 3 (1.88%) 0 (0%)Female 18 (2.50%) 22 (3.46%) 9 (5.48%)
phenomenon was not observed in the males and the median level
remained at 1.3mIU/L for all ages.
Elevated Serum TSH Levels
There were a total of 19 subjects (1 male, 18 female) with elevated
TSH levels. Surprisingly, the prevalence did not differ between the two
sexes. Biochemical hypothyroidism with low FT4 was found in three
(15.7%) of the subjects with elevated TSH. The other 16 subjects were
diagnosed to have subclinical hypothyroidism as defined by normal
thyroid hormones but elevated TSH. Among those with elevated TSH
levels, 12 (63.2%) were positive for either antithyroglobulin or
1 4 3
Thyroid Dysfunction in Ambulatory Chinese Subjects Over the Age of Sixty
antimicrosomal antibodies or both. The lowest FT4 value among these
subjects was 6 pmol/L. The cause for elevated TSH for the rest of the
subjects was radioactive iodine or external radiation in 5 (26.3%) and
thyroidectomy in 2 (10.5%) subjects. On repeating the TSH values of
these 16 subclinical hypothyroid subjects after 6 months, only one
(5.2%) subject was noted to revert to normal. Her initial TSH value
was 6.6 mIU/L.
Suppressed Serum TSH Levels
Suppressed TSH values were present in 28 (1.5%) subjects. No sex
difference was observed in the prevalence of suppressed TSH levels.
Among these subjects, increased serum thyroid hormones (i.e. confirmed
hyperthyroidism) was present in 12 (43%) of them, and their TSH
values were all <0.03 mIU/L. The cause for suppressed TSH was
autoimmune thyroid disease with presence of antithyroid antibodies in
19 (68.8%), nodular goitre in 4 (14.3%) and exogenous thyroid
hormone suppression therapy for thyroid cancer in 5 (18.7%). None
of the subjects volunteered symptoms of hyperthyroidism. The highest
FT4 value amongst these subjects was 109 pmol/L.
Among the 16 subjects with subclinical hyperthyroidism, 2 (12.5%)
had normalization of their TSH value after 6 months. Both of these
patients did not have thyroid antibodies. One subject had a nodular
goitre on ultrasonogram.
DISCUSSION
This report is the first large-scale study of the prevalence of thyroid
dysfunction in ambulatory elderly adults in southern Chinese. The
main cause for thyroid dysfunction in our population is autoimmune
thyroid diseases, which is similar to the findings of surveys performed
in other ethnic populations.
We noticed a few interesting observations in the present study.
Firstly, we did not observe a female preponderance of thyroid
dysfunction in these elderly subjects. Secondly, the prevalence of elevated
TSH in our population was much lower compared with those reported
in Western populations2–7. This could be explained partly by the fact
that the screening was performed on healthy ambulatory subjects and
1 4 4
Annie Wai-chee KUNG, Edward Denis JANUS
that subjects with non-thyroidal illnesses, which could be associated
with abnormal thyroid function tests, were excluded. Furthermore,
some previous studies have also included milder forms of
hypothyroidism such as subjects with exaggerated response to TRH
stimulation, whereas our present study, like most screening studies,
only performed basal TSH estimation. It has been reported that low
prevalence of autoimmune thyroid disease occurs in regions with low
dietary iodine iodine. Robuschi et al. reported a low prevalence (0.6%)
of subclinical hypothyroidism in Geggio, Italy, where there is low
dietary iodine intake as compared with a prevalence of 14% in
Worchester, Masschusetts, USA, where the dietary iodine is much
higher1. Whether the low prevalence of hypothyroidism in our
population is related to a low dietary iodine intake remains to be
confirmed. In clinical practice in our population, hyperthyroidism due
to Graves’ disease accounts for more than 95% of patients with thyroid
dysfunction and hypothyroidism is uncommon (unpublished data).
We observed that the prevalence of suppressed TSH values were
similar to those of published figures in other populations, which varied
from 0.5% to 2.3%2–7. However, the cause for the suppressed TSH
values in our population was mainly autoimmune thyroid disease.
Only 18.7% were taking exogenous thyroxine therapy as compared to
67% in other series6. This might be related to a difference in the
practice of prescribing exogenous thyroxine therapy for thyroid nodules
in the two populations9. Furthermore, a high percentage (43%) of our
subjects with suppressed TSH values were actually biochemically
hyperthyroid. This was much higher as compared with the series
reported by Parle et al. in UK, in which only one out of the 75 subjects
with suppressed TSH values was thyrotoxic7. This suggested that our
patients with thyrotoxicosis presented late, and our elderly patients
might have ignored their early symptoms and only seek medical
treatment when they were very unwell. It has been recently reported
that elderly subjects with subclinical hyperthyroidism had an associated
threefold higher risk of atrial fibrillation in the subsequent decade10.
As low TSH values might be transient, we repeated the TSH in our
subjects with TSH <0.03 mIU/L. Only two (12.5%) subjects had normal
TSH values after six months. This finding differed from other series
which observed that 39 to 61% of the patients with low TSH values
would become normal after a variable period of four weeks to one
year4,7,8. Whether these subjects had associated non-thyroidal illness,
silent thyroiditis, multinodular goitre, solitary adenoma, or subclinical
Graves’ disease was not defined in these studies.
1 4 5
Thyroid Dysfunction in Ambulatory Chinese Subjects Over the Age of Sixty
The median TSH levels were observed to decrease with age in the
females but not in males. This finding differed from some studies
which reported a progressive increase of TSH in women but not in
men11,12 but was similar to that reported by Bermudez et al.13. The
increment in serum TSH concentration in those studies appeared to be
related to the increased prevalence of serum antithyroid antibodies in
women and a higher prevalence of subclinical hypothyroidism.
In conclusion, we saw that thyroid dysfunction was relatively
common in our population. Furthermore, almost half of the subjects
with suppressed TSH values were biochemically hyperthyroid. Detection
and treatment in thyroid disorders was of obvious importance in the
elderly, who were prone to cardiac disease. Given the relatively common
occurrence of thyroid dysfunction and the simplicity of treatment
regimens, strategies should be formulated with respect to thyroid
screening for the elderly in different populations.
SUMMARY
The prevalence of thyroid dysfunction in ambulatory Chinese elderly
was determined by a primary thyrotropin (TSH) screening program
using a super-sensitive TSH assay. The results showed that elevated
TSH values were found in 1.0% and suppressed TSH values in 1.5%
of the subjects. Although the prevalence of subjects with abnormal
TSH values was low in Chinese, many of them had overt rather than
subclinical thyroid dysfunction. The newer, highly sensitive TSH assays
provide much greater diagnostic specificity in these conditions. Detection
and treatment of thyroid disorders is of obvious important in the
elderly, who are prone to cardiac disease. Given the relatively common
occurrence of thyroid dysfunction and the simplicity of treatment
regimens, strategies should be formulated for thyroid screening for the
elderly.
NOTES
1. Robuschi G, Safran M, Braverman LE, Gnudi A, Roti E. Hypothyroidism
in the elderly. Endocr Rev, 1987, 8:142–53.
2. Nystrom E, Bengtsson C, Lindquist O, Nuppa H, Lindstedt G, Lundberg
1 4 6
Annie Wai-chee KUNG, Edward Denis JANUS
PA. Thyroid disease and high concentration of serum thyrotrophin in a
population sample of women. Acta Med Scand, 1981, 210:39–46.
3. Falkenberg M, Kagedal B, Norr A. Screening of an elderly female
population for hypo- and hyperthyroidism by use of a thyroid hormone
panel. Acta Med Scand, 1983, 214:361–5.
4. Sawin CT, Castelli WP, Hershman JP, McNamara P, Bacharach P. The
aging thyroid. Arch Intern Med, 1985, 145:1386–8.
5. Rosenthal MJ, Hunt WC, Gary PJ, Goodwin JS. Thyroid failure in the
elderly: microsomal antibodies as discriminant for therapy. JAMA, 1987,
258:209–13.
6. Bagchi N, Brown TR, Parish RF. Thyroid dysfunction in adults over age
55 years. A study in an urban US community. Arch Intern Med, 1990,
150:785–7.
7. Parle JV, Franklyn JA, Cross KW et al. Prevalence and follow-up of
abnormal thyrotrophin (TSH) concentrations in the elderly in the United
Kingdom. Clin Endocrinol (Oxf), 1991, 34:77–83.
8. Eggertsen R, Petersen K, Lundberg PA, Nystrom E, Lindstedt G. Screening
for thyroid disease in a primary care unit with a thyroid stimulating
hormone assay with low detection limit. BMJ, 1988, 297:1586–92.
9. Cheung PS, Lee JM, Boey JH. Thyroxine suppressive therapy of benign
solitary thyroid nodules: a prospective randomised study. World J Surg,
1989, 13:818–21.
10. Sawin CT, Geller A, Wolf PA, Belanger AJ, Baker E, Bacharach P,
Wilson PWF, Benjamin EJ, D’Agostino PB. Low serum thyrotropin
concentrations as a risk factor for atrial fibrillation in older persons. N
Engl J Med, 1994, 331:1249–52.
11. Erfurth EV, Norden NE, Hedner P, Nilsson A, Ek L. Normal reference
interval for thyrotropin response to thyroliberin: dependence on age,
sex, free thyroxin index and basal concentrations of thyrotropin. Clin
Chem, 1984, 30:196–200.
12. Tunbridge WMG, Evered DC, Hall R, Appleton D, Brewis M, Clark F,
et al. The spectrum of thyroid disease in a community: the Whickman
Survey. Clin Endocrinol, 1977, 7:481–93.
13. Bermudez DF, Surks MI, Oppenheimer JH. Higher incidence of decreased
serum triiodothyronine concentration in patients with no thyroidal disease.
J Clin Endocrinol Metab, 1975, 41:27–30.
1 4 7
The Prevalence of Diabetes Mellitus in Elderly Subjects in Hong Kong
11The Prevalence of Diabetes Mellitus in
Elderly Subjects in Hong Kong
Annie Wai-chee KUNG, Edward Denis JANUS
INTRODUCTION
There is growing evidence to show that the prevalence of non-insulin
dependent diabetes mellitus (NIDDM) in Hong Kong is similar to that
of other Chinese subjects not living in Mainland China and is
significantly higher when compared to those who reside in the
Mainland1–5. This is believed to result from westernization in lifestyle
habits and change in environmental factors so that the prevalence of
diabetes (DM) in overseas Chinese is almost comparable to that among
Caucasians.
As the population in Hong Kong is ageing and DM is a chronic
illness which is associated with multiple systemic complications,
knowledge of the prevalence of DM and its characteristics would
allow better planning of health care services for the elderly. Previous
studies carried out in Hong Kong showed that amongst adults of
working age, the prevalence of DM was 5.1% in men and 3.6% in
women. Increasing age and obesity were noted to be adverse predictive
factors for the development of DM1. Another study performed on a
confined community of about 400 elderly Hong Kong Chinese also
demonstrated a high prevalence of DM at 10% which increased to
17% in those over 75 years. In order to get a more representative
elderly population, ambulatory subjects recruited from different elderly
1 4 8
Annie Wai-chee KUNG, Edward Denis JANUS
day centres in Hong Kong were studied. The prevalence of NIDDM
was determined and characteristics of DM subjects were compared to
those of non-diabetic subjects.
SUBJECTS AND METHODS
A total of 1912 subjects were tested after an overnight fast. Blood was
drawn from an antecubital vein, kept at 4˚C on ice and transferred on
the same morning in an ice box to the laboratory where plasma was
immediately separated and stored until assays were performed. As
elderly Chinese are often reluctant to accept repeated venepunctures as
required for an oral glucose tolerance test (OGTT), a fasting plasma
glucose (FG) of greater than 7.8 mmol/L was used as the screening test
for diagnosis of DM.
The participants were also interviewed and a selected medical history
was obtained. This included their personal data, any previous diagnosis
of DM, coronary artery disease, stroke, hypertension, use of
medications, smoking and alcohol consumption. Furthermore, the
participants were also invited to undergo a 12-lead electrocardiogram
(ECG) to detect abnormalities including ischaemic changes.
For the measurement of plasma glucose, blood was collected into
fluoride tubes (1 mg/ml final concentration). For the measurement of
lipid profile, blood was collected into EDTA tubes. Plasma glucose
was measured using a hexokinase method (Hitachi 747, Boehringer
Mannheim, Germany). Total cholesterol (TC) and triglyceride (TG)
were determined enzymatically (Boehringer Mannheim) on a Hitachi
analyser. High density lipoprotein cholesterol (HDL-C) was quantified
by the same enzymatic method after precipitation of very-low-density
lipoprotein VLDL and LDL with polyethylene glycol (PEG 6000).
LDL-C was calculated according to the Friedwald equation6.
STATISTICAL METHOD
Statistical analysis was performed using the Statistical Package for the
Social Sciences (SPSS). The results were expressed as mean ± SD.
Analysis of variance (ANOVA) was used to compare the groups of
subjects with raised fasting blood glucose, known DM and controls.
1 4 9
The Prevalence of Diabetes Mellitus in Elderly Subjects in Hong Kong
Pearson’s correlation analysis was performed between the biochemical
variables and demographic characteristics of the subjects.
RESULTS
Fasting plasma glucose (FPG) was available in 1862 (97.4%) of the
subjects. Inability to obtain FPG results in the rest of the participants
was either due to inadequate blood sampling or loss of the blood
samples. There were 1508 females and 354 males. The histograms of
the FPG with respect to age and sex are shown in Figures 11.1 and
11.2. By stratefying these subjects into various age groups namely 60–
69 years (the young old), 70–79 years (the old-old) and ≥80 years (the
oldest-old), the prevalences of raised FPG in the females were 6.3%,
8.3% and 7.4% and in the males were 7.3%, 7.0% and 3.0%
respectively. The group of men aged ≥80 years included only 33
individuals whereas all other groups included more than 150 subjects.
The raised FPG individuals, however, included patients with known
history of DM who were not well controlled but excluded those who
had satisfactory control (FPG <7.8 mmol/L) during the time of blood
testing.
More detailed assessment could only be performed on those 1480
(1225 female and 255 male) subjects who had also participated in the
questionnaire survey. The 13 subjects who were less than 60 years old
were excluded from the analysis. This revealed that among the
remaining 1467 subjects, 158 (10.7%) had a known history of DM.
There were 29 males and 129 females (Table 11.1). Fifty-one of these
subjects had a raised FPG of ≥7.8 mmol/L on the day of assessment.
The prevalence of known DM among these elderly subjects was similar
among the three age groups.
Blood screening revealed 74 subjects who had undiagnosed DM
with FPG ≥7.8 mmol/L. There were 11 males and 63 females. The
prevalence was similar in both sexes: female 63/1212 (5.2%); male 11/
255 (4.3%). However, the prevalence of newly diagnosed DM increased
significantly with age (60–69 years, 4.2%; 70–79 years, 5.7%; ≥80
years, 6.0%; p<0.01, Table 11.2). When all patients with DM (known
plus the new cases) were analysed, the prevalence for 60–69 years old
was 15.9%, for 70–79 years old was 15.4%, and for ≥80 years old
was 17.3% (Table 11.3). The demographic and biochemical data of
these 74 subjects were compared to those of the 1235 non-diabetic
1 5 2
Annie Wai-chee KUNG, Edward Denis JANUS
Table 11.1 Prevalence of subjects with known diagnosis of diabetes mellitus
Age (years) 60–69 70–79 ≥ 80
Total number of subjects* 684 (107/577) 650 (124/526) 133 (23/110)(M/F)
Number of DM patients 80 (13/67) 63 (12/51) 15 (4/11)(M/F)
Prevalence of known DM 11.7% 9.7% 11.3%
Chi square: NS* Subjects completed both questionnaire and blood tests
elderly subjects and the results are shown in Table 11.4. The newly
diagnosed diabetic subjects were more obese with greater body weight
and body mass indices (both p<0.005). They also had more adverse
lipoprotein patterns with higher fasting triglycerides (TG), lower HDL-
cholesterol (HDL-C) and higher risk factor ratios as defined by total
cholesterol (TC)/HDL-C. Otherwise, their TC and LDL-C were similar
to non-diabetic subjects. About 10% in each group were chronic
smokers. Their blood pressure and renal function were similar.
Table 11.2 Prevalence of newly diagnosis diabetes mellitus
Age (years) 60–69 70–79 ≥ 80
Total number of subjects* 684 (107/577) 650 (124/526) 133 (23/110) (M/F)
Number of newly 29 (5/24) 37 (5/32) 8 (1/7)diagnosed DM (M/F)
Prevalence of newly 4.2% 5.7% 6.0%diagnosed DM
P<0.01* Subjects completed both questionnaire and blood tests
Table 11.3 Prevalence of NIDDM (both known and newly diagnosed subjects)
Age (years) 60–69 70–79 ≥ 80
Total number of subjects 6 8 4 6 5 0 1 3 3
Total number of NIDDM 1 0 9 1 0 0 2 3
Prevalence of NIDDM 15.9% 15.4% 17.3%
1 5 3
The Prevalence of Diabetes Mellitus in Elderly Subjects in Hong Kong
Table 11.4 Characteristics of subjects with newly diagnosed diabetes mellitus ascompared with non diabetic subjects
Newly diagnosed Non diabetic P valueD M controls
N 7 4 1 2 3 5
Age (years) 70.8± 5.9 70.5± 6.2 N S
Sex (F/M) 1 1 / 6 4 2 1 4 / 1 0 2 0 N S
Fasting blood glucose (mmol/L) 10 .04± 2.37 5.36± 0.67 <0.001
Smokers 10.5% 11.2% N S
Body weight (kg) 60.11± 8.81 56.31± 9.70 <0.005
Body mass index (kg/m2) 25.29± 3.53 24.02± 3.83 <0.005
Systolic blood pressure (mmHg) 148± 21 145± 21 N S
Diastolic blood pressure (mmHg) 80± 16 80± 11 N S
Urea (mmol/L) 6 .76± 1.38 6.27± 1.42 N S
Creatinine (µmol/L) 90.83± 7.56 89.33± 8.13 N S
Total cholesterol (mmol/L) 5 .98± 1.10 6.14± 1.11 N S
Total triglyceride (mmol/L) 1 .79± 0.76 1.43± 2.20 <0.001
HDL-cholesterol (mmol/L) 1 .25± 0.32 1.43± 0.39 <0.001
LDL-cholesterol (mmol/L) 3 .92± 0.95 4.08± 0.71 N S
TC/HDL-C ratio 5 .02± 1.27 4.60± 1.38 <0.01
The data of the 158 subjects with known history of DM were
analysed and compared to the non-diabetic subjects (Table 11.5). The
diabetic subjects were more obese as reflected by higher body weight
(p<0.001) and BMI values (p<0.01). They had raised TG, lower HDL-
C and higher risk ratios compared with the non-diabetic subjects.
Although the diabetic patients had lower TC and LDL-C, this probably
reflects the fact that some of these subjects were on treatment for their
hyperlipidaemia. These subjects also had higher systolic BP (SBP,
p<0.005) and urea levels (p<0.01) than the non-diabetes but similar
diastolic BP (DBP) and creatinine levels. Furthermore, these diabetic
subjects had higher prevalence of abnormal ECG (p<0.02), coronary
artery disease (p<0.0005), hypertension (p<0.001), stroke (p<0.02),
but a lower prevalence of peptic ulcer disease (p<0.05) (Table 11.5).
Correlation studies were performed on the non-diabetic subjects
which showed that FPG was positively correlated to body weight,
BMI, DBP, SBP, TG, TC and TC/HDL-C ratio, and negatively correlated
1 5 4
Annie Wai-chee KUNG, Edward Denis JANUS
Table 11.5 Characteristics of subjects with known diagnosis of diabetes mellitusas compared with non diabetic subjects
Known diagnosed Non diabetic P valueD M controls
N 1 5 8 1 2 3 5
Age (years) 69.8± 6.2 70.5± 6.2 N S
Sex (M/F) 2 9 / 1 2 9 2 1 4 / 1 0 2 0
Fasting blood glucose (mmol/L) 11 .24± 3.47 5.36± 0.67 <0.001
Smokers 9.4% 11.2% N S
Weight (kg) 59.1± 7.9 56.3± 9.7 <0.001
Body mass index (kg/m2) 24.83± 3.14 24.02± 3.83 <0.01
Systolic blood pressure (mmHg) 150± 23 145± 21 <0.005
Diastolic blood pressure (mmHg) 80± 11 80± 11 N S
Urea (mmol/L) 6 .57± 0.98 6.27± 1.42 <0.01
Creatinine (µmol/L) 89 .79± 10.74 89.33± 8.13 N S
Total cholesterol (mmol/L) 5.9± 1.1 6.14± 1.11 <0.01
Total triglyceride (mmol/L) 1.8± 1.1 1.43± 2.20 <0.001
HDL-cholesterol (mmol/L) 1 .30± 0.3 1.43± 0.39 <0.001
LDL-cholesterol (mmol/L) 3.9± 1.0 4.08± 0.71 <0.01
TC/HDL-C ratio 4.83± 1.5 4.60± 1.38 <0.05
ECG with ischaemic changes 13.1% 9.7% <0.02
Coronary artery disease 11.8% 6.2% <0.0005
Hypertension 43.0% 30.7% <0.001
Stroke 6.5% 3.4% <0.02
Peptic ulcer disease 9.2% 14.1% <0.05
to HDL-C (Table 11.6). We also noted that among these normal
controls, smokers had higher creatinine levels (98.76±9.62 vs
85.96±7.54 µmol/L, p<0.001).
The degree of engagement in physical activity of the subjects with
newly diagnosed DM was compared to that of the non-diabetes. It
showed that less diabetic subjects engaged in walking up slopes and
walking with heavy loads in comparison to the controls (Table 11.7).
The other daily activities were similar in both groups. Analysis of their
eating and cooking habits did not reveal any major differences between
the two groups (Table 11.8).
1 5 5
The Prevalence of Diabetes Mellitus in Elderly Subjects in Hong Kong
Tab
le 1
1.6
Corr
elat
ions
of phys
ical
char
acte
rist
ics,
blo
od g
luco
se a
nd lip
id p
rofile
s in
1235 n
on d
iabet
ic s
ubje
cts
BW
BM
ID
BP
SBP
TC
TG
LDL
HD
LRi
sk F
acto
r
FB
G0
.19
0**
0.1
36
**0
.12
3**
0.1
32
**0
.10
5**
0.1
02
**N
S–
0.0
91
*0
.14
5**
BW
0.7
15
**0
.22
3**
0.1
59
**N
S0
.17
2**
NS
–0
.35
4**
0.2
80
**
BM
I0
.17
3**
0.1
29
**N
S0
.18
6**
NS
–0
.29
0**
0.2
44
**
DBP
0.6
27
**N
S0
.12
5**
NS
–0
.11
3**
0.1
33
**
SBP
NS
0.1
17
**N
SN
S0
.11
8**
TC
0.0
98
*0
.16
4**
0.1
44
**0
.39
9**
TG
0.6
19
**–
0.4
18
**0
.57
7**
LDL
NS
0.3
26
**
HD
L–
0.7
49
**
* p
<0.
01;
** p
<0.
001;
NS:
not
sig
nif
ican
tF
BG
=fa
stin
g bl
ood
gluc
ose
BW
=bo
dy w
eigh
tB
MI
=bo
dy m
ass
inde
xD
BP=
dias
tolic
blo
od p
ress
ure
SBP
=sy
stol
ic b
lood
pre
ssur
eT
C=
tota
l cho
lest
erol
TG
=to
tal t
rigl
ycer
ide
LDL
=LD
L-ch
oles
tero
lH
DL
=H
DL-
chol
este
rol
1 5 6
Annie Wai-chee KUNG, Edward Denis JANUS
Table 11.7 Amount of exercise in newly diagnosed DM patients
Newly diagnosed DM Non diabetic subjects P value
Outdoor exercise/walking 85.1% 82.1% N SWalking stairs 70.3% 60.3% N SWalking up slopes 57.3% 70.3% <0.05Walking with heavy load 22.7% 34.7% <0.01
Daily standing time df = 3 N SDaily walking time df = 3 N SWalking speed df = 3 N SWalking frequency/week df = 6 N STai chi df = 6 N SJogging df = 6 N SAerobic df = 6 N SLight housework df = 7 N SMedium housework df = 7 N SHeavy housework df = 6 N S
Table 11.8 Eating and cooking habits of the newly diagnosed DM patients
Newly diagnosed DM Non diabetic subjects P value
Frequency of taking fat/oily food:Eating fried food df = 3 N SEating fat meat df = 3 N SDrinking creamy soup df = 3 N SSquid/cattle fish/shrimp/crab df = 3 N SInternal organs df = 3 N SCanned meat/fish df = 3 N SNuts df = 3 N SDesserts df = 3 N S
Frequency of taking other foods:Fruits df = 3 N SVegetables df = 3 N SRice df = 5 N SNoodles df = 5 N SRice noodles df = 5 N SBread df = 5 N S
Cooking style:Fry df = 3 N SShuffle with oil df = 3 N SPut on a hot oil layer df = 3 N SImmerse in boiling water df = 3 N SCook with hot water df = 3 N SHotpot style df = 3 N SSteam df = 3 N S
1 5 7
The Prevalence of Diabetes Mellitus in Elderly Subjects in Hong Kong
DISCUSSION
This survey documented that in ambulatory elderly subjects in Hong
Kong, about 10% had already been diagnosed to have DM. Screening
revealed a further 5% who had DM but were asymptomatic for their
disease. The prevalence of NIDDM was around 15% among the 60–
80 years old and was more than 17% in those older than 80 years of
age.
It has been recommended that OGTT should be used as the
screening test for diabetes as the sensitivity of FPG alone is lower
compared to the additional criteria of plasma glucose two hours post-
oral glucose load7. However in view of cultural reasons and reluctance
for repeated venepunctures in elderly Chinese population, a single
blood sample was taken and OGTT was not performed. We were
unable to detect those with impaired glucose tolerance and those diabetic
subjects with normal fasting value but elevated two hours post-glucose
loading plasma glucose as defined by the World Health Organisation8.
We believe that this will result in an under estimation of about 3% in
the prevalence of diabetes for our elderly population.
Although the studied subjects in this project were self-referred
volunteers, we believe that they were representative of the elderly
population in Hong Kong as they were recruited from seven different
community day centres distributed all over Hong Kong. The data
obtained from this study agree well with those reported by Woo et al.2
which were collected from a chosen community of elderly subjects
living in sheltered housing. However, whereas only one-third of their
diabetic subjects were aware of the disease, the present study six years
later revealed that two-thirds of the diabetic subjects were previously
diagnosed. Whether this difference was due to increased public and
professional awareness and increased health education provided by
the community day centres or whether this was due to possible
differences in socio-educational level of the two populations remained
to be confirmed. A local study evaluating the effectiveness of adult
health promotion did demonstrate that the participants were more
knowledgeable and conscientious about their health and were healthier
than their counterparts9,10.
The present study also revealed that advancing age and obesity
were adverse factors associated with DM. In this study we also
documented that the newly diagnosed DM subjects were less active
than the controls. It had been shown previously that environmental
1 5 8
Annie Wai-chee KUNG, Edward Denis JANUS
factors such as obesity, physical inactivity, ageing, dietary changes and
urbanization had implication on the etiology of NIDDM4. We were
unable to demonstrate any major differences in the eating habits of the
diabetic patients with the present study. However, as the design of the
questionnaire was aimed only at detecting major differences in the
distribution of carbohydrates, fat and proteins in the diet as well as
the style of cooking, further studies have to be performed in order to
address the effect of dietary changes on the prevalence of DM in our
population.
It is now generally accepted that NIDDM is associated with insulin
resistance and hyperinsulinaemia rather than insulin deficiency.
Furthermore, there is epidemiologic and clinical association between
central obesity, impaired glucose tolerance or NIDDM, hypertension,
dyslipidaemia, and disturbed fibrinolysis11. These cardiovascular risk
factors, often grouped together as Syndrome X, share a common root
of hyperinsulinaemia12. The present study confirmed that the subjects
with a known history of DM had significantly more coronary and
cerebrovascular atherosclerosis as well as more hypertension. Similarly
both known DM and newly diagnosed DM subjects had raised plasma
triglycerides, lower plasma HDL-cholesterols and higher blood pressure
recordings, all of these being atherogenic abnormalities associated with
hyperinsulinaemia.
A more important observation in this study was that even amongst
the non-diabetic elderly subjects, FPG was positively correlated with
body weight and BMI, confirming the importance of obesity in the
aetiology of NIDDM. FPG was also positively correlated with BP
readings, plasma TG levels, TC/HDL-C ratio and negatively correlated
with HDL-C in the non diabetic subjects, i.e. the healthy elderly
controls. Their body mass index was also correlated with both systolic
and diastolic BP. The correlations observed in these ‘healthy elderly
controls’ suggested that the concept of Syndrome X was not only
applicable to NIDDM patients but also to obese non-diabetic subjects.
The findings from this study confirm that NIDDM was highly
prevalent among the elderly in Hong Kong. With an estimated
population of two million elderly subjects in Hong Kong by the year
2000, understanding the problem of DM in this population would
enable better planning of the health care systems for the elderly and
installation of early preventive measures in the younger population. A
programme of education emphasizing healthy dietary habits, exercise
and weight control would certainly be a most cost-effective form of
prevention.
1 5 9
The Prevalence of Diabetes Mellitus in Elderly Subjects in Hong Kong
SUMMARY
The prevalence of non-insulin dependent diabetes mellitus (NIDDM)
in 1480 ambulatory elderly subjects aged 60–90 years was determined
using fasting plasma glucose as a screening test. A questionnaire survey
on history of diabetes and related complications was performed. The
results showed that about 10% had already been diagnosed to have
DM. Screening revealed a further 5% who had DM but were
asymptomatic. The prevalence of NIDDM was around 15% among
the 60–80 years old and was 17% in those older than 80 years of age.
Obesity and advancing age were adverse risk factors associated with
diabetes. The diabetic subjects had significantly more coronary and
cerebrovascular atherosclerosis as well as more hypertension and more
adverse lipid profiles. Even amongst the non diabetic elderly subjects,
fasting blood glucose was positively correlated with body weight and
body mass index, confirming the importance of obesity in the aetiology
of NIDDM. Education emphasizing healthy dietary habits, exercise
and weight control would be the most cost-effective way of preventing
NIDDM.
NOTES
1. Cockram CS,Woo J, Lau E, Chan JCN, Chan AYW, Lau J, Swaminathan
R, Donnan SPB. The prevalence of diabetes mellitus and impaired glucose
tolerance among Hong Kong Chinese adults of working age. Diabetes
Research and Clin Prac, 1993, 21:67–73.
2. Woo J, Swaminathan R, Cockram CS, et al. The prevalence of diabetes
mellitus and an assessment of methods of detection among a community
of elderly Chinese in Hong Kong. Diabetologia, 1989, 30:863–8.
3. Chou P, Chen HH, Hsiao KJ. Community-based epidemiological study
on diabetes in Pu-Li, Taiwan. Diabetes Care, 1992, 15:81–9.
4. Dowse GK, Zimmet PZ, Gareeboo H, et al. Abdominal obesity and
physical inactivity as risk factors for NIDDM and impaired glucose
tolerance in Indian, Creole, and Chinese Mauritians. Diabetes Care,
1991, 14:271–82.
5. Shanghai Diabetes Research Cooperative Group, Shanghai. Diabetes
Mellitus survey in Shanghai. Chinese Med J, 1980, 93:663–72.
6. Friedwald WT, Levy RI,Fredrickson DS. Estimation of the concentration
of low-density lipoprotein cholesterol without the use of the preparative
ultracentrifuge. Clin Chem, 1972, 18:499–502.
1 6 0
Annie Wai-chee KUNG, Edward Denis JANUS
7. Modan M, Halkin H, Karasik A, Lusky A. Effectiveness of glycosylated
hemoglobulin, fasting plasma glucose, and a single post load plasma
glucose level in population screening for glucose intolerance. Am J Epidem,
1984, 119:431– 44.
8. Report of a WHO study group. Technical report series. Diabetes mellitus
WHO, 1985, 11.
9. Chi I, Leung EMF. An evaluation study of the health promotion program
for the elderly in Hong Kong. Department of Social Work and Social
Administration. The University of Hong Kong, 1992.
10. Lubben JE, Weiler PG, Chi I. Effectiveness of health promotion for the
aging. An evaluation of an United States Program. Hong Kong Journal
of Gerontology, 1988, 2:13–8.
11. Ferrannini E, Buzzigoli G, Giorico MA, et al. Insulin resistance in essential
hypertension. N Engl J Med, 1987, 317:350–7.
12. Reaven GM. Role of insulin resistance in human disease. Diabetes, 1988,
37:1595–607.
1 6 1
The Prevalence and Risk Factors of Fractures in Hong Kong
12The Prevalence and Risk Factors of
Fractures in Hong Kong
Annie Wai-chee KUNG
ABSTRACT
A cross-sectional analysis of the problem of osteoporosis in 1225
female and 255 male subjects was performed. One hundred and eighty-
seven subjects with 190 osteoporotic fractures were recorded. The
cumulative life time risk of having an osteoporotic fracture for a female
subject was 25%. A history of fall was obtained in the majority of the
subjects. The adverse risk factors for fractures were lower body weight,
lower body mass index, higher prevalence of previous gastrointestinal
operation and osteoarthritis. Subjects with previous fractures were
also physically less active, and were unsatisfied with their current
physical health. These informations were important in formulating
strategies to prevent osteoporosis and fractures.
INTRODUCTION
As the population ages, the problem of age-related diseases is becoming
more pressing. Osteoporosis has become a recognized major health
problem among the elderly in Hong Kong, especially in women.
Osteoporosis is characterized by decreased bone mass and increased
1 6 2
Annie Wai-chee KUNG
susceptibility to fractures. Earlier studies have reported that the age-
adjusted incidence of hip fractures had increased significantly in the
last 30 years. The estimated age-specific hip fracture rate among women
aged 50 and above in 1991 was 2645 per 100 000 population1. This
figure has tripled that reported in 1966, and is almost as high as that
reported in the Western populations2. With the increasing age of our
population, the number of subjects who will face this health problem
will increase tremendously.
Although fracture risk is to a great extent determined by the bone
density which in turn is very much genetically determined, fracture
incidence varies greatly in different ethnic groups. Increasing age and
estrogen withdrawal in postmenopausal women are among the more
important predisposing risk factors for bone loss2. However, certain
lifestyle habits have also been associated with fractures. The rapid
increase in the incidence of bone fractures in Hong Kong is thought to
be related to the rapid urbanization of the city, resulting in decreased
physical activity and sunlight exposure. Furthermore, inadequate dietary
calcium intake in the southern Chinese population is also a major
contributing factor, as the mean calcium intake in the elderly population
is less than 300 mg per day, which is far below the recommended level
of 1500 mg for postmenopausal women3,4. Whether other lifestyle
habits that contribute to fracture risk in the Western populations apply
similarly to southern Chinese is unclear. The aim of this project was to
determine the prevalence and risk of fracture in southern Chinese
elderly women in Hong Kong and to determine the factors which
might contribute to bone fractures.
METHOD
Subjects
Among the 2035 subjects enrolled for this health screening, 1480
subjects participated in the questionnaire survey, giving a response
rate of 72.7%. All the participants were ambulatory and none of them
were institutionalized. We excluded women who were unable to walk
without the assistance of another person. The participants were
interviewed and a selected medical history was obtained. This included
personal data, reproductive and breast-feeding history, previous
diagnosis of osteoporosis and fractures, osteoarthritis, diabetes mellitus,
1 6 3
The Prevalence and Risk Factors of Fractures in Hong Kong
gastrointestinal surgery, hyperthyroidism, stroke, use of medications
including sex hormones and corticosteroid, living environment and
requirement of social support, smoking and alcohol consumption.
Concerning previous history of fractures, only those with X-ray
documentations were considered as positive. Physical activity, self
assessment of physical ability as well as psychological assessment were
adapted from a questionnaire for elderly subjects prepared by the
United Nations5.
Statistical methods
The results were analysed by SPSS and associations were tested for
statistical significance with two-tail t test, chi square test or analysis of
variance. The cumulative lifetime fracture risk was determined using
the lifetime survival table model.
RESULTS
The prevalence of fractures
A total of 1225 females and 255 male subjects were interviewed. The
mean age of the subjects was 70.6±6.3 years. Two hundred and five
subjects reported a history of bone fracture. After exclusion of fractures
which were associated with major trauma, the data of 187 subjects
were analysed. There were significantly more female than male subjects
(M: 16, F: 171, p<0.001).
A total of 190 fractures were recorded. The number of different
kinds of fractures were as follows: Colles’ fracture 97, lumbar spine
27, hip 17, other sites 49. The mean age at the time of fracture for the
whole group was 60.7±9.9 years. Associated minor trauma or a slip
and fell injury was obtained in 98% of the Colles’ fractures, 95% of
the hip fractures and 60% of the spine fractures.
The data were analysed separately for the male and female subjects.
Among the 255 male subjects, 16 had a history of previous fracture,
giving a prevalence of 6.3%. The mean age at the time of fracture was
62.1±10.8 years. There were ten Colles’ fractures, two hip fractures,
two spine fractures and two fractures occuring at other sites. Although
there was a trend for the prevalence to increase with age (Table 12.1),
1 6 4
Annie Wai-chee KUNG
the difference was not statistically significant probably due to the small
number of subjects in some age group.
For the female subjects, their mean age was 70.6±6.3 years. One
hundred and seventy-one reported a history of bone fracture. Three
women had more than one fracture. The mean age at the time of
fracture was 60.6±9.8 years and the distribution of the age at first
fracture was shown in Table 12.2. There were 87 Colles’ fracture, 15
hip fractures, 25 fractures and 47 fractures at other sites. The age of
fracture did not differ significantly between the three kinds of fracture
in these women: Colles’ fracture 60.3±9.8 years, hip fracture 62.0±11.0
years, spine fracture 60.1±7.2 years (p=NS). The prevalence of fractures
among these ambulatory women increased significantly with age
(Table 12.3, p<0.05), so that one in nine women of age 60–69 had a
history of fracture, and for women of age groups 70–79 and ≥80
years, the prevalence was one in seven and one in five respectively.
Using life table analysis, the cumulative live time risk of having a
fracture at the age of 50, 60, 70, 80 and 90 were 2%, 6%, 13%, 21%
and 25% respectively (Figure 12.1).
Table 12.1 Prevalence of fractures in ambulatory Chinese men
Age (years) 60–69 70–79 ≥80
Number of subjects 1 0 7 1 2 4 2 3
Prevalence of fracture 3.7% 7.3% 13.0%
P value: NS
Table 12.2 Percentage of all fractures according to the age at fracture inambulatory Chinese women
Age at fracture (years) Percentage
≤60 2 . 0
61–65 1 9 . 7
66–70 2 8 . 9
71–75 1 9 . 7
76–80 1 9 . 1
81–85 8 . 6
86–90 2 . 0
>90 0
1 6 6
Annie Wai-chee KUNG
Table 12.4 Characteristics of Chinese female subjects with history of bonefractures as compared to controls
Fracture group Controls P value
Number of subjects 1 7 1 1 0 4 8
Physical characteristics:Age (year) 71.3± 6.4 70.4± 6.3 N SWeight (kg) 54.2± 8.1 55.6± 9.0 <0.05Height (m) 1.51± 0.58 1.51± 0.6 N SBody Mass Index (kg/m2) 23.7± 3.5 24.3± 3.9 <0.05
Reproductive history:
Age at menopause (year) 48.3± 4.7 48.0± 5.4 N SReproductive years (year) 32.0± 5.4 32.3± 5.7 N SNo of pregnancies 4.7± 2.9 5.0± 6.7 N SBreast feeding 35.7% 41.6% N SBreast feeding duration (months) 35.56± 11.5 30.46± 22.2 N S
Habits:Ever smoker 18.4% 16.3% N SDuration of smoking (pack/yr) 19.1± 11.8 22.0± 15.6 N SEver drinker 7.1% 11.3% N S
Medical diseases:NIDDM 12.4% 10.5% N SGastrointestinal operation 12.7% 9.3% <0.05Osteoarthritis 43.8% 32.9% <0.005Irritable bowel 15.8% 6.9% N SHyperthyroidism 5.4% 6.9% N SStroke 2.0% 3.7% N SSteroid use, more than one year 1.5% 1.0% N SEstrogen use, ever user 6.8% 9.3% NS (p=0.07)Calcium, ever user 9.4% 8.0% N S
NS: not significant
walking speed, whereas the other non-weight bearing activities were
similar when compared to those women without fractures (Table 12.5).
Assessment of social background showed that the two groups had
similar characteristics (Table 12.6). In terms of self-assessment of
physical health, those women with previous bone fractures had
significantly more bone pain, bent back and self-awareness of decrease
in height (Table 12.7). Among those with fractures, significantly more
1 6 7
The Prevalence and Risk Factors of Fractures in Hong Kong
Table 12.5 Physical activities of Chinese female subjects with a history of bonefractures as compared to controls
Fracture group Controls P value
Outdoor walking 82.4% 82.8% N SWalking with heavy load 19.0% 25.7% <0.02Walking stairs 56.7% 60.5% N SWalking up slopes 57.6% 59.5% N SDaily standing time df = 3 N SDaily walking time df = 3 N SWalking speed df = 3 <0.005Tai chi 70.5% 68.8% N SLight exercise/aerobics 86.2% 84.6% N SLight housework 31.5% 38.7% N SMedium housework 34.0% 32.3% N SHeavy housework 32.6% 34.7% N S
df: degree of freedomNS: not significant
Table 12.6 Social background of Chinese female subjects with a history of bonefractures as compared to controls
Fracture group Controls P value
Marital status df = 4 N SFamily background df = 3 N SLiving pattern df = 3 N SRequiring social/financial support 77.2% 56.6% N SCurrently working 2.4% 2.2% N SMajor income source df = 4 N SHousewife 49.7% 50.0% N S
df: degree of freedomNS: not significant
women were unsatisfied with themselves (p<0.01) and had a sense of
unattainment (p<0.05) and uselessness (p<0.01) on getting older
although their self-assessment of overall health status did not differ
from those who did not have fractures. Fortunately, these elderly women
were not psychologically disturbed by their physical disability, and
apart from feeling more irritated than before (p<0.01) and being
bordered by minor issues (p<0.05), they were psychologically well
(Table 12.8).
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Annie Wai-chee KUNG
Table 12.7 Self-assessment of well-being in ambulatory Chinese female subjectswith a history of bone fractures as compared to controls
Fracture group Controls P value
Bone pain 64.7% 56% <0.01Kyphosis 21.0% 12.3% <0.001Decrease in height 40.2% 32.9% <0.005Self assessment of health status df = 4 N SCompare with people of similar age df = 2 N SHealth status compared with last year df = 2 N SUnsatisfied with oneself 44.8% 36.7% <0.01Sense of unattainment when getting older 55.4% 42.9% <0.05More energetic than last year 36.1% 34.0% N SFeeling useless as getting older 56.0% 44.7% <0.01
df: degree of freedomNS: not significant
DISCUSSIONS
Our results demonstrated a high prevalence of fractures in our elderly
female population. The mean age at the time of fracture was similar to
that observed in Western populations2. We observed that the cumulative
risk of any fracture at age of 80 in Chinese women is 25%. These data
Table 12.8 Psychological assessment of female subjects with a history of bonefractures as compared to controls
Fracture group Controls P value
Meaningfulness in life 53.2% 51.1% N SAs happy as when they are young 50.0% 54.9% N SThings that make them sad 29.1% 26.4% N SScared of most things 19.4% 17.9% N SMore irritated than before 32.5% 24.6% <0.01Bordered with minor issues 36.6% 34.7% <0.05Feeling difficult in most of their life 51.7% 46.8% N SSatisfied with present situation 86.6% 84.6% N STake things easy 87.6% 88.2% N SFeeling worrisome 29.2% 26.4% N S
NS: not significant
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The Prevalence and Risk Factors of Fractures in Hong Kong
compared similarly with other studies that utilized models which were
based on actual measurement of bone mass6,7. Using their model, Black
et al.6 observed that the lifetime risk of hip fracture in a 50-year-old
white woman is 19% if her radial bone mass is at the 10th percentile
for her age and 11% if her bone mass is at the 90th percentile.
Furthermore the demographic, cultural and lifestyle risks for
osteoporosis were also similar to Western populations. In essence,
older age, females, smaller body frame, decrease in weight bearing
activity, accident and minor trauma were among the most important
factors predisposing to bone fractures. Association of gastrointestinal
operation was probably related to a decrease in calcium absorption,
leading to a negative calcium balance.
As this study was performed on generally well and ambulatory
subjects, we might underestimate the prevalence rate of bone fractures
in our population as we had not included those who did not recover
or survive the fracture, and also excluded those who were
institutionalized after the fracture. Furthermore, the study was based
on retrospective recall which might be associated with inaccurate recall.
Despite all these limitations, the findings from this study were very
similar to those obtained from the large epidemiologic MEDOS study
performed in Europe8 as well as the data collected in USA9.
What can we learn from knowing these adverse risk factors? As
prevention is better than cure, prevention or reduction of bone loss is
the most effective approach to osteoporosis. Firstly, on a population
basis, a change in lifestyle and dietary modification should be called
for. It has been documented that increased dietary calcium could
increase peak bone mass in the young as well as reduce the rate of
bone loss in the postmenopausal subjects10. Dietary calcium
supplementation has also been shown to slow bone loss in women
consuming less than 500 mg calcium daily11. There is thus a need for
proper advise on dietary calcium and dietary modification of our
population. Whether calcium supplementation to every subject and
how much should be given is still under debate12. A change for more
active lifestyle instead of sedentary activity is also a cost-effective
approach to reduce bone loss. Exercise and rehabilitation programme
for the elderly population, especially those resided in elderly homes,
could effectively improve mobility and reduce the incidence of falling
and hence prevent hip fractures, as these older subjects have slow
bone loss but high probability of falling. Encouragement of exercise
among the younger population could also help to reduce the rate of
bone loss.
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Annie Wai-chee KUNG
For individual counselling, knowledge of risk factors are useful in
a number of ways. For patients who are premenopausal, knowledge of
risk factors might enable the physicians to change the risk profiles of
their patients, and physicians may also use this information to allay
unfounded fear of unassociated factors. Also, knowledge of risk factors
would affect the physician’s decision to offer bone mass measurement
and hence affect the decision to institute preventive interventions. Of
course, it will be most desirable to have bone measurements on each
patient who would consider a therapy to prevent further bone loss
without regard for risk factors, as bone mass measurements are accurate
within 1–2% and provide good estimates of fracture risk. However,
even in such circumstances, understanding of risks factors might
influence the decision to institute the type of treatment available. For
example, a perimenopausal woman is advisable to have estrogen
replacement therapy whereas a 75-year-old lady may derive more benefit
from calcium supplement and exercise programme to improve muscle
power and coordination.
In conclusion, our study demonstrated a high prevalence of bone
fractures in postmenopausal Chinese women and certain life-style risks
were adversely associated with bone fractures. Modification of life-
style risks could be a cost-effective method to prevent osteoporosis.
NOTES
1. Lau EMC. Hip fracture in Asia-trends, risk factors and prevention.
Proceedings of Fourth International Symposium on Osteoporosis and
Consensus Development Conference. 1993, 58–61.
2. Melton LJ. Etiology, diagnosis and management. In Riggs B, Melton LJ,
eds. Epidemiology of fractures. New York: Raven Press, 1988, 133–54.
3. Lau E, Donnan SPB, Barker DJP, Cooper C. Physical activity and calcium
intake in fracture of the proximal femur in Hong Kong. Br Med J, 1988,
297:1441–3.
4. Pun KK, Chan LWL, Chung V, Wong FHW. Calcium and other dietary
constituents in Hong Kong Chinese in relation to age and osteoporosis.
J Appl Nutri, 1990, 42:12–7.
5. Question of the elderly aged: report of the Secretary-General United
Nations. New York. Unpublished documented 1981, 81–007748877E(E).
6. Black DM, Cummings SR, Genant HK, Nevitt MC, Palermo L, Browner
W. Appendicular bone mineral and a woman’s lifetime risk of hip fracture.
J Bone Min Res, 1992, 7:633–8.
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The Prevalence and Risk Factors of Fractures in Hong Kong
7. Cummings SR, Black DM, Nevitt MC, Browner W, Cauley J, Ensrud K,
et al. Bone density at various sites for prediction of hip fractures. The
study of Osteoporosis Fractures Research Group. Lancet, 1993, 341:72–
5.
8. Elffors I, Allander E, Kanis JA, Gullberg B, Johnell O, Dequeker J, et al.
The variable incidence of hip fracture in Southern Europe: The MEDOS
study. Osteoporosis Int, 1994, 4:253–63.
9. Riggs BL, Melton LJ. Involutional osteoporosis. N Engl J Med, 1986,
314:1676–86.
10. Johnston CC, Miller JZ, Slemdenda CW, Reister T, Hui S, Christian JC,
et al. Calcium supplementation and increases bone mineral density in
children. New Engl J Med, 1992, 327:82–7.
11. Dawson-Hughes B, Dallal GE, Krall EA, Sahyoun N, Tennenbaum S. A
controlled trial of the effect of calcium supplementation on bone density
in postmenopausal women. New Engl J Med, 1990, 323:878–83.
12. Consensus Development conference: diagnosis, prophylaxis, and treatment
of osteoporosis. Am J Med, 1993, 94:646–50.
1 7 3
Ageing in Hong Kong
13Ageing in Hong Kong
Nelson Wing-sun CHOW, Iris CHI
INTRODUCTION
Hong Kong is a British colony until 1997 when it is returned to China
to become a special administrative region. As over 98% of the
population in Hong Kong are ethnic Chinese, the place has been
dominated by the Chinese culture, though western practices have also
been prevalent especially among the young and the educated. Hong
Kong is no doubt a typical example of where the east meets the west.
This encounter of different cultures is most apparent among the elderly
as most of them have come from an agrarian social and economic
background and are now the first generation to grow old in a highly
industrialized city. It is therefore not surprising to find that the majority
of the elderly in Hong Kong are unprepared for the kind of retirement
life which they are now experiencing.
According to the Chinese tradition, a person is considered old
when he or she reaches the age of 60, and this is also the age commonly
perceived to be elderly in Hong Kong. The planning of both welfare
and housing services for the elderly uses the age of 60 as the cut-off
point, but 65 has been employed for the planning of medical and
The early version of this paper has been published in the International
Handbook on Services for the Elderly, edited by Jordan I. Kosberg, Greenwood
Press, 1994.
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Nelson Wing-sun CHOW, Iris CHI
health services. In March 1991 when the last census was conducted in
Hong Kong, 13.5% of the total population, or 772 400 out of
5 674 114 persons, were found to be aged 60 and over, and 8.7% of
the total were aged 65 and over. It was projected that by the year
2000, more than 15% of the population in Hong Kong would be aged
60 and over and the actual number would be approaching one million.
In terms of the sex ratio, similar to other industrialized countries, the
proportion of male to female elderly population in Hong Kong was
around 2 to 3. Life expectancy in Hong Kong was still rising and
stood at 75 years for males and 81 for females in 1991. As previously
mentioned, the majority of the elderly now living in Hong Kong came
from China and had received little formal education while they were
young, as it was then the period of World War II. As to their marital
status, the 1991 Census findings revealed that nearly 40% of the
elderly population were widowed, while about 5% had never married
and very few had actually been divorced or separated.
Economically, the elderly in Hong Kong were probably among the
poorest in the population. Since most of them were not receiving any
retirement pensions, their only way to maintain a living was to rely on
their own savings or the support of their children if available. For
those who could find a job, they would go on working for as long as
their health permits. In 1991 about a quarter of the elderly population
in Hong Kong were classified as ‘economically active’, implying that
they were still being employed. Judging from the meagre incomes that
most of them received, its was obvious that the elderly had worked
mainly for the reason of maintaining a living.
The relatively inferior economic position of the elderly had produced
an adverse effect in eroding the traditionally prestigious social status
held by the elderly. Though the elderly in Hong Kong were still
described as ‘liken unto a treasure at home’, recent studies indicated
that their social image had dropped so low that it was indirectly
contributing to an increasing number of elderly committing suicides,
and also to the emerging problem of elder abuse. Indeed, evidence
suggested that the younger generations once married were increasingly
unwilling to live with their parents. The 1991 Census found that ‘one
vertically extended nuclear family’ or more commonly known as ‘three-
generation family’ represented only 10.7% of all households, a decrease
from 13.6% in 1981. Other current data on the elderly revealed that
about 4% of the elderly in Hong Kong were living in various types of
institutions, 24% either alone or with another elderly person, thus
leaving about 70% with other members of the family, and one-third
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Ageing in Hong Kong
of these elderly were only living with their spouse. Compared with
other industrialized countries, the percentage of the elderly in Hong
Kong who were still residing with their children was still very high,
but the decreasing trend suggested that many of the three-generation
households were only maintained grudgingly. Some recent studies found
that an increasing number of the elderly were expressing a wish to live
on their own, suggesting that the social value of residing with one’s
children might no longer be as sacrosanct as before.
In addition, the elderly people in Hong Kong were found to have
very limited social network and receiving the least social support from
others as compared with other Chinese elderly residing in Mainland
China and Los Angeles (Lubben and Chi, 1993). A large proportion of
the elderly in this age cohort had never established families in Hong
Kong or left their families in Mainland China during the war time.
Another possible reason was that the current social and political
uncertainties in Hong Kong had led to massive emigration among the
younger generation, hence resulting in weaker social support network
for the elderly.
In terms of physical health status, most of the elderly in Hong
Kong self-evaluated their health as fair and poor; less than one-third
of the elderly thought their health was excellent and very good.
Approximately 17% of the elderly aged 60 and over in Hong Kong
reported that they had no known chronic diseases (Chi et al., 1993).
As for the functional health, close to 6% of the elderly aged 70 and
over in Hong Kong had had difficulties in basic self-care (Ho and
Woo, 1994). In sum, the physical health of the elderly in Hong Kong
in general was comparable to those elderly living in the developed
countries even though they tended to rate their health poor.
However, elderly in Hong Kong seemed to have serious mental
health problems. Compared to other Chinese elderly, Hong Kong elderly
tended to report more negative feelings, such as bored, lonely, frustrated
and depressed (Chi et al., 1993). The difference in feelings might relate
to many different factors. As more elderly in Hong Kong had limited
social support network and financially more dependent on others, their
lives would become harder and it was understandable that they had more
negative feelings towards their lives. Their lower levels of life satisfaction
in a way reflected their disappointment and helplessness. A recent study
on the mental health of the elderly in Hong Kong (Chi and Boey, 1994)
supported the above possible explanations. The best predictors for life
satisfaction as identified in that study were: ‘being financially adequate’,
‘having good social support’, and ‘with high self-care capability’.
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Nelson Wing-sun CHOW, Iris CHI
The social and economic status of the elderly in Hong Kong is
obviously changing rapidly under the pressure of modernization and
urbanization. For a society and culture which has for centuries held
dear the value of filial piety, the eroding status of the elderly has
naturally been viewed with misgiving, and attempts to revive this
traditional value are not unheard of. While a lot can be said about the
importance of preserving filial piety, circumstances have changed so
much that a new strategy of approaching the ageing problem would
probably bring about a better support system for the elderly, and at
the same time promote among the elderly themselves a more positive
outlook towards life.
THE FORMAL STRUCTURE OF CARE TO THE ELDERLY
Since the need of the elderly for care and support outside their families
has only been recognized recently, a formal system to provide care to
the elderly had not been in existence before 1977 when the government
issued a policy paper on developing services for the elderly. Instead of
committing the government to meeting every need of the elderly, the
policy paper pronounced a ‘care in the community’ approach in which
the responsibility of taking care of the elderly would be shared between
the government and the ‘community’, including the family in which
the elderly lived. The adoption of the ‘care in the community’ approach
was based upon the premise that the elderly would be most satisfied
when they were residing with their families; institutional care could
only be a second best and should only be provided when the elderly
persons were too frail to take care of themselves or when their families
were unable to do the job. In terms of provision, the policy paper held
the view that as far as possible, the government should refrain from
directly operating the community support and residential services; they
should best be taken up by non-government organizations (NGOs) as
they would cost less and probably be more effective in enlisting
voluntary support.
Except for the old age allowance which is regarded as an entitlement
of the elderly, all the other public services for the elderly are provided
on the basis of need, and for some a test of means is also required. The
definition of need varies from service to service. In general, the need of
the elderly is measured by their degree of urgency to receive support
and the extent to which it can be met either by the elderly themselves
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Ageing in Hong Kong
or their families, if available. Although most community support and
residential services are operated by different NGOs, similar criteria
have been employed in assessing needs as the services are uniformly
funded by the government. The provision of housing and hospital
services, on the other hand, is administered by two quasi-government
organizations, the Housing Authority and the Hospital Authority, and
each has its own criteria in determining the needs of the elderly.
The formulation of service policies for the elderly lies with the
Secretary for Health and Welfare and two committees, namely the
Social Welfare Advisory Committee and the Medical and Health
Development Advisory Committee, which have been set up to advise
the government. In 1987 a Central Committee on Services for the
Elderly, comprising representatives from both government and non-
governmental organizations, was established to review the various public
services provided to the elderly and a number of improvements were
subsequently made. In addition, the Hong Kong Council of Social
Service, a co-ordinator of NGOs in Hong Kong, established a division
in 1972 to monitor the work of the NGOs in the area of services for
the elderly and to draw up the relevant service standards.
In summary, services for the elderly have been developed in Hong
Kong largely as a result of the efforts of the NGOs, with resources
first coming from local and overseas donations and now from
government subsidies. Although fees are charged for using the various
public services, they are either just nominal or set at a level which the
majority of the elderly can afford. The general principle governing the
provision of these services is that they should be offered to the elderly
who have the greatest demonstrable need. Since public services provided
for the elderly are generally insufficient, elderly persons who are
prepared to pay more may be impatient with the long waiting lists and
turn to the private market to purchase the relevant services. Private
nursing homes and other profit-making home-based services are
becoming a permanent feature of the support system to the elderly.
Hence, despite the effort of the government in recent years to expand
its social services to the elderly, there is still room for the existence of
a private sector to cater for the needs of those who can afford to pay
a higher fee.
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Nelson Wing-sun CHOW, Iris CHI
INCOME MAINTENANCE AND EMPLOYMENT
The provision of income maintenance for the elderly is relatively simple,
and in a way underdeveloped, in Hong Kong. The issue of income
security in old age was discussed in Hong Kong in 1967, when a
government working party was set up to examine its necessity. Although
the working party was in favour of the introduction of a contributory
retirement pensions scheme, the government had not deemed it
necessary, arguing on the ground that the capitalist system of Hong
Kong would best be served when income security matters were left to
the private arrangement between the employers and the employees,
with little interference from the government. As a result, retirement
pensions remained only the entitlement of the government servants
and a small number of the fortunate ones employed in large enterprises.
As to the rest, they had to depend either on their own savings or the
support of their children when they retired. The absence of such an
important social measure was obviously unacceptable and after incessant
demands from the public for the introduction of old age income security
schemes, the government announced in November 1991 that it was
prepared to examine the issue once again and to come up with a
proposal by the end of 1992.
As it now stands, what the elderly in Hong Kong are entitled to is
the old age allowance and the support from public assistance if they
are poor. A Hong Kong resident, who has not been away from the
territory for substantial periods in the five years before reaching the
age 65, can apply for the old age allowance. For those aged between
65 and 69, they have to declare that they have neither an income nor
assets above certain prescribed levels to be eligible. In 1992, the limits
were set at monthly incomes of HK$2600 (US$1 = HK$7.8) for a
single person and HK$3900 for a married couple; assets were set at
HK$100 000 for a single person and HK$150 000 for a married couple.
For applicants reaching the age of 70, no income declaration was
required. The old age allowance which those aged 70 and over can
receive is higher than that given to those aged below 70; in 1992, the
amounts were HK$470 and HK$413 a month respectively. As the old
age allowance is non-means-tested, non-contributory and regarded as
the right of every elderly person residing in Hong Kong, the amount
given has to be kept small in order not to financially overburden the
government. The old age allowance should therefore in no way be
compared to retirement pensions provided in other countries. The
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Ageing in Hong Kong
purpose of the old age allowance, when it was first introduced in
1973, was seen as an incentive to encourage families to take care of
their elderly members; it has never been meant to be enough for the
support of a basic living. In March 1992, over 400 000 elderly persons
were receiving the old age allowance and costing the government an
annual outlay of over HK$2000 million.
The other social security measure which the elderly can avail
themselves of is the public assistance scheme. It has been mentioned
that the majority of the retirees in Hong Kong are deprived of a steady
income from retirement pensions; some of them have therefore found
it necessary to apply for public assistance when they have exhausted
other means to maintain a living. To be eligible for public assistance,
a person has almost to be penniless and it is not surprising that often
only the lonely elderly are eligible. In March 1992, about 60 000
elderly persons in Hong Kong were receiving public assistance, with
the basic rate for a single person set at HK$825 a month. For those
aged between 60 and 69, they could also receive an old age supplement
at HK$413 a month and it was increased to HK$470 a month for
those aged 70 and over. In addition, public assistance recipients were
eligible for a subsidy to cover rent. Admittedly, the total amount
provided under the public assistance scheme is only sufficient for a
living just at the subsistence level, and hardly enough to provide the
elderly with anything more than the bare necessities.
Very little attention has so far been paid to the employment needs
of the elderly, though about a quarter of them are still participating in
the labour force. As no compulsory retirement pensions exist, many of
the elderly have continued to work due to necessity rather than choice.
At present, elderly persons who require employment assistance can
approach the Job Placement Unit of the Labour Department or the
Employment Assistance Service of the Hong Kong Council of Social
Service. As the unemployment rate in Hong Kong has been kept very
low, jobs are available to the elderly who want to work, but may not
necessarily suit their abilities and past experiences.
HEALTH CARE SERVICES
The medical and health care system in Hong Kong is made up of two
parts: an extensive public sector meeting the needs of the general
public and a vigorous private sector catering for those who can afford
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Nelson Wing-sun CHOW, Iris CHI
to pay. In general, about 80% of the patients requiring hospital
treatment make use of the services provided in public hospitals managed
by the Hospital Authority, while the majority of those requiring only
consultative services turn to the private practitioners. As far as the
elderly are concerned, since very few of them are protected by private
medical insurance and most are limited in means, they tend to make
more use of the services provided in public hospitals and out-patient
clinics. For instance, the majority (83.4%) of the elderly in Hong
Kong were frequent users of medical facilities (Chi and Lee, 1989);
over 40% of the hospital beds were being occupied by the elderly (Chi
and Leung, 1992).
The provision of the health care for the elderly was first mentioned
in the 1974 White Paper on ‘Further Development of Medical and
Health Services in Hong Kong’ (Hong Kong Government, 1974). In
that specific document, it proposed that ‘many of the health needs of
the elderly are expected to be met by the general provision currently
available or being planned’. In the past 20 years, the health care
programmes in Hong Kong were mainly concentrated on the acute
care and out-patients clinic services, while the health prevention for
the elderly was not included. This has led to a health care system
which was costly but was not appropriate in meeting the elderly’s
health need.
The public medical and health services currently available to the
elderly consist of: specialist geriatric medical service, community
geriatric assessment services, community nursing service, community
psychiatric nursing service, priority medical consultation for the elderly,
infirmaries for the elderly, psychogeriatric services, hospice care and
preventive health care.
The specialist geriatric medical service started in Princess Margaret
Hospital in 1975. Presently major public and subvented hospitals under
the Hospital Authority have either geriatric departments or teams headed
by consultants, and are providing acute medical treatment, rehabilitation
and day hospital service to elderly people in need. The Community
Geriatric Assessment Service started in 1994 has been providing medical
treatment and rehabilitation to subvented residential home inmates as
well as pre-admission assessment of elderly waiting for subvented aged
homes, care and attention homes and infirmaries to ensure appropriate
placement. Each team is headed by a geriatrician with nurses, therapists
and medical social workers. These teams have been developed by the
geriatric departments or teams of the public hospitals. At present there
are eight community geriatric assessment teams.
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Ageing in Hong Kong
The community nursing service was formally established in 1977.
It is operated on a referral basis and accepts only patients discharged
from hospitals. In 1991 there were over 50 such community nursing
‘stations’ to which patients could be referred to according to their
place of residence. Services rendered by the community nurses include
a wide range of skilled nursing care such as injection, ostomy care,
removal of stitches, catheter care, wound dressing and irrigation.
Rehabilitation exercises, blood pressure measurement, urine testing,
diet instruction and general health education can also be performed.
Although the community nursing service is available to all patients
who have such needs, nearly half of those benefitting from it are the
elderly. Similarly, most of those using the community psychiatric nursing
service belong to the elderly group. The community psychiatric nursing
service is also operated on a referral basis with the purpose of ensuring
continuity in care and prevention of relapses. The above two community
services have both reported success in preventing unnecessary hospital
admissions, thus enabling many elderly patients to continue remaining
in the community.
It has been mentioned that a higher percentage of the elderly than
the general population are making use of the public out-patient clinic
services. Because of the heavy demand, patients using the public out-
patient clinic services often have to wait for several hours for their
turn of consultation. The purpose of the priority medical consultation
scheme for the elderly is to shorten the waiting time of the elderly by
offering them priority to consult the doctor. The actual operation of
the scheme varies from clinic to clinic, but on the whole it has provided
the elderly patients with much convenience.
As for the elderly suffering from chronic physical and mental
illnesses and in need of constant nursing care and some medical
supervision, they would be provided with infirmary care. The existing
planning ratio of infirmary care is five infirmary beds for 1000 elderly
persons aged 65 and over. At the end of 1990, the provision of infirmary
beds stood at around 2000 while the demand as expressed by those on
the waiting list was about 3500, with a shortfall of more than 1500
beds. Since the establishment of the Hospital Authority in December
1991, infirmaries and the central infirmary waiting list (CIWL) have
been placed under Hospital Authority’s management. By August 1995,
there were 1534 infirmary beds in public and subvented hospitals and
the number on CIWL was 4226. The average waiting time was about
three years. In addition to infirmary beds of hospitals under the Hospital
Authority, there are currently 530 elderly in ‘infirmary units’ in the
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Nelson Wing-sun CHOW, Iris CHI
care and attention homes under the Social Welfare Department. The
planning ratio for infirmary beds is still 5 per 1000 elderly aged 65
and over. The requirement will be 3418 beds in the year 2000. The
severe shortage of infirmary beds has not only caused much suffering
among the elderly waiting for admission, but also tremendous stress
upon their families shouldering the burden of care.
There is a further substantial number of elderly persons who are
suffering from both physical and mental problems and are in need of
psychogeriatric services. Depending on the nature of their needs, the
elderly suffering from such problems may be receiving treatment at
psychiatric out-patient clinics, day hospitals, geriatric wards of general
hospitals, or visits by community psychiatric nurses. Like infirmary
care, services provided to meet the needs of the elderly with both
physical and mental problems are in severe short supply. As for the
terminally ill elderly patients, they can now receive hospice care
introduced since the mid-1980s in a few public hospitals.
The purpose of preventive health care is to impart to the elderly
the knowledge of a healthy life-style and the importance of the
prevention of disease. Presently, health promotion work is carried out
by the Central Health Education Unit of the Department of Health
and consists mainly of publicity campaigns and other community
programmes aiming at educating the elderly about disease prevention.
It was not until 1992 that the Governor of Hong Kong first announced
the establishment of seven Elderly Health Centres (EHC) for those
aged 65 and above to promote their health. In the past, the Hong
Kong Government consistently spent around 9% of its annual budget
on health care. The Governor promised to raise the recurrent spending
on health care by 22% in real terms over the next five years (Hong
Kong Government, 1992). Despite the rapid increase of medical
expenditure, it is generally recognized that our health care system is
overloaded. One of the major causes for overloading is that too little
has been done in disease prevention, and these measures have been
implemented too late.
Before 1990 there was no comprehensive adult health promotion
programme in Hong Kong. The government had been very reluctant
in developing the primary health care services for its senior citizens. In
the absence of government’s involvement, several elderly health
promotion programmes were run by the voluntary agencies in small
scale. These were innovative programmes and they were each playing
a unique and crucial role in advocating adult health promotion
programmes in Hong Kong. Without financial support from the
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Ageing in Hong Kong
government, these programmes were constantly under the pressure of
unstable financial condition. In order to survive, these programmes
must charge their participants at cost which inevitably precluded the
most needy, low income elderly.
The Report of the Working Party on ‘Primary Health Care — Health
for All, The Way Ahead’ stated that ‘It is the responsibility of every
government to promote the health of the community and to prevent or
minimize the occurrence of diseases . . . We are therefore concerned that
sufficient emphasis and resources should be directed towards health
promotion and disease prevention’ (Hong Kong Government, 1990).
The Secretary of Health and Welfare further stressed that promotion
for a healthy life-style among the elderly was also important.
The Consultation Paper on Health Promotion (1993) outlined the
range of primary health care service which would be provided by the
first EHC in 1994. The coverage of health care was far from
comprehensive and the participants were required to pay for the services.
Although the fee was not high, it still excluded the poor elderly from
participating in the programme.
In summary, as very few of the elderly in Hong Kong are covered
by private medical insurance, the majority have to turn to the public
sector for their medical and health care needs. Over the last 20 years,
the government has developed a wide range of domiciliary and
institutional services, as part of the larger network for the general
population, to meet the medical and health care needs of the elderly.
The quality of the services is generally acceptable but they are often so
short in supply that they can only be available to those in urgent need.
Despite the low commitment from the government, the recent elderly
health care policy and implementation seems to point to the right
direction. The first government organized EHC was established in
April 1994. The Report of the Working Party on Elderly Services
proposed that four out of the seven EHC adopt an integrative service
delivery model (Hong Kong Government, 1994). The new EHC would
be built in the existing general out-patient clinic, so as to make full use
of the resources and allow for service co-ordination.
HOUSING RESOURCES FOR THE ELDERLY
With a population of over six million people and only 20% usable
land (approximately 200 km2), housing naturally presents itself as the
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Nelson Wing-sun CHOW, Iris CHI
most serious problem for most people living in the congested city. The
public housing programme in Hong Kong was started as early as in
1953 when a fire on Christmas Eve made more than 50 000 people
homeless. At the end of 1991, 40.5% of the population were living in
public and aided housing with another 7.5% in Home Ownership
Scheme estates built by the Housing Authority. The need of the elderly
for housing has long been attended to with the first hostel for the
elderly set up in the late 1960s. Since then a great variety of housing
resources have been developed for them.
Prior to 1985, hostels formed the major form of housing resource
for the elderly, and most who were thus accommodated were lonely
and without a family. In March 1991, 2120 elderly persons were
staying in these hostels which were run by the NGOs with subsidies
from the government. Since 1985, there has been a change in policy;
instead of building more hostels for the elderly, those requiring
accommodation were housed in ‘sheltered housing’ managed by either
the Housing Department or the NGOs. In March 1991, ‘sheltered
housing’ accommodated a total of 2591 elderly persons and would be
further expanded.
Besides the provision of hostels and ‘sheltered housing’, elderly
persons can also apply for accommodation in public housing estates
through either the Elderly Persons Priority Scheme or the Compassionate
Rehousing Scheme. Under the Elderly Persons Priority Scheme, two or
more unrelated persons reaching the age of 58 or over who agree to
live together can apply for rehousing. They can normally be rehoused
within a reasonable period of one to two years. From its implementation
in 1979 up to the end of 1991, about 17 000 elderly persons were
thus rehoused. For elderly persons who want to live by themselves,
they can opt for the Single Persons Allocation Scheme, but due to the
limited supply of single person units in public housing estates, the
waiting time is much longer. Other than the above arrangements,
elderly persons who are faced with social and medical problems can
apply for the 1100 public housing units allocated each year under the
Compassionate Rehousing Scheme, which aims at catering for the
housing needs of families and individuals facing social difficulties.
The above schemes are intended mainly for the elderly who are
capable of self-care or require only minimum assistance. Two other
types of residential care are provided for those who cannot manage on
their own. The first one is homes for the aged which by March 1991
housed a total of 6993 elderly persons. The planned ratio of the
homes for the aged is ten places for every thosuand elderly population.
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Ageing in Hong Kong
Nearly all homes for the aged are run by NGOs with financial support
from the government. The other type is care and attention homes,
more commonly known as nursing homes in other countries, which
are intended for elderly persons requiring not more than two and a
half hours of nursing care per week. In March 1991, 3232 elderly
persons were staying in these homes. In recent years, there has been an
upsurge in demand for nursing care places and the number of the
elderly waiting for admission is often more than those admitted. As a
result, many who can afford to pay a much higher fee have turned to
the private sector. At the end of 1991, it was known that more than
9000 elderly persons were staying in private nursing homes, three
times those in the subsidized sector. Recognizing the increasing demand
for nursing care places, the planned ratio of such services in the
subsidized sector has been increased from eight to 11 for every thousand
elderly population.
In addition to the above housing arrangements, families applying
for public housing can have their waiting period shortened by three
years if they have elderly members included in their households. If
these families are prepared to move to the new towns where public
housing units are more readily available, they can even apply for two
units in the same block so as to facilitate mutual support between the
married children and their elderly parents. Since various measures
have already been introduced to meet the housing needs of the elderly,
no additional financial assistance or tax relief measures are deemed
necessary to help those living in private housing.
Despite the efforts of the government to provide housing for the
elderly, there are still several thousands of them who, for various
reasons such as proximity to their place of work or unwillingness to
move to another district, are occupying just a bed-space in some of the
dilapidated private tenement blocks. These elderly persons, often male,
are termed as the ‘caged men’ as they often surround their bed-space
with fences in order to protect their own belongings. It is also known
that there are about a thousand homeless elderly persons sleeping in
the streets, and plans are in hand to house them in a few specially
designed hostels located in the urban areas.
The existing housing policy for the elderly is thus to accommodate
the elderly in various types of public housing or residential
arrangements. Though the preference of the younger generations today
is to set up their own families, co-residence of elderly persons with
their married children remains the dominant practice and measures are
taken to encourage its continuance.
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Nelson Wing-sun CHOW, Iris CHI
SUPPORTIVE SERVICES FOR THE ELDERLY
It has been mentioned that less than 4% of the elderly in Hong Kong
are living in institutions, while the great majority of them are staying
in the community either by themselves or with their families.
Community support services, comprising home help service, social
centre, multi-service centre and day care centre, constitute an important
part of the social support network. Home help services rendered to the
elderly include the preparation of meals, personal care, escort, laundry
and home management. Around 3000 elderly persons were being served
by home helpers in March 1991. Social centres cater for the elderly
persons social and recreational needs. The planned ratio of such centres
is one per 3000 elderly persons, and in March 1991 there were 155
centres. One multi-service centre is planned for every 25 000 elderly
population. In March 1991, there were 17 such centres. Services
provided include home help, counselling, social activities, laundry,
bathing and canteen facilities as well as the organization of community
education programmes. Day care centres, wherever possible, are
attached to multi-service centres and provide services such as personal
care, nursing care and rehabilitative services.
Supportive medical and health services have already been discussed.
Other services which have the same purpose of assisting the elderly to
remain in the community include respite service and various kinds of
community programmes. After a trial period of two years, respite
service was formally introduced in 1991 to help relieve the burden of
families which had to look after frail elderly members. An outreaching
service for the ‘elderly at risk’ was also started in 1991, for an
experimental period of two and a half years, to reach out to the
elderly in need of support but who would not take the initiative to
come for the services. In addition, mass programmes such as health
education and festivals for the elderly are organized on a regular basis
to encourage the elderly to participate in community activities. Lastly,
it should be noted that a great variety of indigenous organizations,
such as the mutual help associations and the religious bodies, also play
an important role in enabling the elderly to be engaged in the
community by providing them with channels to associate themselves
with other members of the community.
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Ageing in Hong Kong
LEISURE-TIME RESOURCES FOR THE ELDERLY
As the majority of the elderly in Hong Kong are still living with their
families, most of their leisure time are spent in family-related activities.
Studies on the leisure activities of the elderly in Hong Kong found that
the most common activity of the elderly, whether living alone or with
other family members, was watching television. A very high percentage
of the elderly who were living with their married children revealed
that they were so busily occupied with household chores and in looking
after their grandchildren that they had little time left for themselves.
Culturally there is also a resistance among the Chinese elderly to
engage themselves in activities outside the home environment and with
persons other than their own family members.
For the elderly who want to spend their leisure time outside their
homes, social centres for the elderly provide the most convenient venue.
In March 1991, about 70 000 elderly persons were members of the 155
social centres which, other than providing the elderly with various kinds
of social and recreational activities, also played the role of encouraging
the elderly to serve as volunteers for other frail elderly and the
handicapped. In addition, an increasing number of the elderly are now
becoming followers of various religious beliefs, and it is common that
they regard religious activities as their major pursuit in life.
Besides the above more formal activities, as people in Hong Kong
are geographically living close to one another, elderly people who are
residing in the same housing block or nearby often come together for
such activities as playing mahjong or doing tai chi exercises. In fact,
chatting with neighbours is commonly regarded by the elderly as the
most convenient way to spend their leisure time, and this form of
informal companionship may even be more valuable than the formal
ones. Lastly, despite the efforts made by some NGOs to organize
educational programmes for the elderly, they have never been popular,
as the Chinese elderly in Hong Kong generally still believed that to be
wise is not necessarily to be learned.
ADVOCACY AND PROTECTION
There are no laws in Hong Kong to specifically protect the welfare of
the elderly, since they are enjoying the same rights as the other residents.
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Nelson Wing-sun CHOW, Iris CHI
The only benefit exclusively available to the elderly is the old age
allowance which is given on a universal basis to nearly all the elderly
aged 65 and over, subject to an income declaration for those aged
between 65 and 69. Concessionary fares are offered to the elderly for
some community facilities and public transport services to encourage
the elderly to participate in community activities. Another measure
which is seen as an incentive to encourage the children to support
their elderly parents is the dependent parents’ tax allowance which is
increased if the children are not only supporting their elderly parents
but also living with them. It has already been mentioned that applicants
for public housing can have their waiting period shortened by three
years if they have elderly members included in their households.
Since the development of formal support services for the elderly
has only a history of less than 20 years in Hong Kong, most
organizations which aim at seeking a better quality of life and equity
in opportunities for the elderly are established only in recent years.
The Hong Kong Council of Social Service set up a division in 1972 to
co-ordinate the work of the NGOs providing services for the elderly;
since then the division has acted as the main body to work hand-in-
hand with the government in developing various social services to
meet the needs of the elderly. Another organization known as the
Association for the Rights of the Elderly was formed by a group of
social workers in the late 1970s to fight for the rights of the elderly;
this group has not achieved very much as their actions have been
rather sporadic. In the mid-1980s, a group of professionals working in
the field of gerontology came together and formed the Hong Kong
Association of Gerontology; at present, the activities of the Association
include the publication of journals, the organization of seminars and
the promotion of research into the ageing problem. Apart from the
above, care of the elderly has been the focus of many debates in the
Legislative Council, which is the law-making body in Hong Kong. No
doubt, as the population in Hong Kong matures, people here are
showing greater concern for the welfare of their elderly members.
CONCLUSION AND FUTURE PROJECTIONS
The future development of welfare services for the elderly in Hong
Kong is determined, on the one hand, by the rate of increase of demand
for such services and, on the other, the priority given to them in terms
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Ageing in Hong Kong
of the allocation of public resources. The Hong Kong Government
published a policy paper on the future development of welfare services
in 1991 in which it stated that ‘a rising population of elderly persons
will result in a corresponding increase in the demand for services for
the elderly in quantity, variety and duration’. Furthermore, ‘increasing
life expectancy will result in a consistent increase in the age group 75
and above which is a group likely to have a greater need for services
such as long-term health and residential care’. As a result, a rapid
expansion of both community support and residential services for the
elderly was projected in the policy paper over the next ten years, with
a greater proportion of public resources devoted to these purposes.
The government maintained, nevertheless, in the policy paper that
the ‘care in the community’ approach, adopted in 1979 as the guiding
principle for the development of services for the elderly, was the most
appropriate one, though it recognized that ‘while it will remain the
policy to encourage the care of the elderly by family members within a
family context and to strengthen support for their carers, it should
also be recognized that the needs of the elderly vary and that residential
care for some may be the most appropriate service’. It was proposed,
therefore, that instead of merely putting the thrust on the provision of
community support services as in the 1980s and neglecting the needs
for residential care, a more balanced approach would be adopted with
the broad objective of promoting ‘the well-being of the elderly in all
aspects of their life’.
Furthermore, since there was still a severe shortage of community
support services and in order that the ‘care in the community’ approach
might become a reality and not merely a slogan, the policy paper
proposed a strengthening of the social networks in Hong Kong. It was
stated that ‘social networks are part of Chinese culture and tradition
and . . . most clearly demonstrated in the role of the family as the
primary providers of care and welfare and by the contributions of
clansmen associations, neighbourhood organizations and volunteers’.
It has, however, yet to be seen how social networks could be
strengthened to achieve the purpose of enabling the elderly to be
involved in the community. In the meantime, it appears that other
than increasing the supply of community support services, including
public medical and housing services, the following measures are also
necessary:
Firstly, families in Hong Kong need to be helped to provide support
for the elderly. Although the trend towards nuclear families is clear
and there is little likelihood that it will be reversed, greater incentives
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Nelson Wing-sun CHOW, Iris CHI
can be given to individuals who are prepared to live with their elderly
parents. The recent changes in public housing policies regarding the
elderly is an example towards such goal. There is also a tax-exemption
system in Hong Kong; however, the system is symbolic rather than
practical, given the amount of paper work involved and the extremely
low amount of tax money that can be deducted.
Secondly, evidence in Hong Kong shows that children are more
prepared to live with elderly parents who are economically independent.
The introduction of income security measures which ensure the
economic independence of the elderly is therefore urgently called for.
Furthermore, as the absolute number and relative percentage of the
elderly population has increased consistently, the issue of fully utilizing
their working ability will be an important challenge for manpower
management. An appropriate solution will not only help enrich old
age, but will also help release society from social and financial burdens.
The additional manpower in times of labour shortage will help develop
the economy. Today, the overall employment rate of the elderly in
Hong Kong is extremely low. However, many of these elderly have
expressed a strong desire to work (Chi and Lee, 1989). How to satisfy
the elderly’s need for employment is a matter of concern not only to
elderly individuals and their families but also to the society. It is hoped
that the Hong Kong Government and the society will eliminate the
unwritten age-discrimination policy in hiring, so as to promote
employment opportunities for the elderly, and help them meet the
needs of old age.
Thirdly, evidence also shows that most of the elderly in Hong
Kong are still contributing to their families by assisting in caring for
the young and preserving the stability of the family. It is therefore a
matter of paramount importance to maximize the roles of the elderly
in their families and to enhance their contributions. Proper image and
attitude towards elderly people should be addressed. Community
education and family life education are important channels to convey
the correct message to the society.
Fourthly, the elderly in Hong Kong can only contribute to their
families and society when they have good health. Proper and sufficient
health care programmes are essential to maintain their health. At
present, the actual demand for medical services from the elderly exceeds
supply, although the government has promised to increase health care
funds. There are plans to build more hospitals, clinics and nursing
homes. However, there is a shortage of professional personnel, notably
physicians and nurses. The problem of manpower shortage should be
1 9 1
Ageing in Hong Kong
put on the government’s agenda immediately for discussion and action.
Furthermore, to reduce the demand for acute care services, it is
recommended that the government should expand their medical services
in the areas of health promotion and disease prevention to enable the
elderly people to maintain good health.
Hence, the question now facing Hong Kong, as its population
matures, is not simply the increasing necessity of caring for the elderly,
but also the form of care that should be adopted and the ways in
which the community, including the family, can continue to be a
source of support. An approach that integrates the efforts of the
government and the community is most desirable.
REFERENCES
Census and Statistics Department. Hong Kong 1991 population census,
summary results. Hong Kong: Hong Kong Government Printer, 1991.
Central Committee on Services for the Elderly. Report of the Central
Committee on Services for the Elderly. Hong Kong: Health and Welfare
Branch, Hong Kong Government, 1988.
Chi I, Boey KW. Mental health and social support study of the old-old in
Hong Kong. Hong Kong: Department of Social Work and Social
Administration, University of Hong Kong, 1994.
Chi I, Lee JJ. Hong Kong elderly health survey. Hong Kong: Department of
Social Work and Social Administration, University of Hong Kong, 1989.
Chi I, Lee JJ, Hu R, Ye N, Wang R. A comparative study of living conditions
among the elderly in two regions: the case of China and Hong Kong.
American Asian Review, 1993, 11(3):28–56.
Chi I, Leung MF. An evaluation study of the adult health promotion program.
Hong Kong: Department of Social Work and Social Administration,
University of Hong Kong, 1992.
Chow NWS. Aging in Hong Kong. In Leung BKP (ed.) Social issues in Hong
Kong. Hong Kong: Oxford University Press, 1990, 164–78.
Chow NWS. Hong Kong: community care for elderly people. In Phillips DR,
ed. Aging in East and Southeast Asia . London: Edward Arnold, 1992,
65–76.
Ho S, Woo J. Socal and health profile of the old-old population in Hong
Kong. Hong Kong: Department of Community and Family Medicine,
The Chinese University of Hong Kong, 1994.
Hong Kong Government. The aims and policy for social welfare in Hong
Kong. Hong Kong: Hong Kong Government Printer, 1965.
Hong Kong Government. White Paper on further development of medical
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Nelson Wing-sun CHOW, Iris CHI
and health services in Hong Kong. Hong Kong: Hong Kong Government
Printer, 1974.
Hong Kong Government. Services for the elderly, a Green Paper. Hong Kong:
Hong Kong Government Printer, 1977.
Hong Kong Government. Report of the working party on primary health
care — health for all, the way ahead. Hong Kong: Hong Kong
Government Printer, 1990.
Hong Kong Government. Social welfare into the 1990s and beyond. Hong
Kong: Hong Kong Government Printer, 1991.
Hong Kong Government. The next five years — the agenda for Hong Kong.
Hong Kong: Hong Kong Government Printer, 1992.
Hong Kong Government. Report of the working group on care for the elderly.
Hong Kong: Hong Kong Government Printer, 1994.
Lubben JE, Chi I. Cross-national comparison of social support among the
elderly Chinese and Chinese Americans. Paper presented in the XIVth
World Congress of Gerontology at Budapest, Hungary, 1993.
Phillips DR. Hong Kong: demographic and epidemiological change and social
care for elderly people. In Phillips DR (ed.), Aging in East and Southeast
Asia. London: Edward Arnold, 1992, 45–64.
Social Welfare Department. Study of public assistance recipients 1989. Hong
Kong: Social Welfare Department, 1991.
Social Welfare Department. The five-year plan for social welfare development
in Hong Kong: review 1991. Hong Kong: Hong Kong Government
Printer, 1991.
Working Party on the Future Needs of the Elderly. Services for the elderly.
Hong Kong: Hong Kong Government Printer, 1973.
Working Party on Housing for the Elderly. Report of the working party on
housing for the elderly. Hong Kong: Hong Kong Government Printer,
1989.
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Shiu-kum LAM
government, and the young and working, through their Confucius
culture of supporting the elders and their tax payment to the
government, which is meant for their own use in future. Three kinds
of people can look after the elderly: the elderly themselves, until they
become the ‘oldest old’ or when nursing care is needed, their family
members if they are willing, and the health-care workers at nursing
homes and infirmaries. The people of Hong Kong and of any similar
city in Asia will need to plan how best to make use of the monetary
and human resources. Before they can do so, they need to understand
the size of the problem, and the results of this survey on the health of
the elderly in Hong Kong should help.
THE SIZE OF THE ELDERLY PROBLEM
Social background
Two-thirds of the elderly in Hong Kong, as shown in this survey, lived
with their family. This strong sense of Confucius culture to support
the family elders remains an important virtue for the care of the
elderly in Hong Kong. Such a family tie, however, is slowly
disintegrating as the soaring cost of home accommodation shrinks
home spaces and breaks up the Chinese tradition of having three
generations living under the same roof. Indeed, the three-generation
family had declined to about 10% of all households at the 1991
census, and 4% of the elderly in Hong Kong were living in various
types of institutions.
Yet this virtue is vital to the concept of ‘ageing in place’, that is
ageing at home, which is more dignifying, offers better quality of life
and carries less economic burden to the society than the alternative of
ageing at nursing homes. In fact, this survey showed that only 3.5%
were still working and deriving an income, although in the 1991
census, about a quarter of the elderly population were classified as
‘economically active’. Economically, the elderly in Hong Kong are
probably among the poorest in the population, since most of them are
not receiving any retirement pensions. The old age allowance, which is
taken by over 80% of the elderly, is probably designed more for
pocket money than for subsistence (HK$560 or US$70 per month,
1996).
1 9 5
Summing Up: The Economics of Ageing in Hong Kong
Health status
As pointed out by Dr. Leung and Ms. Lo (Chapter 2), chronic illnesses
are prevalent among the Hong Kong elderly, a third complaining of
rheumatism, another third of hypertension, with fractures, peptic ulcer,
diabetes mellitus, chronic bronchitis, coronary heart diseases, thyroid
disorders and stroke trailing closely behind. Seventy percent complained
of hearing problem and 90% had impaired vision. However, chronic
illness does not equate with disability. Eighty percent of the elderly
surveyed were in reasonable physical health, being able to enjoy outdoor
walking, and about two-thirds were able to help in heavy house-work.
The majority were able to carry out most daily activities and over half
were satisfied with their life.
There is little doubt that, if willing, these senior citizens can provide
the society with some useful manpower resources. Much of this is now
spent on looking after the home while the young is at work. With
good planning, it can be deployed to voluntary community work or
even salary-earning job such as looking after the ‘oldest old’ in nursing
homes.
Dietary pattern
This survey showed that the elderly in Hong Kong had a well balanced
healthy diet, with 85% taking fruits daily and over 90% taking
vegetables in their main meals. A higher consumption of fruits and
vegetables had been shown to dramatically reduce the mortality from
strokes in Japan over the past 25 years. Dietary fruits and vegetables
had also been shown to be associated with fewer cancer and fewer
cardiovascular diseases1. While they mostly ate at home for lunch and
dinner, it was interesting that one-third had their breakfast in
restaurants.
Health risks
About 20% of the elderly smoked and 10% drank. Those with
hypertension (a third of them did) as well as those with diabetes (10%
of them had) were, if they were not well looked after, at increased risk
of stroke and coronary heart disease, which necessitated acute
hospitalization and might mean life-long infirmary care afterwards.
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Shiu-kum LAM
The mean cholesterol level of the Hong Kong elderly of 5.9 and
6.2 mmol/L in men and women respectively, as reported by Prof.
Janus (Chapter 8), were similar to those found in the same age group
in the USA in 1980, and appeared to be 10% higher than that reported
previously in Hong Kong five years ago. This is a cause for concern,
and may be one explanation for the rise in coronary heart problems in
Hong Kong. As observed by Prof. Lau and Dr. Lok in their survey
which included mass electrocardiography (Chapters 6 and 7), 14% of
the elderly had clinical evidence of coronary heart disease, and about
10% had arrhythmias. These findings are alarming.
As osteoporosis is common in women after menopause, it is equally
alarming to find in this survey as reported by Prof. Kung (Chapter 12)
that one in four women would have sustained an osteoporotic fracture
by the time they reach 80. Physical inactivity, which was a consequence
of close urban living, was a known contributing factor to osteoporosis.
Previous studies had also shown that the Hong Kong elderly women
consume only one-fifth of the dietary calcium intake recommended for
postmenopausal women. Clearly, a regular educational programme
including the use of prophylaxis oestrogen is needed in this area to
help reduce not only the morbidity of fractures but also the cost to the
society in terms of hospitalization, hip replacements, etc.
Helicobacter pylori is a new germ found in the human stomach in
recent years. This stomach infection increases the chance of the host
having peptic ulcer and stomach cancer. Both of these conditions are
common in Chinese, and are attributable also to stress, smoking, genes,
analgesics, and diet (for ulcer) and to high salt, low dietary vitamin A,
C and E, and low carotine (for cancer). Some disturbing findings are
those of Wong et al. (Chapters 4 and 5) that 70% of the elderly
harboured the infection, that half of these had abnormal stomach on
endoscopy, and that 70% of the organisms were resistant to
metronidazole, a mainstay antibiotic for the eradication of the germ.
And one interesting observation was that low blood albumin (reflecting
under-nutrition) was an association of the infection. A Hong Kong
University team is conducting the world’s first prospective research to
see if eradication of this stomach infection prevents ulcer and cancer in
the community setting2. Before the results become available (set in
1999), personal hygiene (transmission is by oral/faecal route), good
habits, and nutritious food appear to be good strategies.
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Summing Up: The Economics of Ageing in Hong Kong
Before the government officials lie back in complacency, they should
look at the reasons behind the good figure. Other than clean habits,
good genes, and healthy diet, there are two other explanations. The
first, as Prof. Chow and Dr. Chi pointed out (Chapter 13), involves
Table 14.1 People aged 60 and over in Hong Kong requiring nursing care, asdeduced from capacity and waiting list in nursing homes and infirmaries
Capacity
Subvented care and attention homes, approximate 7 2 0 0
Non-profit making care and attention homes 2 1 0 1
Private nursing homes 2 1 1 0 3
Waiting for nursing homes, approximate 6 2 3 0 0
Infirmary beds 1 7 3 2
On waiting list for infirmary beds 4 3 7 3
Total 9 8 8 0 9
Percent of total elderly (857 500) 11.5%
Source: Social Welfare Department, 1995/1996
THE IMPLICATIONS
Citizens of Hong Kong born in 1900 could expect to live to around
50, while those born today can expect to live to around 78 (76 for
men, 81 for women). They have, therefore, gained an extra 28 years
of life expectancy. As more and more people are living to the age they
are designed for, the hope is that they will stay in good shape until a
later age. Otherwise, the medical costs of ageing will climb steeply
There are now 572 nursing homes (including subvented, non-profit-
making, and private) in Hong Kong with a total capacity of 30 425
places, half of which being substandard, for people over 60 who require
some nursing attention. The waiting list is about 62 300. Together
with the infirmary beds of 1732 and their waiting list of 4373, it can
be estimated that those with disabilities in need of nursing care outside
their own homes make up about 11% of the elderly (aged 60 and
above) population in Hong Kong (Table 14.1). In a study in England
and Wales, some 40% of the extra life expectancy gained in the past
20 years was spent in disability. The Hong Kong figure, while likely to
be an underestimate, looks nevertheless favourable.
1 9 8
Shiu-kum LAM
Confucius’ filial piety that encourages the young to look after the
elders, who are, therefore, able to enjoy the luxury of ageing among
their families. This, however, is rapidly breaking up, due to the soaring
housing cost and the consequent dramatic drop in home space (most
families live in an area of about 60 m2), as well as to the increasing
divorce rates and the influence of the Western culture. In the 1991
census, only 10% of the households were made up of a three-generation
family, and one in four of the elderly lived alone or with another
elderly person. Such social separation from their family would mean
less social care, less dignity, painful psychological trauma for the Chinese
who had spent their lives with filial piety for their own parents, and a
natural course toward a greater share of ill health and disability in the
years ahead.
Another explanation is that the Hong Kong elderly are still relatively
young. Their chronic illness such as hypertension, diabetes, high
cholesterol and osteoporosis, which occurred in over half of them as
observed by Dr. Leung and Ms. Lo in this survey (Chapter 2), had not
yet evolved into heart attacks, strokes and fractures. However, given
time and a slip in medical attention, they would. And with better
diagnosis and better hospital care, these acute episodes would end up
in disabilities rather than fatality, and would push up the need for
infirmaries and nursing homes. The recent emphasis by the government
and professionals on the development of geriatric medicine in Hong
Kong, as outlined by Dr. Chu (Chapter 1), is timely and encouraging.
The increased life expectancy will also mean 15 years or so of
physical activity but economic inactivity. As most elderly in Hong
Kong do not receive pension, and since provident fund scheme is still
in its infancy, their financial support comes from their families or out
of their own pockets. The former source is increasingly more difficult,
as the young workers have to look after their own families, pay for
their 20-year-long home mortgage, which nowadays often absorbs
60% of their income, as well as contribute to their own retirement
funds. There are several options. One is to keep people working longer
by extending their retirement age, which is 55 for civil servents and 60
for institutional employees in Hong Kong. Another is to make available
more ‘bridge’ jobs, including looking after the ‘oldest old’. Instead of
‘guillotine retirement’, it appears to make sense to advocate ‘transitional
retirement’, with a period of say five years between the full-time career
and the full retirement. Retirees can also become self-employed. Sixty
percent of Japanese would like to continue working after 65, as revealed
by one survey, because they thought it would help them maintain
1 9 9
Summing Up: The Economics of Ageing in Hong Kong
good health and remain active in the community. Chinese, and for
that matter Asian, thinking should not be too far from this. A final
option is to dish out a table-top Confucius statue to every home.
NOTES
1. National Research Council, Committee on Diet and Health, Food and
Nutrition Board, Commission on Life Sciences. Diet and health:
implications for reducing chronic disease risk. Washington, D.C.: National
Academy Press, 1989.
2. Ching CK, Lam SK, Wong CY, Hu WHC, Ong LY, Gao Z, Chen JS,
Chen BW, Jiang XW, Hou XH, Lu JY, Wang WH. Mass endoscopic
screning for gastric cancer and initiation of Helicobacter pylori (Hp)
eradication therapy in Changle of China. Gastroenterology 1995,
108:A456.
2 0 1
Index
14I n d e x
Vincent TO
AST 115
asymptomatic 157
asymptomatic peptic ulceration 84
atrial fibrillation 92, 93, 94, 95
atrial premature beats 92, 93, 95
atrial tachycardia 93, 95
autoimmune thyroid disease 143
bilirubin 113, 115
biochemical 111
biochemical hypothyroidism 142
birth rate 1, 2
blood collection 27, 32
blood glucose 155
blood pressure 28, 68, 155
blood sugar 26
blood test 30, 57, 89
BMI 117, 122, 126, 153
body height 68
body mass index 104, 111, 155,
165
body weight 68, 103, 130, 153,
155, 165
bone fractures 167
bone mass 170
breakfast habits 51
butter 52
activities of daily living 46, 49, 50, 59
age distribution 44, 68
age effects 126
age-related diseases 11
age-specific 67
ageing 1, 24, 173
ageing in place 194
ageing research 10
alanine amino transferase 113
albumin 68, 69, 113, 114, 115,
116, 126, 196
alcohol consumption 68, 90
alkaline phosphatase 113, 114,
115, 125
ALT 115
Alzheimer’s disease 13
anthropometric and blood pressure
measurements 89
Anti-CagA antibody assay 67
Anti-helicobacter pylori antibody
assay 66
antithyroglobulin 142
antithyroid antibodies 145
arrhythmias 92, 196
aspartate amino transferase 113
Association for the Rights of the
Elderly 188
2 0 2
Index
coronary heart disease 49, 59, 90,
99, 103, 104, 106
coronary risk factors 93, 95
counselling 57
creatinine 113, 114, 115, 116,
125
cytotoxin-producing type 72
daily activities 58, 59
day care centre 186
death rate 2
deformed duodenal bulb 81
dehydroepiandrosterone 12
dementia 11, 13
demographic characteristics 1, 29
dentist 57
Department of Clinical Biochemistry
27, 89, 112
Department of Medicine 22
depression 13
‘desirable’ body weight 136
‘desirable’ height-weight 137
development of geriatric medicine
3
diabetes mellitus 49, 90, 93, 102,
103, 104, 106, 147, 149, 152,
153, 154, 155, 156, 157, 195
diet 69
dietary calcium 169, 196
dietary cholesterol 107
dietary habit 105
dietary iodine 144
dietary pattern 50, 195
Dietetic Department, Queen Mary
Hospital 102
disability 11, 49, 195, 197
discharge planning 5
doctors 31
drinking habits 47, 93
dual therapy 81
duodenal erosion 80, 81
duodenal ulcer 80, 81
Duodenal ulcer scars 80, 81
duodenitis 80, 81
dyspepsia 79
CagA antibody 70
caged men 185
calcium 113, 115, 125
calcium intake 25
calcium supplementation 11, 169
cardiac arrhythmias 87, 92, 93
care and attention homes 6, 185
care in the community 176
Caritas Medical Centre 4
carpal tunnel syndrome 12
census in 1991 101, 174, 198
Central Infirmary Waiting List 7
chloride 113, 115
cholesterol 13, 25, 26, 68, 93, 103,
104, 105, 112, 113, 114, 116,
117, 118, 122, 126, 155, 196
cholesterol food 53
chronic atrial fibrillation 95
chronic bronchitis 49, 195
chronic diseases 175
chronic gastritis tests 26
chronic illness 48, 49, 58, 59, 60,
195, 198
cognitive function 13
Colles’ fracture 163, 164
community education programmes
186
community facilities 188
Community Geriatric Assessment
Service 5, 8, 14, 180
community nursing service 181
community psychiatric nursing
service 181
community support services 186,
189
Compassionate Rehousing Scheme
184
conduction disturbance 92, 93
Confucius 194, 198
Consultation Paper on Health
Promotion 183
cooking method 52, 105
cooking style 69, 156
coronary artery disease 153
coronary heart problem 196
2 0 3
Index
eating and cooking habits 156
ECG 25, 26, 28, 30, 33, 57, 91,
93, 102, 103, 153
economic independence 190
economically active 174, 194
economics of ageing 193
elderly 1, 8, 23, 24, 63, 65, 81, 87,
174
elderly centres 26, 99
elderly discharge programme 14
elderly female 151
elderly health centres 7, 182
elderly helicobacter pylori carriers
75
elderly male 150
Elderly Persons Priority Scheme 184
elderly services 6
elevated serum TSH levels 142
employment of the elderly 179, 190
endoscopy 77, 80
epidemiology 63
epigastric pain 79
eradication therapy 78, 81, 82, 196
estrogen 12
estrogen replacement 170
everyday food 54
exercise 11, 12, 46, 60, 156
eye-sight 48
factors associated with bone fracture
165
faecal incontinence 49, 59
falls 11, 12
family history of CHD 103
family of CHD 106
family tie 194
fast food 105
fasting blood glucose 117, 150,
151, 155
fasting plasma glucose 149
fat 53
fell injury 163
financial support 58, 198
first degree heart block 93
fish 54
follow-up 27
fracture 49, 59, 161, 163, 164, 165,
166, 168, 195, 196
frail elderly 5, 10, 12, 14, 186, 187
Framingham study 106
fruit and vegetables 54
functional ability 49
Fung Yiu King Hospital 4, 5
gammaglutamyl transpeptidase
113
GAP IgG ELISA 76
gastric cancer 64
gastric erosion 80, 81
gastric polyp 80, 81
gastric ulcer 80, 81
gastric ulcer scars 81
gastric xanthoma 80, 81
gastritis 80, 81
gastrointestinal abnormalities 75,
79
gastrointestinal operation 165
genetic basis of ageing 11
Geriatric Clinical Chemistry 124
geriatric day hospital 5
geriatric medicine 2
geriatric out-patient clinics 5
geriatric research 10
geriatric services 4, 5
geriatric team 6
GGT 114, 115
globulin 113, 115
glucose 112, 113, 114
government subsidy 45
haematocrit 122, 123
haematological tests 123
haematological parameters 111, 126
haematology 113
haemoglobin 122, 123
haemorrhage 79
Haven of Hope Hospital 4
HDL 126
HDL-cholesterol 104, 112, 113,
114, 116, 117, 121, 122, 152, 155
2 0 4
Index
health 175
health care services 179
health habits 29, 46
health promotion programme 182
health risks 195
health seeking behaviour when
sick 47
health services 60
health services research 13
health status 47
hearing 48, 60, 195
height 28, 130, 131
height-weight table 129, 132
height-weight table by age 133,
134
Helicobacter pylori 27, 64, 69, 72,
75, 196
Helicobacter pylori infection 63
Helicobacter pylori prevalence 64,
65, 67, 68, 69
hip fracture 11, 163
hip fracture rate 162
history of geriatric medicine 2
Holter monitoring 96
home help service 57, 186
Home Ownership Scheme 184
homes for the aged 7
Hong Kong Association of
Gerontology 188
Hong Kong Cardiovascular Risk
Factor Prevalence 125
Hong Kong Council of Social Service
188
Hong Kong elderly 129
Hong Kong elderly men 132, 133
Hong Kong elderly women 132,
134
Hong Kong Society for the Aged
(SAGE) 21
Hong Kong West hospital cluster 5
hormonal replacement 11, 12
Hospital Authority 177, 181
hospital beds 180
hospital cluster 3
hospitalization 56, 57
hostels 184
households 174
housework 58
Housing Authority 177, 184
housing resources 183
hyperparathyroidism 49
hypertension 49, 90, 93, 102, 103,
104, 106, 153, 195
hyperthyroid 49, 139, 143, 145
hypothyroidism 139
income maintenance 178
infirmary 5, 6, 7, 197
infirmary beds 181, 182, 197
infirmary care 181
institutional care 176
insulin resistance 158
interview 30, 77
iodine 25, 26
kidney function tests 26
Kwong Wah Hospital 4
LDL-cholesterol 104, 113, 114,
116, 117, 120, 122, 126, 152, 155
LDL-receptor 126
left bundle branch block 93
leisure-time resources 187
life expectancy 1, 2, 193, 197, 198
life satisfaction 54
lipid profile 26, 104, 105, 155
lipids 111, 117, 122
lipoprotein patterns 152
lipoproteins 111, 117, 122
liver function tests 26
living alone 8, 187
living with family 187
lunch habits 51
margarine 52
marital status 45
mean corpuscular haemoglobin
122, 123
mean corpuscular volume 122, 123
meat products 54
2 0 5
Index
medical and health services 180
medical illness 68
medicine
traditional Chinese 55
Western 55
mental health 175
methods of cooking 53
metronidazole 82
metronidazole resistant strains 70
migration of elderly to China 9
milk powder 54
milk products 54
mitochondrial 11
multi-dimensional assessment 5
multi-service centre 186
nodular goitre 143
non steroidal anti-inflammatory
drugs (NSAID) 79, 80, 81, 83
non-government organizations
(NGOs) 176, 184
non-insulin dependent diabetes
mellitus (NIDDM) 147, 152,
157
nurse/health worker 57
nursing care 197
nursing homes 6, 7, 197
nut consumption 69
occupational therapy 57
oil 52
oily food 156
old age allowance 178, 179, 188,
194
oldest old 193, 195, 198
osteoporosis 11, 161, 196
Our Lady of Maryknoll Hospital
4
out-patient clinics 56
outcome measures 14
palpitations 87, 89, 90, 91
Pamela Youde Nethersole Eastern
Hospital 4
Parkinson’s disease 11
paroxysmal atrial fibrillation 95
peanut oil 52
peptic ulcer 49, 59, 64, 79, 153,
195
perforation 79
Philadelphia Morale Scale 54, 55,
58, 59
Philadelphia Morale Score 59
phosphate 113, 114, 115
physical activities 167
physiotherapy 56, 57
place for meals 50
planning health and social services
24
plasma glucose 148
platelet 123
policy paper 176
policy paper on welfare 189
potassium 113, 115
prevention of bone loss 169
preventive geriatrics 9
preventive health care 182
primary health care 183
Prince of Wales Hospital 4
Princess Margaret Hospital 4, 180
private medical insurance 183
private nursing homes 8, 9, 185
prophylaxis oestrogen 196
protein 115
psychogeriatric services 182
psychological assessment 168
psychologically disturbed 167
public assistance scheme 179
public housing programme 184
public out-patient clinic services
181
public transport services 188
pyridoxine 12
quality of life 14, 25
Queen Elizabeth Hospital 4
Queen Mary Hospital 4, 5, 27, 88
questionnaire 25, 30, 33, 66, 89,
90, 102, 163
questionnaire interview 29
2 0 6
Index
randomized 78
recruitment 30
rehabilitation 5, 181
rehabilitative services 186
relation to sex 67
renal function 114
Residential Care Homes (Elderly
Persons) Ordinance 8
residential homes 6
resistant to metronidazole 196
retirement age 198
retirement pensions 178
rheumatic disorders 59
rheumatism 49, 195
right bundle branch block 93
risk factors in elderly 99
risk factors associated with diabetes
159
risk factors for CHD 104, 106
Rose questionnaire 102
Rose questionnaire for angina
pectoris 28, 90
Rotary Club of Hong Kong
Northwest 21, 23
Ruttonjee Hospital 4
SAGE 26, 30
sample size 30
scar 80
screening of thyroid function 140
self-assessment of well-being 168
self-care 175
self-evaluated 175
seroprevalence of Helicobacter
pylori 67, 68
serum cholesterol 95, 107
serum free T4 141
serum TSH 141
sex 68
Shatin Hospital 4
sheltered housing 184
side effects of anti-Helicobacter pylori
treatment 81, 82
Single Persons Allocation Scheme
184
sinus bradycardia 93
skimmed milk 54
smoking habits 28, 46, 60, 68, 90,
93, 95, 103, 104, 106
social centres 186, 187
social networks 175, 189
social service 56
social support 175
socio-demographic 44
sodium 113, 115
sodium levels 125
source of income 45
spine fractures 163
St. John Hospital 4
stroke 11, 49, 59, 102, 103, 104,
153
subclinical hyperthyroidism 143,
144
subclinical hypothyroidism 142,
144
subvented care and attention homes
7
sugar 25
suicides 174
supportive services 186
suppressed serum TSH levels 143
surgical operation 57
survey centres 31
syndrome X 158
T3 141
tai chi 156, 167, 187
testosterone 12
thiamine 13
three-generation family 174, 194,
198
three-generation households 175
thyroid cancer 143
thyroid dysfunction 139, 143, 145
thyroid function 94
thyroid function test 25, 26
thyroid hormones 139
thyrotoxicosis 144
thyrotropin (TSH) 139
thyroxine 92
2 0 7
Index
thyroxine therapy 144
triglyceride 25, 68, 104, 112, 113,
114, 116, 117, 119, 122, 152, 155
triple therapy 81
TSH 113, 114, 117
TSH assay 141
TSH levels 145
TSH results 142
TSH screening 141
TSH values 142
Tuen Mun Hospital 4
types of food 52
United Christian Hospital 4
University of Hong Kong, The 22,
29, 89
upper gastrointestinal abnormalities
81
urate 113, 114, 115, 116, 126
urea 113, 114, 115, 116, 125
urinary incontinence 49, 59
urine 26
use of health and social services 57
use of services 56
ventricular premature beats 93,
95
vision 48
visit a doctor 57
visual loss 60
Vitamin D 11
volunteers 27, 29
WBC 123
weight 28, 131
weight bearing activities 165
welfare 189
Wenckebach AV block 93
White Paper 23
White Paper 1974 180
Wong Chuk Hang Complex for the
Elderly 4
Wong Tai Sin Hospital 4
working status 45
World Health Organization 24
X-ray 57
Yan Chai Hospital 4