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The Health ofthe Elderly

in Hong Kong


in Hong Kong


in Hong Kong


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


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


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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

Contents

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)



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.

x

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


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


Benjamin Chun-yu WONG, MRCP(UK)



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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.

xii

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

xiv

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

Contents

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


1Geriatric Medicine in Hong Kong —

An Overview


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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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21


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.

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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


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

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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


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.

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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


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.

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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


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.

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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.

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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

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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

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3Social and Health Status of Elderly People

in Hong Kong


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.

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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

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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


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


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

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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

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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


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


(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


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


(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


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


N = 1480

Figure 3.1 Breakfast habits of the elderly

N = 1480

Figure 3.2 Lunch habits of the elderly

52


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


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


(%) 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


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


(%) 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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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.

74


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.

75

Upper Gastrointestinal Abnormalities in the Elderly Helicobacter Pylori Carriers

5Upper Gastrointestinal Abnormalities inthe Elderly Helicobacter Pylori Carriers


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.

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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


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


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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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

80


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

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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


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

83


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


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


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.

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eradication Helicobacter pylori without anti-acid treatment: randomised

controlled trial. Lancet, 1994, 343:508–10.

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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

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ulcers associated with Helicobacter pylori. N Engl J Med, 1995, 332:139–

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10. NIH Consensus. Helicobacter pylori in peptic ulcer disease. JAMA, 1994,

272:65–9.

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Gastroenterol Clin N Am, 1993, 22:183–98.

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eradication of Helicobacter pylori with triple therapy. Gastroenterol,

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resistance in therapy of Helicobacter pylori infections. Antimicrob Agents

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debate-For. Gastroenterol Clin N Am, 1993, 22:141–51.

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87

Palpitations, Cardiac Arrhythmias and Their Associated Risk Factors in Ambulant Elderly

6Prevalence of Palpitations, Cardiac

Arrhythmias and Their Associated RiskFactors in Ambulant Elderly


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


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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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.

90


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.

91


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.

93


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.

95


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.

96


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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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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


Table 12.5 Physical activities of Chinese female subjects with a history of bonefractures as compared to controls


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


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


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).

1 6 8

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


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


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


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

1 6 9


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.

1 7 0

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.

1 7 1


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.

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Ageing in Hong Kong

13Ageing in Hong Kong


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.

1 7 4


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’.

1 7 6


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

1 7 7

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.

1 7 8


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

1 7 9

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

1 8 0


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.

1 8 1

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

1 8 2


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

1 8 3

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

1 8 4


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.

1 8 5

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.

1 8 6


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.

1 8 7

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.

1 8 8


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

1 8 9

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

1 9 0


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

1 9 2


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.


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.


Working Party on Housing for the Elderly. Report of the working party on

housing for the elderly. Hong Kong: Hong Kong Government Printer,

1989.

1 9 4

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


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.

1 9 6

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.

1 9 7


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


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

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