A 2.1 A resolution structure of an uncleaved alpha(1)-antitrypsin shows variability of the reactive center and other loops

Serpin (serine protease inhibitor) proteins are involved in diverse physiological processes including inflammation, coagulation, matrix remodeling, and cell differentiation. Deficiency of normal serpin functions leads to various hereditary diseases. Besides their clinical importance, serpin proteins draw much attention due to the large conformational changes that occur upon interaction with proteases. We present here the crystal structure of an uncleaved alpha(1)-antitrypsin determined by the multiple isomorphous replacement method and refined to 2.1 A resolution. The structure, which is the first active serpin structure based on experimental phases, reveals novel conformations in the flexible loops, including the proximal hinge region of the reactive center loop and the surface cavity region in the central beta-sheet, sheet A. The determined loop conformation explains the results of recent mutagenesis studies and provides detailed insights into the protease inhibition mechanism. The high-resolution structure of active alpha(1)-antitrypsin also provides evidence for the existence of localized van-der-Waals strain in the central hydrophobic core.

Prediction of body fat by anthropometry in older Chinese people

OBJECTIVE

To derive regression equations for fat percentage by using simple anthropometric measurements applicable in normal and immobile (cannot stand or walk) older people.

RESEARCH METHODS AND PROCEDURES

The study population comprised 352 females and 261 males, apparently well and community-dwelling, aged 69 to 82 years. Fifty-one females and 27 males were recruited for external validation. Body weight, standing height, arm span, triceps and biceps skinfold thicknesses (SFTs), and midarm circumference were measured. The reference method of total body fat percentage was dual-energy X-ray densitometry. Predictive equations for fat percentages were derived by stepwise multiple linear regression on anthropometric indices and gender.

RESULTS

Upper-limb SFTs, body mass index, and gender yielded the more predictive equation. The SEE was 4.1% weight. There was a significant trend of underestimation in overweight subjects, especially in females. The equation using SFTs and midarm circumference was less reliable but more applicable to older immobile people and those with significant kyphoscoliosis.

CONCLUSIONS

The combination of body mass index and upper-limb SFTs gives reliable prediction of fat percentages in older Chinese people, except in the obese.

Inhibition of Cutaneous UV Light–induced Tumor Necrosis Factor-α Protein Production by Allotrap 1258, a Novel Immunomodulatory Peptide¶

Peptides derived from the heavy chain of the HLA Class-I molecules have been shown to modulate immune responses both in vivo and in vitro. Using a computer-aided rational drug design approach, novel immunomodulatory peptides were designed based on peptide 2702.75-85, derived from HLA-B2702. Several peptides were identified which had increased immunomodulatory activity, including peptides RDP1258 and its D-isomer the peptide Allotrap 1258. The present study using Skh/hr hairless mouse skin model evaluated the in vivo effects of Allotrap 1258 on acute UVB-induced skin inflammation. Here we demonstrate that intraperitoneal administration of Allotrap 1258 1 h prior to UV exposure resulted in significantly diminished levels of UV-induced tumor necrosis factor (TNF)-alpha protein production in the epidermis but had no effect on other parameters of the acute UV-induced inflammatory response. By virtue of its ability to suppress TNF-alpha protein production, Allotrap 1258 could prove to be an effective modulator of inflammatory responses.

Population bone mineral density measurements for Chinese women and men in Hong Kong

The aim of the study was to establish population ranges of bone mineral density (BMD) for Hong Kong Chinese men and women for the Hologic QDR 2000 bone densitometer, to compare these values with the manufacturer's reference ranges, to compare these values with population ranges for women obtained for the Norland X26 bone densitometer, and to examine variations between the two densitometers. The subjects were 164 men aged 40-79 years and 436 women aged 20-89 years, who were all ethnic Chinese, recruited from volunteers, social centers for the elderly and general practice clinics. BMD in women began to decline rapidly between ages 50 and 79 years, averaging about 10% loss per decade from the young adult (20-29 years) mean. The percentage losses from young adult mean values in the spine, femroal neck, trochanter and total femur were 23%, 30%, 31% and 33%, respectively, from 20 to 79 years. In the ninth decade no further decrease in BMD occurred with the exception of a further 4% at the hip sites. In men, no decrease in spine BMD occurred between 40 and 70 years. Compared with BMD in the fourth decade, 10%, 13%, and 11% of BMD was lost at the femoral neck, trochanter and total femur, respectively, by the seventh decade. These values show differences compared with the manufacturer's reference ranges for Caucasians and Japanese. BMD values for the spine were comparable between Hologic and Norland densitometers, but Hologic values for femoral neck and trochanteric regions were lower than the Norland values. Data provided by this study may thus be used as normative values for the Hologic QDR2000 bone densitometer, instead of values provided by the manufacturer. BMD values at the hip sites are not interchangeable between Norland and Hologic bone densitometers, and estimation of numbers of the population with osteoporosis will depend on the model of densitometer used.

Telepsychiatry in psychogeriatric service: a pilot study

A pilot study on telepsychiatry was conducted in which a videoconferencing link was established between a regional hospital and a care and attention home. Using this system, a psychogeriatric outreach team provided 149 psychiatric assessments to 45 residents of the care and attention home over 11 months. Videoconferencing was found to be highly feasible. It was acceptable to staff and patients and more cost-effective than on-site visits.

A comparison of polymorphism in the 3'-untranslated region of the prothrombin gene between Chinese and Caucasians in Australia

The 20210G-->A mutation in the 3'-untranslated (UT) region of the prothrombin gene is extremely rare or absent in the Chinese population (0 in 449 subjects, 140 with a history of thromboembolism). This is in contrast to the results from 302 Caucasians from Australia in our study (4.6% in 153 patients with a thromboembolic history and 1.3% in 149 patients with no history). This rarity implies that the variant of the prothrombin gene is probably not the main cause of venous thromboembolism in the Chinese population. Even among Caucasians this mutation accounts for only a minor percentage of all patients with thromboembolism. The relatively low incidence of venous thromboembolism in the Chinese population compared with Caucasians is probably as a result of the low prevalence of factor V Leiden or other environmental or genetic factors.

Alendronate prevents bone loss in Chinese women with osteoporosis

The objectives of the Hong Kong study are to investigate the efficacy of 10 mg alendronate in preventing bone loss at the hip and spine in osteoporotic Chinese women. One hundred osteoporotic Chinese women, aged 60-79 years, were randomized to receive 10 mg of alendronate or placebo, with 500 mg elemental calcium. Bone mineral density (BMD) at the spine and hip were measured at baseline, 6 months, and 12 months. Seventy-eight subjects completed the study. The alendronate-treated group gained more bone at both the spine (p < 0.01) and femoral neck (p < 0.001), with a mean difference (+/-SE) of 2.4% (+/-0.86%) at the spine and 3.98% (+/-0.95%) at the femoral neck. Of the 100 patients, 6 subjects in the alendronate group and 5 subjects in the placebo group had mild gastrointestinal symptoms. We conclude that alendronate (10 mg) was effective in preventing bone loss in postmenopausal osteoporotic Chinese women.

Cardiovascular risk factors and 18-month mortality and morbidity in an elderly Chinese population aged 70 years and over

OBJECTIVE

To determine the influence of some cardiovascular risk factors (hypertension, diabetes mellitus, smoking habit, physical activity, obesity, adverse lipid profile) in elderly Chinese aged 70 years and over, on overall mortality and morbidity from stroke and ischaemic heart disease.

DESIGN

Longitudinal study relating 18-month outcome to baseline values.

SUBJECTS

2,032 subjects (999 men, 1,033 women), mean age 80 years, recruited by random sampling of the Old Age and Disability Allowance Schemes, which covers 90% of the Hong Kong elderly subjects, stratified by sex and 5-year age groups from 70 years onwards.

METHODS

At baseline, subjects were visited by interviewers to collect information regarding medical conditions, smoking habit, physical activity, and to measure their height, weight, skinfold thickness, and waist/hip ratio. A follow-up survey was carried out 18 months later to establish the development of any new stroke or ischaemic heart disease, and to note any deaths and the cause of such deaths from death certification.

RESULTS

In multivariate analysis overall mortality was negatively associated with body mass index and participation in physical activity, after adjusting for age and sex. Death from stroke was associated with a higher systolic blood pressure at baseline. Among survivors, the only significant associations observed were a negative association between body mass index and the development of heart disease, and a positive association between systolic blood pressure and development of stroke.

CONCLUSIONS

Few associations between cardiovascular risk factors and morbidity and mortality were demonstrated in elderly Chinese with a mean age of 80 years. The only modifiable risk factor appears to be systolic blood pressure.

Vegetarianism and ischemic heart disease in older Chinese women

OBJECTIVE

This study compared the risk of ischemic heart disease among older vegetarian Chinese women with that of older non-vegetarian women.

METHODS

90 vegetarian Chinese women over 70 years old in Hong Kong were screened for ischemic heart disease by electrocardiogram (ECG) and cardiovascular questionnaire. They were compared with 90 non-vegetarian women of similar age examined in a previous local survey. The effects of confounding factors were adjusted by stepwise logistic regression analysis.

RESULTS

The percentages of subjects with ischemic heart disease defined by symptoms and ECG or by ECG alone were significantly lower in vegetarian women (p <0.005 and p<0.05 respectively). Vegetarians had lower serum cholesterol levels: more were old age home residents and were less likely to perform regular exercise. On stepwise logistic regression, using probable ischemic heart disease defined by questionnaire and ECG as outcome measure, vegetarianism was the only significant predictor (OR 0.3, 95%CI 0.1-0.6, p<0.005).

CONCLUSIONS

Vegetarian older Chinese women had lower risk of ischemic heart disease when compared with non-vegetarians. Apart from lower serum cholesterol levels, vegetarianism may have other protective factors against ischemic heart disease.

Serum fatty acid, lipid profile and dietary intake of Hong Kong Chinese omnivores and vegetarians

OBJECTIVE

To examine the serum fatty acid and lipid profiles and dietary intake of Hong Kong Chinese omnivores and vegetarians with respect to cardiovascular health.

DESIGN

Random population survey stratified by age and sex.

SUBJECTS

One-hundred and ninety-four omnivore subjects (81 men, 113 women) age 25-70 y, and 60 ovo-lacto-vegetarian adults (15 men, 45 women) age 30-55 y.

MEASUREMENTS

Nutrient quantitation was by a food frequency method. Serum fatty acids were analysed by gas chromatography, and serum lipid by standard laboratory methods.

RESULTS

Compared with omnivores, vegetarians had higher serum concentrations of polyunsaturated (PUFA) and monosaturated fatty acids (MUFA), and lower saturated fatty acids (SFA), long chain omega-3 and trans fatty acids (TFA). They also had lower serum cholesterol and higher apoA-1 concentrations, but the LDL/HDL ratio was not different. The ratio of polyunsaturated to saturated fatty acids intake was higher in vegetarians. Compared with results from populations with higher incidences of coronary heart disease, while lower myristic and palmitic acid concentrations and higher eicosapentaneoic (EPA) and docosahexanoic acid (DHA) may partly account for the difference in incidence, linoleic acid concentration was higher. Although the Chinese vegetarian diet may be beneficial for heart health in that antioxidant and fibre intakes are higher and saturated fat lower, the low EPA and DHA due to omission from dietary source and suppressed formation by high linoleic acid level, and the presence of TFA in the diet, may exert an opposite effect.

CONCLUSION

There are some favourable features in the serum fatty acid profile in the Hong Kong Chinese population with respect to cardiovascular health, but the consumption of TFA is of concern. The Chinese vegetarian diet also contains some adverse features.

Factors predicting stroke disability at discharge: a study of 793 Chinese

OBJECTIVE

To identify factors predicting stroke disability at discharge in a Chinese population.

DESIGN

Retrospective analysis of data collected from stroke patients.

SETTING

A 25-bed stroke rehabilitation unit in Hong Kong.

PARTICIPANTS

A total of 793 Chinese patients with acute stroke consecutively admitted for inpatient rehabilitation.

INTERVENTIONS

All patients received traditional rehabilitation therapies including physical, occupational, and speech therapies when appropriate.

MAIN OUTCOME MEASURES

Disability was measured with the Barthel index (BI), and mild disability at discharge was defined as a BI score of > or =15. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed.

RESULTS

Logistic regression analysis revealed that a BI score of > or = 15 points at admission strongly predicted that the patient's BI at discharge would be > or =15. For those whose BI score at admission was less than 15, these factors correlated negatively with a discharge BI of 15: BI at admission of <5 (OR .08, CI .04-.17); National Institutes of Health stroke scale at admission of >7 (OR .23, CI .12-.43); urinary incontinence at admission (OR .35, CI .21-.60); age > or =65 years (OR .44, CI .25-.77); and abbreviated mental test at admission of <7 (OR .56, CI .33-.94).

CONCLUSIONS

For Chinese stroke patients, the disability at admission is the most important predictor for disability at discharge. Patients with very severe disability, severe neurologic impairment, urinary incontinence, old age, and impaired cognition at admission are less likely to recover to mild disability at discharge. Although hemorrhagic stroke is more common among Chinese populations, it is not an independent predictor for disability at discharge.

Validation of prediction equations for basal metabolic rate in chinese subjects

OBJECTIVES

To examine the validity of existing prediction equations for basal metabolic rate (BMR) and two generated regression equations in healthy Chinese subjects and patients with chronic diseases.

SUBJECTS

One-hundred and thirty-four healthy Chinese volunteers of aged 16-88 among staff working in Shatin Hospital and their relatives, and 30 elderly patients with heart disease, stroke and chronic obstructive airway disease (COAD) were recruited.

INTERVENTIONS

Height, weight, biceps and triceps skinfold thickness, body fat percentage, and BMR were measured in the healthy subjects and patients. Two regression equations were derived from 70 healthy Chinese subjects. Three existing equations (WHO, Liu and Jia equations) and two derived equations were then cross-validated in 64 subjects and 30 patients.

RESULTS

For the healthy Chinese subjects, as well as patients, the BMR calculated by Liu was the closest to the measured BMR among all the equations, although there was slight underestimation for patients.

CONCLUSION

This study confirms that the Liu equation is the most appropriate for predicting BMR in healthy Chinese subjects, but it underestimates the BMR in those with chronic diseases. Fat-free mass is the best predictor of measured BMR.

SPONSORSHIP

Unrestricted research grant in nutrition from the Bristol-Myers Squibb Foundation.

Peripheral volumetric bone mineral density in pre- and postmenopausal Chinese women in Hong Kong

The aim of this cross-sectional study was to use a newly available precise and multislice pQCT (Densiscan 2000) for establishing reference data of volumetric bone mineral density (vBMD) of the distal radius. vBMD of the nondominant wrist was measured in 118 healthy Hong Kong Chinese women aged 41-60. Anthropometric parameters, menstrual status, and handgrip strength were also measured. Results showed that there was a significant age-related decline in trabecular BMD (tBMD), integral BMD (iBMD), and cortical BMD (cBMD), with correlation coefficients ranging from -0.401 to -0.547 (P < 0.001). The annual decline of vBMD was 2.22%, 1.79%, and 0.88% in tBMD, iBMD, and cBMD, respectively. When subjects were divided into premenopausal and postmenopausal groups, we found an age-related decline in tBMD and iBMD, but not in cBMD in both groups. The vBMD values interpreted in mg/cm3 in premenopausal women were 238.4 +/- 57.2 in tBMD, 604.6 +/- 82.9 in iBMD, 1415.5 +/- 129.9 in cBMD, and declined significantly (all P < 0.001) to 193.7 +/-54.7 in tBMD, 500.0 +/- 90.3 in iBMD, and 1306.7 +/- 153.5 in cBMD in the postmenopausal women. On average, 16.7% of the subjects showed their vBMDs to be below-1 SD and only 1.7% of them lower than -2 SD. Linear regression showed that the annual decline of vBMD was faster in postmenopausal women with 2.42% in tBMD, 1.90% in iBMD, and 0.88% in cBMD compared with 1.91% in tBMD, 0.98% in iBMD, and 0.55% in cBMD in the premenopausal women. After adjustment for age, only the iBMD with dominant trabecular elements showed a significantly accelerated decrease after the onset of menopause (P = 0.008). Weak or no association was found among vBMDs with anthropometric parameters, years since menopause, or handgrip strength. In conclusion, we found a significant age-related decline of vBMDs in Hong Kong Chinese women aged 41-60 years, characterized by the early reduction of metabolically active trabecular bone after entering the fourth decade of life, with an accelerated decline after the onset of menopause.

Aspirin-associated intracerebral hemorrhage: clinical and radiologic features

OBJECTIVE

To identify the clinical and radiologic features of intracerebral hemorrhage (ICH) in aspirin users.

BACKGROUND

Although the benefits of aspirin outweigh its hemorrhagic risks for patients at high risk of vascular diseases, prolonged use of aspirin is associated with an increased risk of ICH.

METHODS

The authors enrolled consecutive patients with acute stroke who were admitted to a regional hospital from 1993 to 1998 into a stroke registry. From this registry, they identified all stroke patients who had ICH confirmed by CT scan and then selected those taking regular aspirin before ICH as the study group. For each study patient, they selected the immediate next two patients with ICH but not taking aspirin as controls.

RESULTS

The authors identified 58 aspirin users and 1193 nonusers among all patients hospitalized for ICH. From the group of nonusers, they selected 116 patients as controls. The locations of the hematoma were different (p = 0.002), with more lobar hematoma in the aspirin group (32.8%) than in the control group (10.3%). Prior cerebrovascular disease was the reason for taking aspirin in 37 (64%) patients but five patients had prior ICH.

CONCLUSIONS

The propensity for lobar hematoma in aspirin-associated ICH suggests its pathology may be somewhat different from spontaneous ICH among nonaspirin users. Further research to examine the risks and benefits of aspirin use in certain subgroups at risk of both thrombotic and hemorrhagic events is needed.

Inhibition of tumor necrosis factor mRNA translation by a rationally designed immunomodulatory peptide

Based on sequences of immunomodulatory peptides derived from the heavy chain of HLA Class I, novel immunomodulatory peptides with increased potency were developed by computer-aided rational design. Allotrap 1258 was characterized in detail and shown to inhibit cell-mediated immune responses in vitro and in vivo. Immunomodulatory activity was associated with the capability of the peptides to modulate heme oxygenase (HO) activity. In this study we analyzed the effect of Allotrap 1258 on cytokine expression. Allotrap 1258 inhibited concanavalin A- and lipopolysaccharide-induced human and mouse tumor necrosis factor (TNF) production in vitro and in vivo but had no effect on interleukin (IL)-1, IL-2, IL-4, IL-6, or IL-10 expression. Experiments with HO-1/KO and iNOS/KO mice showed that Allotrap 1258-mediated inhibition of TNF was independent of HO-1 and iNOS. Quantitation of TNF protein expression and mRNA steady state levels demonstrated that Allotrap 1258-mediated inhibition occurred at the translational level. Deletion of the AU-rich element in the 3'-untranslated region (UTR) of TNF mRNA, a region known to be involved in TNF mRNA translation, had minimal effect on Allotrap 1258-mediated inhibition. However, replacement of the TNF 3'-UTR with the human globin 3'-UTR rendered the peptide inactive. This demonstrates that besides AU-rich elements, other sequences in the 3'-UTR of TNF mRNA are involved in translational control of TNF expression. Such sequences are necessary for Allotrap 1258-mediated inhibition of TNF production.

Relationships among diet, physical activity and other lifestyle factors and debilitating diseases in the elderly

Diet and physical activity are two major lifestyle factors that play a role in the prevention or management of debilitating conditions affecting older people. Both under- and overnutrition predispose to diseases. Low sodium and high potassium intakes, as well as the consumption of fruits and vegetables are associated with a reduction of hypertension and diseases arising from hypertension such as stroke and dementia. Dietary patterns (consumption of quantity and types of fats, cholesterol, vegetable oils, fish) are important in the prevention of coronary heart disease. Calcium and vitamin D intakes are important factors in the development of osteoporosis, while various dietary factors have been linked to the development of cancer. Physical activity is important in the prevention of functional decline and increased survival, reduced incidence of falls and fractures, and has various cardiovascular health benefits. Apart from prevention of diseases, exercise also has an important role in improving function in some chronic diseases such as heart failure or chronic obstructive pulmonary disease. Both diet and exercise interact, so that public health recommendations often take the form of lifestyle modification advice in the prevention of disease and disability.

The alpha-synuclein gene and Parkinson disease in a Chinese population

OBJECTIVE

To study the Ala53Thr and Ala30Pro mutations of the alpha-synuclein gene in a large number of Chinese patients with Parkinson disease (PD) as well as controls.

METHODS

We recruited 183 Chinese patients with sporadic PD, 17 with younger-onset PD (onset age <50 years), and 7 with PD and a positive family history as well as 227 unaffected Chinese control subjects from the outpatient departments of 2 major hospitals in Hong Kong. All subjects were assessed for the the diagnosis of PD by a consultant neurologist or geriatrician. Subjects were interviewed with a standard questionnaire that also questioned for family history. Venous blood samples were obtained from the subjects and genomic DNA was extracted and studied for the presence of Ala53Thr mutation in exon 4 and Ala30Pro mutation in exon 3 of the alpha-synuclein gene using a polymerase chain reaction restriction fragment length polymorphism method.

RESULTS

None of the Chinese PD patients or controls had either the Ala53Thr (exon 4) or Ala30Pro (exon 3) mutation of the alpha-synuclein gene.

CONCLUSION

We failed to discover Ala53Thr or Ala30Pro mutations in a large number of Chinese patients with PD and control subjects, adding to the emerging consensus that variations in the alpha-synuclein gene are associated with PD in few families worldwide.

Using the comprehensive geriatric assessment technique to assess elderly patients

OBJECTIVE

To review the concept, components, and characteristics of the Comprehensive Geriatric Assessment technique.

DATA SOURCES

Medline and non-Medline literature search.

STUDY SELECTION

The following key words were used: Comprehensive Geriatric Assessment; all available years of study were reviewed.

DATA EXTRACTION

Studies that assessed the Comprehensive Geriatric Assessment technique's benefits were examined.

DATA SYNTHESIS

By using the Comprehensive Geriatric Assessment programme, accurate diagnoses can be made, treatable illness can be screened for, therapeutic plans can be formulated, and the optimal placements of patients can be achieved. Assessment should be performed at each level of geriatric care; various well-validated scales are used to measure the activity of daily living of patients. The Comprehensive Geriatric Assessment programme can improve functional status; reduce the use of medications, nursing homes, and medical services; and reduce mortality rates. Most studies confirm that a successful programme requires careful patient targeting, implementation of the programme by attending physicians, and patient adherence to the recommendations made.

CONCLUSION

A well-targeted Comprehensive Geriatric Assessment programme and the control of patients' adherence to recommendations are effective in improving the well-being of elderly patients.

Alleviation of graft-versus-host disease after conditioning with cobalt-protoporphyrin, an inducer of heme oxygenase-1

BACKGROUND

Recently, we demonstrated that elevated expression of heme oxygenase-1 (HO-1 or Hsp-32) resulted in the modulation of several immune effector functions. Here we evaluated whether induction of HO-1 after administration of cobalt protoporphyrin (CoPP) can prevent the development of acute graft-versus-host-disease (GVHD).

METHODS

Acute GVHD was initiated by injection of unfractionated spleen cells from C57BL/6 into B6D2/F1 mice.

RESULTS

Administration of CoPP resulted in increased survival: 85% of CoPP-treated animals survived for >100 days compared with only 29% of saline-treated control animals (P<0.05). In contrast, administration of ZnPP, a well-known inhibitor of HO, accelerated GVHD development. The protective effect of CoPP therapy seemed to be caused by immunomodulation of donor cells, because treatment of cell donors prevented development of acute GVHD in 80% of recipients compared with 0% in control animals. Spontaneous lymphocyte proliferation could be measured with splenocytes harvested from animals developing GVHD but not with splenocytes from recipients of CoPP-treated donor cells. CoPP-treatment had no effect on interleukin-2 or interleukin-4 synthesis but inhibited interferon-gamma production. Mice with active GVHD demonstrated a defective lympho-proliferative response to alloantigens or concanavalin A. However, spleen cells isolated from survivors (on day 100) responded normally. Flow cytometric analysis of splenic T cell populations revealed a severe reduction in recipient type (H-2b,d) cells in mice with active GVHD, whereas in protected mice the number of cells remained normal.

CONCLUSION

The results from this study confirmed our previous observation that up-regulation of HO-1 activity is associated with down-regulation of several immune effector functions. This resulted in protection from acute GVHD in a parent into F1 mouse model.

The influence of income on morbidity, mortality and dependency in elderly Hong Kong Chinese

The association between income and mortality, morbidity and dependency is examined in a 3-year prospective follow-up study of 2032 subjects aged 70 years and above in the Hong Kong Special Administrative Region, China. Subjects were recruited using stratified disproportional random sampling of the Old Age and Disability Allowance Schemes, covering over 90% of the population. Subjects were interviewed at baseline and after 36 months. Presence or absence of disease was based on self-report of doctor diagnosis together with a check of medication taken. Functional status was measured using the Barthel Index. For the disease analysis, subjects with the disease being analyzed at baseline were excluded; similarly for the dependency analysis, subjects who were dependent at baseline were excluded. Chi-square test, univariate and multiple logistic regression were used to examine the association between income and mortality, development of new disease, and dependency. There was no association between income and mortality, or with development of new disease. Development of dependency was associated with lower income at baseline. An income of less than 1000 HK dollars per month increased the risk of dependency by 1.8-fold (95%CI 1.1-2.9). However, this association disappeared after adjustment for age and sex. Absolute income is not an important factor contributing to mortality, morbidity and dependency in elderly Chinese aged 70 years and above. A freely accessible health and social service at low or no cost, the survivor effect, or other factors may account for the lack of association with income, contrary to findings from studies of whole populations worldwide. Therefore manipulating income alone is unlikely to affect these outcomes in the elderly.

An estimate of long-term care needs and identification of risk factors for institutionalization among Hong Kong Chinese aged 70 years and over

BACKGROUND

The goal of this study is to estimate the long-term care needs of the Hong Kong Chinese population age 70 years and older, and to identify risk factors for institutionalization.

METHODS

A three-year prospective follow-up study was carried out in Hong Kong Special Administrative Region, China. 2,032 subjects aged 70 years and older were recruited territory-wide by stratified random sampling of the Old Age and Disability Allowance register, covering over 90% of the elderly population. A questionnaire was administered at baseline to obtain information on social, functional, physical, and mental health status, and place of residence. A repeat interview was carried out at 36 months. The number of subjects moving from home to institution or vice versa, and the number who had died, were noted. Univariate analysis was performed to determine risk factors for institutionalization, and backward stepwise multiple logistic regression was used to identify independent factors predisposing to institutionalization.

RESULTS

The institutionalization rate per year is estimated to be 0.7% for the 70-79 age group, and 1.5% for the 80+ age group. Using population figures projected by the Hong Kong Census, the corresponding number of places required will be 24,150 and 42,000, respectively, for the two age groups by 2005, whereas the number of government subvented places projected to be available is unlikely to be more than 40,000 for the whole population. Age, being a woman, being single, not having a formal education, cognitive impairment, physical dependency, and the presence of depressive symptoms were factors predisposing to institutionalization. In multivariate analysis, age, marital status, and dependency were identified as independent factors.

CONCLUSION

The requirement for institutional places is unlikely to be met by government, the shortfall likely to be met by the private sector. Maintenance of functional independence, good social support network, engagement in social activities, and good informal carer support may reduce demand for institutional care.