Masterclass 9 - Patient-centred and Quality Care for Older Patients

It has been over three years since the first case of COVID-19 was reported in Hong Kong on 23 January 2020. As of 29 January 2023, a total of 2.6 million COVID-19 positive cases and over 13,000 deaths were reported during the fifth wave, which started on 31 December 2021. Older adults aged 70 and above accounted for 11.4% of all reported cases but 87% of all deaths. Among those older adults who died, 51% were unvaccinated and 11% received only one dose of Covid vaccine. Moreover, over 40% of all deaths were residents of care home, who were mostly frail elderlies with multiple comorbidities. Besides, older adults are also vulnerable to suffer from complications arising from COVID-19, treatment in isolation facilities of hospitals and post-COVID conditions, like breathlessness, fatigue and cognitive impairment etc. The impact of social distancing and isolation also led to a deterioration of physical and mental health of older adults with or without COVID-19. Sarcopenia, loneliness, anxiety, depressive symptoms and even suicidal ideation or elder abuse were reported more often in older adults during the pandemic. An accelerated decline of cognition and worsening of behavioral symptoms were notable among patients with cognitive impairment. There were also more deaths due to cardiovascular disease among older adults in Hong Kong during the first year of pandemic. During the COVID-19 pandemic, geriatric teams in different hospitals have been playing crucial roles by providing telemedicine consultation, outreach medical and nursing support to residents at care homes, quarantine centers and community treatment facilities. Other significant work also included coordination of evacuation and hospital discharge at care homes, infection control advice and promotion of COVID-19 vaccination to elderly population.

Hong Kong is facing the challenge of fast population aging. One of the natural parts of many disease process is eating problem with poor appetite and swallowing difficulty. Unless there is a valid advance directive (AD) or advance care planning (ACP) opted not for enteral feeding, family members and healthcare professionals often feel obliged to start tube feeding. This explains partly the popularity of nasogastric (NG) tube feeding in older people. As yet, evidence has shown that NG feeding does not offer extra benefits to older patients. NG tube or gastrostomy feeding are not effective in preventing aspiration pneumonia. Enteral feeding fails to improve serum albumin, body weight and lean muscle mass. The use of feeding tube brings patient discomfort, increased application of physical restraints and possibility of pressure sore development. Older people in residential care homes for the elderly (RCHE) with feeding tubes are repeatedly transferred to emergency because of tube complications. Evidence is also lacking for survival benefits in older people with tube feeding. 


Careful hand feeding (CHF) or comfort feeding has been advocated as an alternative for older people with advanced dementia and eating problems. Hospital Authority Guidelines on Life-Sustaining Treatment in the Terminally ill was updated in 2016, providing a clear picture of CHF from the ethical perspective. Yet, there are many practical barriers in carrying out CHF in hospitals including manpower issues and the urge to discharge patients quickly due to high volume of patients. The present talk will introduce the CHF program in Fung Yiu King Hospital (FYKH), a geriatric step-down hospital in Hong Kong West Cluster (HKWC). The results of the outcome study on the CHF program conducted in FYKH will be shared. In addition, the present talk will review international literature on CHF, including a recently published local control study comparing NG tube feeding and CHF. Way forward for CHF in local hospitals will be discussed.