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Module on Health Assessment
Hong Kong Reference Framework
for Preventive Care for Older Adults
in Primary Care Settings
Module on Health Assessment
Revised Edition 2016
First published: 2013
Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
Content
1. IMPORTANCE OF HEALTH ASSESSMENT....................................................................................... 3
2. DELIVERY OF PREVENTIVE CARE SERVICE: USE EVERY OPPORTUNITY FOR
PREVENTION........................................................................................................................................................ 4
3. RECOMMENDATIONS ON SYSTEMATIC HEALTH ASSESSMENT............................................ 5
3.1. IDENTIFYING THE RIGHT PEOPLE (CASE FINDING) .............................................................. 5
3.2. BASELINE ASSESSMENT .............................................................................................................. 5
3.3. FORMULATION OF PERSONALIZED PREVENTIVE CARE PLAN .......................................... 8
3.4. CARE CO-ORDINATION ................................................................................................................. 8
3.5. MONITORING AND REVIEW ........................................................................................................ 9
4. HEALTH ASSESSMENT AND PREVENTIVE CARE PLAN FOR DIFFERENT CATEGORIES OF
OLDER ADULTS ..................................................................................................................................................11
4.1. INDEPENDENT WITH NO KNOWN CHRONIC DISEASES ......................................................11
4.2. INDEPENDENT WITH CHRONIC DISEASES ............................................................................ 13
4.3. OLDER ADULTS WITH DISABILITIES....................................................................................... 13
5. ASSESSMENT TOOLS .......................................................................................................................... 16
6. INFORMATION TO PATIENTS AND CARERS ................................................................................ 21
ANNEX
ANNEX 1.
ASSESSMENT ON ACTIVITIES OF DAILY LIVING .................................................... 22
ANNEX 2.
TIMED UP AND GO TEST ............................................................................................... 28
ANNEX 3.
ONE LEG BALANCE TEST ............................................................................................. 29
ANNEX 4.
MEASUREMENT OF VISUAL ACUITY (VA) USING A 6-METRES SNELLEN CHART.. 30
ANNEX 5.
AMSLER GRID TEST ....................................................................................................... 32
ANNEX 6.
WHISPERED VOICE TEST AND AUDIOSCOPE ........................................................... 33
ANNEX 7.
GERIATRIC DEPRESSION SCALES ............................................................................... 34
ANNEX 8.
PATIENT HEALTH QUESTIONNAIRE (PHQ) ............................................................... 39
ANNEX 9.
ORAL HEALTH ASSESSMENT TOOL............................................................................ 41
ANNEX 10. MALNUTRITION UNIVERSAL SCREENING TOOL FOR HONG KONG CHINESE ...
(HKC-MUST) ..................................................................................................................... 42
ANNEX 11. CHINESE NUTRITION SCREENING TOOL (CNS) ....................................................... 43
ANNEX 12. MINI-NUTRITIONAL ASSESSMENT (MNA) ................................................................ 46
ANNEX 13. ABBREVIATED MENTAL TEST (AMT) ......................................................................... 49
ANNEX 14. MINI-COG TEST ............................................................................................................... 50
ANNEX 15. GLOSSARY ........................................................................................................................ 53
ACKNOWLEDGMENTS ............................................................................................................................ 55
REFERENCES ............................................................................................................................................. 57
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
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Module on Health Assessment
1. Importance of Health Assessment
The significant increase in the number of older people and the associated age-related disabilities
and chronic diseases create challenges to the existing health care system. It has been shown that
targeted, proactive and community-based preventive care is more cost-effective than downstream
acute care. Therefore, targeted intervention for various health risks at their early stages is of
paramount importance not only to the health care system, but also to individual older adult’s
active ageing.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
2. Delivery of Preventive Care Service: Use Every
Opportunity for Prevention
It has been shown that only 0.5% of clinical encounters in local primary care among the
older people are done for physical check-up 1. Therefore, more effective measures at
primary care settings should be considered to promote healthy ageing and minimise the
health risks of older adults. It has been suggested that apart from designated appointments
in primary care settings, the health assessment can also be performed opportunistically over
time and during multiple visits. Indeed, every clinic visits to primary care providers can be
an opportunity for screening of physical, psychological and social problems2,3. In fact, 80%
of the population in Hong Kong have consulted primary care providers in one year and with
the average of 8 primary care visits per year4. This provides huge opportunities for primary
care providers to discuss with their patients on various preventive care services. Moreover,
continuity of care as one of the key attributes of family doctor has been shown to improve
the consistency with which preventive services are delivered, family doctors can thus take
a more proactive role in health promotion and health assessment for older adults. Having
good rapport with their patients, family doctors are also in a prime position to motivate their
patients to perform various preventive care activities.
Notwithstanding the above, it is worth to note that screening is the testing of people who do
not suspect they have a problem. Once a disease is suspected, prompt clinical management
should be instituted. Moreover, screening involves a system not just a test and there is
always a trade-off between benefit, harm and affordability. Hence, screening programme if
implemented should be occurred at settings where screening service is provided and relevant
supporting service is readily accessible.
For details of evidence-based recommendations on preventive care for older adults, please
refer to Chapter 5.1 to 5.5 in the Core Document.
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3. Recommendations on Systematic Health
Assessment
In order to have effective implementation of the evidence-based recommendations, the
service delivered should be personalised in accordance with individual’s needs. A structural
model should also be put in place to enable family doctors to take the lead in conducting
health assessment.
Taking all these into considerations, a baseline assessment can be taken as a foundation for
early identification of major problems and designing of subsequent preventive care plans.
Task delegation (e.g. database development), patient reminders, call and recall systems to
identify needs as well as coordination with other health care professionals and community
partners are also essential to ensure consistent delivery of the preventive services.
Systematic health assessment is thus recommended as one of the strategies for delivering
preventive services to older adults and its core components are:
Identifying the right people (case finding)
Baseline assessment
Formulation of personalized preventive care plan
Care co-ordination
Monitoring and review
3.1. Identifying the right people (case finding)
It has been shown that the distribution of health service utilisation across a population tends
to be very uneven, with a small proportion of people who have complex health care needs
accounting for a large share of total health care resources. Therefore, in order to ensure
that a programme is cost-effective, it is crucial that those individuals at higher risk and who
are amenable to preventive care are targeted. Models are now being developed that seek to
systematically assess how effective preventive care is likely to be5. If older adults at risk can
be identified before they deteriorate, there is more potential to reduce future health care cost.
3.2. Baseline assessment
The baseline assessment aims to systematically review and properly document the level of
function and risk profile of an older adult such that a personalized preventive care plan can
be delineated. It should build on existing information about the older person and should
include physical, psychological and social factors. Issues that are suggested to be covered in
the baseline assessment are summarized in Table 1.
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Table 1. Suggested issues to be covered in the baseline assessment
History
Review patient’s
medical and
psycho-social history
√ Past medical history
√ Family history of significant illnesses
√ Current medications (include over-the-counter medicines
and herbal remedies) and any medications that may cause
dry mouth as a side effect
√ Lifestyle behaviour including smoking and drinking habit,
diet pattern, physical activities
√ Dental health problems (e.g. difficulty with chewing or
brushing teeth) and dry mouth
√ Vaccination history (especially seasonal influenza
vaccination and pneumococcal vaccination)
√ Psychological status e.g. mood and emotion status
√ Social history such as marital status, home environment,
financial support, family support and social network
√ Functional status: current level of mobility e.g. independent,
walk with aids. Current ability and needs in terms of
activities of daily living, and any recent deterioration.
Any significant change in lifestyle and mood
√ History of fall
Focused physical examination
To perform
√ Check height, weight, body mass index and waist
examination to
circumference
identify risk factors
√ Measure blood pressure and check pulse
and common chronic √ Assess patient’s cognitive function if any clinical suspicion
diseases
of dementia which based on direct observation, with due
consideration of information obtained by way of patient
reports and concerns raised by family members, friends,
caretakers or others if any
√ Functional status as indicated: hearing, vision, mobility,
cognition, mood
√ Obtain other measurements deemed appropriate based on
medical and psycho-social history
Investigations
Early identification
√ Check fasting blood glucose
of diabetes mellitus,
√ Check total cholesterol and HDL-cholesterol
hyperlipidaemia, cervical √ Check cervical smear if indicated (see Chapter 5.4.2a in
Core Document)
and colorectal cancer
√ Check faecal occult blood (see Chapter 5.4.2b in Core
Document)
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To ensure that all aspects of baseline assessment are considered, a checklist or template can
be helpful in daily practice and the chart below is one of the examples for reference.
Baseline Assessment template
Demographics
Social History
Marital Status
No. of children
Who are you living with?
Smoking: Y/N
Duration:
Drinking: Y/N Duration:____
Quit since:
Amount:
____ standard drink(s) per day/ week
Exercise: Y/N
Occupation (previous/ current):
Type of exercise:
Retired since:
_____ minutes per day/ week
Financial Support:
Mobility status (e.g. unaided, walk with aids):
Abilities on self care: □ Independent □ Need assistance □ Dependent
History of fall: ________________
Drug History (include OTC medications and herbal remedies)
Drug/ other allergy
Family History
□ HT □ DM □ IHD □ Stroke □ Dementia □ Cancer ________________
□ Others _________________________________
Vaccination History
Influenza Y/N Last Injection:
Pneumococcal Y/N Last injection:
Others:
Oral Health
Any feeling of dry mouth? Y/N
Any chewing problem? Y/N
Any problem brushing your teeth? Y/N
Physical Exam
BP
Regular pulse? Y/N
Waist circumference
Height:
Weight:
BMI
Others:
Investigations:
Fasting blood glucose
FOBT
Total cholesterol _______ HDL-Cholesterol __________
Others: __________
Cervical smear
Psychological status: depressed mood □ Yes □ No
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Common health problems require interventions
Smoking:
□ Yes □ No
Drinking:
□ Yes □ No
Exercise:
□ Yes □ No
Diet:
□ Yes □ No
Hearing impairment:
□ Yes □ No
Visual impairment:
□ Yes □ No
Incontinence:
□ Yes □ No
Fall risk:
□ Yes □ No
Dental problem:
□ Yes □ No
Depression:
□ Yes □ No
Cognitive impairment:
□ Yes □ No
Social isolation:
□ Yes □ No
Others: ____________
□ Yes □ No
Suggested schedule of subsequent assessment: ___________
Referral (if applicable):
3.3. Formulation of personalized preventive care plan
Based on the risk profile and functional capacity obtained from baseline assessment, a
personalised preventive care plan can be formulated for different categories of older adults.
As older adults tend to have complex health and social care needs, so the preventive care
advice and health promotion should be personalized in accordance with the individual’s
needs and with due considerations of referral for more comprehensive assessment when
required.
The role of carers in maintaining the health and wellbeing of older people should also be
acknowledged. Carers (including family members and friends) can often provide valuable
knowledge about the older person’s condition, previous illnesses, and behaviour, and,
therefore, should be involved in discussions about treatment and care options.
The preventive care plan proposed for different categories of older adults (i.e. independent
with no known chronic diseases, independent with chronic diseases, and older adults with
disabilities) are described in Chapter 4 of this document.
3.4. Care co-ordination
Once a problem has been identified in the process of preventive care, the family doctors
may choose to make the initial intervention themselves or may choose to refer the
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patient to other professional discipline or to a community centre from which additional
services would be helpful. More often, the care process involves multiple health care
workers and care co-ordination is needed in the context of a multidisciplinary team.
Fundamental to care co-ordination is the presence of a family doctor who involves in
continual communication with patients and their carers to help them to navigate the
different levels of health care system, as well as in close liaison with other health care
workers to deliver a personalised care.
3.5. Monitoring and review
The implementation of preventive care plan should be monitored to ensure that an individual
is receiving an appropriate follow up and package of care. The monitoring process can also
allow preventive care plan to be constantly reviewed and changed where necessary. The
frequency of such monitoring may vary depending on the individual’s level of need.
The various components of the systematic health assessment are summarized in Figure
1 below. When all the different components are effectively combined into an integrated
strategy, it could be considered that a ‘programme approach’ to preventive care has been
created. (Those older adults with hypertension or diabetes should have their own pathway of
risk assessment as described in the two Hong Kong Reference Frameworks for Hypertension
and Diabetes Carea )
If screening programme is to be organised, all activities along the screening pathway should
be appropriately planned, coordinated, monitored and evaluated. It is also important that the
screening offered is adequately resourced for interventions to address the needs identified.
Older adults offered the screening should be fully informed of the potential individual
benefits and harms of screening. They should be reminded that health assessment cannot
screen out all hidden illnesses and they need to beware of any symptoms despite normal
health assessment findings and seek medical advice at once for subsequent management.
a
Hong Kong Reference Framework for Hypertension for Adults in Primary Care Settings is available at
http://www.pco.gov.hk/tc_chi/resource/professionals_hypertension_pdf.html and
Hong Kong Reference Framework for Diabetes Care for Adults in Primary Care Settings is available at
http://www.pco.gov.hk/tc_chi/resource/professionals_diabetes_pdf.html
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
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Figure 1. Different components of the systematic health assessment
Identify
target older
adults
Baseline
Assessment
Formulate
care plan
Care coordination
Monitoring
and review
• A systematic approach in identifying appropriate target older
adults
• Early identification of common health probiems
• Define the level of function and risk profile
• To formulate a personalised preventive care plan for different
categories (i.e. independent with no known chronic diseases,
independent with chronic diseases, older adult with disabilities)
• Family doctor co-ordinates with a team of health care professionals
to deliver a personalised care and help older adult to navigate the
different levels of health care system
• Monitor and review the implementation of preventive
care plan
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4. Health Assessment and Preventive Care Plan for
Different Categories of Older Adults
4.1. Independent with no known chronic diseases
Considerable geographic variation in the prevalence of major chronic diseases among older
people suggests that chronic diseases are not an inevitable part of ageing.
Healthy and active ageing is achievable through lifestyle modification. Therefore, the ideal
goal for all older adults is to maintain physical independence and biological reserve as
well as enjoy psychosocial well-being through primary prevention and health promotion.
Measures that aimed at preventing chronic diseases (such as taking regular physical
activities, not smoking, and eating a balanced diet throughout life) are important basic steps
towards healthy ageing.
The recommended preventive care activities are summarized in Table 2 below.
Table 2. Recommendations on preventive care for independent older adults with no
known chronic diseases
Preventive Care
1. Vaccination
2. Promotion of
healthy lifestyle
- Smoking
- Drinking
- Physical
activity
- Diet and
nutrition
- Oral health
3. Screening for
overweight and
underweight
Recommendations (based on Chapter 5.15.5 in the Core Document)
- Arrange seasonal influenza
- Arrange pneumococcal vaccination
- Smoking cessation advice
- Moderation of alcohol intake
- Advise regular physical activities
Frequency
Annually
As indicated
Every opportunities
- Advise healthy eating habit and balanced diet
- Oral hygiene advice.
Check BMI +/- waist circumference
Monitor body weight and assess risk of
malnutrition
Annually
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4. Screening for HT
5. Screening for DM
6. Screening for
hyperlipidaemia
7. Screening for
cervical cancer
Measure blood pressure and check pulse
Check blood for fasting blood sugar
Check blood for lipid profile (total and
HDL-cholesterol)
Check cervical cytology test
8. Screening for
colorectal cancer
9. Screening for
functional
impairment
- Hearing
- Vision
- Continence
- Falls
- Dental
Check faecal occult blood test (FOBT)
-
Mood
Cognition
Social
-
Screening for hearing impairment
Screening for visual impairment
Screening for incontinence
Screening for risk factors of fall
Screening for dry mouth and difficulty
in chewing and brushing teeth
Screening for depression
Screening for dementia#
Screening for social isolation
Annually
Every 1-3 years
Every 1-3 years
Every 3 years after
two consecutive
normal annual
cytology tests
Every 1-2 years
Opportunistic or
when clinically
indicated (please
refer to Chapter
5.4.3 to Chapter 5.5
in the Core
Document)
# Primary care providers should assess cognitive function whenever cognitive impairment
or deterioration is suspected.
For those independent and healthy older adults, the systematic health assessment can
be performed regularly (e.g. on annual basis) for review of the risk profile and early
identification of chronic diseases. On the other hand, as functional decline can occur at
any time after untoward events, so the schedule of systematic health assessment does not
preclude family doctors from screening of other important functional domains during other
clinical encounters with these older adults. And the strategy of opportunistic screening
of various functional domains at each clinic visit would serve as a complementary tool to
systematic health assessment. For instance, primary care providers should assess cognitive
function whenever cognitive impairment or deterioration is suspected, based on direct
observation, patient report, or concerns raised by family members or carers.
The tools used to screen for various functional domains are described in Chapter 5 of this
document.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
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4.2. Independent with chronic diseases
The objectives of preventive services in this group of older adults are to appropriately
manage their chronic diseases with reference to both secondary and tertiary prevention, as
well as to maintain functional independence.
It is suggested to review the risk profile and functional level regularly (e.g. on annual basis)
for this group of older adults. And as these older adults are at higher risk of functional
decline, opportunities during each subsequent clinic visit should be taken to screen for
various functional domains (e.g. hearing impairment, visual impairment, incontinence, fall
risk, depression and cognitive impairment), such that timely interventions to maximise
functional capacity can be arranged.
The number of these functional domains screened depends on the time available, the urgency
of the patient’s problems, and the family doctor’s intuitive sense of likelihood of obtaining
any additional pertinent information. Some domains that are particular important in those
older adults with chronic diseases (i.e. use of medications, depression, social support and
network) should be screened more frequently and suggested to be at least annually.
As untoward event can occur at any time, an older adult can therefore move rapidly from
the stage of independence to disability. To facilitate progress review of preventive care
activities for an individual older adult, the checklist for different stages of an older adult are
summarized in Table 3.
4.3. Older adults with disabilities
Older adults with disabilities in this document refer to those complicated with multiple
co-morbidities and functional deficits which limit their capacity to perform desired
physical, mental and social activities. The objective of preventive care for this group
of older adults is to prevent further loss of function and maximise the ability to
remain as independent as possible, so as to facilitate their integration in society. More
often, a comprehensive assessment which involves extensive evaluation on physical,
psychological, social, and functional capabilities is needed, and thus a multidisciplinary
approach would be beneficial to this group of older adults. Collaboration with
community partners and other health care professionals could be considered when
family doctors encounter difficulties in performing comprehensive assessment or
interventions at their own clinic setting.
Limitations in ability to carry out ordinary daily physical activities are commonly seen in
this group of older adults, so the assessment process can begin with an individual’s ability
to perform tasks that are required for living by reviewing the two key divisions of functional
ability: Basic Activities of Daily Living (ADL) and Instrumental Activities of Daily Living
(IADL). The tools used to screen for various functional domains are described in Chapter 5
of this document.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
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Older adults with disabilities are vulnerable to mental health problems and social
deprivation. Improving care for older adults with disabilities and co-morbid mental health
problems may therefore require closer working not only between mental and physical health
care services, but also with social care and a range of other social support services. The
social support services that available to patients and carers are signposted in Annex 3 of the
Core Document.
The recommended preventive care activities are summarized in Table 3.
Table 3. Checklist of preventive care activities for an older adult at different stages
Preventive care activities
Independent Independent with Older adults with
with no known chronic diseases
disabilities
chronic
diseases
Vaccination
Influenza & pneumococcal vaccinations
Promotion of healthy lifestyle
Smoking
Drinking
Physical activity
Diet and nutrition
Oral health
Screening for overweight and
BMI +/- waist circumference
underweight
Monitor body weight and assess risk of malnutrition
Screening for HT
Blood pressure and pulse
Screening for DM
Fasting blood sugar
Screening for
Total cholesterol and HDL-cholesterol
hyperlipidaemia
Cancer screening:
Cervical cytology test
Cervical and colorectal
FOBT
cancer
Opportunistic screening of
Hearing
functional impairment
Vision
Incontinence
Falls
Dental
Depression
Dementia#
Social isolation
Risk assessment of chronic
Annual risk assessment of HT and DM if
diseases
any
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Review use of medications
Assess abilities on self care
and daily living
Assess social network and
carer support
End-of-life care
Assess social
network
Screen for problems related to
medication use and polypharmacy
Screen for self care Assess Basic ADL
and daily living
and Instrumental
problems
ADL
Assess the need
Screen for carer
of social and carer stress
support
End-of-life
planning if deemed
necessary
# Primary care providers should assess cognitive function whenever cognitive impairment
or deterioration is suspected.
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5.
Assessment Tools
In a busy primary care setting, it is difficult to systematically review the comprehensive
checklist for every older adult. To identify the common functional disabilities, it is
preferable to design a screening tool that is brief, easy to administer and compatible with
busy day-to-day practice yet capable of predicting which patients are likely to benefit from
more detailed assessment. A reasonable strategy at busy primary care settings is to first
administer a preliminary screening tool to detect the most characteristic sign(s) of functional
impairment that warrant for further detail assessment.
Ideally, a screening tool should have good validity and sensitivity. The tool to be
used should also be standardised to ensure consistency of performance and have
good inter-rater reliability (i.e., it will obtain the same results regardless of who is
using it). The tools described in Table 4 are based on literature review and expert
recommendations with due considerations on the suitability and applicability at
local primary care setting, but by no means exhaustive.
Upon performing the screening and assessment tools, the health care workers should be
cautious that:
They should understand the tools well and be competent in performing the assessment.
The screening tools are just complementary to and not replacing good professional
judgment.
To choose which cut-off point depends on striking the balance between sensitivity and
specificity. Patients should have in-depth assessment if there is any clinical suspicion,
even though they do not meet the cut off threshold.
They should note that there are copyright issues related to the use of some assessment
tools.
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Table 4. Recommended strategies for opportunistic screening of various functional
disabilities
Functional
Preliminary screening
disabilities
Inabilities on
Check if the patient:
self-care or daily 1. need any assistive
living
devices for walking or
2. need assistance for
daily activities of any
kinds
Fall risk
The module on
falls in elderly
has been
released in
February 2015.
Please refer to
the module for
details.
Impaired vision
Ask the patient:
1. Whether there is history
of two or more falls
within the last twelve
months?
Further evaluation and corresponding
actions
For any positive response, assess
Basic ADL and Instrumental ADL
(Annex 1).
Determine underlying causes for the
inability if any.
Explore potential for reversibility
in function and institute appropriate
medical, social or environmental
interventions if necessary.
Consider the need of rehabilitation
and further assessment if low score
in Basic ADL and Instrumental ADL.
Any positive answer to the screening
questions signifies that the person
screened is at a high risk of fall that
warrants comprehensive fall
assessment and multifactorial
intervention.
2. Whether the patient is
presented with acute fall? -
3. Whether there is presence
of clinical conditions (e.g.
stroke, Parkinson’s
disease, osteoarthritis)
that leads to either
weakness of the lower
limb, balance and/or gait
impairment?
Ask the patient,
1. ‘Do you have any visual
problems?’ OR
2. ‘Do you have difficulty
in reading or doing any
of your daily activities
because of your
eyesight?’ (even with
wearing glasses)
-
-
Balance and gait should be evaluated
in persons with history of fall or fall
risk. The Timed Up and Go Test
(Annex 2) is a frequently used test of
gait or balance.
The performance of One Leg Balance
Test can provide information on the
risk of injurious fall (Annex 3).
If any positive response, check visual
acuity by Snellen Chart (Annex 4)
together with pinhole
If patient complains of seeing line
distortion or scotoma, add Amsler
Grid Test (Annex 5).
Obtain detailed history, perform
physical examination and
investigations where appropriate
Refer to ophthalmologist for
suspected eye disease(s) in which
treatment is more complicated or
not easily available in primary care
settings
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Impaired hearing Ask the patient, ‘Do you or
your family think that you
may have hearing loss?’
-
For patients with refractive errors
but otherwise have no other eye
symptoms and signs, consider
providing advice to visit optometrist
for prescription of eyeglasses
-
If positive response, can further
assess the patient by whispered voice
test or using an audioscope (Annex 6)
If hearing impairment is suspected
and affect activities of daily living,
further clinical evaluation should be
arranged and managed as appropriate
Patients with chronic otitis media
or sudden hearing loss, or who
have their daily activities affected
by hearing impairment should be
referred to an otolaryngologist for
further assessment
If positive response, patients
should be assessed to determine
the diagnostic category as well
as underlying aetiology. This can
usually be determined on the basis
of history 6,7,8,9, physical examination
and urinary culture and microscopy
If surgery is indicated or disabling
incontinence which refractory to
conservative treatment, referral to
specialists should be considered
For any positive response, proceed
to the 15-items Geriatric Depression
Scale GDS-15 (Annex 7) or Patient
Health Questionnaire (PHQ)-9
(Annex 8)
Individuals who score 8 or more
points in GDS-15 or 5 or more points
in PHQ-9 should have full diagnostic
interviews that use standard criteria
(DSM IV) and further management
as appropriate
Patients with suicidal risk should be
managed immediately
-
-
Incontinence
Ask the patient, ‘Did
you ever lose your
urine or get wet?’
-
-
Depression
Ask the patient, ‘Over the
past 2 weeks, have you
felt down, depressed, or
hopeless?’ AND
‘Over the past 2 weeks,
have you felt little interest
or pleasure in doing things?’
(Annex 8)
Or use GDS-4 (Annex 7)
-
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
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Oral health
Ask the patient:
-
If positive response, patient should be
advised to consult a dentist as soon
as possible
1. 'Do you have any oral
The module on
discomfort and problem
Dental Health
in chewing?'
Care for Older
In addition, for institutionalized elderly,
2. 'Do you have any
Persons has
difficulty in cleaning your consider to use the Oral Health Assessment
been released in
teeth (and/or dentures)?' Tool (OHAT) (Annex 9).
December 2015.
3. 'Do you have any feeling
Please refer to
of dry mouth?'
the module for
details.
Malnutrition
Monitor body weight
and
ask for any history of
weight loss during the
past 6 months
-
-
-
-
Unintentional weight loss of 5% over
the previous 1 month or 10% over
the past 6 months should trigger for
assessment of malnutrition risk and
look for underlying causes.
Consider malnutrition assessment
tools (i.e. C-MUST, CNS or MNA)
for institutionalised older adults
(Annex 10, 11 and 12).
Consider a thorough nutritional
assessment which includes
medical history, medications
review, dietary evaluation,
oral problems, gastrointestinal
disorders, neurological disorders,
psychiatric disorders, social aspects,
anthropometry, together with initial
laboratory work up (e.g. albumin,
RFT, LFT, and CBP with lymphocyte
count) for those with high risk of
malnutrition.
Management of malnutrition in older
adults requires a multidisciplinary
approach that treats the underlying
causes, improved nutritional status
and multi-factorial intervention on
co-morbidities.
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Table 4.1 Recommended strategies for assessment of cognitive impairment
Further evaluation and
corresponding actions if
cognitive impairment is
present
Initial assessment
Primary care providers should assess cognitive
function whenever cognitive impairment or
deterioration is suspected.
The following is common clinical presentations of
cognitive impairment:
1.
Impaired ability to acquire and remember new
information as manifested by symptoms such as
repetitive questioning or conversations,
misplacing personal belongings, forgetting events
or appointments, getting lost on a familiar route.
2.
Impaired reasoning and handling of complex
functional tasks to an extent that it interferes with
everyday activities e.g. inability to manage
finances, poor decision-making ability, inability
to plan complex or sequential activities.
3.
Language impairment e.g. having difficulty
thinking of common words while speaking,
hesitations or speech, spelling, and writing errors.
4.
Decline in emotional control or motivation e.g.
emotional lability, irritability, loss of empathy,
loss of drive, social withdrawal, decreased interest
in previous activities.
5.
Change in personality and behaviour e.g.
coarsening of social behaviours.
6.
Impaired visuospatial abilities e.g. inability to
recognize faces or common objects or to find
objects in direct view despite good visual acuity,
inability to operate simple instruments or orient
clothing to the body.
- Perform Abbreviated Mental
Test (Annex 13), Mini-Cog
Test (Annex 14) or MiniMental State Examination
(MMSE)10 #
- MMSE has additional benefit
in assessing the severity of
dementia #
- Conduct appropriate
investigations to rule out
potentially reversible causes
- Referral to neuroimaging and
specialist should be arranged
according to the results of
clinical assessment
It should be noted that
MMSE is under copyright
protection; permission for use
at a cost would be required.
#
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6. Information to Patients and Carers
Involving the individual and the carer in the care planning process is important, because an
engaged patient and carer is more likely to manage various health conditions effectively.
Therefore, alongside all of the steps mentioned in Chapter 3, attention also needs to be given
to:
Provide sufficient information to patients and their carers on their health status to
facilitate shared decision-making and have open discussions about preventive care
options.
Empower the patients such that they can have sufficient confidence on self-care
Psychological support for carers and families
Explore appropriate social resources for the patients and their carers
Details on practical information related to health care of older adults can be found in Annex
3 of the Core Document.
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Annex 1.
Assessment on activities of daily living
Barthel Index of Independence in Activities of Daily Living (ADL) refers to basic self-care
activities that a person performs daily (e.g., eating, dressing, bathing, transferring, using the
toilet, controlling bladder and bowel functions). Inability to independently perform even
one activity may indicate a need for supporting services (Table 5).
Complex daily tasks are assessed by Instrumental Activities of Daily Living (IADL), and
Lawton’s version is commonly used in local setting. Lawton’s Instrumental Activities of
Daily Living refers to activities that are needed to live independently (e.g., doing housework,
preparing meals, taking medications properly, managing finances, using a telephone). IADL
are associated with independent living in the community and provide a basis for considering
the type of services necessary in maintaining independence. The Chinese Lawton IADL
with 3 point scale can be an option for local primary care settings, though the cut-off scores
have yet to be established (Table 6).
Deficits in ADL and IADL11,12 restrict older adults to live independently in the community,
and signal the need for more in-depth evaluation of the individual’s socio-environmental
circumstances and the need for additional assistance.
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Table 5. The Barthel Index of Activities of Daily Living 13, 14, 15
The Barthel Index
Bowels
Transfer
0 = incontinent (or needs to be given enemata) 0 = unable – no sitting balance
1 = occasional accident (once/week)
1 = major help (one or two people,
2 = continent
physical), can sit
Patient’s Score:_______________________
2 = minor help (verbal or physical)
3 = independent
Bladder
Patient’s Score:
0 = incontinent, or catheterized and unable to
manage
Mobility
1 = occasional accident (max. once per 24
0 = immobile
hours)
1 = wheelchair independent, including
2 = continent (for over 7 days)
corners, etc.
Patient’s Score:_______________________
2 = walks with help of one person (verbal
or physical)
Grooming
3 = independent (but may use any aid, e.g.,
0 = needs help with personal care
stick)
1 = independent face/hair/teeth/shaving
Patient’s Score:
(implements provided)
Patient’s Score: _______________________
Dressing
0 = dependent
Toilet use
1 = needs help, but can do about half
0 = dependent
unaided
1 = needs some help, but can do something
2 = independent (including buttons, zips,
alone
laces, etc.)
2 = independent (on and off, dressing, wiping) Patient’s Score:
Patient’s Score:_______________________
Stairs
Feeding
0 = unable
0 = unable
1 = needs help (verbal, physical, carrying
1 = needs help cutting, spreading butter, etc.
aid)
2 = independent (food provided within reach) 2 = independent up and down
Patient’s Score: _______________________
Patient’s Score:
Bathing
0 = dependent
1 = independent (or in shower)
Patient’s Score:
Source: Modified version adapted with permission from Collin et al. (1988)
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Instructions: Choose the scoring point for the statement that most closely corresponds to
the patient’s current level of ability for each of the 10 items. Information can be obtained
from the patient’s self-report, from a separate party who is familiar with the patient’s
abilities (such as a relative), or from observation.
Scoring: Sum the patient’s scores for each item. Total possible scores range from 0 – 20,
with lower scores indicating increased disability. If used to measure improvement after
rehabilitation, changes of more than two points in the total score reflect a probable genuine
change, and change on one item from fully dependent to independent is also likely to be
reliable.
Guidelines for the Barthel Index of Activities of Daily Living
General
•
The Index should be used as a record of what a patient does, NOT as a record of what a
patient could do.
•
The main aim is to establish degree of independence from any help, physical or verbal,
however minor and for whatever reason.
•
The need for supervision renders the patient not independent.
•
A patient’s performance should be established using the best available evidence. Asking
the patient, friends/relatives, and nurses will be the usual source, but direct observation
and common sense are also important. However, direct testing is not needed.
•
Usually the performance over the preceding 24 – 48 hours is important, but occasionally
longer periods will be relevant.
•
Unconscious patients should score ‘0’ throughout, even if not yet incontinent.
•
Middle categories imply that the patient supplies over 50% of the effort.
Bowels (preceding week)
•
If needs enema, then ‘incontinent.’
•
‘Occasional’ = once a week.
Bladder (preceding week)
•
‘Occasional’ = less than once a day.
•
A catheterized patient who can completely manage the catheter alone is registered as
‘continent.’
Grooming (preceding 24 – 48 hours)
•
Refers to personal hygiene: doing teeth, fitting false teeth, doing hair, shaving, washing
face. Implements can be provided by helper.
Toilet use
•
Should be able to reach toilet/commode, undress sufficiently, clean self, dress, and
leave.
•
‘With help’ = can wipe self and do some other of above.
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Feeding
•
Able to eat any normal food (not only soft food). Food cooked and served by others,
but not cut up.
•
‘Help’ = food cut up, patient feeds self.
Transfer
•
From bed to chair and back.
•
‘Dependent’ = No sitting balance (unable to sit); two people to lift.
•
‘Major help’ = one strong/skilled, or two normal people. Can sit up.
•
‘Minor help’ = one person easily, OR needs any supervision for safety.
Mobility
•
Refers to mobility about house or ward, indoors. May use aid. If in wheelchair, must
negotiate corners/doors unaided.
•
‘Help’ = by one untrained person, including supervision/moral support.
Dressing
•
Should be able to select and put on all clothes, which may be adapted.
•
‘Half’ = help with buttons, zips, etc., but can put on some garments alone.
Stairs
•
Must carry any walking aid used to be independent.
Bathing and Showering
•
Usually the most difficult activity.
•
Must get in and out unsupervised, and wash self.
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Table 6. Chinese Lawton Instrumental Activities of Daily Living Scale (3 point Scale) 16
日常家居及社區活動能力評估
Item
Score
1 “你能唔能夠自己用電話號碼呢 ?” 包括找電話號碼 , 打及接聽電話
2
不需要任何幫助
1
需要一些幫忙
0
完全不能自己做
2 “你能唔能夠自己搭車呢 ?” 包括自己上到正確的車 , 俾車錢 / 買車票 ,
上 / 落車
( 假設你必須要搭交通工具去一個遠的地方 , 例如探朋友 / 睇醫生 )
不需要任何幫助
2
需要一些幫忙
1
完全不能自己做
0
3 “你能唔能夠自己買嘢呢 ?” 包括自己揀貨品 , 俾錢及攞番屋企
( 假設你必須要到附近商店買食物或日用品 )
不需要任何幫助
需要一些幫忙
完全不能自己做
4 “你能唔能夠自己煮食呢 ?” 包括自己諗食乜 , 準備材料 , 煮熟食物及放
入碗碟裡
( 假設你必須要自己準備兩餐 )
不需要任何幫助
需要一些幫忙
完全不能自己做
5 “你能唔能夠自己做家務呢 ?” 包括簡單家務 ( 如抹檯 , 執床 , 洗碗 ) 及
較重的家務 ( 如抹地 / 窗 )
( 假設你必須要自已做家務 )
不需要任何幫助
需要一些幫忙
完全不能自己做
6 “你能唔能夠應付簡單的家居維修呢 ?” 例如換燈泡 , 維修檯及上緊螺絲等
( 假設你必須要自已做 )
不需要任何幫助
需要一些幫忙
完全不能自己做
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
2
1
0
2
1
0
2
1
0
2
1
0
Module on Health Assessment
7 “你能唔能夠自己洗衫呢 ?” 包括清洗及曬自己的衫 , 被 , 床單等
( 假設你必須要洗自己的衫 , 被 , 床單等 )
不需要任何幫助
需要一些幫忙
完全不能自己做
8 “你能唔能夠自己服用藥物呢 ?” 包括能依照指示在正確的時間內服用
正確的份量
( 假設你必須要自已查藥油或食藥等 )
不需要任何幫助
需要一些幫忙
完全不能自己做
9 “你能唔能夠處理自己的財務呢 ?” 包括日常錢銀的找續 , 交租 / 水電費
及到銀行提款
( 假設你必須要買嘢 , 自己交租 / 水電費及有將錢放在銀行 )
不需要任何幫助
需要一些幫忙
完全不能自己做
總分
2
1
0
2
1
0
2
1
0
/18
Source: Chinese version adapted with permission from Tong & Man (2002)
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Annex 2.
Timed Up and Go Test 17, 18, 19, 20
Instructions:
1. Begin the test with the patient sitting correctly in a standard arm chair (approximate
seat height of 46 cm), the patient’s back should rest on the back of the chair. The chair
should be stable and positioned such that it will not move when patient moves from
sitting to standing.
2.
Mark on the floor 3 metres away from the chair so that it is easily seen by the patient.
3.
Ask the patient to perform the following series of manoeuvres:
Rise from the chair
Walk at regular pace for 3 metres to the mark on the floor, customary walking aid
is allowed
Turn around and walk back to the chair
Sit down in the chair
4.
Start timing when patient rise from the chair and stop timing when the patient is seated
again correctly in the chair.
5.
The patient may use any walking aid that is usually used during ambulation, but may
not be assisted by another person.
The patient can be given a practice trial that is not timed before testing.
6.
Interpretation:
Balance and gait should be evaluated in persons with history of fall or fall risk. The Timed
Up and Go Test (TUG) is a frequently used test of gait or balance. The Timed Up and Go
Test is to measure the time to rise from the chair, walk at regular pace for 3 metres, turn
around and walk back to the chair and finally sit down. Cut off values for fall risk are
variable in literatures, which may reflect different subjects characteristics and
methodologies. The cut off value of 14 seconds is conventionally adopted to discriminate
fallers and non-fallers in healthy, highly functional older people. On the other hand, in frail
elderly, a time score of less than 20 seconds identifies elderly people who are independently
mobile while more than 30 seconds indicates a need of assistance for mobility task. TUG
should be considered together with other relevant factors (e.g. medical and drug history,
physical assessment, circumstances of the fall) to identify individuals at high risk of falls.
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Annex 3.
One Leg Balance Test 21, 22
It has been recognized that balance impairment leads to recurrent falls. One-leg balance is a
simple clinical static balance test in which a subject is asked to stand unassisted on one leg.
Impaired One Leg Balance Test is defined as being unable to stand on one leg for 5 seconds
and has been identified as a predictor of injurious falls in community-dwelling older adults.
Procedures:
1) Patient is asked to choose a leg to stand on (whichever the patient feel more
comfortable with)
2) Flex the opposite knee allowing the foot to clear the floor, and balance on one leg as
long as possible
3) The assessor records whether the patient is able to balance for 5 seconds
Older adult who is unable to stand ≥5 seconds would be considered as impaired One Leg
Balance.
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Annex 4. Measurement of Visual Acuity (VA)
using a 6-metres Snellen Chart 23, 24, 25, 26
Equipments:
1. 6 metres (20 feet) visual acuity (VA) chart (e.g. Snellen’s E Chart)
2. Pointer
3. Occluder
4. Pinhole
Procedure:
1 Test the patient’s right eye by covering the left eye (always test the right eye first)
2 Instruct and encourage the patient to read the VA chart until the smallest line possible
3 If the patient is able to read more than half of the letters on a particular line, instruct him/
her to try reading the next line (with smaller letters) before determining the best VA
4 If more than half of all the smallest letters of a line can be read correctly, record the VA
of that particular line, minus the number of letters missed in that line. Examples: If 3
out of 5 of the letters of the 6/6 line can be read correctly, record VA as 6/6-2. If 4 out of
5 of the letters of the 6/7.5 line can be read correctly, record VA as 6/7.5-1
5 If less than half of the all the letters of a line can be read correctly, record the VA of the
previous line (with bigger letters)
6 If the patient is unable to achieve an acceptable VA (i.e. 6/12 or better), recheck the VA
with a pinhole. If the VA improves with pinhole, record the best VA with pinhole.
Record method:
7
VA (= Visual Acuity)
PH (= Pinhole)
Rt 6/30
Rt 6/30
Lt 6/60
Lt 6/30
Repeat the same procedures for left eye by covering the right eye
Points to note:
1 Ensure there is sufficient illumination on the visual acuity (VA) chart (e.g. use a well-lit
room)
2 Ensure the chart is at the same eye level of the patient
3 Position the patient at the appropriate distance from the VA chart. If there is limited
space, a mirror should be used with the distance reduced to half
4 Pinhole test is a quick way to distinguish between impaired vision due to uncorrected
refractive errors and other ocular pathology. The pinhole focuses light and temporarily
removes the effects of refractive errors such as myopia, hyperopia and astigmatism.
Refractive error is likely when the VA is improved with pinhole test. However, it
should be noted that studies (Rabbetts (2000); and Eagan et al. (1999)) have shown that
the pinhole test has some limitations, such as its being affected by imprecise positioning
and its being prone to errors due to luminance effects.
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5
6
Record method:
5.1 The numerator is the test distance and the denominator is the distance that a
person with normal vision can see that particular line. Example: 6/30 means a
patient can only see the letters of a line at 6 metres whereas a person with normal
vision can see the same letters at 30 metres.
5.2 If the patient cannot read one letter from a line, represent it using a minus sign.
Example: 6/30-1 means there is a letter cannot be read from that line
5.3 If the patient has refractive error, he/she should wear the glasses for the testing,
and ‘with glasses’ should state in the record
5.4 Normal vision: 6/6
5.5 VA can also be expressed as a decimal that is equal to the numeric value of the
Snellen fraction so 6/6 would become 1.0 and 6/12 would be 0.5.
Sometimes VA is recorded in other notations e.g. logMAR. LogMAR stands for
Minimum Angle of Resolution which can be converted to a Snellen fraction for
comparison.
Table 7. Different VA measurement systems
LogMAR
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Snellen 20ft
20/200
20/160
20/125
20/100
20/80
20/63
20/50
20/40
20/32
20/25
20/20
Snellen 6m
6/60
6/48
6/38
6/30
6/24
6/20
6/15
6/12
6/10
6/7.5
6/6
Decimal
0.10
0.125
0.16
0.20
0.25
0.32
0.40
0.50
0.63
0.80
1.00
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Annex 5.
Amsler Grid Test 27
The Amsler grid is a grid of horizontal and vertical lines with a central dot used to assess
a person's central visual field. Amsler Grid Test has been used to screen for age-related
macular degeneration (AMD), and although specific, it is relatively insensitive in detecting
a variety of ocular problems. Studies have shown that the sensitivity of Amsler Grid Test
for the detection of AMD varies from 9% in early AMD to 34% in late AMD. Although
the Amsler Grid Test has the benefit of being inexpensive and easily used, the high false
negative rate means that great care must be taken in interpreting a negative result. Therefore
it is suggested to use Amsler Grid Test as a diagnostic tool that aids in the detection of visual
disturbances caused by changes in the macula instead of using it as a screening tool.
Instructions:
The patient should wear single vision reading glasses if any
Patient should stand a distance of 30cm from the chart, with one eye covered
Ask the patient to focus on the central dot
Ask if all four corners and all four sides of the chart are seen
Ask if there are any areas of the chart that are missing or distorted in any way and are
any of the lines not straight or unequal in size
Repeat the procedure with another eye
Amsler grid, as seen by a person with
normal macula function
Amsler grid, as viewed by a person with age
related macular degeneration
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Annex 6.
Whispered voice test and audioscope 28, 29
The whispered voice test has a sensitivity of 87-96% and a specificity of 70-90% for
detecting hearing loss. One systematic reviewed showed that whispered voice test is a
simple and accurate test for detecting hearing impairment. However there is some concern
regarding the overall reproducibility of the test, particularly in primary care settings.
Attempts to standardize the test have been made (e.g., by whispering only after full
expiration), but there is no reliable way to control the loudness of the whispers, and robust
descriptions of inter-observer variability and test-retest reliability are lacking. Therefore, the
results of whispered voice test should be interpreted with caution and should be correlated
with patient’s clinical conditions.
Conducting the whispered voice test
1.
2.
3.
4.
5.
6.
7.
The examiner stands arm's length (0.6 metre) behind the seated patient and whispers
a combination of numbers or letters (for example, one-two-three) and then asks the
patient to repeat the exact sequence
The examiner should quietly exhale before whispering to ensure as quiet a voice as
possible
If the patient responds incorrectly, the test is repeated using a different combination
of numbers or letters
The patient is considered to have passed the screening test if they repeat at least three
out of a possible six numbers or letters correctly
The examiner should stand behind the patient to prevent lip reading
Each ear is tested individually, starting with the ear with better hearing, and during
testing the non-test ear is masked by gently occluding the auditory canal with a finger
and rubbing the tragus in a circular motion
The other ear is assessed similarly with a different combination of numbers or letters
Audioscope
The audioscope, a hand-held device, is held directly in the external auditory canal with a
probe tip sealing the canal.
Tones are presented at each frequency (i.e., delivers a 25- to 40-dB pure tone at 500 Hz,
1000 Hz, 2000 Hz, and 4000 Hz), and the patient is asked to indicate whether he or she can
hear the tone.
Patients unable to hear a predetermined series of tones may then be referred for formal
audiometric assessment.
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Annex 7.
Geriatric Depression Scales 30, 31, 32, 33
A) Geriatric Depression Scale 15-item Cantonese Version (GDS-15)
老人抑鬱短量表 (GDS-15) – 廣東話口語化版本
在施行此短量表時，先說出題目的口語化版本“問 <1>”，若在個別題目中 , 受試者
對於問題內容未能掌握清楚，或在評分方面出現問題，則需依次序讀出“問 <2>”。
個別較難理解的題目，則設有“問 <3> ”。給受試長者未能掌握“問 <2>”的意思，
則需讀出“問 <3> ”。
評分方法：請依照每條題目的評分方法，給予該題目分數。受試者在短量表的總分是
１５條題目的分數總和（即最多是１５分）。在個別題目中，如受試者最終未能掌握
題目內容，或未能給予確實答案，則不用給予任何分數。為統一填寫短量表總分的格
式，可參考下列方法：
受訪者所得分數
受訪者最終能回答的題目總數
例一：12/15 即受試者回答所有題目並 15 題 (15)，總分則為 12 分 (12)
例二：12/13 即受試者最終只能回答 13 題 (13)，總分則為 12 分 (12)
( 總分≧ 8 指示有抑鬱的傾向 )
1. 你基本上對自己的生活感到滿意嗎？
問 <1>: 喺上個禮拜裏面，你滿唔滿意自己嘅生活呢？
如受試者說“都冇乜滿意唔滿意”或類似的意思，請
問 <2>: 咁你係滿意多啲，抑或唔滿意多啲呢？
答案
是 / 滿意
否 / 不滿意
滿意多啲
唔滿意多啲
問 <1>
問 <2>
給予分數
0分
1分
0分
1分
2. 你是否已放棄了很多以往的活動和嗜好？
問 <1>: 喺上個禮拜裡面，你有冇放棄好多以前嘅活動或者嗜好呢？
如受試者未能掌握問題內容，請
問 <2>: 喺上個禮拜裡面，好多以前你鍾意做嘅嘢，係咪已經冇做啦？
如受試者說他從來沒有興趣或者嗜好，請
問 <3>: 咁喺上個禮拜裡面，你喺朝早或日頭有冇啲嘢做吓？
例如 : 晨運、落街行吓，同人傾吓偈，或者響屋企做吓家務呢 ?
問 <1> 及問 <2>
問 <3>
答案
給予分數
是
1分
否
0分
可由受試者自由說出答案，如受試者答案的意思是他仍然有參予
一些活動，不論是多或少，在這條問題上給予”0”分，否則給
予 “1”分。
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
3. 你是否覺得生活空虛？
問 <1>: 喺過去呢個禮拜裏面，你係咪覺得生活空虛呢？
如受試者未能掌握問題，請
問 <2>: 喺上個禮拜裏面，你係咪覺得做人都幾百無聊賴呢？
答案
給予分數
問 <1> 及問 <2>
是
1分
否
0分
4. 你是否常常感到煩悶？
問 <1>: 喺上個禮拜裏面，你係咪成日覺得好煩悶呀？
問 <1>
答案
是
否
給予分數
1分
0分
5. 你是否很多時感到心情愉快呢？
問 <1>: 你上個禮拜心情係咪成日都咁好呢？
如受試者說“冇乜好唔好”或“都喺咁上下” 之類的說話，請
問 <2>: 咁你上個禮拜，係開心嘅時候多啲，定係唔開心嘅時候多啲呢？
問 <1>
問 <2>
答案
是
否
開心多啲
唔開心多啲
給予分數
0分
1分
0分
1分
6. 你是否害怕將會有不好的事發生在你身上呢？
問 <1>: 喺上個禮拜裏面，你有無擔心有啲唔好嘅嘢會發生喺你身上呢？
答案
給予分數
問 <1>
有
1分
冇
0分
7. 你是否大部份時間感到快樂呢？
問 <1>: 喺上個禮拜裏面，你係咪成日都覺得開心呀？
如受試者說“都冇乜開心唔開心”或者“一半一半啦”之類的說話，請
問 <2>: 咁你喺上個禮拜裏面，係開心多啲，抑或唔開心多啲呢？
問 <1>
問 <2>
答案
是
否
開心多啲
唔開心多啲
給予分數
0分
1分
0分
1分
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
8. 你是否常常感到無助？
問 <1>: 喺上個禮拜，你有冇覺得無論做乜嘢，都係冇用呢？
如受試者未能掌握問題”，請
問 <2>: 喺上個禮拜，你有冇覺得無論做乜嘢，都係無補於事呢？
問 <1> 及問 <2>
答案
是
否
給予分數
1分
0分
9. 你是否寧願留在院舍 / 屋企裏，而不出外做些有新意的事情？
問 <1>: 喺上個禮拜裏面，你喺咪寧願留低響老人院 / 屋企，都唔想落街做啲有新
意嘅事呢？
如受試者未能掌握問題，請
問 <2>: 喺上個禮拜裏面，你喺咪寧願留低響老人院 / 屋企，都唔想落街做啲特別
嘅事情呢？
如受試者說從來都不喜歡落街或類似的答案，或受試者表示想過但沒有精
力，請
問 <3>: 咁你上個禮拜其實想唔想落街行吓，做啲你平時少做嘅嘢呢？
問 <1> 及問 <2>
問 <3>
答案
是
否
想
唔想
給予分數
1分
0分
1分
0分
10. 你是否覺得你比大多數人有多些記憶的問題呢？
問 <1>: 喺上個禮拜裏面，你有冇覺得你嘅記性比其他老人家差呢呢？
如受試者說“我點知佢哋啲記性好唔好呢？”或“唔識去同人比較”之類
的說話，請
問 <2>: 咁比起兩三個禮拜前，你上個禮拜記性有冇差到呢？
問 <1> 及問 <2>
答案
有
冇
給予分數
1分
0分
11. 你認為現在活著是一件好事嗎？
問 <1>: 喺上個禮拜裏面，你有冇覺得做人係一件好事呢？
如受試者未能掌握問題，請
問 <2>: 喺上個禮拜裏面，你覺得做人係有意思嘅，係唔係呢？
問 <1> 及問 <2>
答案
是/有/係
否 / 冇 / 唔係
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
給予分數
0分
1分
Module on Health Assessment
12. 你是否覺得自己現在一無是處呢？
問 <1>: 喺上個禮拜裏面，你係咪覺得自己好無用呢？
如受試者說“都無乜所謂啦”或“都唔識分有用同冇用”，請
問 <2>: 喺上個禮拜裏面，你有冇覺得自己完全冇用呢？
問 <1> 及問 <2>
答案
是
否
13. 你是否感到精力充足？
問 <1>: 喺上個禮拜，你係咪覺得精力充沛呢？
如受試者未能掌握問題，請
問 <2>: 喺上個禮拜，你係咪好夠精力呢？ 或
喺上個禮拜，你係咪好夠精神呢？
答案
問 <1> 及問 <2>
是
否
給予分數
1分
0分
給予分數
0分
1分
14. 你是否覺得自己的處境無望？
問 <1>: 喺上個禮拜裏面，你有無覺得你嘅處境係無晒希望呢？
問 <1>
答案
是
否
給予分數
1分
0分
15. 你覺得大部份的人的境況比自己好嗎？
問 <1>: 喺上個禮拜裏面，你係咪覺得大部份人嘅情況都好過你呢？
問 <1>
答案
是/係
否 / 唔係
給予分數
1分
0分
Source: Chinese version adapted with permission from Wong et al. (2002)
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
B) Geriatric Depression Scale 4-item Cantonese Version (GDS–4)
4-items Geriatric Depression Scale (GDS-4) has been shown to be an excellent alternative to
GDS 15. With the cut-off point of 2 or more, it has the sensitivity of 76% and specificity of
65% in the age group 60 to 74. In the group aged 75 years or more, it has the sensitivity of
60% and specificity of 81%.
The Cantonese version is specially designed for Cantonese-speaking Chinese. For each
question, an alternate version <2> is provided in case the respondent finds question <1>
difficult to understand or answer; <2> is used only when <1> fails to obtain an answer.
Responses scored 1 point are boldfaced and underlined; otherwise, a score of zero is given.
Total scores ≥2 are considered elevated (i.e., probably clinically depressed).
以下的問題是人們對一些事物的感受，答案是沒有對與不對。請想一想，在過去
一星期內，你是否曾有以下的感受。如有的話，請圈「是」，若無的話，請圈
「否」。
問 <1> 你上個禮拜心情係咪成日都咁好呢？
問 <2> 咁你上個禮拜，係開心時候多啲，定係唔開心時候多呢？
問 <1> 喺上個禮拜裡面，你喺咪成日行唔安坐唔定？
問 <2> 喺上個禮拜裡面，你喺咪成日覺得囉囉攣，冇辦法靜落嚟？
問 <1> 喺上個禮拜裡面，你有無覺得做人係一件好事呢？
問 <2> 喺上個禮拜裡面，你覺得做人係有意思嘅，係唔係呢？
問 <1> 喺上個禮拜裡面，你喺咪成日都悶悶不樂？
問 <2> 喺上個禮拜裡面，你喺咪覺得好似依個世界冇嘢可以令自己
開心咁？
是/否
0/1
是/否
1/0
是/否
0/1
是/否
1/0
備註：如得分是 2 分或以上，須進一步評估長者的情緒狀況
Geriatric Depression Scale, 4-item Chinese Version
This is the version before the Cantonese version was developed. This version does not
contain an alternate question.
1.
2.
3.
4.
你是否大部份時間都感到心情愉快呢？
你是否整天也覺得煩躁和坐立不安？
你認為現在活著是一件好事嗎？
你感到情緒低落嗎？
Source: Chinese version adapted with permission from Cheng & Chan (2004)
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
Annex 8. Patient Health Questionnaire (PHQ)34, 35, 36
A)
Patient Health Questionnaire (PHQ)-9
The Patient Health Questionnaire (PHQ) was primarily developed for use in primary care
setting and has shown good validity with overall accuracy of 85%, sensitivity of 75%
and specificity of 90%). The Chinese version of PHQ-9 has been translated using an
internationally accepted translation methodology and have been validated locally. The
PHQ-9 scoring system can be used for disease severity stratification and monitoring. The
change of symptom frequency and severity can be reflected by the change of scores, and
thus it can also be used to monitor the change of depressive symptoms with treatments.
在過去兩個星期 , 你有多經常受以下問題困擾 ?
完全
沒有
( 請用「√」勾選你的答案 )
1.
2.
3.
4.
5.
6.
做任何事都覺得沉悶或者根本不想做任何事
情緒低落、抑鬱或絕望
難於入睡；半夜會醒或相反地睡覺時間過多
覺得疲倦或活力不足
胃口極差或進食過量
不喜歡自己 - 覺得自己做得不好、對自己失望或有
負家人期望
7. 難於集中精神做事，例如看報紙或看電視
8. 其他人反映你行動或說話遲緩 ; 或者相反地，
你比平常活動更多─坐立不安、停不下來
9. 想到自己最好去死或者自殘
0
0
0
0
0
0
一半
幾天 以上的 近乎
天數 每天
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
0
0
1
1
2
2
3
3
0
1
2
3
(1-9 題 ) 總分 : _______________________
Scoring
Normal
0–4
Mild
5–9
Moderate
10 – 14
Moderately severe
15 – 19
Severe
≧ 20
Source: Reproduced with permission from Pfizer Inc. Copyright ©1999 Pfizer Inc.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
B)
Patient Health Questionnaire (PHQ)-2
The PHQ-2 includes the first two items of the PHQ-9.
在過去兩個星期 , 你有多經常受以下問題困擾 ?
完全
沒有
1. 做任何事都覺得沉悶或者根本不想做任何事
2. 情緒低落、抑鬱或絕望
0
0
一半
幾天 以上的 近乎
天數 每天
1
2
3
1
2
3
Source : Reproduced with permission from Pfizer Inc. Copyright © 1999 Pfizer Inc.
The PHQ-2 has the advantage of easy to administer, training time is minimal and subject
acceptance is high. The purpose of PHQ-2 is not to establish diagnosis or to define severity,
but rather to screen for depression in a “first step” approach. As a screening tool, the PHQ-2
has similar performance to the PHQ-9 in identifying older adults with depression. A PHQ-2
score of 3 or more has a sensitivity of 84% and a specificity of 90% for a major depression.
Patients with positive screen for PHQ-2 should be further evaluated by PHQ-9 or other
validated tools.
Scores for PHQ-2 range from 0-6. A cut-off score of 3 or above is recommended for
screening purpose of PHQ-2.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
Annex 9.
Oral Health Assessment Tool
入院初次評估
口腔健康評估
院友姓名：
入院後評估
牙齒 / 口腔狀況及清潔度：
上顎真牙
下顎真牙
上牙托
下牙托
項目
0 ＝正常
＊如以下有「不清潔」的項目，請通知前線護 日期 ：
理員加密清潔。
有 沒有
( 如有 ) : 清潔 不清潔
日常口腔 牙齒清潔：
可自行清潔
有 沒有
( 如有 ) : 清潔 不清潔
有 沒有
( 如有 ) : 清潔 不清潔
可自行清潔，但需要護理員協助
有 沒有
( 如有 ) : 清潔 不清潔
不能自理，需要護理員幫助清潔
1 ＝輕微變化
假牙狀況 • 沒有破損
•
• 很多時都有戴
上
•
• 假牙有標上名
字
•
口唇
• 光滑，淺紅色， •
•
濕潤
舌頭
•
口腔唾液 •
牙肉和口 •
腔黏膜
•
牙齒狀況 •
2 ＝不健康
假牙只有一個破損 •
部位
只在進食 / 儀容需要 •
時戴上
假牙沒有標上名字
乾，皺，咀角紅 / 損 •
有 白 / 紅 斑， 流 血
或 損傷情況少於三
星期
•
有 正 常 的 紋 • 有深紋
理， 淺 紅 色， • 有白 / 紅斑，或損傷
情況少於三星期
濕潤
組 織 濕 潤， 唾 • 組織乾涸有黏性
•
液似水般可自
由流動
淺 紅 色， 有 輕 • 乾， 光 滑， 瘀 紅 色 •
微 紋 理， 有 彈
或腫脹
性
• 有 白 / 紅 斑， 有 牙
假牙底下的牙
瘡， 流 血 或 損 傷 情 •
況少於三星期
肉應該是淺紅
• 假牙底下的牙肉有
色和光滑
紅色或損傷情況少
於三星期
沒 有 蛀 爛 的 牙 • 1-3 隻蛀爛的牙齒或 •
齒或牙腳
牙腳
•
假牙多於一個破損
部位
假牙遺失 / 從不戴
上
評分 跟進
牙醫記錄
( 由牙醫填寫 )
1 ＝特別
護理
2 ＝轉介
有 白 / 紅 斑， 流 血
或 損傷情況多過三
星期
紅， 光 滑， 有 白 /
紅斑，或損傷情況
多過三星期
組 織 乾， 紅， 沒 有
唾液分泌
有 白 / 紅 斑， 有 牙
瘡，流血或損傷情
況多過三星期
假牙底下的牙肉有
紅色或損傷情況多
過三星期
牙醫姓名 :
________________
檢查日期 :
________________
多過 3 隻蛀爛的牙
1或2＝
齒或牙腳
轉介
上，下顎任何一方
少於 4 隻牙齒而沒
有配帶假牙
牙齒 / 口腔 • 沒 有 行 為 上 或 • 有 提 及 牙 痛 或 有 行 • 面部有異常腫脹
痛楚
語言表達痛楚
為 上 表 達 痛 楚， 例 • 加上有提及牙痛或
• 面部沒有異常
如拒絕進食
有行為上表達痛
腫
楚，例如拒絕進食
總結跟進
下次評估日期：
通知前線護理員進行特別護理
_________________________
轉介牙科醫生
負責人姓名：_____________
Source: Adapted from Dental Unit, Department of Health
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
Annex 10. Malnutrition Universal Screening Tool
for Hong Kong Chinese (HKC-MUST)
The Malnutrition Universal Screening Tool aims at detect under nutrition on the basis
of knowledge about the association between impaired nutritional status and impaired
function37. It was primarily developed for use in the community, where serious confounders
of the effect of under nutrition are relatively rare38. It was demonstrated to have high
reliability and good concurrent and predictive validity.
Malnutrition Universal Screening Tool for Hong Kong Chinese (HKC-MUST)
*BMI score is set according to Asian data for reference.
The Malnutrition Universal Screening Tool (MUST) is adapted / reproduced here with the kind permission of BAPEN (British
Association for Parenteral and Enteral Nutrition)
Source of reference: BAPEN2003 (http://www.bapen.org.uk) and Hospital Authority Co-ordinating Committee-Grade (Dietetics)
2007 June authentication
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
Annex 11. Chinese Nutrition Screening Tool
(CNS)39
The Chinese Nutrition Screening (CNS) is a useful screening tool to detect the risk of
malnutrition for the institutionalised Chinese older adults. It is particularly useful when
biochemical and anthropometric data are not available which is common in old aged home
settings. It is more likely to identify risk of malnutrition at an early stage since it also
includes physical and mental aspects that frequently affect the nutritional status of the
elderly40. It was validated locally and by using the cut-off point of 21, it has a sensitivity
of 60.9% and specificity of 72.9% with a negative predictive value of 92.3% and a positive
predictive value of 25.8% for malnutrition41.
A.
B.
C.
D.
Chinese Nutrition Screening Tool (CNS)
In the past three months, has there been any change in food intake?
0 = serious loss of appetite
1= appetite decreased, but not seriously
2= no change in appetite
3 = appetite has improved
Ask the patient
In the past three months, have you eaten more or less than usual?
If less, is it a lot less, or only slightly less?
In the past three months, has there been a change in body weight?
0 = body weight decreased
1= no change in body weight
2 = body weight increased
Ask the patient
In the past three months, has your body weight increased or decreased?
Have your clothes felt tighter or looser?
Has your weight kept the same, unchanged?
Patient’s activity level
0 = can only lie in bed or sit in wheelchair
1 = can transfer from bed and sit in wheelchair, but unable to go out
2 = can go out
Ask the patient
Can you transfer from bed and sit in wheelchair?
Can you go out?
In the past three months, have you suffered from acute illness?
0 = yes
1 = no
Ask patient, medical or nursing staff, or check medical record
Score
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
E. Are you happy?
0 = very unhappy
1 = unhappy
2 = reasonably happy
Ask patient, medical or nursing staff or check medical record
Ask patient: Do you have relatives or friends who pass away recently?
Have you recently moved house or moved into an old age home?
F. Do you live alone?
0 = yes
1 = no
This question refers to normal living condition, not the current status when
people are staying in hospital or old age home
G. Do you have to take five or more medication a day?
0 = yes
1 = no
H. Does the patient have pressure sore, inflamed skin or skin ulcer?
0 = yes
1 = no
Ask patient, medical or nursing staff or check medical record
I. How many meals do you have in a day?
0 = one
1 = two
2 = three or more
Ask patient, medical or nursing staff, or check medical record
A meal is defined to be two or more food items eaten by patient sitting down
J. In the past week, have you taken the following food?
1. one portion of milk (or milk powder), cheese, ice cream, yogurt or egg
0 = one portion or less
1 = two to three portions
2 = four portions or more
2. One portion of bean, bean soup, soya bean curd, soya milk
0 = one portion or less
1 = two or three portions
2 = four portions or more
3. One portion of meat, fish or poultry (chicken, duck, geese, pigeon)
0 = one portion or less
1 = two to three portions
2 = four portions or more
One portion of food is equivalent to one glass or 250ml of milk, one piece of
cheese, one egg, or half bowlful.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
K. In the past week, have you taken the following food?
One portion of fresh fruit or fresh fruit juice
0 = one portion or less
1 = two to three portions
2 = four portions or more
One portion is equivalent to one fresh fruit or 250ml of fruit juice
L. In one day, how much liquid food do you drink (water, fruit juice, soup, congee,
soft drink)?
0 = three portions or less
1 = four to five portions
2 = six portions or more
One portion is equivalent to one glass or 250ml of milk or one bowlful.
M. Patient’s feeding status
0 = need assistance
1 = can self feed with difficulty, may need some assistance
2 = self feed independently
N. How do you rate your health as compared with people of your age?
0 = worse, not too good
1 = the same
2 = better
If there is suitable equipment and patient is able to stand to have height measured,
please answer the following question:
O. Patient’s body mass index:
0 = <16
1 = >16
Total Score (max = 32 points)
Malnutrition Indicator Score
≤21: at risk of malnutrition
≥22: well nourished
Source: Reproduced with permission from The Journal of Nutrition Health and Aging, 2005,
and Woo et al. (2005)
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
Annex 12. Mini-Nutritional Assessment (MNA)
Mini Nutritional Assessment (MNA) is designed specifically to screen for malnutrition in
institutionalised older adults. It consists of 18 assessment items divided into four parts:
anthropometric, general, dietary, and self-assessment which have shown high predictive
value for morbidity and mortality.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
Source: Reproduced with permission from Hong Kong East Cluster Nutrition Information Web.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
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營養調查細則
項目
E
註釋
判斷是否患有痴呆症或憂鬱症，一般應以醫生的診斷為依據「嚴重」者指
影響基本日常活動
H至M
「每日」是指最近兩週的飲食習慣
H
「4 種藥」如 : 醫生開 Daonil , Glucophage 都是醫糖尿，祇算一種藥
J
1( 中號 ) 碗飯 = 相等於五滿湯匙飯
1( 中號 ) 碗飯計 250 毫升，一般即 300 毫升碗八分滿
K
1 份水果 = 1 個中型水果，如橙、蘋果、梨等
1 份蔬菜 = 3 兩煮熟蔬菜或 1 碗蔬菜
L
1 兩瘦肉 ( 生秤 ) = 1 隻大麻雀牌體積
1 兩肉 ( 煮熟 ) = 直徑 7 公分長之塑膠醬油碟之份量
M
「營養奶或奶粉」需注意開奶所用奶粉份量及使用之盛器容量，再評估
長者飲用正確奶量
例子 :3 殼加營素開水至 8 安士，祇可換算作營養奶 1/2 杯
P, Q
屬主觀答案，須用心聆聽，以揣摩長者回應
上臂中點圓周測量法
•透過量度及監察上手臂的變化，可反映長者的營養狀況
•理想範圍為 20 公分或以上
•若低於 17 公分，則是營養不良的初步指標
定出上手臂中點之位置 ( 見下圖 )
1. 指導被測者站直，把其左手手肘彎成 90 度，並使其掌心向下。
若被測者不能直立，患者可以平躺或坐下測定。
2. 肩峰頂點與肱骨的肘頭 ( 手肘 ) 頂端，二處各作記號。
3. 軟尺的零位置與肩峰位置對齊後，拉長至肘頭號位。
4. 量度兩點所成直線之間的距離，取其中點，並在同一直線上做記號
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Annex 13. Abbreviated Mental Test (AMT) 42
10-question test to screen for cognitive impairment in geriatrics patients
Test includes short term memory (Q3) and long term memory (Q1,7,8,9), attention (Q10)
and orientation (Q2,4,5,6)
1. 請講出你的年齡 ________
2. 現在是什麼時間 ________
3. 我告訴你一個地址，請你緊記。這地址是 ‘上海街四十二號’ ________
4. 今年是甚麼年份 ________
5. 這裏是什麼地方 ________
6. 你認識這兩位人士嗎 ( 在周圍任何兩位人士 ) ________
7. 請講出你的出生日期 ________
8. 請講出中秋節的日期 ________
9. 請講出香港特首的名字 ________
10. 請由二十倒數至一 ________
總得分：
( 答對 = 1 分 ; 答錯 = 0 分 )
Best cut off is 6 (with sensitivity 96% and specificity 94%)
Source: Reproduced with permission from the Hong Kong Medical Journal, 1995, Hong
Kong Academy of Medicine and Chu et al. (1995)
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Annex 14. Mini-Cog Test 43
The Mini-Gog test is a 3-minute instrument to screen for cognitive impairment in older
adults in the primary care setting. The Mini-Cog uses a three-item recall test for memory
and a scored clock-drawing test (CDT). The latter serves as an “informative distracter”
helping to clarify scores when the memory recall score is intermediate. The Mini-Cog was
as effective as or better than established screening tests in both an epidemiologic survey in a
mainstream sample and a multi-ethnic, multilingual population comprising many individuals
of low socioeconomic status and education level. In comparative tests, the Mini-Cog was at
least twice as fast as the Mini-Mental State Examination. The Mini-Cog is less affected by
subject ethnicity, language, and education, and can detect a variety of different dementias.
Moreover, the Mini-Cog detects many people with mild cognitive impairment (cognitive
impairment too mild to meet diagnostic criteria for dementia).
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Source: Mini-CogTM Copyright S.Borson. Reproduced with permission.
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Annex 15. Glossary44, 45, 46, 47, 48, 49
Screening
Screening is the presumptive identification of unrecognized disease or defect by the
application of tests, examinations or other procedures which can be applied rapidly.
Screening tests sort out apparently well persons who probably have a disease from those
who probably do not. A screening test is not intended to be diagnostic. Once a disease is
suspected, prompt clinical management should be instituted. Moreover, screening involves a
system not just a test and there is always a trade-off between benefit, harm and affordability.
Hence, screening programme if implemented should be occurred at settings where screening
service is provided and relevant supporting service is readily accessible.
Population-based screening
Population-based screening is offered systematically to all individuals in the defined target
group within a framework of agreed policy, protocols, quality management, monitoring and
evaluation by applying a screening test for a disease which is considered important and will
produce a net benefit that is cost effective and that the community considers acceptable.
Opportunistic screening
Opportunistic screening occurs when a test is offered to individuals when they present to a
health care practitioner for reasons unrelated to that disease, and particularly for individuals
who may be predisposed to that disease, e.g. individuals with particular risk factors or at
increased risk, and the disease can be controlled better when detected early in the natural
history. The differences between population-based screening and opportunistic screening
are described in the table below.
Targets
Process
Population-based screening
 Targeted to general population.

 Adequate staffing and facilities for 
testing, diagnosis, treatment and
programme management should be
available prior to the commencement 
of the screening programme.
 There is proactive invitation of the
target population.
 An organised integrated process

where all activities along the
screening pathway are planned,
coordinated and monitored
Opportunistic screening
Targeted to individuals rather than
general population.
The decision to initiate the health
care encounter is made by the
individual rather than being invited.
The primary care doctor acts on
appropriate opportunities during
the consultation process for disease
prevention.
The choice of the disease to be
screened depends on circumstances
in the consultation and has to be
legitimate and selective.
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Example  Cervical cancer screening
 Opportunistic screening of
programme.
dementia.
Women aged between 25 and 64
The primary care doctor is aware
who have ever had sex are invited to
of cues pointing to the possibility
have cervical cytology test every 3
of dementia during the consultation
years after two consecutive normal
process, though the patient comes
annual cytology tests.
for the condition unrelated to
cognitive problem. The primary
care doctor then takes the
opportunity and performs screening
test for dementia.
Primary prevention
Primary prevention aims to reduce the incidence of disease by personal and communal
efforts, such as decreasing environmental risks, enhancing nutritional status, immunizing
against communicable diseases, or improving water supplies. It is a core task of public
health, including health promotion.
Secondary prevention
Secondary prevention aims to reduce the prevalence of disease by shortening its duration.
If the disease has no cure, it may increase survival and quality of life. It seldom prevents
disease occurrence; it does so only when early detection of a precursor lesion leads to
complete removal of all such lesions. It is a set of measures available to individuals and
communities for the early detection and prompt intervention to control disease and minimise
disability; e.g., by the use of screening programs.
Tertiary prevention
Tertiary prevention consists of measures aimed at softening the impact of long term disease
and disability by eliminating or reducing impairment, disability, and handicap; minimising
suffering; and maximizing potential years or useful life.
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Acknowledgments
This Module on Health Assessment was developed with the active support and invaluable
contribution of the Members of the Sub-group on Health Assessment.
Members of the Sub-group on Health Assessment (2013)
Convenor
Dr Felix CHAN Hon-wai
Hong Kong West Cluster Service Director
(Primary and Community Health Care);
Chief of Service, Department of Medicine,
Tung Wah Group of Hospitals Fung Yiu King Hospital;
Consultant Physician (Geriatrics)
Members
Dr Mark CHAN Suen-ho
Dr Eunice CHAN Yin-chiu
Dr Rudolph CHOW Wai-man
Dr Henry KONG Wing-ming
Prof Timothy KWOK Chi-yui
Prof Claudia LAI Kam-yuk
Prof Lam Tai-pong
Dr LAU Ho-lim
Dr Christina MAW Kit-chee
Dr Francis MOK Chun-keung
Private General Practitioner
Specialist in Family Medicine,
United Christian Nethersole Community Health Service
Private General Practitioner;
Honorary Clinical Assistant Professor,
Department of Family Medicine and Primary Care,
The University of Hong Kong
Fellow of Hong Kong College of Community Medicine
Professor, Division of Geriatrics,
Department of Medicine and Therapeutics,
The Chinese University of Hong Kong
Professor, School of Nursing,
The Hong Kong Polytechnic University
Professor and Chief of Postgraduate Education,
Department of Family Medicine and Primary Care,
Li Ka Shing Faculty of Medicine,
The University of Hong Kong
Vice-President (General Affairs),
The Hong Kong College of Family Physicians
Senior Manager (Elderly and Community Care),
Hospital Authority
Chairman, Specialty Board in Geriatric Medicine,
Hong Kong College of Physicians
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Mr Bobby NG
Representative of Hong Kong Occupational Therapy
Association;
Senior Occupational Therapist, Occupational Therapy
Department, Kowloon Hospital, Hospital Authority
Dr WONG Man-shun
Council Member, Association of Licentiates of
Medical Council of Hong Kong
Dr Nelson WONG Chi-Kit
Head of Corporate Medical Scheme Service,
Dr Vio & Partners
President, Tung Wah College
Prof Thomas WONG
Kwok-shing
President, Hong Kong Doctors Union
Dr YEUNG Chiu-fat
The following service units of the Department of Health:
Dental Service
Elderly Health Service
Professional Development and Quality Assurance
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References
1
Patient morbidity and management patterns of community-based primary health care
services in Hong Kong. Hong Kong Med J 2011. 17(Suppl 3): p. S33-7.
2
Canadian Task Force on the Periodic Health Examination. The Periodic Health
Examination 1984. A Report of the Periodic Health Examination Task Force. Ottawa,
Ontario: Health Services Directorate, Health Services and Promotion Branch,
Department of National Health and Welfare: 1984; 15.
3
US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed.
Baltimore, Md: Williams & Wilkins. 1996.
4
Lam CLK, Leung GM, Mercer SW, Fong DYT, Lee A, Lam TP, Lo YYC. Utilization
patterns of primary health care services in Hong Kong: does having a family doctor
make any difference? HKMJ. 2011; 1(suppl): S28-S32.
5
Lewis GH (2010). Predictive Modelling in Action: How ‘virtual wards’ help high-risk
patients receive hospital care at home. Commonwealth Fund website. Available at:
http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2010/
Aug/Predictive-Modeling-in-Action.aspx . Accessed on 18 Nov 2011
6
The Royal Australian College of General Practitioners. Guidelines for Preventive
Activities in General Practice. 8th Edition. [Internet]. South Melbourne (Australia): The
Royal Australian College of General Practitioners; c2013. Available at:
http://www.racgp.org.au/your-practice/guidelines/redbook/. Accessed on 8 Aug 2013
7
Continence Foundation of Australia. Promoting bladder and bowel health, 2008.
8
O'Neil B, Gilmour D. Approach to urinary incontinence in women. Diagnosis and
management by family physicians. Can Fam Physician. 2003; 49: 611-8.
9
Shamliyan, T., Prevention of fecal and urinary incontinence in adults. Evidence report/technology
assessment No. 161. Rockville: Agency for Healthcare Research and Quality. 2007.
10
Chiu H, Lee HC, Chung WS, Kwong PK. Reliability and validity of the Cantonese
Version of Mini-Mental State Examination – a Preliminary Study. J Hong Kong Coll
Psychiatr. (1994) 4 , SP2, p25-28. Available at: http://easap.asia/journal_file/9402_
V4N2_p25.pdf. Accessed on 18 Nov 2011
11
University of Iowa Geriatric Education Library -Geriatric Assessment tools. [Internet].
Available at: http://www.healthcare.uiowa.edu/igec/tools/ . Accessed on 18 Nov 2011
57
Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
12
University of Michigan Medical School - Geriatric Functional Assessment 2003.
[Internet]. Available at: http://www.med.umich.edu/lrc/coursepages/M1/
HGD/GeriatricFunctionalAssess.pdf . Accessed on 18 Nov 2011
13
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int
Disabil Stud. 1988;10(2):61-63.
14
Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J.
1965;14:61-65.
15
Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability?
Int Disabil Stud. 1988;10(2):64-67.
16
Tong YC, Man WK. The Validation of the Hong Kong Chinese Version of the Lawton
Instrumental Activities of Daily Living Scale for Institutionalized Elderly Persons.
Occupational Therapy Journal of Research: Occupation, Participation and Health
2002;22(4): 132- 142.
17
Podsiadlo D, Richardson S. The Time “Up & Go”: A Test of Basic Functional Mobility for
Frail Elderly Persons. Journal of the American Geriatrics Society 1991; 39(2): 142-148.
18
Shumway- Cock A, Brauer S, Woollacott M. Predicting the Probability for Falls in
Community-Dwelling Older Adults Using the Timed Up & Go Test. Physical Therapy
2000; 80(9): 896-903.
19
Schoene D, Wu SM, Mikolaizak AS, Menant JC, Smith ST, Delbaere K, Lord SR.
Discriminative ability and predictive validity of the timed up and go test in identifying
older people who fall: systematic review and meta-analysis. J Am Geriatr Soc. 2013
Feb;61(2):202-8.
20
Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful
predictor of risk of falls in community dwelling older adults: a systematic review and
meta-analysis. BMC Geriatrics 2014;14:14.
21
Vellas B.J., Wayne S.J., Romero L et al. One-leg balance is an important predictor of
injurious falls in older person. J Am Geriatr Soc 1997; 45: 735-738.
22
Jonsson E, Seiger A, Hirschfeld H. One-leg stance in healthy young and elderly adults: a
measure of postural steadiness? Clinical Biomechanics. Aug 2004. 19(7):688-94.
23
Diabetic Complication Screening Manual (2006). Professional Services and Medical
Development Division, HA, the Diabetes Educators Group and the Hong Kong Society
of Endocrinology, Metabolism and Reproduction.
58
Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
24
Rabbetts, R. B. (2000) Bennett & Rabbetts’ Clinical Visual Optics. Butterworth, Oxford. p.45.
25
Eagan, S. M. , Jacobs, R. J. and Demers-Turco, P. L. (1999) Study of luminance effects
on pinhole test results for visually impaired patients. Optom. Vis. Sci. 76, p.50-58.
26
Visual Acuity Measurement Standard (1984). International Council of Ophthalmology
(ICO) (http://www.icoph.org/dynamic/attachments/resources/icovisualacuity1984.pdf )
27
Loewenstein A, Malach R, Goldstein M, et al. Replacing the Amsler grid - a new
method for monitoring patients with age-related macular degeneration. Ophthalmology
2003;110:966–970.
28
Screening and Management of Adult Hearing Loss in Primary Care: Clinical Applications.
JAMA. 2003; 289(15): 1986-1990.
29
Whispered voice test for screening for hearing impairment in adults and children:
systematic review. BMJ. 2003 October 25; 327(7421): 967.
30
Lee HB, Chiu HFK, Kwok WK, CM Leung, Kwong PK, Chung DWS. Chinese elderly
and the GDS short form. Clinical Gerontologist 1993; 14(2), 37 – 42.
Lee, HCB, Chiu, HFK, & Kwong, PPK (Jan & July 1994). Cross-validation of the
Geriatric Depression Scale Short Form in the Hong Kong Elderly. Bulletin of the Hong
Kong Psychological Society, 32/33, 72-77.
31
32
Wong MTP, et al. Development and inter-rater reliability of a standardized verbal
instruction manual for the Chinese Geriatric Depression Scale-short form. Int J Geriatr
Psychiatry 2002; 17, 459-463.
33
Cheng ST, Chan ACM. A brief version of the Geriatric depression scale for the Chinese.
Psychological Assessment 2004, Vol 16, No 2, 182-186.
34
Teddy M Chen, Frederick Y Huang, Christine Chang, Henry Chung. Using the PHQ-9 for
depression screening and treatment monitoring for Chinese Americans in Primary Care.
Psychiatric Services. July 2006, 57: 976-981.
35
Lowe B, Unutzer J, et al. Monitoring depression treatment outcomes with the Patient
Health Questionnaire-9. Medical Care 2004;1194-1201.
36
Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a
Two-Item Depression Screener. Medical Care 2003, (41) 1284-1294.
37
Malnutrition Advisory Group (MAG). MAG guidelines for Detection and Management of
Malnutrition. British Association for Parental and Enteral Nutrition, 2000, Redditch, UK.
59
Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings
Module on Health Assessment
38
Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN Guidelines for Nutrition
Screening 2002. Clinical Nutrition 2003, 22(4): 415-421.
39
K. Lok, J. Woo, E. Hui, T. Kwok, Usefulness of the Chinese Nutrition Screening (CNS)
tool in predicting 12 month mortality in elderly Hong Kong Chinese living in Institution.
The Journal of Nutrition, Health & Aging, Vol 13, Number 2, 2009.
40
Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN Guidelines for Nutrition
Screening 2002. Clinical Nutrition 2003, 22(4): 415-421.
41
Lok K, Woo J, Hui E, Kwok T. Usefulness of the Chinese Nutrition Screening (CNS)
Tool in Predicting 12 month Mortality in Elderly Hong Kong Chinese Living in
Institutions. The Journal of Nutrition, Health and Aging 2009; 13(2): 96-101.
42
L W Chu, et al. Validation of Abbreviated Mental Test (Hong Kong version) in the
elderly medical patients. HKMJ 1995;1: 207-211.
43
Borson, S., et al., The mini-cog: a cognitive 'vital signs' measure for dementia screening
in multi-lingual elderly. Int J Geriatr Psychiatry, 2000. 15(11): 1021-7.
44
Miquel Porta. A Dictionary of Epidemiology. 5th ed. Oxford University Press; 2008.
45
Wald N. Opportunistic screening. Journal of Medical Screening. 1994;1:208.
46
The Royal Australian College of General Practitioners. Guidelines for preventive activities in
general practice 8th edition [Internet]. c2013 [cited 8 Aug 2013]. Available from:
http://www.racgp.org.au/download/Documents/Guidelines/Redbook8/redbook8.pdf
47
Australian Health Ministers’ Advisory Council. Population Based Screening Framework
[Internet]. c2008 [cited 5 Jun 2012]. Available from: http://www.cancerscreening.
gov.au/internet/screening/publishing.nsf/Content/pop-based-screening-fwork/$File/
screening-framework.pdf
48
National Health Committee. Screening to Improve Health in New Zealand: Criteria to assess
screening programmes [Internet]. c2003 [cited 5 Jun 2012]. Available from: http://nhc.health.
govt.nz/publications/nhc-publications-pre-2011/screening-improve-health-new-zealand
49
Oxford Handbook of Public Health Practice. 2nd ed. Oxford University Press. 2006; Part
3: Sect. 3.6, Assuring screening programmes.
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Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings