Relationship between Fried's frailty phenotype and oral frailty in long-term care residents

Oral frailty: A concept analysis

AIM

To clarify the concept of oral frailty to provide a clear and standardized conceptual basis for further research in older people.

DESIGN

Rodgers and Knafl's evolutionary concept analysis approach.

METHODS

The narrative analysis detailedly extracted and synthesized the attributes of oral frailty, as well as its antecedents, consequences and related terms under the guidance of Rodgers' evolutionary method.

DATA SOURCES

Multiple databases including Pubmed, CINAHL and Cochrane were searched using selected search terms 'oral frail*', 'oral health' and 'aged' respectively. Articles written between 2013 and 2023 were included, and grey literature was excluded.

RESULTS

A total of 32 articles were included for further analysis and synthesis. The attributes of oral frailty were hypofunction, predisposing in nature, non-specific and multidimensional. Antecedents of prefrailty were classified into four categories, namely, sociodemographic characteristics, comorbidity, physical function and psychosocial factors. Consequences of oral frailty include three themes: increased risk of adverse outcomes, poor nutritional status and possibility of social withdrawal. Related terms that had shared attributes with oral frailty were oral health, functional dentition, oral hypofunction and deterioration of oral function.

CONCLUSIONS

Oral frailty is an age-related phenomenon reflected in decreased oral function. The findings of this concept analysis are conducive to understanding and clarifying the oral frailty, which can help clinicians or other healthcare providers to consider how to distinguish oral frailty in older adults and further promote the development of this field.

IMPACT

Oral frailty is increasingly recognized as an age-related phenomenon reflected in decreased oral function. As it is newly proposed, no consensus has been reached regarding the theoretical and operational concept of it. Through clarifying the concept, this paper will guide future healthcare research on oral frailty regarding the influencing factors, mechanisms and interventions, thus raising the awareness with regard to oral health among older adults. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: In the context of older adults, oral frailty is a concept that requires further research to guide future theoretical development, and the influencing factors, mechanisms and interventions need to be further studied. Raise awareness with regard to oral health among older people and more attention will be paid to the early identification and intervention of oral frailty, so as to further improve the quality of life of older adults.

Physical frailty intensifies the positive association of oral frailty with poor global cognitive function and executive function among older adults especially for females: a cross-sectional study

BACKGROUND

Oral frailty is reported to increase the risk of new onset of mild cognitive impairment. Whereas, the association of oral frailty with cognition among older adults in both physical frail and non-physical frail status has not been sufficiently explored, and whether there are sex differences in the association is unclear. This study investigated the association of oral frailty and physical frailty with global cognitive function and executive function among older adults, as well as the sex differences in such association.

METHODS

This cross-sectional study included 307 participants aged ≥ 60 years old from communities between June 2023 and August 2023, in Nanjing, China. Global cognitive function and executive function were assessed by using the Montreal Cognitive Assessment (MoCA) and Trail Making Tests A (TMT-A), respectively. Oral frailty was identified by the combination of natural tooth, Oral Frailty Index-8 (OFI-8), and oral diadochokinesis. Physical frailty was measured by using Fried phenotype model which contained 5 criteria: unintentional weight loss, weakness, exhaustion, slowness, and low physical activity. Multiple linear regression analyses for overall participants and stratified by sex and presence or absence of physical frailty were performed, respectively, to examine the association between oral frailty and cognitive functions.

RESULTS

The median age of participants was 70 years old. The study included 158 (51.5%) females, 53 (17.3%) individuals with physical frailty, and 65 (21.2%) participants with oral frailty. After adjustment, the association between oral frailty and global cognitive function was observed in the physical frailty group (B = -2.67, 95% Confidence Interval [CI]: -5.27 to -0.07, p = 0.045) and the females with physical frailty (B = -4, 95% CI: -7.41 to -0.58, p = 0.024). Oral frailty was associated with executive function in overall participants (B = 0.12, 95% CI: 0.01 to 0.22, p = 0.037), physical frailty group (B = 23.68, 95% CI: 1.37 to 45.99, p = 0.038). In the adjusted models, oral frailty was significantly associated with executive function in all females (B = 0.21, 95% CI: 0.05 to 0.36, p = 0.009), in females without physical frailty (B = 0.19, 95% CI: 0.02 to 0.36, p = 0.027), and in females with physical frailty (B = 48.69, 95% CI: 7.17 to 90.21, p = 0.024).

CONCLUSIONS

Physical frailty intensifies the positive association of oral frailty with poor global cognitive function and executive function among older adults, particularly among females. It is ponderable to consider sex differences and facilitate the management of physical frailty when it comes to promoting cognitive health based on the perspective of oral health among older adults.

Oral frailty: a concept analysis

BACKGROUND

Oral frailty has become a worldwide problem among older adults. Although researchers have conducted various studies on oral frailty, its definition remains controversial.

PURPOSE

To clarify the concept of oral frailty.

METHODS

Online databases PubMed, Web of Science, CINAHL, Cochrane Library, ProQuest, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), and Wanfang database were searched from inception to September 20, 2023. The reference lists of relevant studies were searched manually. Eligible articles, theses, and books were analyzed using Walker & Avant's concept analysis model.

RESULTS

The attributes of oral frailty were abnormal oral structure and/or decline in multi-faceted oral function and coexisting decline in physical, cognitive and social functions. Its antecedents were aging, social frailty, and severe periodontitis, whereas its consequences were decline in physical health and mental health, social withdrawal, lower quality of life and systemic frailty.

CONCLUSION

Oral frailty could result in worse conditions among older adults physically, psychologically and socially. Tools based on the concept analysis need to be developed to comprehensively assess oral frailty.

An analysis of influencing factors of oral frailty in the elderly in the community

OBJECTIVE

This study aimed to investigate the current situation of oral frailty (OF) in the elderly in the community in China and analyse its influencing factors.

METHODS

Using convenience sampling, 380 elderly people from three communities in our city were selected as participants in the study. The Oral Frailty Index-8, the Frailty Scale, the Oral Health Assessment Tool, the Mini-nutritional Assessment Scale and the Pittsburgh Sleep Quality Index were used to investigate and analyse OF influencing factors.

RESULTS

In this study, the 380 elderly participants were categorized into three groups: frailty, pre-frailty, and non-physical frailty, based on their responses to the questionnaires.The influencing factor analysis showed that age, gender, education level, frailty score, frailty stage, number of dentures, dry mouth, subjective chewing difficulty, oral health score and sleep quality were the influencing factors of OF in the elderly in the community (R2 = 0.712, F = 434.73, P < 0.05). The evaluation of the prediction results showed that the frailty score (area under the curve [AUC]: 0.751, 95% confidence interval [CI]: 0.683-0.862), subjective chewing difficulty (AUC: 0.765, 95% CI: 0.655-0.831) and sleep quality (AUC: 0.736, 95% CI: 0.652-0.781) had a higher predictive value for OF.

CONCLUSION

The main OF influencing factors in the elderly in the community are age, gender, education level, physical frailty (PF) score, PF stage, number of dentures, dry mouth, subjective chewing difficulties, oral health score and sleep quality. Nursing staff should pay attention to the OF of the elderly in the community and take targeted intervention measures in time to reduce and control OF occurrence and progression.

Association between animal protein intake, oral frailty and calf circumference in middle-aged and older adults: a cross-sectional analysis from the Shika study

OBJECTIVE

To investigate the relationship between oral frailty (OF), nutrient intake and calf circumference (CC) in middle-aged and older adults.

DESIGN

Cross-sectional study.

SETTING

Residents of four model districts of Shika town, Ishikawa Prefecture, Japan, using data from November 2017 to February 2018.

PARTICIPANTS

One hundred and ninety-four residents aged ≥50 years in four model districts of Shika town. The OF total score ≥3 was defined as OF. Participants were divided into OF and non-OF groups and divided into the low-CC/kg and the high-CC/kg groups.

OUTCOME MEASURES

The primary outcome is to use a two-way analysis of covariance to analyse the interaction between the two CC/kg groups and the two OF groups on nutrition intake. The secondary outcome is to use multiple regression analysis to investigate the nutrients significantly related to CC/kg when stratified by OF, with age, sex, body mass index, drinking status, smoking status and regular exercise as input covariates.

RESULTS

A two-way analysis of covariance revealed a significant interaction between the two CC/kg groups and the two OF groups on animal protein intake (p=0.039). Multiple comparisons using the Bonferroni analysis revealed a significantly lower animal protein intake in the OF group than in the non-OF group with a low CC/kg (p=0.033) but not in the group with a high CC/kg. The multiple regression analysis stratified by OF revealed a positive correlation between animal protein intake and CC/kg (p=0.002).

CONCLUSIONS

The present results revealed a significantly lower animal protein intake in the OF group than in the non-OF group in the low-CC/kg group, but no such difference was observed in the high-CC/kg group. Further longitudinal studies are needed to elucidate this relationship.

Towards an operational definition of oral frailty: A e-Delphi study

OBJECTIVES

Building upon our recently developed conceptual definition of oral frailty (the age-related functional decline of orofacial structures), this e-Delphi study aims to develop an operational definition of oral frailty by identifying its components.

METHODS

We used a modified e-Delphi study to reach a consensus among international experts on the components of oral frailty. Twelve out of fifteen invited experts in the field of gerodontology participated. Experts responded to three rounds of an online 5-point scale questionnaire of components to be included or excluded from the operational definition of oral frailty. After each round, scores and rationales were shared with all experts, after which they could revise their position. A consensus was reached when at least 70% of the experts agreed on whether or not a component should be included in the operational definition of oral frailty.

RESULTS

The experts achieved a high level of agreement (80 - 100%) on including eight components of oral frailty and excluding nineteen. The operational definition of oral frailty should include the following components: 1) difficulty eating hard or tough foods, 2) inability to chew all types of foods, 3) decreased ability to swallow solid foods, 4) decreased ability to swallow liquids, 5) overall poor swallowing function, 6) impaired tongue movement, 7) speech or phonatory disorders, and 8) hyposalivation or xerostomia.

CONCLUSION

This e-Delphi study provided eight components that make up the operational definition of oral frailty. These components are the foundation for the next stage, which involves developing an oral frailty assessment tool.

Oral frailty among dentate and edentate older adults in long-term care

BACKGROUND

The objectives of this study were to compare oral frailty (OFr) among edentate and dentate older adults living in long-term care facilities (LTCF) and to clarify how edentulism and oral disease burden (ODB) of dentate older adults are associated with OFr.

METHODS

The population of this study comprised 94 edentate and 209 dentate residents in LTCF in Helsinki, Finland, who had previously participated in a nutritional study. The participants underwent a clinical oral examination. The dentate residents were further divided into three ODB groups based on asymptotic dental score. The edentate and different ODB groups were compared with each other regarding demographics and oral and medical findings. OFr was defined as ≥ 2 of following: having a diet of soft/pureed food, residue of food in the oral cavity, inability to keep the mouth open during examination, unclearness of speech, dry mouth. The association between OFr and edentulousness and various levels of ODB was analyzed by a multivariate logistic model.

RESULTS

Participants with low ODB had significantly less OFr than their edentate peers (p = 0.009). Furthermore, the edentate and dentate with high ODB had similar odds for OFr.

CONCLUSIONS

Edentulousness and high ODB are equally harmful conditions and may predispose to OFr. This study suggests that maintaining healthy natural teeth and good oral health (low ODB) may protect against OFr.

TRIAL REGISTRATION

The Ethics Committee of the Hospital District of Helsinki and Uusimaa approved the protocols for the nutritional status and oral healthcare studies and the merging of the data, including patient medical records (Register number HUS/968/2017).

Comorbid health conditions and their impact on social isolation, loneliness, quality of life, and well-being in people with dementia: longitudinal findings from the IDEAL programme

BACKGROUND

Most people with dementia have multiple health conditions. This study explores (1) number and type of health condition(s) in people with dementia overall and in relation to age, sex, dementia type, and cognition; (2) change in number of health conditions over two years; and (3) whether over time the number of health conditions at baseline is related to social isolation, loneliness, quality of life, and/or well-being.

METHODS

Longitudinal data from the IDEAL (Improving the experience of Dementia and Enhancing Active Life) cohort were used. Participants comprised people with dementia (n = 1490) living in the community (at baseline) in Great Britain. Health conditions using the Charlson Comorbidity Index, cognition, social isolation, loneliness, quality of life, and well-being were assessed over two years. Mixed effects modelling was used.

RESULTS

On average participants had 1.8 health conditions at baseline, excluding dementia; increasing to 2.5 conditions over two years. Those with vascular dementia or mixed (Alzheimer's and vascular) dementia had more health conditions than those with Alzheimer's disease. People aged ≥ 80 had more health conditions than those aged < 65 years. At baseline having more health conditions was associated with increased loneliness, poorer quality of life, and poorer well-being, but was either minimally or not associated with cognition, sex, and social isolation. Number of health conditions had either minimal or no influence on these variables over time.

CONCLUSIONS

People with dementia in IDEAL generally had multiple health conditions and those with more health conditions were lonelier, had poorer quality of life, and poorer well-being.

Relationship between oral frailty, health-related quality of life, and survival among long-term care residents

PURPOSE

We evaluated oral frailty (OFr) and its association with health-related quality of life (HRQoL), energy and protein intake, and survival among older long-term care residents.

METHODS

This cross-sectional study with a 3-year follow-up for survival assessed 349 residents in long-term care facilities (73% female, mean age 82 years). We defined OFr with six signs (dry mouth, food residue on oral surfaces, unclear speech, inability to keep mouth open or pain expression during the clinical oral examination, diet pureed/soft) and OFr severity was categorized as Group 1, (mild) = 0-1 signs, Group 2 (moderate) = 2-4 signs, and Group 3 (severe) = 5-6 signs. We measured HRQoL with 15D instrument, and energy and protein intake by a 1- to 2-day food record. Mortality was retrieved from central registers on March 2021.

RESULTS

Of the residents, 15% had 0-1, 67% 2-4 and 18% 5-6 OFr signs. HRQoL decreased linearly from Group 1 to Group 3. OFr correlated with such dimensions of HRQoL as mobility, eating, speech, excretion, usual activities, mental function, and vitality. We found no association between OFr categories and energy and protein intake. Survival decreased linearly from Group 1 to Group 3.

CONCLUSIONS

OFr was common among older long-term care residents and OFr severity predicts poorer outcomes. The six oral signs denoting OFr may be used at the bedside to screen residents at risk for OFr.

Oral conditions and other symptoms among older persons in long-term care facilities during the end of life

AIMS

The purpose was to examine the association between oral conditions and other symptoms in long-term care facilities during the last days of life.

METHODS

A retrospective case-control study approach was used in this study, with the Minimum Data Set (MDS, ver. 3.0 2015) that was maintained and administrated by the Centers for Medicare and Medicaid Services (CMS). Residents with oral conditions (n = 4304) were selected with any oral conditions (e.g., ulcers, inflamed/bleeding gums, mouth/facial pain). The control cases (n = 12 912) were selected using propensity analysis.

RESULTS

Oral conditions had significant impacts on depression, poor appetite, pain, shortness of breath, and constipation. Although no statistically significant differences in trouble sleeping, vomiting, internal bleeding, and dehydration were found between the cases with oral conditions and the control, more residents with oral conditions reported trouble sleeping and dehydration compared to the control.

CONCLUSIONS

It is important to provide preventive and proactive intervention for oral conditions, not only to minimize the negative effects of oral conditions on other symptoms in long-term care facilities, but also to share philanthropic support with people who might be suffering other symptoms due to oral conditions at the end of life.

Dysphagia and its association with other health-related risk factors in institutionalized older people: A systematic review

BACKGROUND

Dysphagia is considered a geriatric syndrome that is characterized by inability to or difficulty in safely and effectively forming or moving the food bolus toward the esophagus. This pathology is very common and affects approximately 50% of institutionalized older people. Dysphagia is often accompanied by high nutritional, functional, social, and emotional risks. This relationship implies a higher rate of morbidity, disability, dependence, and mortality in this population. This review is aimed at studying the relationship between dysphagia and different health-related risk factors in institutionalized older people.

METHOD

We conducted a systematic review. The bibliographic search was performed in the Web of Science, Medline, and Scopus databases. Data extraction and methodological quality were evaluated by two independent researchers.

RESULTS

Twenty-nine studies met the inclusion and exclusion criteria. A clear relationship between the development and progression of dysphagia and a high nutritional, cognitive, functional, social, and emotional risk in institutionalized older adults was found.

CONCLUSIONS

There is an important relationship between these health conditions that shows the need for research and new approaches to considerations such as their prevention and treatment as well as the design of protocols and procedures that will help reduce the percentage of morbidity, disability, dependence, and mortality in older people.

Subgingival microbiome at different levels of cognition

Oral health and declining cognition may have a bi-directional association. We characterized the subgingival microbiota composition of subjects from normal cognition to severe cognitive decline in two cohorts. Memory and Periodontitis (MINOPAR) include 202 home-living participants (50-80 years) in Sweden. Finnish Oral Health Studies in Older Adults (FINORAL) include 174 participants (≥65 years) living in long-term care in Finland. We performed oral examination and assessed the cognitive level with Mini Mental State Examination (MMSE). We sequenced the 16S-rRNA gene (V3-V4 regions) to analyse the subgingival bacterial compositions. The microbial diversities only tended to differ between the MMSE categories, and the strongest determinants were increased probing pocket depth (PPD) and presence of caries. However, abundances of 101 taxa were associated with the MMSE score. After adjusting for age, sex, medications, PPD, and caries, only eight taxa retained the significance in the meta-analyses of the two cohorts. Especially Lachnospiraceae [XIV] at the family, genus, and species level increased with decreasing MMSE. Cognitive decline is associated with obvious changes in the composition of the oral microbiota. Impaired cognition is accompanied with poor oral health status and the appearance of major taxa of the gut microbiota in the oral cavity. Good oral health-care practices require special deliberations among older adults.

Can Measurement of Ultrasonic Echo Intensity Predict Physical Frailty in Older Adults?

Echo intensity (EI) of the tongue in ultrasonography is an easy and quantitative assessment of tongue function. Elucidating the relationship between EI and frailty, is expected to aid in the early detection of frailty and oral hypofunction in older adults. We assessed tongue function and frailty in older outpatients visiting a hospital. The subjects were 101 individuals aged 65 or older (35 men and 66 women, mean age 76.4 ± 7.0 years). Tongue pressure and EI were measured as assessments of tongue function and grip strength, and Kihon Checklist (KCL) scores were measured as assessments of frailty. In women, a significant correlation was not found between the mean EI and grip strength, whereas a significant correlation was noted between each score of the KCL and the mean EI; the scores increased as the mean EI increased. A significant positive correlation was found between tongue pressure and grip strength, but no significant correlation was observed between tongue pressure and the KCL scores. In men, no significant correlation was found between tongue assessments and frailty, except for a significant positive correlation between tongue pressure and grip strength. The results of this study suggest that EI of the tongue is positively associated with physical frailty in women and may be useful for early detection of physical frailty status.

Association between Bone Mineral Density and Oral Frailty on Renal Function: Findings from the Shika Study

The association between oral frailty (OFr) and body action has been investigated, but its association with systemic function remains unclear. Therefore, this cross-sectional study examined the association between OFr with decreased bone mineral density (BMD) and renal function in residents of Shika town, Ishikawa Prefecture, Japan aged ≥40 years. This study included 400 inhabitants. The OFr total score was assessed using three oral domains in the Kihon Checklist (a self-reported comprehensive health checklist), the number of teeth, and brushing frequency per day. Measurements were the estimated glomerular filtration rate (eGFR) and the osteo-sono assessment index (OSI). Using a two-way analysis of covariance (p = 0.002), significantly lower OSI was indicated in the eGFR < 60 and OFr group than in the eGFR of < 60 and non-OFr group after adjusting for age, body mass index, and drinking and smoking status as confounding factors. Multiple logistic regression analysis confirmed this relationship (p = 0.006). Therefore, lower BMD seems to be associated with lower renal function only when accompanied by OFr. Further longitudinal studies are needed to confirm these results.

Current Application of iPS Cells in the Dental Tissue Regeneration

When teeth and periodontal tissues are severely damaged by severe caries, trauma, and periodontal disease, such cases may be subject to tooth extraction. As tooth loss leads to the deterioration of quality of life, the development of regenerative medicine for tooth and periodontal tissue is desired. Induced pluripotent stem cells (iPS cells) are promising cell resources for dental tissue regeneration because they offer high self-renewal and pluripotency, along with fewer ethical issues than embryonic stem cells. As iPS cells retain the epigenetic memory of donor cells, they have been established from various dental tissues for dental tissue regeneration. This review describes the regeneration of dental tissue using iPS cells. It is important to mimic the process of tooth development in dental tissue regeneration using iPS cells. Although iPS cells had safety issues in clinical applications, they have been overcome in recent years. Dental tissue regeneration using iPS cells has not yet been established, but it is expected in the future.

Oral hypofunction and association with need for daily assistance among older adults in long-term care

BACKGROUND

Oral hypofunction (OHF) is related to occlusal status and bite force. It has specific symptoms and varying degrees of severity.

OBJECTIVES

OHF was determined with five signs. The relationships between OHF and need for assistance in oral hygiene, moving, eating, and occlusal status in older adults living in long-term care (LTC) were examined.

METHODS

A comprehensive clinical oral examination was conducted on 393 residents who lived in LTC in Helsinki, Finland. The five signs to determine OHF were mouth dryness, visible food residue on oral or denture surfaces, ability to keep the mouth open during examination, clearness of speech, and diet of pureed or soft food. Score points of 0-2 were given for each sign and the sum was categorized as mild, moderate, or severe OHF. Participants were divided into three groups accordingly, and occlusal status was determined based on contact units. In addition, nurses collected background information on number of medications and level of cognition. Need for assistance was based on oral hygiene, moving, and eating.

RESULTS

Of participants (n=319), 21% showed severe and 41% moderate OHF. Occlusal status differences between the OHF groups were significant. OHF severity associated linearly with increased severity of cognitive impairment and increased need for assistance in oral hygiene, eating, and moving.

CONCLUSIONS

OHF score based on the five signs can be used to determine OHF severity. OHF was common and associated with occlusal status, cognitive impairment, and need for assistance in oral hygiene, moving, and eating in older adults living in LTC.

Association between Oral Frailty and Physical Frailty among Rural Middle-Old Community-Dwelling People with Cognitive Decline in Taiwan: A Cross-Sectional Study

This cross-sectional study was conducted to clarify the association between oral frailty (OF) and physical frailty (PF). In total, 308 Taiwanese middle-old (75−84 years) community-dwelling people with cognitive decline were recruited from random rural community health care centers. Eight items were considered for the evaluation of their OF status. The Study of Osteoporotic Fracture index was used for frailty assessment, which revealed that 22% of the participants had PF. In an adjusted model, PF was significantly associated with the OF subdomains of difficult to eat hard food (p = 0.009), choking (p = 0.008), denture use (p = 0.008), and inability to chew hard food (p = 0.001); and high risk of OF (OR = 3.03; p = 0.002). After eight steps with elimination of the least significant independent variable, age (p= 0.008), self-reported health status of fair (p = 0.000) and poor (p = 0.000), mild cognitive impairment (p < 0.001) and denture use (p = 0.011) were found to be the indispensable predictors for PF. The logistic regression model with 5 indispensable variables had a predictive value of 78.2%. Longitudinal analyses are needed to examine whether OF is a risk factor for PF onset.