Nutrition, general health status and oral health status in hospitalised elders

Assessment and Improvement of Masticatory Performance in Frail Older People: A Narrative Review

According to the World Health Organization (WHO), the estimated number of older adults is around 962 million and is projected to increase to 2.1 billion by 2050. The oral frailty concept is associated with gradual oral function loss in relation to aging. There is a need to emphasize the improvement of oral function based on an evaluation of masticatory performance in patients with various oral conditions or systemic diseases and especially in the frail elderly. The present narrative review presents an overview of the current state of the assessment and improvement of masticatory performance in frail older people. To fully encompass oral frailty, oro-facial hypofunction, or oro-facial fitness, dental Patient Reported Outcomes (dPROs) should be included; nevertheless, there are limited evidence-based rehabilitation approaches. The concept of oral frailty, oro-facial hypofunction, or oro-facial fitness should involve dental Patient Reported Outcomes (dPROs), and in this sense, there are only a few evidence-based rehabilitation procedures to improve oro-facial hypofunction besides prosthodontics. It must be considered that reduced neuroplastic capacity in old individuals might preclude a positive outcome of these strategies that might need to be accompanied by functional training and nutritional counseling.

Oral Health and Nutritional Intake in Community-Dwelling 90-Year-Old Japanese People: A Cross-Sectional Study

INTRODUCTION

This study aimed to determine the relationship between dentition, mastication, salivation and nutritional intake in 90-year-old Japanese people.

METHODS

This cross-sectional study included 84 participants (39 men and 45 women) aged 90 years. We used questionnaires to collect demographic information, smoking status, nutritional intake and higher-level functional capacity. Nutritional intake was assessed using the validated Brief-Type Self-Administered Diet History Questionnaire, and higher-level functional capacity was assessed using the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC) questionnaire. Oral examinations, masticatory performance tests, stimulated salivary flow rate (SSF) tests, blood tests, blood pressure tests and body mass index (BMI) assessments were conducted. Univariable and multivariable linear regression analyses were performed.

RESULTS

Multivariable linear regression analyses adjusted for sex, education, TMIG-IC and BMI ≤20 kg/m² showed that participants with masticatory performance <173 mg/dL had lower intake of folic acid and vitamin A than those with masticatory performance ≥173 mg/dL. SSF was positively associated with intake of vitamin A. The number of teeth was positively associated with the intake of β-carotene. With smaller effect sizes, masticatory performance, SSF and number of teeth were also associated with the intake of various micronutrients and carbohydrates.

CONCLUSION

Lower masticatory performance, lower SSF and fewer teeth were associated with a lower intake of several micronutrients, such as vitamin A, β-carotene and folic acids, in Japanese individuals of advanced age. Oral health practitioners should pay careful attention to the nutritional intake of older people with poor mastication, dry mouth and severe tooth loss.

Care need and dry mouth as risk indicators for impaired taste and smell

To identify whether reduced saliva secretion or xerostomia symptoms are risk indicators for impaired taste and smell, depending on age and care needs. This cross-sectional study evaluated taste and smell in patients categorized into different age groups (<65> years) and different care need, with and without dry mouth. Of the 185 patients included, 119 were classified as “dry mouth” and 66 as “without dry mouth”. Overall, 103 (55.7%) were female and 37 (20%) needed care. There was no difference between “dry mouth” and “without dry mouth” regarding identification of odors or tastes, but a difference in the number of correctly identified odors and tastes in favor of “without care need” patients (p < 0.05). The ability to identify smells and tastes was negatively influenced by age, number of medications, and number of comorbidities, but subjective dry mouth had no impact. According to our results, subjective dry mouth is not a risk factor for an impaired ability to recognize smells and tastes. However, care need representing age, the number of medications taken, and the number of chronic comorbidities is a risk indicator.

Oral health as a gateway to overall health and well-being: Surveillance of the geriatric population in the United States

AIMS

Little evidence exists to confirm that better oral health is associated with better overall health and well-being. The present study aimed to examine the impact of oral health on the overall health of the population greater than 65-year old in the entire United States.

METHODS AND RESULTS

Data from National Health and Nutrition Examination Survey (NHANES) 2015-2016 were used. Variables included demographics and perceptions of oral health and overall health and well-being. Weighted prevalence estimates were calculated using mean, standard deviation, and percentage as appropriate. Chi-square tests and logistic regressions were performed to examine the association of oral health with physical health, mental health, general health, and systemic disease conditions. Analyses showed statistically significant relationships between oral health, physical, mental and general health, energy levels, work limitation, depression, and appetite. Out of the 10 systemic diseases being investigated, six of them were directly related to oral health outcome.

CONCLUSION

This study provided strong empirical evidence that oral health is directly associated with different disease conditions and contributes largely to an individual's general health, particularly in the elderly. In the current landscape of patient-centered and value-based care, addressing the oral health needs of the elderly, who generally find themselves with limited access to care, should be a priority.

Hyposalivation and 10-year all-cause mortality in an elderly Japanese population

OBJECTIVE

To evaluate the association of salivary flow rate with all-cause mortality among older Japanese adults. We hypothesised that hyposalivation would be a marker for mortality.

BACKGROUND

Hyposalivation, which is an objectively measurable decrease in salivary flow, is highly prevalent among older adults. It is associated with malnutrition and poor general health.

METHODS

The study population comprised 600 community-dwelling Japanese adults (306 men and 294 women), who were 70 years old at baseline. They underwent stimulated salivary flow rate (SSFR) measurements and were followed up during a 10-year study period. After stratification by sex, the hazard ratios of all-cause mortality were estimated using Cox proportional hazards regression analysis comparing groups with and without hyposalivation (ie, SSFR < 0.7 mL/min).

RESULTS

The baseline prevalence of hyposalivation was 27.8% (85/306) among men and 47.3% (139/294) among women. During a mean (standard deviation) follow-up period of 104 (27) months, 80 deaths occurred: 60 (75.0%) deaths among men and 20 (25.0%) deaths among women. After adjusting for the number of remaining teeth, smoking status, exercise, hypoalbuminemia, diabetes and cardiovascular disease, hyposalivation at baseline was significantly associated with all-cause mortality among men (adjusted hazard ratio, 1.71; 95% confidence interval, 1.01-2.89). In contrast, no association between SSFR and all-cause mortality existed among women.

CONCLUSION

Hyposalivation could be a marker for all-cause mortality among older community-dwelling Japanese men. Future studies investigating the association between SSFR and cause-specific mortality are warranted.

Risk factors for reduced salivary flow rate in a Japanese population: the Hisayama Study

The purpose of this study was to determine distinct risk factors causing reduced salivary flow rate in a community-dwelling population using a prospective cohort study design. This was a 5-year follow-up survey of 1,377 community-dwelling Japanese individuals aged ≥40 years. The salivary flow rate was evaluated at baseline and follow-up by collecting stimulated saliva. Data on demographic characteristics, use of medication, and general and oral health status were obtained at baseline. The relationship between reduced salivary flow rate during the follow-up period and its predictors was evaluated after adjustment for confounding factors. In a multivariate logistic regression model, higher age and plaque score and lower serum albumin levels were significantly associated with greater odds of an obvious reduction in salivary flow rate (age per decade, odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.03-1.51; serum albumin levels <4 g/dL, OR = 1.60, 95% CI = 1.04-2.46; plaque score ≥1, OR = 1.53, 95% CI = 1.04-2.24). In a multivariate linear regression model, age and plaque score remained independently associated with the increased rate of reduced salivary flow. These results suggest that aging and plaque score are important predictors of reduced salivary flow rate in Japanese adults.

Nutrition and prevalence of undernutrition assessed by different diagnostic criteria in nursing homes for elderly people

BACKGROUND

Undernutrition is the state produced by the intake of insufficient energy, macronutrients or micronutrients. The present study aimed to assess the prevalence of undernutrition using 10 different diagnostic criteria described in the literature and to assess its association with energy intake in an institutionalised elderly population.

METHODS

The cross-sectional study included 213 subjects, aged 65-96 years (135 women and 78 men), who lived in seven nursing homes in the province of Murcia, on the Mediterranean coast of Spain. Dietary intake and anthropometric and biochemical parameters were assessed, and 10 different diagnostic criteria, taken from studies of elderly subjects similar to our population, were applied.

RESULTS

The mean dietary intakes appeared to cover the recommended dietary intake for a Spanish elderly population. However, only 58.2% of the studied subjects consumed 100% of the recommended dietary intake and 15.5% of the subjects had an energy intake below 80% of the recommended dietary intake. Depending on the criteria used for the diagnosis, the proportion of patients with undernutrition varied between 2% and 57%. When the relationship between undernourishment, as defined by the different methods and intake deficiency, was assessed, a statistically significant relationship was only found for five of the 10 diagnostic criteria assessed.

CONCLUSIONS

  Research needs to focus on the development and evaluation of specific nutritional assessment tools for application to older people aiming to improve the detection of those suffering (or who are at risk of suffering) undernutrition.

The association of tooth loss with all-cause and circulatory mortality. Is there a benefit of replaced teeth? A systematic review and meta-analysis

We systematically reviewed whether the number of teeth is related to all-cause or circulatory mortality and whether replaced teeth are protective against all-cause or circulatory mortality. The search was based on the PubMed database. All cohort studies published in peer-reviewed journals were selected. Studies on periodontal disease and mortality were excluded if they did not provide information on the number of teeth. Risk estimates from studies with appropriate exposure definition, confounder adjustment and sample size were included in a meta-analysis. Three high-quality studies found a relationship between the number of teeth and circulatory mortality, whereas a moderate study did not. Two out of four moderate- to high-quality studies reported a relationship between the number of teeth and all-cause mortality. No study has investigated whether replaced teeth are protective against mortality. Therefore, denture use was taken as proxy. The methodological quality of studies on denture use and mortality was generally low to moderate. The findings of two moderate studies indicated an effect of prosthodontic replacements on all-cause mortality, which was supported in bias analysis. It is open whether competing risks of cause-specific death other than circulatory mortality reduce an effect of the number of teeth on all-cause mortality. An effect of denture use on circulatory mortality remains to be established, as well as whether the number of replaced teeth affects mortality. Specifying the role of potential pathways by which tooth loss-related mortality is mediated will possibly increase the value of dental treatment for general health.

Relationship between subjective assessment of oral health and medical expenses in community-dwelling elderly persons

Objectives

The increasing medical expenses of elderly persons in Japan’s rapidly ageing society have become a major concern. It is therefore important to elucidate the factors associated with such escalation. Here, we focused on the relationship between subjective self-assessment of oral health, as an index of general health, and medical expenses (excluding dental repair) under the hypothesis that oral health contributes to general medical expenses. Several studies have shown that oral health status is correlated with general health status among elderly persons. We speculated that oral health status might show a relation with medical costs among elderly persons. However, few studies have investigated this relationship to date.

Materials and Methods

Participants were 259 elderly subjects (range: 65–84 years; 120 men, 139 women) residing independently. Subjective assessment of oral health was evaluated by their responses (‘Good’, ‘Not good’ and ‘Not at all good’) on a survey questionnaire. The correlation between subjective assessment of oral health and medical expenditure was analysed using Spearman’s rank method, the Mann–Whitney U-test and the Kruskal–Wallis test. Medical expenses were used as the dependent variable in multinomial logistic regression analysis with background and intraoral factors as independent variables.

Results

A slight yet statistically significant correlation was observed between subjective assessment of oral health and outpatient treatment fees.

Conclusion

The findings revealed that subjective assessment of oral health is significantly and independently related to the medical expenses of community-dwelling elderly persons after adjusting for social background, living environment and physical factors.

Oral health, general health, and quality of life in older people

The purpose of this report is to review the interrelationship between poor oral health conditions of older people and general health. The impact of poor oral health on quality of life (QOL) is analyzed, and the implications for public health intervention and oral health care are discussed. Findings from the current research may lead to the following conclusions: The available scientific evidence is particularly strong for a direct relationship between diabetes and periodontal disease; the direct relationship between periodontal disease and cardiovascular disease is less convincing. General and associated oral health conditions have a direct influence on elder people's QOL and lifestyle. The growing number of elderly people challenges health authorities in most countries. The evidence on oral health-general health relationships is particularly important to WHO in its effort to strengthen integrated oral health promotion and disease prevention around the globe.

Serum markers of chronic dehydration are associated with saliva spinability

Findings of a relationship between saliva and dehydration have been observed, but the precise nature of these relationships is unclear and no evidence of a direct link has been found. In particular, no study reports a relationship between chronic dehydration and saliva conditions in community-dwelling older adults. This study aimed to identify whether salivary conditions are sensitive to body hydration markers in an elderly population. A total of 403 subjects aged 76 years participated in the study. Stimulated saliva flow rate and spinability of saliva were measured. In addition, determinations of serum levels of uric acid, blood urea nitrogen (BUN), creatinine, sodium and potassium were made. Dehydration was defined as uric acid >/= 7 mg dL(-1) according to the standard value. The salivary spinability were significantly associated with the concentration of uric acid (OR=2.06, P=0.044) according to multiple logistic regression analysis. In addition, after adjusting for gender, the uric acid concentration and the salivary spinability was significantly associated with BUN, potassium and creatinine levels. The subjects with high uric acid levels (>/= 7 mg dL(-1)) had the most elastic saliva. Both BUN and serum creatinine are the most commonly used indicators of renal function. Therefore, our findings might demonstrate that older adults who are dehydrated showed highly elastic saliva, which was associated with renal function. In conclusion, this study suggests that there is a significant relationship between chronic dehydration status and salivary spinability level.

[Optimal nutritional status assessment parameters in gastroenterological patients on hospital admission]

BACKGROUND/AIM

There are no recommendations for the optimal nutritional status assessment parameters (NSAPs) in the current literature. The aim of this study was to define the optimal NSAPs for nutritional status assessing in gastroenterological patients on hospital admission.

METHODS

Nutritional status of 612 gastroenterological patients was evaluated at the admission using 6 NSAPs: unintentional weight loss (WL), body mass index (BMI), triceps skinfold thickness (TSF), mid-upper arm muscle circumference (MAMC), serum albumin concentration (ALB), and lymphocyte counts (LYM). According to their nutritive status, the patients were classified as well nourished (normally nourished and obese), moderately undernourished and severely undernourished. Based on the similarities and differences in the assessment results, obtained according to each of 6 parameters, the optimal nutritional assessment parameters were defined, separately for the well-nourished/undernourished patients and for moderately/severely undernourished patients.

RESULTS

The incidence of malnutrition was in the range 5.9-29.7%. The results based on MAMC, ALB, and LYM were similar (25.2-29.7%; p > 0.05), while the results based on WL, BMI, and TSF differed significantly (5.9-19.9%; p = 0.001-0.015). The assessment based on BMI was the most severe criterion, while the assessment according to MAMC was the mildest criterion in selection of malnourished patients. The assessment according to MAMC was the mildest criterion for the selection of severe malnourished patients (severely malnouorished patients accounted for 70.1%), while BMI and LYM were the most severe criteria (severely malnouorished patients accounted for 22.2% and 27.3%, respectively). The results based on BMI and LYM were similar (Wilcoxon test; p > 0.05).

CONCLUSION

Combining BMI with MAMC is sufficient for the assessment of the nutritional status of gastroenterological patients on admission, as well as for differentiation between severely malnourished and moderately malnourished patients.

A two-colour chewing gum test for masticatory efficiency: development of different assessment methods

OBJECTIVE

The aim of this study was to investigate different assessment methods of a two-colour chewing gum test for masticatory efficiency to determine its validity for research and clinical purposes.

MATERIALS AND METHODS

Twenty adult volunteers, eleven women and nine men (mean age of 27.5 years), participated in this study. All participants perceived their masticatory efficiency as normal. The task was to chew five samples of a two-colour chewing gum for 5, 10, 20, 30 and 50 cycles respectively. Maximum bite force was measured. All samples were assessed twice by two independent operators both, as 'bolus' and after flattening to 1 mm thick 'wafers'. The latter were scanned and the unmixed pixels counted using Adobe Photoshop Elements to calculate the ratio of unmixed colour to the total surface.

RESULTS

Digital image processing confirmed a significant correlation between colour mixing and chewing duration (P < 0.001). Subjective assessment proved less accurate with fair to substantial intra-examiner agreement for 'bolus' (0.20 < kappa < 0.63) and substantial to almost perfect agreement for 'wafer' (0.60 < kappa < 0.88). Inter-examiner agreement was consistently moderate or substantial only for specimen chewed 20 cycles or longer. No significant correlation was found between the colour mixture and the maximum bite force.

CONCLUSION

Digital image processing of the two-colour chewing gum test specimen provides reliable quantitative data for chewing efficiency. Visual assessments were less reliable but might still be useful in screening for chewing deficiencies in a clinical setting. In this context, the test should be performed with a flattened specimen chewed, probably for 20 cycles.

Sarcopenia is predictive of nosocomial infection in care of the elderly

Protein-energy malnutrition and nosocomial infection (NI) are frequent in elderly patients, and a causal link between the two has often been suggested. The aim of the present study was to identify the nutritional parameters predictive of NI in elderly patients. We assessed on admission 101 patients (sixty-six women, thirty-five men, aged over 65 years) admitted to an acute care of the elderly department. Sarcopenia was detected by dual-energy X-ray absorptiometry, with appendicular skeletal muscle mass expressed with respect to body area. Weight, BMI, albuminaemia, serum transthyretin and C-reactive protein values were also determined on admission, and known risk factors, such as functional dependence and invasive biomedical material, were also evaluated. After up to 3 weeks of hospitalisation, patients were classified according to whether they had developed an NI. After 3 weeks of hospitalisation, we found that twenty-nine patients had suffered an NI, occurring after a mean of 16.1 d. Patients who were sarcopenic on admission had a significantly higher risk of contracting an NI (relative risk 2.1, 95 % CI 1.1, 3.8). None of the other morphometric or biological parameters differed significantly between the two groups of patients on admission. Patients who experienced an NI were also more likely, on admission, to have a medical device (P=0.02 to P=0.001 depending on the device), to have swallowing problems (P=0.002) or to have restricted autonomy (P<0.01). Sarcopenia on admission to an acute care of the elderly unit, as measured by X-ray absorptiometry, was therefore associated with a doubled risk of NI during the first 3 weeks of hospitalisation.

Salivary sIgA and cortisol: markers for functional dependence in older adults

Elderly persons with health problems and physical limitations have reduced independence. Since poor functional ability is a known risk factor for disease among older populations, including oral disease, this study was undertaken to assess whether salivary defense factors and the stress hormone cortisol are significant markers for functional dependence. Oral examinations; salivary and microbial analyses; and interviews using the Activities of Daily Living (ADD index, the Mini Nutritional Assessment (MNA) and the Perceived Life Stress Questionnaire (PLSQ) were conducted for 123 dentate subjects. Of the subjects, 80 lived independently in the community or in apartments at the Baycrest Centre for Geriatric Care in Toronto, Canada, and 43 resided in the Baycrest nursing home or the Baycrest Hospital. Whole saliva samples were assayed for total secretory immunoglobulin A (sIgA), sIgA1, sIgA2, total protein and cortisol using ELISA. Dependent residents in the nursing home/hospital scored significantly lower in the nutritional assessment, had higher mean PLSQ scores, increased total protein and cortisol concentrations, and reduced salivary flow rates in comparison to ambulatory residents in the community/apartments. In multivariable logistic regression, factors associated with functional dependence were: being male, perceiving income as inadequate, having low salivary flow rate and drinking less than 5 cups of water per day. These results indicate that salivary flow and cortisol may be useful markers of functional dependence; however, the ability of these markers to predict functional decline cannot be confirmed until longitudinal studies are conducted.

Mundgesundheit, Zahnstatus und Ernährung im Alter

The loss of natural teeth impairs essentially the chewing function and can only partly be restored by the insertion of dental prostheses. Equally, xerostomia and dysphagia may aggravate the nutritional intake in older adults. Often denture wearers do subjectively not notice the adjustment of their food choice and the employment of special preparation techniques. Finally the dental state influences the nutritional intake. A reduced number of teeth correlates with the intake of less calories, proteins, fat, non-starch polysaccharides and vitamins. Often missing calories are compensated by an increased consumption of sugar and fat. Especially edentulous persons with a low level of education choose a diet which is rich in fat and sugar. Further the daily intake of fruit and vegetables diminishes along with fewer occlusal contacts in posterior teeth. The restoration of the chewing function by dental intervention does not lead to an improvement of the nutritional intake by itself and should therefore always be complemented by nutritional advice.

Impact of dry mouth on oral symptoms and function in removable denture wearers in Japan

OBJECTIVE

The purpose of this study was to determine the association of dry mouth with oral symptoms and function, such as denture instability, discomfort, soreness in denture-bearing tissue, and dissatisfaction with chewing, tasting, or speaking in removable denture wearers.

STUDY DESIGN

The subjects were 493 removable denture wearers with a mean age of 67.3 years. Perception of oral dryness was measured by a questionnaire. A multiple logistic regression analysis was used to determine the effect of the dry mouth on oral symptoms and function after controlling for age and gender.

RESULTS

Oral dryness during eating was related to dissatisfaction with chewing (odds ratio, 10.5; P < .001) and speaking (odds ratio, 3.5; P < .05) and overall dissatisfaction (odds ratio, 6.3; P < .01) in complete denture wearers. Feeling of dry mouth was likely to be associated with soreness in denture-bearing tissues in both complete and removable partial denture wearers.

CONCLUSIONS

There was a significant association of the perception of dry mouth among a group of denture wearers with oral symptoms and function.

Oral health promotion for our ageing Australian population

The ageing Australian population living in the new millennium has dental needs that are very different and more complex than those experienced by previous older adult cohorts during the twentieth century. A summary of the oral health status of older Australians is presented, together with a review of the important relationships between general health and oral health. The key to maintaining and improving older adults' oral health status is the use of oral health promotion strategies that focus not only on dental characteristics, but also on the life characteristics of older adults, and on their quality of life issues. Traditionally, there has been very limited geriatric oral health promotion, with several myths contributing to this situation. Contemporary geriatric oral health promotion in the new millenium has an evidence-based and planned approach. It encompasses not only the treatment of oral diseases and conditions, but has an increased focus on the prevention of oral diseases and conditions to enhance oral health status and older adults' quality of life. Using the Ottawa Charter and a functional dependence classification, a geriatric oral health promotion matrix is presented, using a specific example of Australian residential care.

Oral status, cognitive and functional capacity versus oral treatment need in nursing home residents: a comparison between assessments by dental and ward staff

OBJECTIVES

The aim of this study was to study the relationships between cognitive and functional capacity versus oral health and treatment need and to compare oral status assessments and oral treatment need, assessed by nurses and dental professionals, respectively.

DESIGN

Cross-sectional survey.

SETTING

Nursing home.

SUBJECTS

One hundred and ninety-two nursing home residents were examined in 1997.

MAIN OUTCOME MEASURES

Cognitive and functional capacity in different groups of residents regarding oral health and treatment need, measured by a comprehensive assessment with the Resident Assessment Instrument (RAI) and dental status in a separate examination protocol, recorded by a dentist.

RESULTS

There was a significant correlation between being dentate and having need of oral treatment. Those who were able to chew also had significantly better cognitive and functional capacity. Oral treatment need was identified most often by the dentist, intermediately by the RAI assessment and least frequently by the residents themselves.

CONCLUSIONS

Being dentate and having a loss of cognitive and functional capacity is predictive of oral treatment need among nursing home residents. Enhanced interaction between nurses and dental professionals needs to be promoted for better awareness of preventive measures and better regular oral care for frail and dependent elderly persons.

Nutrition as a mediator in the relation between oral and systemic disease: associations between specific measures of adult oral health and nutrition outcomes

Recent associations between oral health and systemic disease have led to renewed interest in the mouth and its contribution to health outcomes. Many pathways for this relationship have been postulated, among them the potential mediating role of nutrition. The link between various nutrients and systemic disease has been established, but relatively little work has been done in relating oral conditions with nutrition. We searched MEDLINE, from 1966 to July, 2001, to identify articles relating specific oral measures to nutrition outcomes. We included original articles written in English with a sample size greater than 30 that used objective oral health measures. We reviewed a total of 56 articles. Only a small proportion of these studies were methodologically sound. Although many studies were small and cross-sectional, the literature suggests that tooth loss affects dietary quality and nutrient intake in a manner that may increase the risk for several systemic diseases. The impact of tooth loss on diet may be only partially compensated for by prostheses. To date, there is little information relating periodontal disease and oral pain and nutrition. A few studies suggest poorer nutrition among individuals with xerostomia and altered taste. Further, impaired dentition may contribute to weight change, depending on age and other population characteristics. There is a paucity of well-designed studies addressing oral health and nutrition. Before we can acquire a better understanding of how nutrition and oral health interrelate, however, more studies will be required to confirm these associations-preferably longitudinal studies with larger sample sizes and better control of important confounders.

Nursing personnel's views on oral health from a health promotion perspective: a grounded theory analysis

The aim of this study was to develop a model for how nursing personnel view oral health in general and the oral health of the care receivers in particular, applying a health promotion perspective and using grounded theory analysis. Data were collected through interviews with 17 nursing personnel, selected by strategic sampling. Analysis of the transcribed interviews showed that there were four strategies, related to staff education, hospital resources, and leadership motivation. The strategies were grounded in data and emerged from the interaction between the two main categories: 'the valuation of the importance of oral health' and 'the behavior towards oral health maintenance'. They were characterized as the routine, theoretical, practical, and flexible strategies, with the latter considered ideal. As increased knowledge is one important part in enhancing the nursing personnel's ability to perform oral hygiene procedures, there is a need for education among nursing personnel, primarily among those using a routine strategy.

Nutrition and oral health

Reduced chewing function in community-dwelling older people with adequate general health is linked to having fewer than 20 teeth present or to wearing removable dentures. By chewing for longer periods of time or swallowing larger food particles they are normally able to compensate for the impaired function. The masticatory function can be restored by adequate prosthetic therapy, which results in increased activity of the masticatory muscles during chewing and reduces the chewing time and the number of chewing strokes until swallowing. In frail or dependent elderly people undernutrition is prevalent because of health problems, reduced appetite and poor quality of life. Poor oral health and xerostomia are often associated with a reduced body mass index and serum albumin level and the avoidance of difficult-to-chew foods. Maintenance or re-establishment of masticatory function is an integral part of the medical health care of these patients, with the aim of improving their nutritional status and quality of life.

Nutritional status and chewing capacity in nursing home residents

Chronically ill elderly persons sustain a high risk for protein-energy malnutrition (PEM). In this study we explored some of the complex associations between nutritional status, dental health and cognitive and physical function in 192 nursing home residents (mean age 84+/-8 years, 80% female). Nutrition-related data from the Resident Assessment Instrument (RAI) were compiled into a Nutrition Score (NuSc; 0-1 = non-PEM, 2 = risk for PEM, and 3-7 = PEM). Chewing capacity, according to number and condition of occlusal contacts, was determined by a Clinical Dental Functionality score (CDF). The Cognitive Performance Scale (CPS) and activities of daily living (ADL) were determined according to the RAI. Fifty percent of the residents had NuSc > or = 2, and 25% had NuSc > or = 3. One third did not have the dental prerequisites for chewing. i.e., < 4 occlusal contacts. Almost half of the residents had severe cognitive dysfunction, and over two thirds were severely limited in their ADL activities. Subjects with > or = 4 occlusal contacts, i.e., technical chewing capacity, had better NuSc (1.5+/-1.4) than those not able to chew (2.4+/-1.6, p=0.0005). In univariate logistic regression, the odds for NuSc > or = 2 increased with reduced ADL functions. inability to chew and poor cognition. In multivariate logistic regression, ADL and chewing capacity were significantly related to NuSc > or = 2. When NuSc > or = 3 was chosen as cut-off, only ADL was related to malnutrition. In conclusion, half of this group of nursing home residents appeared to be malnourished, or were at risk for PEM. Reduced physical function was the strongest predictor of PEM, while impaired chewing capacity was associated with risk for PEM.

Successful aging--the case for prosthetic therapy

Reduced chewing ability in community-dwelling older people is linked to the presence of removable dentures and having fewer than 20 natural teeth present. Compensation is provided by chewing longer and swallowing larger food particles. Replacement of posterior tooth loss by fixed or removable prostheses increases the activity of the masticatory muscles, and reduces chewing time and the number of chewing strokes until swallowing. In residents of nursing homes and long-term care facilities undernutrition is prevalent because of general medical problems, reduced appetite, and poor quality of life. Poor oral health and xerostomia are often present and may have a negative effect on masticatory function and nutrition, precipitating avoidance of difficult-to-chew foods. There is no evidence that the provision of prosthetic therapies can markedly improve dietary intakes; however, it might improve oral comfort and quality of life and avoid enteral alimentation.

Perception of dry mouth in a sample of community-dwelling older adults in Japan

The purpose of this study was to examine the prevalence of perceived dry mouth among a group of independently-living elderly persons in Japan, and to determine its association with general disease, medication, and dental status, as well as its effect on oral function. The study population consisted of participants of the Senior Citizens' College. The subjective sensations of oral dryness on waking and while eating a meal were measured by a questionnaire. The number of usable questionnaires was 1003 or 77.9%. The mean age of the subjects was 66.3 +/- 4.2 years, and 53.0% were male. More than one-third (37.8%) of the subjects reported oral dryness on waking. Only 9.1% of them noticed a subjective feeling of dry mouth during eating. Persons who had at least one of these symptoms made up 41.0%. A multiple stepwise logistic regression analysis indicated the following results: Perception of dry mouth on waking was more frequent among males (p < 0.001), persons who had a low BMI (p < 0.05), and those taking two or more prescribed drugs (p < 0.01). Sensation of dry mouth when eating was more frequent among subjects with a low BMI (p < 0.001) and those who wore a denture in the maxillary arch (p < 0.05). Perception of dry mouth when eating was associated with self-assessed chewing ability (p < 0.01) and dissatisfaction with speaking clearly (p < 0.05), as well as dental status. However, dissatisfaction with tasting a meal had a significant relationship with the reports of mouth dryness on waking (p < 0.01). Our findings suggest that a substantially higher percentage of persons have the perception of dry mouth on waking than when eating, which was associated with medications, being male, and having a low BMI. This perception may influence oral function, especially the reported dissatisfaction with tasting foods.

A longitudinal analysis of salivary flow in control subjects and older adults with type 2 diabetes

OBJECTIVE

Many diabetics complain of xerostomia, a condition that can affect oral health, nutritional status, and diet selection. This study's purposes were (1) to investigate the effect on salivary flow of type 2 diabetes and change in glycemic control in a group of older adults over time and (2) to compare flow rates with subjective complaints of xerostomia.

STUDY DESIGN

A total of 39 older adults, 24 with type 2 diabetes and 15 who were nondiabetic (controls), aged 54-90 years, participated in a 1-year follow-up study. Diabetic status was determined by means of glycosylated hemoglobin (HbA1c) levels and 2-hour glucose tolerance tests. Poor glycemic control was defined as HbA1c > 9%. Unstimulated whole, unstimulated parotid, and stimulated parotid saliva flow rates were measured for all subjects by a single examiner at baseline and 1 year later. Each subject completed a standardized xerostomia questionnaire at every visit.

RESULTS

Age, sex, and duration of diabetes did not adversely affect salivary flow rates. Subjects with poorly controlled diabetes had significantly lower stimulated parotid saliva flow rates at both visits. There were no significant changes in flow rates over time on the basis of diabetic status or glycemic control. Subjects with diabetes reported significantly more complaints of thirst but not of xerostomia at 1 year.

CONCLUSIONS

These results suggest that older adults with poorly controlled diabetes may have impaired salivary flow in comparison with subjects with better controlled diabetes and nondiabetic subjects, yet they may not have concomitant xerostomic complaints. There were no significant changes in salivary flow rates or glycemic control over the 1-year period.

[Unexplained weight loss in the elderly: role of gastric fibroscopy, study of a cohort of 77 patients with a 13-month follow-up]

PURPOSE

In case of unexplained weight loss, chest X-ray, abdominal ultrasonography and gastroscopy are usually recommended. However, gastroscopy is not usually performed in elderly patients.

METHODS

We evaluated 77 patients (mean age: 80 +/- 8 years) hospitalized in our geriatric unit between January 1995 and May 1997 for unexplained weight loss. All patients underwent chest X-ray, abdominal ultrasonography and gastroscopy.

RESULTS

These investigations led to diagnosis in respectively 17, 15 and 46 patients. The etiology of weight loss was unique in 47 patients, while in 30 other patients at least two or three causes could be described. Gastroscopy appeared to be the most useful test, as it allowed description of eight cases of cancer, 29 cases of peptic ulcer, two cases of candidosis, and one case of actinomycosis in patients who did not present any clinical sign.

CONCLUSION

Sixty-five patients were followed-up for a mean period of 13 +/- 21 month; 33 patients died. The condition of 23 patients improved either slightly or definitely. Simple investigations led to diagnosis in 95% of the cases. However, 42% of the patients died within 3 months. Gastroscopy appears to be the most valuable test, leading to diagnosis in more than half of the cases. With adapted treatment, the condition of 75% of the patients with gastro-intestinal lesions improved.

Salivary function and glycemic control in older persons with diabetes

OBJECTIVE

There is no consensus on the possible association between diabetes and salivary dysfunction in older persons with diabetes. This study's purpose was to investigate the effect of diabetes and glycemic control on salivary function in an older population.

STUDY DESIGN

Twenty nine persons with type 2 diabetes and 23 nondiabetic control subjects participated (age range, 54-90 years). Diabetic status was determined by a glycosylated hemoglobin (HbA(1c)) test and a 2-hour glucose tolerance test. Poor glycemic control was defined as HbA(1c) >9%. Unstimulated whole saliva, unstimulated parotid, and stimulated parotid flow rates were measured, and subjects completed a standardized xerostomia questionnaire.

RESULTS

Persons with poorly controlled diabetes had lower (P =.01) stimulated parotid flow rates than persons with well-controlled diabetes and nondiabetic control subjects. There were no significant differences in xerostomic complaints based on diabetic or glycemic control status or salivary flow rates.

CONCLUSIONS

These results provide some evidence that poorly controlled diabetes may be associated with salivary dysfunction in older adults who have no concomitant complaints of xerostomia.

Socio-medical condition and oral functional status in an older institutionalised population

OBJECTIVES

To investigate the association between the general medical condition, the socio-economic status, and some factors related to the functional status of the stomatognathic system.

DESIGN

A survey in an elderly population.

SUBJECTS

257 older adults, with a mean age of 83.7 years.

SETTING

Residential homes for the elderly.

INTERVENTION

Examination of the medical records on the overall health and the drugs consumed, a structured interview on the socio-economic status, the complaints for xerostomia, the subjective chewing difficulties, and a clinical evaluation of the number of natural teeth and the number of posterior occluding pairs of teeth contacts (premolars and molars).

RESULTS

Multiple pathology and polypharmacy were recorded. 25% of the residents had no occluding posterior tooth contact (natural or prosthetic) and 62% were edentulous. 43% of the residents reported complaints for xerostomia, and 46% for chewing difficulties when eating specific food types. Xerostomic feelings and chewing problems were not related to age. Chewing difficulties were not related to the number of natural teeth, but to the number of posterior occluding teeth contacts, natural or prosthetic (less than two). From all medical conditions examined, only the psychiatric disorders were significantly related to dental status (p < 0.05). Moreover, the number of remaining natural teeth was related to socio-economic status, while the number of posterior occluding teeth contacts was also inversely related to the duration of institutionalisation (p < 0.05).

CONCLUSIONS

Psychiatric disorders, low socio-economic status and increased duration of institutionalisation were most closely related to poor dental status. The presence of more than two posterior occluding teeth contacts, natural or prosthetic, benefit the very old patient in terms of reduced subjective chewing difficulty. A formal oral care delivery system for the institutionalised elderly, and particularly for those suffering from psychiatric disorders, is imperative.

Associations between self-assessed masticatory ability, nutritional status, prosthetic status and salivary flow rate in hospitalized elders

OBJECTIVES

To compare the association between self-assessed masticatory ability and nutritional status with general health status, salivary flow and dental/prosthetic status.

DESIGN

A questionnaire and a cross-sectional clinical investigation combined with a measurement of salivary flow rates.

SUBJECTS AND METHODS

A cohort of 99 elderly, non-psychiatric patients in a geriatric hospital; clinical examination to determine dental and prosthetic status, oral health and whole unstimulated (USFR) and stimulated (SSFR) salivary flow rates, examination of anthropometric measures, serum albumin level and body mass index (BMI); questionnaire designed to produce yes or no answers related to masticatory function, nutritional status, appetite and prosthesis function; mini mental score examination (MMES).

MAIN OUTCOME MEASURES

USFR, SSFR, BMI, anthropometric measures and serum albumin level; complaints related to appetite and xerostomia.

RESULTS

Mean age of the 99 patients was 82.5 +/- 4.04 with a MMES of > 21; 50% with malnutrition of severe or intermediate degree, and 86% with moderately or severely reduced serum albumin concentration; 55% reported recent loss of appetite and 52% had symptoms of oral dryness. Recent loss of appetite was associated with reduced serum albumin and complaints of dry mouth and lack of appetite was associated with BMI < 21, 10% weight loss during the preceding 6 months, SSFR < or = 0.5 ml min-1 and wearing dentures. Complaints on poor retention of the maxillary denture were associated with recent weight loss and SSFR < or = 0.5 ml min-1.

CONCLUSIONS

Malnutrition in hospitalized elders is primarily associated with recent loss or lack of appetite whereas complaints related to dentures are associated with poor denture quality.