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.

Association of medication use with falls and mortality among long-term care residents: a longitudinal cohort study

BACKGROUND

Falls in long-term care are common. The aim of our study was to explore how medication use is associated with incidence of falls, related consequences, and all-cause mortality among long-term care residents.

METHODS

Five hundred thirty two long-term care residents aged 65 years or older participated in this longitudinal cohort study in 2018-2021. Data on medication use were retrieved from medical records. Polypharmacy was defined as use of 5-10 medications and excessive polypharmacy as use of > 10 medications. The numbers of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment. Participants were followed for three years for mortality. All analysis were adjusted for age, sex, Charlson Comorbidity Index, Clinical dementia rating, and mobility.

RESULTS

A total of 606 falls occurred during the follow-up. Falls increased significantly with the number of medications used. Fall rate was 0.84/person-years (pyrs) (95% CI 0.56 to 1.13) for the non-polypharmacy group, 1.13/pyrs (95% CI 1.01 to 1.26) for the polypharmacy group, and 1.84/pyrs (95% CI 1.60 to 2.09) for the excessive polypharmacy group. Incidence rate ratio for falls was 1.73 (95% CI 1.44 to 2.10) for opioids, 1.48 (95% CI 1.23 to 1.78) for anticholinergic medication, 0.93 (95% CI 0.70 to 1.25) for psychotropics, and 0.91 (95% CI 0.77 to 1.08) for Alzheimer medication. The three-year follow-up showed significant differences in mortality between the groups, the lowest survival rate (25%) being in the excessive polypharmacy group.

CONCLUSION

Polypharmacy, opioid and anticholinergic medication use predicted incidence of falls in long-term care. The use of more than 10 medications predicted all-cause mortality. Special attention should be paid to both number and type of medications when prescribing in long-term care.

Relationship of occlusal status with health-related quality of life among older adults in long-term care facilities

BACKGROUND

Loss of teeth is common among residents in long-term care facilities (LTCF). To maintain occlusal support, lost teeth may be replaced with removable dentures.

OBJECTIVES

The relationship of occlusal status with health-related quality of life (HRQoL) was evaluated.

METHODS

A cross-sectional FINORAL study (FINnish ORAL Health Studies in older adults), including comprehensive geriatric assessment, was performed in LTCF. Demographic and medical information was retrieved from medical records. HRQoL was assessed with the 15D instrument and nutritional status with Mini-Nutritional Assessment (MNA). A standardised questionnaire filled in by trained nurses collected information on need for assistance in personal care or mobility, eating, and food consistency and swallowing difficulties. Clinical oral examination focusing on occlusal status was conducted for 338 residents. Four study groups (Gr) were established: Gr1 ≥ 10 natural teeth occlusal contact units (CU) (N = 51), Gr2 < 10 natural teeth CU (N = 87), Gr3 having CU of removable denture/s with or without natural teeth (N = 89), and Gr4 no CU (N = 111).

RESULTS

15D index score (adjusted for age, sex, MNA, and Charlson comorbidity index) showed higher HRQoL in Gr1 and Gr3; Gr1 participants had significantly higher crude values in mobility and Gr3 participants in eating, speech, and mental function than the other groups. Differences were present between the study groups in nutritional status, swallowing difficulties, and need for assistance in eating and mobility.

CONCLUSION

Occlusal status of partial or complete denture/s with or without natural teeth or natural teeth having 10 or more occlusal CU was associated with higher HRQoL than other statuses.

Home-Applied Dual-Light Photodynamic Therapy in the Treatment of Stable Chronic Periodontitis (HOPE-CP)-Three-Month Interim Results

A single-site, randomized clinical trial was designed to determine the efficacy of regular home use of Lumoral® dual-light antibacterial aPDT in periodontitis patients. For the study, 200 patients were randomized to receive non-surgical periodontal treatment (NSPT), including standardized hygiene instructions and electric toothbrush, scaling and root planing, or NSPT with adjunctive Lumoral® treatment. A complete clinical intraoral examination was conducted in the beginning, at three months, and at six months. This report presents the three-month results of the first 59 consecutive randomized subjects. At three months, bleeding on probing (BOP) was lower in the NSPT + Lumoral®-group than in the NSPT group (p = 0.045), and more patients in the NSPT + Lumoral®-group had their BOP below 10% (54% vs. 22%, respectively, p = 0.008). In addition, patients in the NSPT + Lumoral®-group improved their oral hygiene by visible-plaque-index (p = 0.0003), while the NSPT group showed no statistical improvement compared to the baseline. Both groups significantly reduced the number of deep periodontal pockets, but more patients with a reduction in their deep pocket number were found in the NSPT + Lumoral® group (92% vs. 63%, p = 0.02). Patients whose number of deep pockets was reduced by 50% or more were also more frequent in the NSPT + Lumoral®-group (71% vs. 33%, p = 0.01). Patients with initially less than ten deep pockets had fewer deep pockets at the three-month follow-up in the Lumoral® group (p = 0.01). In conclusion, adjunctive use of Lumoral® in NSPT results in improved treatment outcomes at three months post-therapy.

Oral disease burden of dentate older adults living in long-term care facilities: FINORAL study

BACKGROUND

A growing number of older adults have natural teeth and are at high risk of oral diseases, which are induced by oral bacterial accumulation and proceed unnoticed and quietly. Our aim was (1) to examine the association of oral disease burden (ODB) with health and functioning among dentate long-term care residents, and (2) to find easily detectable signs for nurses to identify residents' poor oral health.

METHODS

In this cross-sectional observational study dentists examined 209 residents' oral status, and nurses assessed residents for their functioning and nutrition in long-term care facilities in Helsinki, Finland. ODB was defined by asymptotic dental score (ADS). Six clinical signs of residents' poor oral health were considered as potentially easy for nurses to detect: lesions on lips, teeth with increased mobility, lesions on oral mucosa, eating soft or pureed food, unclear speech, and needing assistance in eating. The association of these was tested with high ODB as outcome.

RESULTS

Participants were grouped according to their ADS scores: low (n = 39), moderate (n = 96) and high ODB (n = 74). ODB was linearly associated with coronary artery disease and poor cognitive and physical functioning: needing assistance in eating, poor ability to make contact, and unclear speech but not with other diseases including dementia or demographic characteristics. Furthermore, ODB was linearly associated with eating soft or pureed food. Of the six selected, easily detectable signs, having at least two positive signs gave 89% sensitivity to detecting high ODB.

CONCLUSION

Poor oral health was common and ODB accumulated among residents with poor functioning. Nurses may use a few easily detectable signs to screen residents' oral health when considering a resident's need for consultation with an oral health professional.

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

BACKGROUND

oral frailty (OFr) may be called a syndrome lacking a consensus on its definition.

OBJECTIVE

the aim was to prove the relationship between OFr to the phenotype of frailty, general health and nutrition in long-term care.

DESIGN

the FINnish ORAL Health Study in Long-Term Care study is a cross-sectional clinical research comprising findings on oral and general health and nutrition.

SETTING

participants were divided into groups according to the number of OFr signs: Group 1 (0-1 sign), Group 2 (2-4 signs) and Group 3 (5-6 signs).

SUBJECTS

the study includes data on 349 older residents of long-term care facilities in Helsinki, Finland.

METHODS

frailty status was defined according to Fried's frailty phenotype. OFr was evaluated with six signs: dry mouth, diet of pureed or soft food, residue of food on oral surfaces, unclear speech, inability to keep mouth open during the clinical oral examination and pain expression during the examination.

RESULTS

a significant linear relationship across the OFr groups with Fried's frailty phenotype was found (P for linearity = 0.008, adjusted by gender and age). A linear trend existed between OFr groups and general health; prevalence of dementia and malnutrition increased from Group 1 to Group 3. The need for help with eating and oral hygiene procedures increased from Group 1 to Group 3. Moreover, OFr had a linear relationship with chewing and swallowing difficulties.

CONCLUSIONS

OFr is related to Fried's frailty phenotype, general health, nutrition and need for help with daily activities.

Burden of Oral Symptoms and Health-Related Quality of Life in Long-Term Care Settings in Helsinki, Finland

OBJECTIVES

Poor oral health may complicate eating and deteriorate nutritional status. However, little is known about how the burden of oral symptoms (OS) is associated with the health-related quality of life (HRQoL) of vulnerable older people in institutional settings. This study explores how the burden of certain OS (chewing problems, swallowing difficulties, dry mouth) is associated with functioning, morbidity, nutritional status and eating habits. It also examines the association between the OS burden and HRQoL.

DESIGN

A cross-sectional study in 2017.

SETTING

All long-term care wards in Helsinki, Finland.

PARTICIPANTS

2401 older residents (74% females, mean age 83.9).

MEASUREMENTS

Nurses assessed the residents and completed questionnaires on the participants' demographics, functional status, diagnoses, OS and eating habits. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) and HRQoL with a 15-dimensional instrument (15D).

RESULTS

Of the residents, 25.4% had one OS and 16.6% two or three OS. OS burden was associated linearly with poorer cognitive and physical functioning and a higher number of comorbidities, edentulousness without dentures, and less frequent teeth brushing/denture cleaning. OS burden was also associated with malnutrition, lower BMI and eating less during main meals. In the multivariate analyses adjusted for various confounding factors, a higher number of OS was associated with lower HRQoL. OS burden correlated with nearly all dimensions of HRQoL.

CONCLUSION

Oral symptoms are associated with generic HRQoL. Therefore, OS should be regularly assessed and managed in daily care.

Associations between Nutritional Status and Health-Related Quality of Life among Long-Term Care Residents in Helsinki

OBJECTIVES

We evaluated the associations between nutritional status and health-related quality-of-life (HRQoL) among older long-term care residents in Helsinki.

DESIGN AND PARTICIPANTS

All 3767 older (≥65 years) long-term care residents in Helsinki in 2017 were invited to participate in this cross-sectional study. After refusals and exclusions of residents without sufficient information, 2160 residents remained.

MEASUREMENTS

Data on characteristics, nutritional status (Mini Nutritional Assessment, MNA) and HRQoL (15D) were collected by trained nurses.

RESULTS

Of the participants, 64% were at-risk of malnutrition and 18% suffered from malnutrition. Residents in the "malnourished" group were more dependent in activities of daily living (ADL) functioning, suffered more often from dementia, had lower cognitive level, used less medications, and were eating more often inadequately. HRQoL was statistically significantly associated with MNA total score in both female and male residents. There was a curvilinear correlation between MNA and 15D score in females: 0.50 (95% CI 0.46 to 0.53) and males: 0.56 (95% CI 0.50 to 0.61). In partial correlation analysis, all dimensions of 15D, except for sleeping and breathing, were positively associated with MNA score. In these analyses no significant differences emerged between males and females when the results were adjusted for age and dementia.

CONCLUSIONS

Nutrition plays an important role in HRQoL among older long-term care residents.

Changes in malnutrition and quality of nutritional care among aged residents in all nursing homes and assisted living facilities in Helsinki 2003-2011

BACKGROUND

While nutritional problems have been recognized as common in institutional settings for several decades, less is known about how nutritional care and nutrition has changed in these settings over time.

OBJECTIVES

To describe and compare the nutritional problems and nutritional care of residents in all nursing homes (NH) in 2003 and 2011 and residents in all assisted living facilities (ALF) in 2007 and 2011, in Helsinki, Finland.

METHODS

We combined four cross-sectional datasets of (1) residents from all NHs in 2003 (N=1987), (2) residents from all ALFs in 2007 (N=1377), (3) residents from all NHs in 2011 (N=1576) and (4) residents from all ALFs in 2011 (N=1585). All participants at each time point were assessed using identical methods, including the Mini Nutritional Assessment (MNA).

RESULTS

The mean age of both samples from 2011 was higher and a larger proportion suffered from dementia, compared to earlier collected samples. A larger proportion of the residents in 2011 were assessed either malnourished or at-risk for malnutrition, according to the MNA, than in 2003 (NH: 93.5% vs. 88.9%, p<0.001) and in 2007 (ALF: 82.1% vs. 78.1%, p=0.007). The use of nutritional, vitamin D and calcium supplements, and snacks between meals was significantly more common in the 2011 residents, compared to the respective earlier samples.

CONCLUSIONS

In 2011, institutionalized residents were more disabled and more prone to malnourishment than in 2003 or 2007. Institutions do seem to be more aware of good nutritional care for vulnerable older people, although there is still room for improvement.

Dentition, nutritional status and adequacy of dietary intake among older residents in assisted living facilities

OBJECTIVE

We examined the relationships between dentition, nutritional status and dietary intakes of energy, protein and micronutrients among older people in assisted living facilities in Helsinki.

BACKGROUND

Poor dentition is associated with malnutrition. Less is known about how dentition is associated with detailed nutrient intakes in institutionalised older people.

MATERIALS AND METHODS

This cross-sectional study assessed 343 participants (mean age 83 years). Dentition was assessed by trained ward nurses and divided into edentulous participants without dentures (group 1), edentulous participants with removable dentures (group 2) and those with any natural teeth (group 3). Nutritional status was assessed by Mini Nutritional Assessment (MNA). The energy, protein and nutrient intakes were calculated from detailed 1-day food diaries and compared with the recommendations of the Finnish National Nutrition Council as a measure of dietary adequacy. Assessment included also participants' cognitive and functional status.

RESULTS

Of the participants, 8.2, 39.1 and 52.8% were in groups 1, 2 and 3, respectively. Altogether 22% were malnourished according to MNA. Group 1 had the poorest nutritional status. A large proportion of participants consumed less than the recommended amounts of energy, protein or micronutrients. Half of the participants consumed <60 g/day of protein. The intake of protein was significantly lower in group 1 than in other two groups.

CONCLUSION

Malnutrition and inadequate protein intake were very common and associated with dentition among older people with multiple disabilities in assisted living facilities. Assessment of dental status should be part of good nutritional care in long-term care.

Caregiver-reported swallowing difficulties, malnutrition, and mortality among older people in assisted living facilities

OBJECTIVE

The aim of this study is to explore the prevalence of swallowing difficulties (SWD) and their associations with nutritional status, eating habits, nutritional care, and mortality among older people in assisted living.

DESIGN

A cross-sectional study with interviews and nutritional assessments at baseline and 3-year follow-up for mortality.

SETTING

Assisted living facilities in the Helsinki metropolitan area, Finland.

PARTICIPANTS

All residents (N=1466) in assisted living facilities.

MEASUREMENTS

Personal interviews yielded information on demographics, medical history, functional status, SWDs and eating habits. Residents' nutritional status was assessed with the Mini Nutritional Assessment (MNA). Three-year mortality data were retrieved from central registers.

RESULTS

SWDs were common; 11.8% of subjects suffered from them. Those with SWDs were older, more often female, and more frequently had Parkinson's disease, chronic obstructive pulmonary disease (COPD), and chronic/ recurrent infections than those without SWDs. No differences were present between the groups in prevalence of stroke or dementia, but more severe cognitive decline occurred among those with SWDs. According to the MNA, 30.6% of those with SWDs were malnourished (<17 points), whereas the respective figure for those without SWDs was 11.0% (p < .001). Those with SWDs ate more often fluid or puréed food (27.8% vs. 3.8%, p < .001), ate more often little or quite little of their food portion (32.6% vs. 23.5%, p < .010), and consumed less fluids (< 5 cups/day 51.7% vs. 35.6%, p< .001) than those without SWDs. Of those with SWDs, 55.0% died by the end of follow-up, whereas the respective figure for those without SWDs was 41.5%. In logistic regression analysis using age, sex, comorbidities, and MNA as covariates, SWDs continued to predict mortality (OR=1.49, 95% CI=1.04 -2.12).

CONCLUSIONS

SWDs are common and associated with poor nutrition and risk of death of patients in assisted living facilities. Nurses should be trained to assess SWDs and nutritional problems in order to take optimal care of these residents.

Dentition status, malnutrition and mortality among older service housing residents

BACKGROUND

Oral health status and oral health problems can affect eating habits and thus consequently the nutritional status of frail older people.

OBJECTIVES

To assess older service house residents' dentition and its associations with nutritional status and eating habits, and as well as to explore the prognostic value of dentition status for mortality.

DESIGN

A cross-sectional study with a three-year follow-up.

METHODS

In 2007, we assessed the nutritional status of all residents in service houses in the two cities of Helsinki and Espoo in Finland (N=2188). Altogether 1475 subjects (67%) participated in the study; dentition status data were available for 1369 of them. Using a personal interview and assessment, trained nurses familiar to the resident collected the subjects' demographic data, medical history, functional and cognitive status, information on dentition status, oral symptoms, eating habits and diets. We assessed nutritional status with the Mini Nutritional Assessment (MNA), and retrieved information on mortality from central registers on 6 July 2010.

RESULTS

Edentulousness was common; more than half of the residents (52%) had lost all their teeth: 7% (n=94) were totally edentulous without prosthesis (Group 1), 45% (n=614) had removable dentures (Group 2), and 48% (n = 661) of the residents, had some natural teeth left (Group 3). Dentition status was associated with age, gender, education and disability. According to the MNA, 13% were malnourished, 65% were at risk for malnutrition, and 22% were well nourished. Edentulousness without prosthesis was associated with malnutrition, oral symptoms and infrequent use of oral care services. In Group 1, 52% were deceased during follow-up period. The respective figures for Groups 2 and 3 were 48% and 40% (p=0.004). However, in Cox regression analysis adjusted for age, gender, comorbidity and MNA score, dentition status no longer predicted mortality.

CONCLUSION

Edentulousness is still common among older service housing residents. Edentulousness without prosthesis was associated with poor nutritional status, oral symptoms and infrequent use of dental services. These findings suggest the need for co-operation between nursing staff and oral care services.

Oral hygiene and associated factors among frail older assisted living residents

The aim of this study was to determine the associations of older assisted living residents' tooth brushing habits with health and nutritional status. We assessed the tooth brushing habits, nutritional status, oral health, use of dental services, and morbidity of 1,447 assisted living residents in the Helsinki metropolitan area of Finland. Of the residents, 17% did not clean or had not cleaned their teeth and/or dentures daily. Those not cleaning their teeth and/or dentures daily were more often male, less educated and had a mean length of stay in assisted living longer than those who cleaned their teeth and/or dentures daily. They were more often malnourished and dependent in ADLs. In addition they more often had poorer oral health and used fewer dental services. Poor tooth brushing habits indicate poor oral and subjective health. More attention should focus on the oral hygiene of frail older assisted living residents.