A prospective cohort study on factors related to dental care and continuation of care for older adults receiving home medical care.

Information on the effects of dental treatment must be identified and factors that hinder the continuation of dental treatment must be identified to provide appropriate domiciliary dental care (DDC). This study aimed to clarify the treatment outcomes of DDC for older adults and the factors that impede the continuation of such care. This prospective study was conducted at a Japanese clinic specializing in dental care for older adults. The functional status, nutritional status, oral assessment, details of the dental treatment, and outcomes after 6 months of older adults receiving DDC were surveyed. The Oral Health Assessment Tool (OHAT) was used for oral assessment. Cox proportional hazards analysis was used to analyze the factors at the first visit that were associated with treatment continuation. A total of 72 participants (mean age, 85.8 ± 6.9) were included. Twenty-three participants (31.9%) could not continue treatment after 6 months. The most frequently performed procedures were oral care and dysphagia rehabilitation, followed by prosthetic treatment, then tooth extraction. The percentage of participants with teeth that required extraction after 6 months and the total OHAT score decreased significantly. The Barthel Index, Mini Nutritional Assessment Short-Form, and rinsing ability were significantly associated with treatment continuation. Furthermore, instrumental activities of daily living (ADL) and the OHAT "tongue" sub-item were correlated with treatment continuation. In conclusion, DDC improved the oral health status of older adults after 6 months. Factors that impeded treatment continuation were decreased ADL, decreased nutritional status, difficulty in rinsing, and changes in the tongue such as tongue coating.

Intramuscular condition of swallowing-related muscles using shear-wave elastography: A preliminary study in healthy adults.

BACKGROUND: Assessing the internal condition of swallowing-related muscles and muscle strength and size is important because their deterioration may lead to dysphagia. However, there are few reports on stiffness of swallowing-related muscles measured using shear-wave elastography (SWE) and their qualitative characteristics. OBJECTIVES: We measured stiffness of swallowing-related muscles using SWE to investigate the relationship between muscle stiffness and body composition as well as other relevant variables in healthy adults. METHODS: Thirty healthy adults were included in this cross-sectional study. We evaluated stiffness of the genioglossus muscle (GGM) and geniohyoid muscle (GHM) using SWE. Skeletal muscle mass index, body mass index (BMI), handgrip strength, tongue pressure, and cross-sectional areas of the muscles were measured, and we determined their relationship with muscle stiffness. RESULTS: For muscle stiffness, the mean value for the middle GGM was 7.08 ± 1.92 kPa, that for the posterior GGM was 9.31 ± 2.68 kPa, and that for the GHM was 8.84 ± 2.15 kPa. In multiple regression analysis, with stiffness of the posterior GGM as the dependent variable, BMI (ß = -.473, p = .039) was a significant negative explanatory variable. However, with the GHM stiffness as the dependent variable, BMI (ß = .419, p = .033) was a significant positive explanatory variable. CONCLUSION: Stiffness of the posterior GGM was positively correlated with BMI and that of the GHM was negatively correlated with BMI. Stiffness, as measured using SWE, has the potential to capture the intramuscular characteristics of swallowing-related muscles, particularly the posterior GGM.

Problems experienced when swallowing solid oral dosage forms in older Japanese patients with dysphagia: A cross-sectional study.

AIMS: We aimed to assess the difficulty in taking solid oral dosage forms (SODFs) among older people with dysphagia and clarify the relationship between difficulty in swallowing SODFs and swallowing function. METHODS AND RESULTS: Outpatients from a dysphagia clinic aged ≥65 years were asked yes-or-no questions about the applicability of eight items regarding difficulty in taking SODFs. Additionally, a videofluorographic swallowing study (VFSS) was performed to assess their swallowing function. The Kruskal-Wallis test and Spearman's rank correlation coefficient were used to analyze the relationship between difficulty in taking SODFs and swallowing function. RESULTS: Among the 93 participants, the average number of SODFs consumed was 5.8 ± 3.1. In the questionnaire, the average number of "yes" answers was 2.2 ± 2.2, and 65 patients (71.0%) answered "yes" to at least one question. Additionally, no significant relationship was observed between the perceived difficulty in swallowing SODFs and VFSS findings. CONCLUSION: Approximately 70% of participants reported subjective difficulty in taking SODFs, showing that patients uniformly reported perceived difficulty in taking SODFs regardless of actual swallowing function. The results of this study suggest that patients must be questioned thoroughly about their SODFs use, regardless of the objective severity of their dysphagia.

Factors associated with the maintenance in food texture for dependent older people with dysphagia living in nursing home - A retrospective cohort study.

OBJECTIVES: Maintaining the texture of the food that nursing home residents eat is critical for maintaining quality of life and preventing malnutrition. The aim of the present study was to identify the conditions necessary for maintaining food texture for this population. MATERIALS AND METHODS: The study included 143 people for whom reevaluation 1-year post-baseline was possible from among 256 dependent older people who consumed solid food on admission to a nursing home (baseline). The age, sex, primary disease, activities of daily living, nutritional status, oral status, swallowing ability, primitive reflexes, and food texture of the participants were determined. The participants who ate pureed or jelly after 1 year were identified and evaluated to determine factors related to maintenance of a solid diet. RESULTS: A total of 21 participants (14.7%) changed to a pureed or jelly diet after 1 year. Multivariate analysis showed good activities of daily living (p < .05), good swallowing ability (p < .05), and maintained nutritional status (p < .05) to be correlated with solid food maintenance. CONCLUSIONS: Maintaining activities of daily living, feeding and swallowing ability, and nutritional status appear to be important factors for the maintenance of a solid diet.

Association between denture use and food form in older adults requiring long-term care: A multicenter cross-sectional study.

PURPOSE: This study aimed to determine whether denture use contributes to maintaining and improving food forms in long-term care facility (LTCFs) residents. METHODS: In 888 residents of 37 LTCFs in Japan, the following were investigated: nutritional intake status, food forms, age, sex, Barthel index (BI), clinical dementia rating (CDR), number of teeth present, number of occlusal supports, swallowing function, and use of dentures. Among all residents, those who were well-nourished and had ≤9 occlusal supports were analyzed. Based on standardized criteria, the food forms consumed by the subjects were divided into two groups: dysphagia and normal diet, which were further classified into four levels. Analysis was performed using a generalized estimation equation with the four levels of food forms as dependent variables and age, sex, BI, CDR, presence of dysphagia, number of teeth present, and use of dentures as independent variables. RESULTS: The final analysis included 622 (70.0%) residents. Of these, 380 (61.1%) used dentures. The analyses revealed that food form was significantly associated with age (adjusted odds ratio [OR], 0.98), BI (OR, 1.04), number of teeth present (OR, 1.03), presence of dysphagia (OR, 0.44), and use of dentures (OR, 2.82). CONCLUSIONS: Denture use was associated with food forms among Japanese LTCF residents. This indicates that the use of dentures is related to the maintenance of food forms, even in the elderly who participate in few activities of daily living, have reduced cognitive function, and require long-term care.

Relationship between maintenance of occlusal support achieved by home-visit dental treatment and prognosis in home-care patients-a preliminary study.

AIM: To determine whether occlusal maintenance and reconstruction by dental intervention is associated with the prognosis of older home-care patients. METHODS: The study participants were 289 older home-care patients (101 males, mean age 82.2 ± 7.7 years) who received visiting dental treatment from dental clinics in the region between 2012 and 2018. The participants were followed up for 1000 days after receiving the necessary dental treatment in a home-visit setting. The participants were divided into three groups: those with natural tooth occlusion, those whose molar occlusion was maintained or reconstructed by dentures, and those whose occlusion was not reconstructed. Factors associated with prognosis were determined using the Cox proportional hazard model, with occlusal status, comorbidities, the activity of daily living, and residence status as explanatory variables. RESULTS: In the overall population, occlusal status (hazard ratio [HR] of those with occlusal disintegration versus those with natural tooth occlusion: 2.1, confidence interval [95% CI]: 1.18-3.82) and age (HR: 2.28, 95% CI: 1.44-3.61) were identified as significant factors. In the group of participants aged <85 years, only occlusal status (HR of those with occlusal disintegration versus those with natural tooth occlusion: 3.4, 95% CI: 1.34-8.68) was a significant factor. In the group of participants aged ≥85 years, occlusal status was not significantly associated with prognosis. CONCLUSIONS: The maintenance and acquisition of occlusal support achieved by dental treatment contribute to improved prognosis in older patients younger than 85 years requiring home nursing care. Geriatr Gerontol Int 2022; 22: 976-981.

Two case reports using a proposed oral risk assessment tool for older people near the end of life.

OBJECTIVES: We developed a prototype technique that expresses the need for intervention and the effectiveness of the treatment when "not being at risk of injury to the oral cavity or to general health" due to the presence of teeth or prostheses is taken as the desired outcome of dental treatment for older people near the end of life. The objective of this study was to use the prototype risk assessment matrix to identify the risk for each patient according to their course and show the effectiveness of treatment. MATERIAL AND METHODS: We produced a prototype Dental Risk Map (Dental R-map) based on the risk map method of risk management. Risk is classified into three levels according to the level of tolerability: (A) Risk for which watchful waiting should be included among measures to be considered; (B) risk for which intervention should be considered; or (C) risk requiring urgent intervention. RESULTS: We report the application of this technique to two men in their 80s. Both were assessed as risk tolerability Level C, requiring immediate intervention. Dental treatment eliminated this risk in one and reduced it to Level B in the other. CONCLUSIONS: We developed the prototype Dental R-map to identify oral risks and indicate the need for intervention to address these risks and the effectiveness of treatment for older people near the end of life. We used the Dental R-map for two patients and successfully avoided oral risks that might cause physical injury in both cases until their deaths.

Jaw-Opening Force as a Useful Index for Dysphagia: A Cross-Sectional and Multi-Institutional Study.

INTRODUCTION: Jaw-opening force (JOF) can be a potential screening tool for dysphagia. However, confounding variables such as comorbidities or physical and oral functions that are associated with the physiology of swallowing have not previously been examined. Adjusting for these variables could reveal the relationship between JOF and dysphagia and indicate whether JOF is an independent factor associated with dysphagia. We therefore aimed to assess the efficacy of using JOF for dysphagia screening in this multi-institutional study. METHODS: Community-dwelling older adults over the age of 65 years (N = 403) who visited the university dental hospitals and participated in health surveys (mean age ± standard deviation, 77.1 ± 7.0 years; range, 65-96 years) between November 2018 and January 2020 were included in this study. The JOFs of all participants were measured. The measured JOF was compared with the presence of dysphagia, which was defined using the Functional Oral Intake Scale and the Eating Assessment Tool-10. RESULTS: Multiple logistic regression analysis revealed that the presence of dysphagia was independently associated with JOF, calf circumference, and dependence after adjusting for age and sex. DISCUSSION/CONCLUSION: Decreased JOF can be a risk factor for dysphagia in older adults.

Development of the Sakiika transport test: A practical screening method for patients with oral-phase dysphagia.

PURPOSE: This study aimed to develop a simple screening test for mastication, "the Sakiika (squid jerky) transport test (STT), which evaluates the vertical jaw movement coordinated with the lateral tongue movement during stage I transport, and investigate the possibility of its clinical application. METHODS: The study included 73 people with dysphagia (mean age, 78.5 ± 7.8 years; median age, 79.0 years; interquartile range, 75.0-84.0). The STT evaluated the ability of a participant to transport a piece of squid jerky placed on the midline of the tongue to the molar region. The STT score was defined as the number of vertical jaw movements occurring as the tongue transported food to the molars. A cutoff value was set by comparing the STT scores with masticatory function evaluated via a videofluoroscopic swallowing study and with food texture evaluated using the Food Intake LEVEL Scale (FILS). RESULTS: The STT scores counted by the two examiners had a κ coefficient of 0.79, indicating good reliability. The STT score was significantly associated with both the presence of masticatory movement ( p = 0.019) and food texture classified by FILS ( p = 0.032) at cutoff value of "3" (3 vertical movements). The STT showed 62% sensitivity and 75% specificity for masticatory movements. CONCLUSION: The STT could be a useful screening test to assess the presence or absence of food transportation to the molars for mastication in older patients with dysphagia. In addition, the STT could be useful in identifying the need to modify food texture to meet functions.

Pneumonia incidence and oral health management by dental hygienists in long-term care facilities: A 1-year prospective multicentre cohort study.

OBJECTIVE: To investigate the association between oral health management (OHM) by dental hygienists and the occurrence of pneumonia, and determine the effectiveness of OHM in pneumonia prevention. BACKGROUND: In long-term care facilities in Japan, the need for professional OHM is increasing with an increase in the number of severely debilitated residents. MATERIALS AND METHODS: A 1-year prospective multicentre cohort study was conducted using data from 504 residents (63 men; mean age: 87.4 ± 7.8 years) in Japanese long-term care facilities. Basic information, medical history, willingness to engage in oral hygiene behaviour, need for OHM and oral conditions were investigated at baseline. In addition, information on the occurrence of pneumonia was collected using a follow-up survey after one year. A Poisson regression analysis with robust standard errors was conducted, with pneumonia as the dependent variable, and factors associated with OHM and pneumonia occurrence as explanatory variables. RESULTS: Overall, 349 (69.2%) residents required OHM by dental hygienists during that year of follow-up. Of those, 238 (68.2%) were provided with OHM, and 18 (7.5%) developed pneumonia. Among the 111 patients (31.8%) who were not provided with OHM, 21 (18.9%) developed pneumonia. The OHM group had lower pneumonia rates than the non-OHM group (prevalence rate ratio: 0.374; 95% CI: 0.210-0.665). CONCLUSION: Oral health management by dental hygienists was associated with a lower incidence of pneumonia among residents of long-term care facilities, underlining the importance of professional OHM for such individuals. It is recommended that OHM be practised routinely in long-term care facilities.

Masticatory movements and food textures in older patients with eating difficulties.

OBJECTIVES: To investigate whether masticatory movements in older patients with eating difficulties were associated with oral motor function, physical function, and appropriate food textures. BACKGROUND: There are few reports on the association between masticatory movements and food textures in older patients with eating difficulties. MATERIALS AND METHODS: This cross-sectional study involved outpatients at a clinic that specialised in eating and swallowing rehabilitation. Masticatory movements were evaluated as normal or abnormal masticatory path patterns. Oral and physical functions were assessed in terms of oral and physical status, muscle strength and motor skills. The appropriate food texture was determined based on fibreoptic endoscopic evaluation of swallowing and a video fluoroscopic swallowing study. The associations between food texture and masticatory organ, muscle strength and motor skills were analysed. RESULTS: A total of 126 outpatients (75 men and 51 women; mean age, 78.2 years; SD, 9.6 years) were included in the analysis. 68 participants (54.0%) showed abnormal masticatory movements. Masticatory movement was associated with masticatory performance (odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.98-0.99), oral diadochokinesis (OR = 0.55, CI = 0.35-0.86) and stepping test (OR = 0.92, CI = 0.86-0.97). Masticatory movement (OR = 2.94, CI = 1.23-7.01) and the number of natural teeth (OR = 0.94, CI = 0.89-0.99) were associated with normal food. CONCLUSION: Masticatory movements in older patients with eating difficulties may be associated with appropriate food textures whilst being influenced by individual differences in systemic motor control. Masticatory movements may be as important as teeth to enjoy eating.

COVID-19 Infection-Related Weight Loss Decreases Eating/Swallowing Function in Schizophrenic Patients.

BACKGROUND: In older people with psychoneurological diseases, COVID-19 infection may be associated with a risk of developing or exacerbating dysphagia. The aim of the present study was to examine the relationship between eating/swallowing function and COVID-19 infection. METHODS: Subjects were 44 inpatients with confirmed COVID-19 infection being treated for schizophrenia in a psychiatric ward. Eating function was assessed using the Food Intake Level Scale (FILS) before and after infection. We also evaluated age, comorbidities, COVID-19 hospital stay, obesity index, weight loss rate, and chlorpromazine equivalent. RESULTS: Subjects had a mean age of 68.86 years. Pre-infection, 20 subjects had a FILS score of 7-9 (presence of eating/swallowing disorder) and 24 subjects had a score of 10 (normal). Eating function after infection resolution showed decreasing FILS score compared to that before infection in 14 subjects (74.14 years). Six subjects (79.3 years) transitioned from oral feeding to parenteral feeding. A ≥ 10% weight loss during infection treatment was significantly associated with decreased eating function and a transition to parenteral feeding. Chlorpromazine equivalents, comorbidities, and number of days of hospitalization showed no associations with decreased eating function. CONCLUSIONS: Preventing malnutrition during treatment for COVID-19 infection is important for improving post-infection life prognosis and maintaining quality of life (QOL).

Factors predicting the effects of dysphagia rehabilitation on multidimensional functional status in elder outpatients: A prospective cohort study.

OBJECTIVE: This study aimed to clarify the relationship between the oral intake function and functional status, as well as to determine the aspects of functional status potentially predicting the effects of dysphagia rehabilitation in the maintenance stage, in elder outpatients. METHODS: This study was conducted in a clinic, specialised in rehabilitation of patients with dysphagia. The participants were 93 non-tube-fed patients 65 years of age or older. The participants were scheduled to undergo the initial examination for oral intake function and functional status, and then to receive dysphagia rehabilitation for 1 year. After rehabilitation period, oral intake function was re-evaluated, and the elements of functional status potentially related to the effects of dysphagia rehabilitation were determined. RESULTS: It was found that the lower the participants' oral intake function levels, the higher the prevalence of reduced parameters of functional status. After 1-year dysphagia rehabilitation, the oral intake function was maintained or improved in 70 (75.3%) participants, but had diminished in 23 (24.7%). Our analysis revealed that participants with higher Vitality Index scores and MMSE at the time of initial examination were significantly more likely to show maintained or improved oral intake function at 1 year (odds ratio[OR], 1.76; 95% confidence interval [CI], 1.14-2.71; OR, 1.17; 95% CI, 1.06-1.28, respectively). CONCLUSIONS: It became apparent that the lower the oral intake function level at the initial examination, the higher the prevalence of reduced multidimensional functional status. Mental function was found to predict the effects of dysphagia rehabilitation in the maintenance stage.

Effect of dysphagia rehabilitation in patients receiving enteral nutrition at home nursing care: A retrospective cohort study.

OBJECTIVE: We considered the effect of dysphagia rehabilitation and investigated parameters associated with the resumption of oral intake in the elderly patients receiving home nursing care who were not eating by mouth. METHODS: The participants were 116 patients aged ≥65 years (66 men and 50 women, mean age 79.7 ± 8.9 years) who were receiving home nursing care and not eating by mouth because of dysphagia. All patients underwent dysphagia rehabilitation for 6 months with the objective of resuming oral intake. After 6 months of dysphagia rehabilitation, the patients' eating status was assessed using the Functional Oral Intake Scale (FOIS) and the associations of the post-intervention FOIS score with age, history of pneumonia, duration of enteral nutrition, body mass index (BMI), alertness, physical function (ability to walk) and swallowing function at the initial examination. RESULTS: Functional Oral Intake Scale scores increased significantly after 6 months rather than those at the initial evaluation (P < .001). Eighty patients (69.0%) resumed oral intake (FOIS score ≥2), thirty patients (25.9%) of whom became capable of daily oral intake (FOIS score ≥3). Swallowing function was associated with the resumption of oral intake. In addition, physical function before dysphagia rehabilitation was an important factor to resume daily oral intake. CONCLUSIONS: The results of the present study suggest that the resumption of oral intake by patients receiving enteral nutrition requires improvement in swallowing function. In addition, anyone who cannot walk may not recover daily oral intake.

Relationship between oral environment and development of pneumonia and acute viral respiratory infection in dependent older individuals.

AIM: The importance of oral care has been recognized for the prevention of airway infections in older individuals who require long-term care. The present prospective cohort study was carried out a decade ago to identify risk factors with numerous intraoral conditions as possible predictors involved in the onset of pneumonia and acute viral respiratory infection (AVRI) in older people requiring long-term care during a 6-month follow-up period (including winter). METHODS: This study included 1785 older individuals residing in 31 long-term care facilities in which dental hygienists were involved in instruction on daily oral care. Primary end-points were development of pneumonia and AVRI during the 6-month follow-up period. Several factors related to each participant's general condition, oral environment, swallowing function and vaccinations (or lack thereof) were evaluated by calibrated dentists and dental hygienists before the study onset. RESULTS: During the 6-month follow-up period, 74 participants (4.1%) developed pneumonia, and 28 participants (1.6%) developed AVRI. Cox proportional hazard analysis showed that poor nutritional status and the presence of dysphagia were significant risk factors for pneumonia onset. The presence of dry mouth and halitosis were significant risk factors for AVRI. CONCLUSIONS: This prospective multicenter cohort study identified poor nutritional status and dysphagia as independent risk factors for the development of pneumonia, and dry mouth and halitosis as independent risk factors for the development of AVRI in older people who require long-term care and who routinely receive professional oral care. Geriatr Gerontol Int 2019; 19: 1136-1140.

Multicentered epidemiological study of factors associated with total bacterial count in the saliva of older people requiring nursing care.

AIM: To clarify whether the number of present teeth, independent of other well-known factors, was associated with the total bacterial count in the saliva of older people requiring care at nursing homes in a multicentered epidemiological survey. METHOD: The participants were 618 older people (mean age 86.8 ± 6.9 years; 122 men, 496 women) residing in 14 nursing homes across Japan. The dependent variable was the participant's salivary bacterial count, and the independent variables were basic demographic data, oral conditions and activity of daily living (measured by Barthel Index). Statistical analysis was first carried out by Student's t-test, Pearson's correlation coefficient analysis and Spearman's rank correlation coefficient analysis. Independent variables found to have a significant relationship to their salivary bacterial count by the univariate analyses were further examined by stepwise multivariate analysis. RESULTS: The independent variables shown by univariate analysis to have a significant positive relationship with higher salivary bacterial count were presence of food residue (P = 0.001), absence of mouth dryness (P = 0.001), need of oral care assistance (P = 0.001), inability to keep the mouth opened (P = 0.009), inability to gargle (P = 0.002), denture use (P = 0.004), higher number of present teeth (P = 0.006) and lower Barthel Index (P = 0.001). Subsequent multivariate analysis identified presence of food residue (P = 0.031), higher number of present teeth (P = 0.043) and lower Barthel Index (P = 0.001) as independent associated factors for higher salivary bacterial count. CONCLUSIONS: The present study found that presence of food residue, higher number of present teeth and decreased activity of daily living were significantly related to higher bacterial count in the saliva of older people requiring care. Geriatr Gerontol Int 2017; 17: 219-225.

Tongue thickness relates to nutritional status in the elderly.

Many elderly people under long-term care suffer from malnutrition caused by dysphagia, frequently leading to sarcopenia. Our hypothesis is that sarcopenia may compromise oral function, resulting in dysphagia. The objectives of this study were to evaluate sarcopenia of the lingual muscles by measuring the tongue thickness, and elucidate its relationship with nutritional status. We examined 104 elderly subjects (mean age = 80.3 ± 7.9 years). Anthropometric data, such as triceps skinfold thickness and midarm muscle area (AMA), were obtained. The tongue thickness of the central part was determined using ultrasonography. Measurement was performed twice and the mean value was obtained. The relationship between tongue thickness and nutritional status was analyzed by Pearson's correlation coefficient and Spearman's rank correlation coefficient. AMA and age were identified by multiple-regression analysis as factors influencing tongue thickness. The results of this study suggest that malnutrition may induce sarcopenia not only in the skeletal muscles but also in the tongue.

Tooth loss as risk factor for foreign-body asphyxiation in nursing-home patients.

Foreign body asphyxiation causes severe medical conditions including pneumonia in the elderly requiring nursing care. The objective of this study was to elucidate the relationships between insufficient occlusal support due to tooth loss and the onset of asphyxiation accidents, and determine preventive measures for such accidents in nursing homes in Japan. The subjects were 437 elderly (110 men and 327 women) requiring nursing care. The frequency and risk factors for asphyxiation accidents and the food causing asphyxiation were examined in these subjects for 2.5 years, from June 2006 to December 2008. During the study period, 51 of the 437 subjects suffered asphyxiation. Self-feeding ability and loss of occlusal support were associated with a covariate-adjusted relative ratio for asphyxiation of 3.1 (95% confidence interval (CI)=1.50-6.44) and 1.7 (95% CI=1.12-2.74), respectively. To prevent asphyxiation in elderly people, it was found that maintaining or restoring occlusal support may be required. It was concluded that self-feeding ability and loss of occlusal support are significant risk factors for foreign-body asphyxiation among elderly people requiring nursing care.