Oral health-related multiple outcomes of holistic health in elderly individuals: An umbrella review of systematic reviews and meta-analyses

Understanding poor oral health among older adults in Türkiye: socioeconomic and healthcare access challenges

BACKGROUND

Oral health is an integral part of overall well-being, and older individuals are particularly vulnerable due to age-related changes and barriers to healthcare access. Despite Türkiye's comprehensive public health insurance system, significant disparities in oral health persist, highlighting the need for targeted research and interventions. This study assesses the oral health of people aged 65 and older in Türkiye and explores the factors linked to poor oral health, such as individual characteristics, lifestyle, socioeconomic status, social support, overall health, and access to healthcare services.

METHODS

A secondary analysis was performed using the cross-sectional 2022 Türkiye Health Survey, which gathered data from 3,144 individuals aged 65 and above. Oral health was self-reported, with poor oral health defined as participants rating their dental and gum condition as 'bad' or 'very bad.' Factors assessed included age, gender, education, social support, healthcare access, and the presence of chronic diseases.

RESULTS

Among the participants, 25.8% reported poor oral health. Key factors associated with this included being older, female, having lower levels of education, difficulty communicating in one's mother tongue, experiencing limitations in daily activities, and facing cost-related barriers to dental care. Multivariable analysis found that cost related barriers and limitations in daily activities had the strongest impact on oral health. The study also highlighted the importance of social support in maintaining better oral health.

CONCLUSIONS

Poor oral health in older adults in Türkiye is strongly influenced by cost-related barriers, limitations in daily activities, and lack of social support. Expanding public dental services, reducing out-of-pocket costs, and integrating oral health into chronic disease programs are critical steps. Providing culturally sensitive and mobile care options can also address mobility challenges and enhance oral health outcomes for the elderly.

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.

Tooth morbidity and its impact on oral related quality of life in elderly tribal population-The Irula experience

INTRODUCTION

Oral diseases are a major global health challenge, posing health and economic burdens that have profound impacts on the quality of life, disproportionately affecting marginalized populations such as tribal communities. Among scheduled tribes in India, the Irula community belongs to one of the tribes most vulnerable by poor access to health care and education. The elders in the population have increased incidence and prevalence rates of tooth morbidities-an increased incidence of caries, non-carious lesions, and periodontitis-related conditions that affect oral health related quality of life (OHQOL) dimensions.

OBJECTIVES

This study aims to assess tooth morbidity and tooth loss among older Irula community members, identify risk factors, and evaluate how oral and physical comorbidities have been associated with OHRQoL.

METHODS

A cross-sectional study was conducted on elderly persons aged 60 years and above in Thiruvallur district, Tamil Nadu, India. A multi-stage random sampling technique was employed in the study. Data were collected by semi-structured questionnaires covering demographics, medical history, oral health practices, and quality of life by clinical dental examination. The tools used included the International Caries Detection and Assessment System (ICDAS) the Smith and Knight Tooth wear index for non-carious lesions, and the Community Periodontal Index for Treatment Needs (CPITN) index for periodontal disease Furthermore, quality of life assessment was carried out utilizing the Geriatric Oral Health Assessment Index (GOHAI). Subsequently, Descriptive and multivariate logistic regression analyses were performed to determine the predictors of OHRQoL.

RESULTS

The prevalence of carious lesions was 38.5%, non-carious lesions 70%, periodontitis 70.8%, and tooth loss 53.6%. Only 2.3% of participants had restorative dental treatments. Multivariate analysis reveals that illiteracy (AOR = 0.163, p = 0.003), arthritis (AOR = 0.340, p = 0.001), carious lesions (AOR = 1.402, p = 0.031), periodontal disease (AOR = 1.663, p = 0.002), and tooth loss (AOR = 2.744, p = 0.001) affected OHRQoL significantly.

CONCLUSION

The results regarding the elderly community of Irula point towards the severe oral health disparities observed among them; thus, this raises an urgent need to develop a public health intervention for this eminent existing fact. Removing education and socioeconomic barriers, improving access to dental health care, and advocating culturally appropriate preventive programs could increase OHRQoL. Longitudinal study and policy-driven approaches should be carried out in future studies for sustainable health equity of the tribal population.

Oral health of nursing home residents in Flanders, Belgium, and its associated factors

Oral health in care-dependent older adults is often compromised due to care dependency associated with deteriorating general health. This cross-sectional study assessed the oral health of 458 nursing home residents in Flanders, with a mean age of 82.7 years (70.3% female), using the optimised Oral Health Section of the interRAI Suite of Instruments and validated dental indices. Among residents with natural teeth (53.9%), poor oral hygiene (75.7%), poor tooth condition (56.6%), and poor gum condition (49.9%) were common. High dental plaque levels yielded a mean Oral Hygiene Index of 4.5, and 44.0% of participants had untreated caries with pulp involvement. A mean Modified Gingival Index of 1.8 indicated mild inflammation of the entire gingiva. Denture hygiene was inadequate in 68.5% of cases. Self-reported issues included dry mouth (32.8%) and chewing difficulties (23.4%). The higher correlation coefficients were observed between oral hygiene and gum condition (r = 0.324, p < 0.0001) and between chewing difficulty and pain (r = 0.247, p < 0.0001). Bivariate analyses showed cognitive and functional impairments were strongly linked to poor oral hygiene and gingival health. These findings highlighted the persistent need to improve oral health care in nursing home residents, particularly among those with cognitive decline or reduced self-care abilities.Trial registration: ClinicalTrials.gov NCT06536322- Retrospectively registered July 23rd, 2024.

Multi-organ frailty is enhanced by periodontitis-induced inflammaging

BACKGROUND

The incidence of periodontitis is high in older individuals. However, its impact on multi-organ frailty remains unclear. We developed mouse models with varying severity and duration of periodontitis to examine its effects.

METHODS

We generated mouse models with mild and severe periodontitis, categorizing the disease duration into 3-month and 5-month periods for analysis. The organs assessed for frailty included the gastrocnemius muscle, soleus muscle, brain, and femur.

RESULTS

Our study found that periodontitis induced systemic inflammation resembling inflammaging and other symptoms characteristic of age-induced frailty. Notably, muscle impairment developed specifically in slow-twitch muscles, and the femur emerged as the most vulnerable bone, exhibiting reduced bone mineral density even with mild and short-duration periodontitis. This condition resulted in the co-occurrence of bone fragility and slow-twitch muscle dysfunction. Cognitive function assessment revealed increased activated microglia and decreased adult neurogenesis in the hippocampus, impairing spatial learning. Thus, periodontitis induced both physical and cognitive frailties. Therapeutic intervention for the periodontitis, which halted the exacerbation of bone resorption markers, did not restore femur bone mineral density.

CONCLUSION

This study underscores the role of periodontitis in inducing multifaceted organ frailty with vulnerability, varying by organ, and the necessity of early intervention, particularly regarding bone density loss.

[Impact of dental anxiety on the oral health-related quality of life of older adults in a rural area of Peru]

Objective

To determine the prevalence of oral health problems and dental anxiety in rural older adults, and their impact on oral health-related quality of life (OHRQoL).

Methods

A cross-sectional descriptive and analytical study was conducted among older adults in San Juan de Siguas, Arequipa, involving 64 participants aged 60 and above who provided informed consent. Sociodemographic, clinical, and oral health data were collected through structured interviews, using the Modified Dental Anxiety Scale (MDAS) and the OHIP-5 questionnaire to assess dental anxiety and OHRQoL, respectively. Binary logistic regression was applied to analyze the relationship between dental anxiety and OHRQoL, adjusting for relevant variables.

Results

Participants had an average age of 68.5 years, the majority were women (54.7%), and most lacked health insurance (85.9%). All participants had decayed teeth, and 68.8% had experienced tooth loss. Half of the participants exhibited moderate dental anxiety (mean MDAS: 11.6), and the impact on OHRQoL was moderate (mean OHIP-5: 8.4). Logistic regression revealed that each one-unit increase in dental anxiety (MDAS) increased the odds of a greater impact on OHRQoL by 1.49 times. Additionally, participants satisfied with dental care were 4.67 times more likely to report a greater impact.

Conclusions

Dental anxiety worsens OHRQoL in rural older adults due to access barriers and negative dental care experiences.

Geriatric Oral Health and Quality of Life Among the Indigenous Irula Tribes of Tamil Nadu

OBJECTIVES

This study aims to assess the oral health-related quality of life (OHRQoL) among the Irula tribes and to know the factors influencing quality of life among the elderly irula tribes of Tamil Nadu.

METHODS

This cross-sectional study was conducted in the Northern district of Tamil Nadu, including 486 Irula individuals aged 65 and above. Participants were selected using a multistage sampling method. Data were collected through a structured questionnaire, including the Geriatric Oral Health Assessment Index (GOHAI) to evaluate OHRQoL. The study tool covered demographics, medical history, and oral health issues. Data analysis was performed using SPSS version 23, with logistic regression applied to account for confounders.

RESULTS

The sample primarily consisted of individuals aged 65-69 years (55.6%), with a predominance of females (76.3%). The majority were Hindu (94.9%) and lived in nuclear families (88.3%). Educational levels were low, with 66.5% being illiterate. Most participants were agricultural laborers (64.6%) and had low monthly incomes. GOHAI results revealed that many respondents faced significant oral health challenges, including difficulties with eating, speaking, and discomfort. Multivariate analysis showed that educational level significantly affected OHRQoL, with higher education correlating with better quality of life. Arthritis was associated with poorer OHRQoL, while other health conditions did not show significant impacts.

CONCLUSION

The study highlights severe oral health issues among the Irula community, with significant physical and psychological impacts. Educational attainment plays a crucial role in OHRQoL, while arthritis notably affects quality of life. The findings emphasize the need for targeted oral health interventions and increased awareness in tribal communities to improve overall health outcomes. Further research in larger populations is necessary to comprehensively understand and address geriatric oral health needs.

Evaluating oral health status in elderly Irula tribes of Tamil Nadu by using the Geriatric Oral Health Assessment Index

Introduction

Oral diseases are a significant global health issue, with over 3.5 billion cases worldwide. Caries and periodontitis are primary contributors to tooth loss, which not only incurs significant rehabilitation costs but also profoundly affects overall well-being. Tribal communities represent a notable indigenous segment, comprising 8.6% of India's total population, primarily concentrated in the central and western regions. This study assesses the oral health-related quality of life (OHRQoL) among the elderly Irula population by using the Geriatric Oral Health Assessment Index (GOHAI).

Methods

A cross-sectional research was undertaken in the Irula settlements of Thiruvallur district, Tamil Nadu, focusing on inhabitants over 60 years who had lived there for at least 6 months. People who were chronically ill or who refused to agree were excluded. Data were gathered using a questionnaire that included demographic information, economic status, personal habits, and health issues. OHRQoL was evaluated using the GOHAI, and descriptive statistics such as range, mean, and standard deviation (SD) for continuous variables were used. To account for possible confounders such as age, education, and socioeconomic status, multivariate analysis was performed using logistic regression.

Results

This study results comprised mostly females (76.4%) and individuals aged 60-64 years (44.8%). Most participants were Hindu (94.1%), married (72.5%), and illiterate (61.9%). A majority lived in nuclear families (87.6%) and were agricultural laborers (60.0%). Many participants never experienced limitations in eating due to dental issues (64.0%). Gender, education, and physical comorbidities significantly influenced OHRQoL, with females and those with higher education reporting better quality of life.

Conclusion

The study underscores the significant impact of oral health on the quality of life among the elderly Irula population. Factors such as gender, education, and physical comorbidities play crucial roles in OHRQoL. The findings highlight the need for targeted oral health interventions and further research to address disparities and improve oral health outcomes in this underserved population.

Climbing the longevity pyramid: overview of evidence-driven healthcare prevention strategies for human longevity

Longevity medicine is an emerging and iterative healthcare discipline focusing on early detection, preventive measures, and personalized approaches that aim to extend healthy lifespan and promote healthy aging. This comprehensive review introduces the innovative concept of the "Longevity Pyramid." This conceptual framework delineates progressive intervention levels, providing a structured approach to understanding the diverse strategies available in longevity medicine. At the base of the Longevity Pyramid lies the level of prevention, emphasizing early detection strategies and advanced diagnostics or timely identification of potential health issues. Moving upwards, the next step involves lifestyle modifications, health-promoting behaviors, and proactive measures to delay the onset of age-related conditions. The Longevity Pyramid further explores the vast range of personalized interventions, highlighting the importance of tailoring medical approaches based on genetic predispositions, lifestyle factors, and unique health profiles, thereby optimizing interventions for maximal efficacy. These interventions aim to extend lifespan and reduce the impact and severity of age-related conditions, ensuring that additional years are characterized by vitality and wellbeing. By outlining these progressive levels of intervention, this review offers valuable insights into the evolving field of longevity medicine. This structured framework guides researchers and practitioners toward a nuanced strategic approach to advancing the science and practice of healthy aging.

Oral status of older adults receiving home medical care: A cross-sectional study

AIM

This study examined the oral status and the presence of teeth requiring treatment among older adults receiving home medical care.

METHODS

This cross-sectional study was conducted at a Japanese dental clinic specializing in geriatric treatment. We recruited older adults receiving home medical care in the community who had begun to receive domiciliary dental care. The Japanese version of the Oral Health Assessment Tool (OHAT-J), as well as the presence of teeth requiring extraction and the need for assistance in maintaining oral hygiene were used to evaluate the participants' oral health and its association with other items.

RESULTS

Ninety-three participants (44 male and 49 female, median age: 87.0 years) were surveyed. The median OHAT-J score was 6. The duration since the previous dental visit was 23 months. Sixty-two (73.8%) of 84 participants with ≥1 natural tooth had severe caries or teeth with severe mobility that required extraction. Logistic analysis revealed that requiring assistance in maintaining oral hygiene, mild dementia, severe dementia, and depression were significantly associated with an OHAT score of ≥6.

CONCLUSIONS

Older adults receiving home medical care had poor oral health, with approximately 70% of them requiring tooth extraction. The need for assistance in maintaining oral hygiene and poor mental status contribute to poor oral health. Geriatr Gerontol Int 2024; 24: 706-714.

Nutrition Status Plays a Partial Mediation Role in the Relationship between Number of Teeth and Frailty: A Cross-Sectional Multicenter Study

INTRODUCTION

Although the relationship between the number of teeth and frailty has been extensively studied, the mediating role of nutrition status in the association between the number of teeth and frailty remains to be clarified.

METHODS

A number of 6,664 participants lived in the communities of West China were analyzed in our study. Physical frailty was determined based on the phenotype established by Fried. Nutrition status was evaluated using the Mini Nutrition Assessment-Short Form (MNA-SF) scale. Multiple linear regression was employed to evaluate the direct relationships between the number of teeth, nutrition, and frailty. Mediation models and structural equation model (SEM) pathway analysis were used to test the mediating role of nutrition status in the relationship between the number of teeth and frailty.

RESULTS

Among the 6,664 participants aged over 50 years old, the prevalence of frailty was 6.2%. Multiple linear regression analysis showed a significant total relationship between the number of teeth (β = -0.359, 95% CI: -0.473 to -0.244, p < 0.001) and frailty. After adjusting for MNA-SF scores, the relationship between the number of teeth and frailty remained significant (β = -0.327, 95% CI: -0.443 to -0.211, p < 0.001), indicating a partial mediating effect of nutrition. Mediation analysis verified that nutrition partially mediated the relationship between the number of teeth and frailty (indirect effect estimate = -0.0121, bootstrap 95% CI: -0.0151 to -0.0092; direct effect estimate = -0.0874, bootstrap 95% CI: -0.1086 to -0.0678) in the fully adjusted model. This mediating effect occurred through influencing weight loss, low level of physical activity, and debility. SEM framework pathway analysis confirmed the association between the number of teeth, nutrition, and frailty.

CONCLUSIONS

Our findings demonstrated that frailty was correlated with the number of teeth and poorer nutritional status, with nutrition partially mediating the correlation between the number of teeth and frailty. Our results supported early nutritional evaluation and intervention in oral health to decrease the risk of frailty.

[Recommendations for the prevention of healthcare-associated infections in nursing homes]

Nursing homes (NH) although conceptually they should look as much like a home as possible, NH have unquestionable similarities with a nosocomium as they are places where many patients with underlying diseases and comorbidities accumulate and where the transmission of microorganisms between residents and between residents and caregivers is frequent.We have not found any recommendations specifically aimed at the prevention of nosocomial infections in MRI by the major Public Health Agencies and, therefore, the Health Sciences Foundation (Fundación de Ciencias de la Salud) has convened a series of experts and 14 Spanish scientific societies to discuss recommendations that could guide NH personnel in establishing written programs for the control and reduction of these infections. The present document is the result of these deliberations and contains suggestions for establishing such control programs on a voluntary and flexible basis in NH. We also hope that the document can help the health authorities to encourage this control activity in the different territorial areas of Spain. In our opinion, it is necessary to draw up a written plan and establish the figure of a coordinator or person responsible for implementing these projects. The document includes measures to be implemented and ways of quantifying the reality of different problems and of monitoring the impact of the measures established.

Chewing ability and associated factors in older adults in Germany. Results from GEDA 2019/2020-EHIS

BACKGROUND

Oral well-being is an important component of general well-being and quality of life, as it is greatly influenced by the ability to chew and speak, and thus by central factors of social interaction. Because quality of life and participation are important factors for health in older age, the aim of this article was to examine the chewing ability, including associated factors, for the older population in Germany on the basis of a nationally representative sample.

METHODS

Database is the German Health Update (GEDA 2019/2020-EHIS), a population based cross-sectional survey of the Robert Koch Institute. In the telephone interview, participants aged 55 years and older were asked: "Do you have difficulty biting and chewing on hard foods such as a firm apple? Would you say 'no difficulty', 'some difficulty', 'a lot of difficulty' or 'cannot do at all/ unable to do'?" Prevalences and multivariate prevalence ratios (PR) were calculated with 95% confidence intervals (95% CI) from log-Poisson regressions. Sociodemographic, health-, behavioral- and care-related characteristics were investigated as associated factors.

RESULTS

The analyses were based on data from 12,944 participants (7,079 women, 5,865 men). The proportion of people with reduced chewing ability was 20.0%; 14.5% had minor difficulty, 5.5% had major difficulty. There were no differences between women and men. The most important associated factors for reduced chewing ability were old age (PR 1.8, 95% CI 1.5-2.1), low socioeconomic status (PR 2.0, 95% CI 1.7-2.5), limitations to usual activities due to health problems (PR 1.9, 1.6-2.2), depressive symptoms (PR 1.7, 1.5-2.1), daily smoking (PR 1.6, 95% CI 1.3-1.8), low dental utilization (PR 1.6, 95% CI 1.4-1.9), and perceived unmet needs for dental care (PR 1.7, 95% CI 1.5-2.1).

CONCLUSIONS

One fifth of adults from 55 years of age reported reduced chewing ability. Thus, this is a very common functional limitation in older age. Reduced chewing ability was associated with almost all investigated characteristics. Therefore, its prevention requires a holistic view in the living environment and health care context of older people. Given that chewing ability influences quality of life and social participation, maintaining or improving chewing ability is important for healthy aging.

Gender differences in oral health among prisoners: a cross-sectional study from Taiwan

BACKGROUND

The prevalence of oral diseases among Taiwanese prisoners has rarely been investigated. This study aimed to estimate the gender-specific prevalence of oral disease in a sample of Taiwanese prisoners.

METHODS

We included 83,048 participants from the National Health Insurance (NHI) Program. Outcomes were measured using the clinical version of the International Classification of Diseases, Ninth Revision (ICD-9-CM). For prevalence, we provide absolute values and percentages. We also performed a χ2 test to assess sex and age group differences in the percentage of disease in the oral cavity, salivary glands, and jaw.

RESULTS

The prevalence rate of oral diseases was 25.90%, which was higher than that of the general population. The prevalence of oral diseases in female prisoners was higher than that in male prisoners (p < 0.001), and the prevalence of oral diseases in prisoners aged ≤ 40 was higher than that of prisoners aged > 40. Among all cases of diagnosed oral diseases, the top three diseases were dental hard tissue diseases (13.28%), other cellulitis and abscesses (9.79%), and pruritus and related conditions (2.88%), respectively. The prevalence of various oral diseases in female prisoners was significantly higher than that in male prisoners.

CONCLUSION

Oral disease is common among Taiwanese prisoners. Female prisoners had a higher prevalence of oral, salivary gland, and jaw diseases than male prisoners. Therefore, early prevention and appropriate treatment are required and also a need for gender-specific oral disease products given the differences in the prevalence of oral disease among male and female prisoners.

Association of a lesser number of teeth with more risk of developing depressive symptoms among middle-aged and older adults in Japan: A 20-year population-based cohort study

OBJECTIVES

This 20-year prospective cohort study aimed to longitudinally explore the relationship between the number of teeth and the incidence of depressive symptoms among community-dwelling middle-aged and older adults.

METHODS

Data were collected from the National Institute for Longevity Sciences-Longitudinal Study of Aging (NILS-LSA) database from 2002 to 2022 (3rd-9th waves). Data of adults aged ≥40 years were analyzed and those who had depressive symptoms at baseline (3rd wave), had missing data, or did not participate in follow-up, were excluded. We collected data on the number of teeth at baseline. Depressive symptoms were defined as a score of ≥16 on the Center for Epidemiologic Studies Depression Scale. The generalized estimating equation (GEE) model was used to examine the longitudinal relationships between the number of teeth at baseline and the subsequent incidence of depressive symptoms.

RESULTS

The final analysis included 1668 participants, with a mean (standard deviation) age of 58.8 (11.1) years and a mean follow-up time of 12.9 years. After GEE analysis with adjustment for multiple covariates, compared to participants with ≥20 teeth, participants with 10-19 teeth and < 10 teeth at baseline were associated with a higher risk of depressive symptoms. The subgroup analysis showed that the effect was stronger in men than in women.

CONCLUSIONS

Among middle-aged and older community dwellers, particularly men, a small number of teeth after the age of 40 was associated with the future incidence of depressive symptoms.

International Delphi Study to Optimize the Oral Health Section in interRAI

Introduction: The oral health (OH) of care-dependent older people is generally poor. Since caregivers are mainly responsible for older people's daily care, they can be considered important intermediaries to improve their OH by performing regular OH assessments. The interRAI instruments are introduced in 37 countries to assess care needs and facilitate care planning across different health care settings. The oral health section (OHS) within the interRAI instrument used in long-term care facilities was optimized for the Belgian context to identify residents who need assistance with daily oral care and/or need to be referred to a dentist. This Delphi study evaluated whether the OHS is also relevant and useful in other countries and modified the OHS accordingly until an international consensus was reached. Participants were experts in OH for older people. During 2 rounds of online questionnaires, experts rated the content, assessment process, triggering of Clinical Assessment Protocols, and accompanying guidelines and instruction videos of the optimized OHS. Based on the experts' comments and suggestions collected during the first round, the OHS was adjusted and presented to the experts in the second round for re-evaluation. The first and second questionnaires were completed by 48 and 42 oral health experts from 29 and 27 countries where the interRAI instruments are introduced, respectively. Five experts from 5 countries where interRAI is not introduced also participated in both rounds. After the second round, a consensus of over 86% was reached on all criteria. International consensus on the OHS was reached, considering national and cultural differences that may affect OH. The next step in this research is to evaluate the assessment process to identify potential barriers and facilitators to achieving reliable OH assessments internationally. Furthermore, the effect of the OHS at the level of the resident and of the caregivers will be evaluated.