Association of Oral Function and Dysphagia with Frailty and Sarcopenia in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

Temporal relationship between malnutrition and oral function impairment in older adults with dysphagia: A cross-lagged panel model

OBJECTIVES

This study aimed to longitudinally investigate the temporal relationship between tongue pressure and malnutrition in older adults with dysphagia and to determine the antecedent factors.

DESIGN

This is a retrospective cohort study.

SETTING AND PARTICIPANTS

In total, 177 participants aged ≥65 years with dysphagia who visited a specialized dysphagia rehabilitation clinic between 2014 and 2018 were enrolled.

MEASUREMENTS

Malnutrition was assessed based on the phenotypic criteria (unintentional weight loss, low body mass index, and reduced skeletal muscle mass) from the Global Leadership Initiative on Malnutrition framework. Tongue pressure was measured using a tongue pressure measuring device. The bidirectional association between tongue pressure and malnutrition was examined, adjusting for age, sex, cognitive function, occlusal support status, and comorbidities.

RESULTS

In the Cross-Lagged Panel Model, a significant cross-lagged effect was observed from tongue pressure to malnutrition at 6 months (β = -0.135, p < 0.001) and 12 months (β = -0.112, p = 0.028). However, the pathway from malnutrition to tongue pressure was not significant. Logistic regression analysis also revealed that baseline tongue pressure was significantly associated with malnutrition at 6 months (odds ratio [OR] = 0.91, 95% confidence interval [CI]: 0.86-0.95) and 12 months (OR = 0.89, 95% CI: 0.84-0.94). During the follow-up period, tongue pressure improved; however, the prevalence of malnutrition increased.

CONCLUSIONS

Decreased tongue pressure may precede malnutrition in older adults with dysphagia; however, a reverse relationship was not observed. The findings suggest the importance of incorporating oral function assessment as part of the risk assessment for malnutrition.

Tongue strength in progressive supranuclear palsy

PURPOSE

Tongue weakness is common in patients with neurologic disease, including parkinsonism. The aim of this study is to describe tongue strength in progressive supranuclear palsy and its relationship to dysphagia and dysarthria.

METHODS

Participants were 119 (58 female) individuals with probable or possible progressive supranuclear palsy. Each participant underwent a motor speech assessment to determine type and severity of dysarthria. Quantification of dysphagia included the Modified Barium Swallow Impairment Profile, the Penetration-Aspiration Scale, and the Functional Oral Intake Scale. Anterior elevation tongue strength was assessed by measuring maximum pressure exerted by the tongue on an air-filled bulb positioned against the hard palate.

RESULTS

Mean maximum tongue elevation pressure was 38 kPa. Tongue strength correlated significantly with age, dysarthria severity, and disease severity. Tongue strength was not differentially affected by dysarthria type, but was weakly correlated with pharyngeal dysphagia severity.

CONCLUSIONS

Average tongue strength in speakers with progressive supranuclear palsy is lower than reported for neurologically healthy adults and for patients with Parkinson's Disease. Likely reflecting a combination of age-related loss of muscle mass and damage to the basal ganglia and/or pyramidal tracts, reduced tongue strength on its own does not appear to be a primary driver of swallowing difficulties in this population. Further study is warranted to better understand the physiologic mechanisms contributing to reduced tongue strength in PSP, how tongue strength changes as disease progresses, and what other mechanisms contribute to dysphagia in PSP.

Association between oral health status and frailty in older adults: a systematic review and meta-analysis

Aim

This study aims to explore the association between oral health status and frailty in older adults using comprehensive and objective oral health measurement indicators.

Method

This study conducted a collection and retrieval of relevant literature in the following English databases: PubMed, Embase, Cochrane Library, and Web of Science (up to July 1, 2024). After screening the literature according to the specified inclusion and exclusion criteria, the quality of the literature was assessed using the Joanna Briggs Institute critical appraisal tool and the Newcastle-Ottawa Scale. The degree of heterogeneity was then represented by the I 2 statistic, and based on this result, a random-effects or fixed-effects model was determined for analysis. Odds ratios (OR)/standardized mean differences (SMD) and 95% confidence intervals were employed to identify the association between various oral health indicators and frailty. Sensitivity analysis was performed for all outcomes.

Results

A total of 28 articles were included. Number of teeth (SMD: -0.591), functional dentition (≥21 teeth) (OR: 0.236), no false teeth (OR: 0.733), ≤20 teeth/with denture (OR: 2.320), tooth brushing daily (OR: 0.562), tongue pressure/decreased tongue pressure (SMD: -0.582/OR: 1.618), occlusal force/occlusal force reduced (SMD: -0.526/OR: 1.846), oral diadochokinesis hypofunction (OR: 1.876), poor mixing ability (OR: 2.303) and oral health assessment tool scores ≥4 (OR: 2.501) were correlated with frailty in older adults.

Conclusion

Various types of oral health indicators are associated with frailty in older adults. Investigating the relationship between oral health and frailty in older adults is of significant importance for preventing frailty, ensuring the quality of life for older adults, and promoting healthy longevity.

Systematic review registration

PROSPERO CRD42024587687.

Establishment of a Mandarin Chinese Version of the Oral Frailty Index-8 and Exploration of the Association Between Oral Frailty and Sarcopenia

Objective: The aim of our study was to introduce a Mandarin Chinese version of the oral frailty assessment and explore the relationship between oral frailty and sarcopenia. A total of 409 elders (171 male, 238 female) participated in surveys using the Mandarin Chinese version of the Oral Frailty Index-8 (OFI-8) in Kaohsiung, Taiwan. Method: The translation of the Mandarin Chinese version of OFI-8 adhered to the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) reporting guidelines. The eight-item questionnaire assessed tooth status, oral function, and other subjective measures. Additionally, sarcopenia was evaluated using the SARC-F questionnaire. Result: Among the participants, 195 participants were classified as non-oral frailty and 214 participants were oral frailty. Significant differences were observed in age, gender, body mass index (BMI), education level, and scores on the SARC-F questionnaire between the non-oral frailty and oral frailty populations. In logistic regression model, oral frailty showed a significant and positive association with the SARC-F score (adjusted odds ratio 2.130, 95% confidence interval 1.580-2.872, p-value < 0.001), even after adjusting for age, gender, BMI, and education level. Conclusion: This study has developed a valuable Mandarin Chinese version of the oral frailty screening questionnaire, the OFI-8. Oral frailty is significantly and positively associated with a higher risk of sarcopenia, particularly among the elderly, males, and those with lower education levels. This measure proves to be practical for assessing oral health status in the Chinese community, promoting oral frailty research within the Mandarin Chinese population, and addressing the challenges associated with defining oral frailty in future studies.

Dysphagia and geriatric syndromes in older patients admitted to an intermediate care unit: prospective observational study

BACKGROUND

Dysphagia is a geriatric syndrome often unrecognized or underestimated, and there is a lack of studies in a heterogeneous population in intermediate care (IC) services. This study aims to describe the prevalence of dysphagia and its association with geriatric syndromes in older patients in IC.

METHODS

Prospective cohort study of patients 70 years and older admitted to an IC unit. At admission, the severity of the clinical conditions, comorbidity, delirium, frailty, sarcopenia, nutritional status, and medications were assessed. Each patient was evaluated with the 3-OZ test, and dysphagia was confirmed by a speech therapy consultation. Two multivariable logistic regression models were used to evaluate the association of dysphagia at admission with geriatric syndromes (model 1), along with the severity of illness and admission diagnosis (model 2).

RESULTS

A total of 455 patients were included. The prevalence of dysphagia was 10% and there was a high prevalence of mild-moderate dysphagia in patients with cognitive impairment and moderate risk of malnutrition. In the univariate analysis, an association was found between dysphagia and sarcopenia, malnutrition, and use of antipsychotics. In Model 1, higher odds of dysphagia were associated with the severity of comorbidity (Odds Ratio 6.49, 95% Confidence Interval: 2.02-20.78), and cognitive impairment (OR 0.91, 95% CI: 0.88-10.62); in Model 2, the severity of clinical conditions-NEWS2 (OR 1.61, 95% CI: 1.23-2.13) was associated with dysphagia, besides the severity of comorbidity and cognitive impairment. In a subset of 300 patients, delirium was also associated with dysphagia.

CONCLUSIONS

The study provides novel information on dysphagia prevalence in patients admitted to an IC unit and its association with geriatric syndromes. Additional research is needed to further define the relationship between geriatric syndromes and dysphagia, and to adequately standardize speech therapist treatments.

Dysphagia development in heart failure patients: A scoping review

OBJECTIVE

Dysphagia significantly affects older adults, particularly those with heart failure (HF). This scoping review aimed to delineate the development of dysphagia and its contributing factors in patients with HF.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, and CENTRAL databases up to September 2023, focusing on studies involving HF patients aged 60 and above, particularly those assessing post-hospitalization dysphagia.

RESULTS

Of 1,076 identified studies, nine were relevant. The prevalence of dysphagia at admission was 23.6 % (14.1 - 32.9), with 9.4 % (4.5 - 13.8) persisting until discharge. The evaluation of dysphagia primarily relies on oral intake assessments, highlighting several risk factors, including high inflammation, low energy intake, advanced age, low Barthel Index scores, poor oral health, antipsychotic usage, and low maximum tongue pressure. It is important to note potential author bias and overlap among study populations.

CONCLUSIONS

This review highlights the significant development of dysphagia in patients with HF, and the prevalence of newly developed dysphagia was 23.6 % (14.1 - 32.9). Key risk factors include older age, high inflammation, low activities of daily living, and sarcopenia, which is suggested as a pathogenic mechanism in dysphagia. Future research should focus on diverse samples, investigate the impact of sarcopenia and cachexia, and objectively assess swallowing function.

Oropharyngeal functions are related to physical activity level and quality of life in older adults

This study aimed to investigate the relationship between oropharyngeal functions and physical activity levels and quality of life in older adults. The Clinical Frailty Scale and Simple Questionnaire to Rapidly Diagnose Sarcopenia were used to assess frailty. Oropharyngeal functions were assessed using the Test of Masticating and Swallowing Solids (TOMASS) and Yale Swallowing Protocol (YSP). The Physical Activity Scale for the Elderly (PASE) was used to assess physical activity, and Short Form-36 (SF-36) to assess quality of life. There was a negative correlation between TOMASS and work-related activities (p = 0.024) and between YSP and total score and household activities (p < 0.05). There were negative correlations between role-physical and number of bites (p = 0.034) and total time of TOMASS (p < 0.001), and between role-emotional and number of bites, total time of TOMASS and YSP (p < 0.05). In conclusion, poor oropharyngeal function is associated with reduced physical activity and poorer quality of life in older adults.

Association Between Phase Angle and Tongue Pressure in Older Inpatients with Connective Tissue Diseases

To investigate the association between tongue pressure (TP) and phase angle (PhA) in patients with connective tissue diseases (CTDs) aged 65 years or older. This retrospective cross-sectional study was conducted on 189 patients with CTDs who underwent hospital rehabilitation. TP was measured using a tongue pressure measuring device, and PhA was calculated from the bioimpedance analysis readings. Statistical analyses included multivariate linear regression with TP and receiver operating characteristic curves to determine PhA cutoff values indicative of low TP, defined as < 24.3 kPa for men and < 23.7 kPa for women. A total of 189 patients with CTDs (mean age 75 years; 49 men and 140 women; mean PhA 4.0°; mean TP 27.7 kPa) were included in the analysis. Fifty-five patients had low TP. Patients with low TP had lower PhA values than those with normal TP (mean PhA values 3.5° versus 4.3°). After adjusting for confounding factors, PhA (β = 0.387, p < 0.001) was significantly associated with TP. Cutoff values for PhA predicting low TP were identified as 3.9° for men and 3.5° for women. PhA is associated with TP, independent of other factors, in older inpatients with CTDs. The identified PhA cutoff values could enable the early detection of declining TP.

Association between oral health-related quality of life and physical frailty among community-dwelling older adults: A 2-year longitudinal study

BACKGROUND

Frailty is a major health concern among older adults, and its association with oral health-related quality of life (OHRQoL) remains underexplored in longitudinal studies.

OBJECTIVE

To investigate the association between baseline OHRQoL and physical frailty incidence at a 2-year follow-up in community-dwelling older adults.

DESIGN

Prospective longitudinal study.

SETTING

The study was conducted within the Tosa Longitudinal Aging Study framework in Japan.

PARTICIPANTS

This study included 144 community-dwelling older adults (50 men and 94 women; median age, 81.0 years) with complete data who participated in the Tosa Longitudinal Aging Study in 2016 and 2018 and were not categorized as physical frailty in 2016.

MEASUREMENTS

Baseline assessment included OHRQoL, which was evaluated using the General Oral Health Assessment Index (GOHAI; range 12-60), with higher scores indicating better OHRQoL, oral function, and general health status. The incidence of physical frailty was defined using the revised Japanese version of the Cardiovascular Health Study criteria. The association between the GOHAI score and physical frailty was assessed using logistic regression analysis.

RESULTS

The median baseline GOHAI score was 58. The incidence of frailty after a 2-year follow-up was 13.9 % among the participants (18.0 and 11.7 % for men and women, respectively). Each point of the GOHAI score was associated with an 11 % reduction in frailty risk over 2 years after adjusting by age, sex, number of teeth, Food Diversity Score, Geriatric Depression Scale score, eating alone, smoking, and more than five medications (adjusted odds ratio: 0.893; 95 % confidence interval: 0.810-0.984).

CONCLUSIONS

This longitudinal study showed that a higher baseline OHRQoL, based on the GOHAI score, was linked to a lower incidence of physical frailty among community-dwelling older adults after 2 years.

Social Isolation Among Older Adults With Dysphagia Requiring Home Health Care: A Cross-Sectional Study

BACKGROUND AND OBJECTIVES

We hypothesized that community-dwelling older adults with impaired swallowing functions have a higher risk of social isolation than individuals without impaired function. The aim of this study was to identify the association of dysphagia with social isolation in home care patients using daily interaction frequency and laughter frequency as indicators of social interaction.

METHODS

One hundred ninety home care patients, aged ≥65 years, were included in this cross-sectional questionnaire survey. The patients' basic information, level of care required, and social background as a percentage of public health care costs were obtained. Swallowing function, assessed with the Food Intake Level Scale (FILS), was evaluated from the medical records. Respondents answered how often they interacted with people outside their family, the number of people they interacted with, and how often they laughed in their daily lives. Logistic regression analyses were performed to examine factors associated with social isolation.

RESULTS

Laughter frequency was significantly lower in the dysphagia group (P=0.011). The interaction frequency was lower in those who needed more care (odds ratio (OR) (95% confidence interval (CI)) = 0.16 (0.03, 0.78)) and lower in those with dysphagia (0.40 (0.17, 0.97)). The number of exchanges was lower for those with dysphagia (0.22 (0.09, 0.58)) and needed more care (0.10 (0.02, 0.60)) and higher for those with dementia (2.86 (1.22, 6.66)).

CONCLUSIONS

Swallowing function is significantly associated with social interaction between homebound older adults and others. An approach to maintaining and improving swallowing function in older people requiring home healthcare may help maintain social interaction and prevent social isolation.

Sarcopenia, dysphagia, and frailty in community-dwelling older adults: An analysis of mediation and moderated mediation models

Sarcopenia, dysphagia, and frailty are geriatric syndromes that commonly occur with age and are associated with various adverse health consequences. Nevertheless, the complex associations among them require further study to be clarified. The objectives of this study were to investigate (1) the potential role of dysphagia as a mediator in the association between sarcopenia and frailty and (2) the potential role of taste and smell dysfunction as a moderator of this mediator effect in community-dwelling older adults. A total of 352 older adults (mean age = 70.48 ± 5.31 years; 57.67% female) enrolled in this cross-sectional study. The SARC-F, Eating Assessment Tool-10 (EAT-10), and Edmonton Frailty Scale (EFS) were used to assess sarcopenia, dysphagia, and frailty, respectively. The Taste and Smell Dysfunction Questionnaire (TSDQ) was employed to assess taste and smell dysfunction. Frailty was present in 21.86%, sarcopenia risk in 39.77%, and dysphagia in 26.99% of the participants. The mediation analysis showed that the SARC-F had a significant effect on the EAT-10 (B = 1.001; p < 0.001), which in turn had a significant effect on the EFS (B = 0.129; p < 0.001). The direct (B = 0.659; p < 0.001), indirect (B = 0.129), and total (B = 0.778; p < 0.001) effects of SARC-F on EFS were significant. Of the association between sarcopenia and frailty, 16.6% was explained by dysphagia. The moderated mediation analysis showed that the TSDQ (B = 0.127; p < 0.001) moderated the association between SARC-F and EAT-10 and that the EAT-10 mediated the association between SARC-F and EFS only in older adults who scored moderate and high on the TSDQ (B = 0.049 and B = 0.114, respectively). The EAT-10 partially mediates the association between the SARC-F and the EFS, implying that sarcopenia affects frailty indirectly via dysphagia. Furthermore, taste and smell dysfunction moderates this mediator effect, with sarcopenia functioning as a mediator in older adults who scored moderate and high on the TSDQ. Therefore, it is plausible to anticipate that if someone has taste and smell dysfunction in addition to sarcopenia, they are more likely to have dysphagia and, ultimately, frailty. These findings emphasize the importance of addressing sarcopenia, taste and smell dysfunction, and dysphagia concurrently in frailty management in older adults.

Perioperative gum-chewing training prevents a decrease in tongue pressure after esophagectomy in thoracic esophageal cancer patients: a nonrandomized trial

Tongue pressure (TP) decreases significantly after esophagectomy in esophageal cancer patients (ECPs). Meanwhile, 2 weeks of gum-chewing training (GCT) significantly increased TP in healthy university students. We examined whether perioperative GCT would decrease the proportion of patients exhibiting a decline in TP at 2 weeks postoperatively, and prevent postoperative complications, in thoracic ECPs (TECPs). This was a single-center interventional study, and nonrandomized study with a historical control group (HCG). TECPs who underwent first-stage radical esophagectomy were recruited. Thirty-two patients of 40 in the gum-chewing group (GCG) were completed perioperative GCT in 3 times daily. Propensity score matching was performed with covariates related to TP including preoperative age, sex, body mass index, and the repetitive saliva swallowing test result, and yielded a matched cohort of 25 case pairs. Eleven GCG patients [44.0%] exhibited significantly lower TP at 2 weeks postoperatively than before esophagectomy was significantly fewer than that of 19 patients [76.0%] in the HCG. The median number of fever days (> 38 °C) in the 2 weeks after esophagectomy in the GCG was significantly fewer than those in the HCG. Perioperative GCT may prevent postoperative TP decline and postoperative dysphagia-related complications after esophagectomy.

Extremely Poor Post-discharge Prognosis in Aspiration Pneumonia and Its Prognostic Factors: A Retrospective Cohort Study

There is little evidence regarding the long-term prognosis of patients with aspiration pneumonia. This study aimed to investigate post-discharge survival time and prognostic factors in older patients hospitalized for aspiration pneumonia. This retrospective cohort study included patients aged ≥ 65 years hospitalized for aspiration pneumonia and discharged alive from a tertiary care hospital in Japan between April 2009 and September 2014. Candidate prognostic factors were patient's age, sex, body mass index (BMI), performance status, chronic conditions, CURB-65 score, serum albumin level, hematocrit concentration, nutritional pathway at discharge, and discharge location. Kaplan-Meier curves were determined and multivariable survival analysis using Cox regression model was performed to analyze the effect of each factor on mortality. In total, 209 patients were included in this study. The median age was 85 years, 58% of the patients were males, 33% had a performance status of 4 and 34% were discharged home. Among the patients, 65% received oral intake, 23% received tube feeding, and 21% received parenteral nutrition at discharge. During the follow-up period, 77% of the patients died, and the median post-discharge survival time was 369 days. Besides male sex and low BMI, tube feeding (adjusted hazard ratio (aHR) = 1.70, 95% confidence interval (CI) 1.11-2.59) and parenteral nutrition (aHR = 4.42, 95% CI 2.57-7.60) were strongly associated with mortality. Long-term prognosis of patients hospitalized for aspiration pneumonia was extremely poor. The nutritional pathway at discharge was a major prognostic factor. These results may be useful for future care and research.

Maximum Anterior Tongue Strength and Maximum Lip Strength in Healthy Spanish Adults: A Proposal of Reference Values

Adequate tongue and lip strengths are needed for normal speech, chewing, and swallowing development. The aim was to evaluate the influence of sex and age on maximum anterior tongue strength (MTS) and maximum lip strength (MLS) in healthy Spanish adults to establish reference values that can be used in clinical practice.This cross-sectional study comprises 363 subjects (mean age 47.5 ± 20.7 years) distributed by sex (258 women and 105 men) and across three age groups: Young (18-39 years), middle-aged (40-59 years), and older adults (> 59 years). MTS and MLS were determined using the Iowa Oral Performance Instrument (IOPI). The mean MTS was 49.63 ± 13.81 kPa, regardless of sex, and decreased with age. The mean MLS was statistically higher for men (28.86 ± 10.88 kPa) than for women (23.37 ± 6.92 kPa, p = 0.001), regardless of age.This study provides the first reference values for the standardized measurement of MTS and MLS in a healthy adult Spanish-speaking population using the IOPI.

Alterations in the sarcopenia index are associated with inflammation, gut, and oral microbiota among heart failure, left ventricular assist device, and heart transplant patients

BACKGROUND

Sarcopenia, characterized by loss of muscle mass and function, is prevalent in heart failure (HF) and predicts poor outcomes. We investigated alterations in sarcopenia index (SI), a surrogate for skeletal muscle mass, in HF, left ventricular assist device (LVAD), and heart transplant (HT), and assessed its relationship with inflammation and digestive tract (gut and oral) microbiota.

METHODS

We enrolled 460 HF, LVAD, and HT patients. Repeated measures pre/post-procedures were obtained prospectively in a subset of LVAD and HT patients. SI (serum creatinine/cystatin C) and inflammatory biomarkers (C-reactive protein, interleukin-6, tumor necrosis factor-alpha) were measured in 271 and 622 blood samples, respectively. Gut and saliva microbiota were assessed via 16S ribosomal ribonucleic acid sequencing among 335 stool and 341 saliva samples. Multivariable regression assessed the relationship between SI and (1) New York Heart Association class; (2) pre- versus post-LVAD or HT; and (3) biomarkers of inflammation and microbial diversity.

RESULTS

Median (interquartile range) natural logarithm (ln)-SI was -0.13 (-0.32, 0.05). Ln-SI decreased across worsening HF class, further declined at 1 month after LVAD and HT, and rebounded over time. Ln-SI was correlated with inflammation (r = -0.28, p < 0.01), gut (r = 0.28, p < 0.01), and oral microbial diversity (r = 0.24, p < 0.01). These associations remained significant after multivariable adjustment in the combined cohort but not for all individual cohorts. The presence of the gut taxa Roseburia inulinivorans was associated with increased SI.

CONCLUSIONS

SI levels decreased in symptomatic HF and remained decreased long-term after LVAD and HT. In the combined cohort, SI levels covaried with inflammation in a similar fashion and were significantly related to overall microbial (gut and oral) diversity, including specific taxa compositional changes.

A Comparison of Oral Function in Older In- and Outpatients: An Observational Study

(1) Background: Insufficient data exist regarding oral function among older adults in Europe. Therefore, we aimed to assess and compare oral function between older in- and outpatients and identify predictors of low masticatory performance. (2) Methods: Patients were consecutively recruited from the outpatient center (n = 31) and the inpatient geriatric department (n = 31) at a tertiary University Hospital in Switzerland in 2023. Assessments on oral function included the total number of intraoral eruptive teeth, number of supporting zones with dentures, maximal bite force (Dental Prescale II, Fuji Film Corp., Tokyo, Japan), and masticatory performance (Hue-Check Gum©, University of Bern, Bern, Switzerland) using a visual (SA1-SA5) and a digital (SD_Hue) scale. The visual and digital assessment of masticatory performance showed a strong correlation (Kendall tau = 0.83). Low masticatory performance was defined as SA-Grade 1-2 (vs. SA3-SA5 as reference). In a multivariate model adjusting for age, sex, and clinical setting, we investigated associations of maximal bite force, few eruptive teeth, and few supporting zones with low masticatory performance. (3) Results: Mean age was 81.9 (standard deviation (sd) 5.2) years, and 62.9% were female. Overall, maximal bite force was 247 N (sd 261). A total of 39 patients (63.9%) had a low masticatory performance, 62.9% a low maximal bite force, and 50% a low number of eruptive teeth (<10). Masticatory performance, number of eruptive teeth, and maximal bite force did not significantly differ between in- and outpatients. The number of supporting zones was significantly higher in outpatients compared to inpatients (median 4, interquartile range (IQR) 4-4; vs. 4, IQR 2-4; p = 0.03). In the multivariate model, maximal bite force and a low number of eruptive teeth were independently associated with low masticatory performance (adjusted odds ratio 7.4 (95% CI, 1.8-30.4; p < 0.01), and OR 7.8 (95% CI, 1.7-36.4; p < 0.01), respectively). (4) Conclusions: Impaired oral function is highly prevalent in both European older in- and outpatients to a similar degree. The association of low masticatory performance with maximal bite force and with a low number of eruptive teeth may indicate that a basic screening should include either of these parameters to identify impaired oral function.

Mapping Dysphagia Research Trends in Community Dwelling Older Adults: A Bibliometric Analysis

BACKGROUND

In recent years, research on dysphagia has gained significant traction as one of the key topics of oral health research pertaining to the aged. Numerous academics have studied dysphagia in great detail and have produced numerous excellent scientific research findings.

OBJECTIVE

To review the literature regarding dysphagia in community-dwelling older adults and identify the knowledge and trends using bibliometric methods.

METHODS

The literature on dysphagia in older adults in the community was gathered from the Web of Science Core Collection (WoSCC), with inclusion criteria specifying English-language publications. The retrieval deadline was November 28, 2022. We extracted the following data: title, year, abstract, author, keywords, institution, and cited literature, and used CiteSpace (version 6.1.R3) to visualize the data through the knowledge map, burst keyword analysis, cluster analysis, and collaborative network analysis.

RESULTS

A total of 979 articles and reviews were retrieved. Regarding productivity, the top 2 countries were the United States (n =239) and Japan (n =236). Hidetaka Wakabayashi (n =26) was one of the most prolific writers. The first paper in the frequency ranking of references cited was a white paper: European Society for Swallowing Disorders and European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome (n =53). "Prevalence" (n =173), "risk factor" (n =119), and "aspiration pneumonia" (n =108) were the most frequently occurring keywords (excluding defining nouns). The study identified reliability, tongue pressure, home discharge, and swallowing function as research hotspots from 2020 to 2022.

CONCLUSION

Prevalence, risk factors, and pneumonia are significant areas of study. Tongue pressure and sarcopenia are research hotspots and potential targets. In the future, research on dysphagia needs to refine strategies for prevention and control, as well as provide tertiary preventative services.

Longitudinal association between oral function and underweight onset among community-dwelling older adults: Role of regular self-weighing

AIMS

Regular self-weighing is effective in weight management and may help to mitigate the risk of underweight among older adults. We examined which factors of oral function are associated with a risk for underweight among community-dwelling older adults and whether regular self-weighing can mitigate that risk.

METHODS

This was a cohort study. Self-administered questionnaires were mailed to 7665 older adults in March 2019 (response rate 74.3%) and 7591 in March 2020 (response rate 74.7%). Among those who responded to both surveys, 3594 older adults who were not underweight in March 2019 were included (follow-up rate: 59.2%). We examined the association between dysphagia, poor masticatory function, and dry mouth and the development of underweight, and whether regular self-weighing reduced the risk for underweight.

RESULTS

The average age ± standard deviation of participants was 71.1 ± 3.4 years. There was a significant association between swallowing difficulty and the occurrence of underweight (odds ratio = 1.65, p = .012). However, this relationship did not differ significantly with regular self-weighing (p = .477).

CONCLUSIONS

These study findings suggest that to prevent underweight among community-dwelling older adults, it is important to focus on those with poor swallowing function.

Effect of oral function and postoperative eating patterns on salivary bacterial counts in gastrointestinal tract surgery patients: A preliminary study

Background/purpose

Perioperative oral care is widely provided to prevent postoperative pneumonia and surgical site infections in patients undergoing surgery under general anesthesia. However, there is a lack of clarity regarding the kind of oral care that should be provided for different patients. The purpose of this study was to clarify the factors that influence the increase in salivary bacterial counts before and after gastrointestinal surgery to identify patients with a particular need for oral care.

Materials and methods

Twenty patients undergoing gastrointestinal surgery were examined before surgery for denture use, number of remaining teeth, regular dental care, Oral Hygiene Index-Simplfied tongue coating, tongue pressure, bite pressure, masticatory efficiency, and dry mouth. Saliva samples were collected before surgery, in the fasting period after surgery, and in the oral feeding period. Total bacterial counts were determined by real-time PCR, and factors associated with bacterial counts were investigated.

Results

Patients with decreased oral functions, such as tongue pressure, bite pressure, and masticatory efficiency, tended to have higher salivary bacterial counts in the preoperative, fasting, and oral feeding periods. Regarding the pre- and postoperative changes, salivary bacterial counts increased in the fasting period compared to the pre-operative period and returned to preoperative values in the oral feeding period.

Conclusion

Perioperative oral care is important for patients with reduced oral function because the number of bacteria in saliva tends to be higher in such patients. As the number of bacteria in saliva increases during the fasting period, oral care is important, and oral feeding should be restarted as soon as possible.

Effects of Oleanolic Acid Derived from Wine Pomace on Periodontopathic Bacterial Growth in Healthy Individuals: A Randomized Placebo-Controlled Study

Periodontal disease is caused by oral pathogenic bacteria and is associated with systemic disease and frailty. Therefore, its prevention is crucial in extending healthy life expectancy. This study aimed to evaluate the effect of orally administered oleanolic acid, extracted from wine pomace, on periodontopathic bacterial growth in healthy individuals. In this randomized, placebo-controlled, double-blind, parallel-group comparison study, 84 healthy adults were assigned to a placebo (n = 29), low-dose (n = 29, 9 mg oleanolic acid), or high-dose (n = 26, 27 mg oleanolic acid) groups. The number of oral bacteria in their saliva, collected before and 5 h after administration, was determined using the polymerase chain reaction-invader technique. The proportion of periodontopathic bacteria among the total oral bacteria in the saliva was calculated. Oleanolic acid significantly decreased the proportion of Porphyromonas gingivalis among the total oral bacteria in a dose-dependent manner (p = 0.005 (low-dose) and p = 0.003 (high-dose) vs. placebo, Williams' test). Moreover, high-dose oleanolic acid decreased the proportion of Tannerella forsythia (p = 0.064 vs. placebo, Williams' test). Periodontopathic bacteria are closely associated with the development and progression of periodontal disease; thus, the continuous daily intake of oleanolic acid derived from pomace may be helpful in maintaining a healthy oral microbiome by controlling the proportion of periodontopathic bacteria.

Efficacy of Episil® in patients with hematologic malignancies: a comparative study

BACKGROUND

Episil® is a nonabsorbable liquid medical material used to coat and protect the mucosa in patients with oral mucositis. A few studies have reported its efficacy in patients with head and neck cancer. However, reports on its use in patients with hematologic malignancies are scarce. Thus, we aimed to evaluate the efficacy of Episil for the treatment of oral mucositis in patients with acute myelogenous leukemia, malignant lymphoma, acute lymphocytic leukemia, multiple myeloma, and myelodysplastic syndrome.

METHODS

Between May 2018 and March 2019, a total of thirty-seven patients with acute myelogenous leukemia, malignant lymphoma, acute lymphocytic leukemia, multiple myeloma, and myelodysplastic syndrome who received Episil® for the treatment of oral mucositis were included in this study. All patients were treated at the Hiroshima Red Cross and Atomic-bomb Surgery Hospital. To determine the severity of oral mucositis, 22 out of the 37 patients were interviewed and compared objectively using the Common Terminology Criteria for Adverse Events, version 3.0. In addition, subjective measures of the effects of oral mucositis were assessed using an original evaluation protocol (a unique evaluation chart specific to the Department of Oral Surgery, Hiroshima Red Cross & Atomic-bomb Survivors Hospital).

RESULTS

Out of 37 participants recruited in the study, 31 (84%) described the sensation of Episil® as very good or good. Moreover, the severity of mucositis was found to decrease after the use of Episil® in seven patients out of 22 (19%), particularly in those with mucositis at multiple sites. Participants' evaluations revealed pain relief and improvement in speech and feeding functions. Participants with grade 3 mucositis reported a greater improvement in pain relief, speech, and feeding functions than those with grade 2 mucositis.

CONCLUSIONS

This study suggests the efficacy of Episil® in treating oral mucositis in patients with hematologic malignancies, particularly in those with oral mucositis at multiple sites. In addition to pain relief, Episil® may improve speech and feeding functions.

Prevalence of dysphagia in patients after orthopedic surgery

OBJECTIVES

Oropharyngeal dysphagia is one of the most prevalent health complications in older adults. The prevalence of postoperative dysphagia is expected to rise with the increasing number of older patients undergoing orthopedic surgery; however, the specific prevalence and contributing factors remain unclear. This scoping review aimed to identify the prevalence and factors related to postoperative dysphagia in older orthopedic patients.

METHODS

This review included studies published up to September 2022 on postoperative patients aged ≥ 60 years who underwent orthopedic surgery. We searched MEDLINE, EMBASE, CINAHL, CENTRAL, Web of Science, and Ichushi-Web.

RESULTS

In total, 21 of the 2158 identified studies were reviewed. The studies were classified into the three categories according to the surgical site: cervical spine disease (n = 12), hip fracture (n = 7), and others (n = 2). The estimated dysphagia prevalence rates [95 % confidence interval] of cervical spine disease, hip fractures, and others were 16 % [8-27], 32 % [15-54], and 6 % [4-8], respectively. Factors related to postoperative dysphagia included cervical alignment in cervical spine disease, being older within the cohort, preoperative health status, malnutrition, and sarcopenia in hip fractures.

CONCLUSIONS

The prevalence of postoperative dysphagia after orthopedic surgery was highest for hip fractures, followed by cervical spine and others. These results suggest non-neurogenic dysphagia in older patients undergoing orthopedic surgery and indicate that sarcopenia may contribute to postoperative dysphagia in this population. Therefore, further research should clarify the trajectory of postoperative dysphagia and the effectiveness of rehabilitation for postoperative dysphagia after orthopedic surgery.

Prevalence and risk factors for dysphagia in older adults after thyroid and parathyroid surgery

BACKGROUND

We aimed to determine the prevalence and risk factors for dysphagia in adults 65 years and older before and after thyroidectomy or parathyroidectomy.

METHODS

We performed a longitudinal prospective cohort study of older adults undergoing initial thyroidectomy or parathyroidectomy. We administered the Dysphagia Handicap Index questionnaire preoperatively and 1, 3, and 6 months postoperatively. We compared preoperative and postoperative total and domain-specific scores using paired t tests and identified risk factors for worse postoperative scores using multivariable logistic regression.

RESULTS

Of the 175 patients evaluated, the mean age was 71.1 years (range = 65-94), 73.7% were female, 40.6% underwent thyroidectomy, 57% underwent bilateral procedures, and 21.1% had malignant diagnoses. Preoperative swallowing dysfunction was reported by 77.7%, with the prevalence 22.4% greater in frail than robust patients (P = .013). Compared to preoperative scores, 43.4% and 49.1% had worse scores at 3 and 6 months postoperatively. Mean functional domain scores increased by 62.3% at 3 months postoperatively (P = .007). Preoperative swallowing dysfunction was associated with a 3.07-fold increased likelihood of worse functional scores at 3 months. Whereas frailty was associated with preoperative dysphagia, there was no association between worse postoperative score and age, sex, race, frailty, body mass index, smoking status, gastroesophageal reflux disease, comorbidity index, malignancy, surgical extent, or type of surgery.

CONCLUSION

Adults 65 years and older commonly report swallowing impairment preoperatively, which is associated with a 3.07-fold increased likelihood of worsened dysphagia after thyroid and parathyroid surgery that may persist up to 6 months postoperatively.

U-shaped association between plasma C-peptide and sarcopenia: A cross-sectional study of elderly Chinese patients with diabetes mellitus

Limited research exists regarding the relationship between fasting plasma C-peptide levels and sarcopenia. As a result, our study aimed to examine this association in elderly Chinese diabetic patients. This cross-sectional study included 288 elderly patients with diabetes mellitus from the Fourth People's Hospital in Guiyang who were enrolled prospectively between March 2020 and February 2023. The independent variable of interest was fasting plasma C-peptide, while the dependent variable was sarcopenia. Data on several covariates, including demographic factors, lifestyle habits, co-morbidities, anthropometric indicators, and laboratory indicators, were also collected. Of the 288 participants, 27.43% (79/288) had sarcopenia. After adjusting for potential confounding variables, we found a U-shaped association between fasting plasma C-peptide levels and sarcopenia, with inflection points identified at approximately 774 pmol/L and 939 mmol/L. Within the range of 50-744 pmol/L, each 100 pmol/L increase in CysC was associated with a 37% decrease in the odds of sarcopenia (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.49 to 0.83; P < 0.001). Additionally, within the range of 939-1694 pmol/L, each 100 pmol/L increase in fasting plasma C-peptide was associated with a 76% increase in the odds of sarcopenia (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.11 to 2.81; P = 0.017). Our study revealed a U-shaped association between fasting plasma C-peptide levels and the likelihood of sarcopenia, with lower risk in the range of 774-939 pmol/L. These findings may assist in the development of more effective prevention and treatment strategies for sarcopenia in elderly diabetic patients.

Comparative Study of Surgical Outcomes of Occipitocervical and Atlantoaxial Fusion for Retro-Odontoid Pseudotumor

OBJECTIVE

To compare the surgical and radiographic outcomes of occipitocervical fusion (OCF) with those of atlantoaxial fusion (AAF) in patients with cervical myelopathy caused by retroodontoid pseudotumors (ROPs).

METHODS

This retrospective, comparative study included 26 patients; 12 underwent occipitocervical fusion (OCF) (group O) and 14 retroodontoid pseudotumor (AAF) (group A) with a minimum 2-year follow-up. Neurologic outcomes were evaluated using the Japanese Orthopedic Association (JOA) score. Radiologic assessment included the maximum anteroposterior (AP) diameter of the anteroposterior-retroodontoid pseudotumor (AP-ROP), C2-7 angle, O-C2 angle, C1-2 angle, atlantodental interval (ADI), range of motion (ROM) of the ADI, C2-C7 sagittal vertical axis (C2-7 SVA), and T1 slope. Global spinal alignments (pelvic incidence [PI] minus lumbar lordosis [LL] [PI-LL], pelvic tilt, sacral slope, and C7 sagittal vertical axis) were also compared between the groups.

RESULTS

Both groups had equally good clinical outcomes with equal complication rates. Three patients had a three-level fusion, 5 cases had a four-level fusion, and 4 cases had more than five-level fusion in group O. All cases had a single-level fusion in group A. Surgical time was significantly shorter in group A. AP-ROP was significantly downsized postoperatively in both groups and was more prominent in group O. C2-7 SVA was significantly increased and C2-7A ROM was significantly reduced in group O at the final follow-up. The PI-LL showed a significant increase in group O at the final follow-up.

CONCLUSIONS

Although OCF and AAF were similarly effective for cervical myelopathy with ROP, AAF was less invasive, and spinal alignment was better maintained postoperatively in AAF than OCF.

Sarcopenic Dysphagia and Simplified Rehabilitation Nutrition Care Process: An Update

Sarcopenic dysphagia is characterized by weakness of swallowing-related muscles associated with whole-body sarcopenia. As the number of patients with sarcopenia increases with the aging of the world, the number of patients with sarcopenic dysphagia is also increasing. The prevalence of sarcopenic dysphagia is high in the institutionalized older people and in patients hospitalized for pneumonia with dysphagia in acute care hospitals. Prevention, early detection and intervention of sarcopenic dysphagia with rehabilitation nutrition are essential. The diagnosis of sarcopenic dysphagia is based on skeletal and swallowing muscle strength and muscle mass. A reliable and validated diagnostic algorithm for sarcopenic dysphagia is used. Sarcopenic dysphagia is associated with malnutrition, which leads to mortality and Activities of Daily Living (ADL) decline. The rehabilitation nutrition approach improves swallowing function, nutrition status, and ADL. A combination of aggressive nutrition therapy to improve nutrition status, dysphagia rehabilitation, physical therapy, and other interventions can be effective for sarcopenic dysphagia. The rehabilitation nutrition care process is used to assess and problem solve the patient's pathology, sarcopenia, and nutrition status. The simplified rehabilitation nutrition care process consists of a nutrition cycle and a rehabilitation cycle, each with five steps: assessment, diagnosis, goal setting, intervention, and monitoring. Nutrition professionals and teams implement the nutrition cycle. Rehabilitation professionals and teams implement the rehabilitation cycle. Both cycles should be done simultaneously. The nutrition diagnosis of undernutrition, overnutrition/obesity, sarcopenia, and goal setting of rehabilitation and body weight are implemented collaboratively.

Improving physical performance reduces dysphagia via improvement of tongue strength in patients with acute heart failure: a two-wave cross-lagged mediation model analysis

BACKGROUND

Physical performance improvement through whole-body exercise may have a positive impact on dysphagia via improvement of maximum tongue pressure (MTP).

AIMS

The present study aimed to quantitatively analyze whether improvement in physical performance reduces dysphagia by improving MTP in patients with acute heart failure (AHF).

METHODS

A total of 146 patients with AHF and dysphagia were included. Dysphagia was defined as a functional oral intake scale (FOIS) score < 6. The short physical performance battery (SPPB) indexed physical performance. A two-wave cross-lagged mediation model was used to examine whether an improvement in SPPB results improves the FOIS score via an improvement in MTP. The SPPB, MTP, and FOIS scores (T1: baseline, T2: hospital discharge) were included in the model.

RESULTS

A total of 146 patients were included in the final analysis. The SPPB result at T1 positively affected MTP (β = 0.150, P = 0.030) and the FOIS score (β = 0.249, P = 0.002) at T2. MTP at T1 also positively affected the FOIS score at T2 (β = 0.189, P = 0.026). Furthermore, the SPPB result indirectly affected the FOIS score by affecting the MTP (indirect effect = 0.028; 95% CI = 0.010, 0.078).

DISCUSSION

This study contributes to the knowledge base regarding the potential of exercise therapy as a new treatment strategy for dysphagia in patients with AHF.

CONCLUSION

An improvement in SPPB results improved the FOIS score by improving the MTP in patients with AHF.

Evaluation of Esophageal Dysphagia in Elderly Patients

PURPOSE OF REVIEW

While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence.

RECENT FINDINGS

In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.

Prevalence of frailty and its association with oral hypofunction in older adults: a gender perspective

BACKGROUND

Previous studies have indicated an association between oral hypofunction and frailty in community-dwelling older adults. However, this issue has not been evaluated in institutionalized older patients. We aimed to determine the prevalence of physical frailty in this particularly vulnerable group and evaluate its association with oral hypofunction, analyzing possible differences by gender.

METHODS

This cross-sectional study was conducted in private and public care homes in Guayaquil (Ecuador) from January 2018 until December 2019. Participants were classified as robust, pre-frail, and frail according to the Fried's frailty phenotype. Oral hypofunction was defined as the presence of at least three positive items in the following list: poor oral hygiene, oral dryness, reduced occlusal force, decreased masticatory function, and deterioration of swallowing function. The relationships between frailty and oral hypofunction were analyzed using logistic regression models for the whole sample and stratified by gender. Statistical analyses were performed using STATA 15.0 software (Stata Corp. LP, College Station, TX, USA).

RESULTS

Among the 589 participants analyzed (65% women), the median age was 72 years (interquartile range: 66-82). Pre-frailty and frailty were presented in 66.7% and 28.9% of them respectively. Weakness was the most frequent item (84.6%). There was a significant relationship between frailty and oral hypofunction in women. In the overall sample, the frequency of frailty was 2.06 times higher (95% CI 1.30-3.29) in patients with oral hypofunction, and this association was maintained in women (ORa: 2.18; 95% CI 1.21-3.94). Reduced occlusal force and decreased swallowing function were items significantly associated with the presence of frailty (ORa: 1.95; 95% CI 1.18-3.22 and ORa: 2.11; 95% CI 1.39-3.19, respectively).

CONCLUSION

The prevalence of frailty and pre-frailty was high among institutionalized older people and was associated with the presence of hypofunction, especially in women. Decreased swallowing function was the most strongly item associated with frailty.

The Relationship between Low Skeletal Muscle Mass and Subsequent Oral Intake Ability among the Aged Population

This study aimed to determine the relationship between skeletal muscle mass in an aged population with limited oral intake upon admission and functional oral intake at the subsequent 3-month follow-up. Methods: This was a retrospective cohort study using the Japanese Sarcopenia Dysphagia Database involving older adults (≥60 years) with limited oral intake (Food Intake Level Scale [FILS] level of ≤8). People without skeletal muscle mass index (SMI) data, unknown methods of SMI evaluation, and SMI evaluation by DXA were excluded. Data for 76 people (47 women, 29 men) were analyzed (mean [standard deviation] age: 80.8 [9.0] years; median SMI: women, 4.80 kg/m²; men, 6.50 kg/m²). There were no significant differences in age, FILS upon admission and methods of nutrition intake between the low (n = 46) and the high skeletal muscle mass groups (n = 30), although the proportion of sex between the two groups was different. The FILS level at the time of follow-up differed significantly between the groups (p < 0.01). The SMI upon admission (odds ratio: 2.99, 95% confidence interval: 1.09-8.16) were significantly associated with the FILS level at the time of follow-up after adjustment for sex, age, and history of stroke and/or dementia (p < 0.05, power = 0.756). Conclusion: A low skeletal muscle mass is a disadvantage for achieving a subsequent fully functional oral intake ability among the aged population with limited oral intake upon admission.

Easy-to-swallow mooncake using 3D printing: Effect of oil and hydrocolloid addition

3D printing is a promising technology for food production, capable of producing and developing personalized food products. In recent years, research on the application of 3D printing technology to create easy-to-swallow foods for the elderly with dysphagia has received extensive attention. In this study, we applied dual nozzle 3D printing technology to develop an easy-to-swallow mooncake food using a traditional Chinese food, mooncake, as a model system. We optimized the printing dough ink formulation by setting up soybean oil gradient experiments and Arabic gum gradient experiments, and then we applied the optimized dough ink as the crust of the mooncake to produce easy-to-swallow mooncakes. The experimental results show that the addition of 2.5 g of soybean oil and 0.125 g of Arabic gum could improve the texture of the dough product and reduce its hardness and adhesiveness. The mooncake produced with this crust dough ink was rated in the IDDSI texture level four, which met expectations. Therefore, this work provides insights into the development of easy-to-swallow food products.