Factors contributing to fecal incontinence in older people and outcome of routine management in home, hospital and nursing home settings

Objective: Fecal loading, cognitive impairment, loose stools, functional disability, comorbidity and anorectal incontinence are recognized as factors contributing to loss of fecal continence in older adults. The objective of this project was to assess the relative distribution of these factors in a variety of settings along with the outcome of usual management. Methods: One hundred and twenty adults aged 65 years and over with fecal incontinence recruited by convenience sampling from four different settings were studied. They were either living at home or in a nursing home or receiving care on an acute or rehabilitation elderly care ward. A structured questionnaire was used to elicit which factors associated with fecal incontinence were present from subjects who had given written informed consent or for whom assent for inclusion in the study had been obtained. Results: Fecal loading (Homes 6 [20%]; Acute care wards 17 [57%]; Rehabilitation wards 19 [63%]; Nursing homes 21 [70%]) and functional disability (Homes 5 [17%]; Acute care wards 25 [83%]; Rehabilitation wards 25 [83%]; Nursing homes 20 [67%]) were significantly more prevalent in the hospital and nursing home settings than in those living at home (P < 0.01). Loose stools were more prevalent in the hospital setting than in the other settings (Homes 11 [37%]; Acute care wards 20 [67%]; Rehabilitation wards 17 [57%]; Nursing homes 6 [20%]) (P < 0.01). Cognitive impairment was significantly more common in the nursing home than in the other settings (Nursing homes 26 [87%], Homes 5 [17%], Acute care wards 13 [43%], Rehabilitation wards 14 [47%]) (P < 0.01). Loose stools were the most prevalent factor present at baseline in 13 of the 19 (68%) subjects whose fecal incontinence had resolved at 3 months. Conclusion: The distribution of the factors contributing to fecal incontinence in older people living at home differs from those cared for in nursing home and hospital wards settings. These differences need to be borne in mind when assessing people in different settings. Management appears to result in a cure for those who are not significantly disabled with loose stools as a cause for their fecal incontinence, but this would need to be confirmed by further research

Consistent effects of whey protein fortification on consumer perception and liking of solid food matrices (cakes and biscuits) regardless of age and saliva flow

Although there are numerous high protein products on the market, they are typically not designed with, or for, older consumers. This is surprising considering that dietary guidelines recognise the need for higher protein intake in later life. Protein fortified products are, however, associated with negative sensory attributes and poor consumer acceptance. This paper investigates the extent of mouthdrying sensations within a high protein solid food matrix, along with the effect of age and saliva flow. Solid models using cakes and biscuits, with or without protein fortification, were investigated. The sensory profile and physical properties were analysed and two volunteer studies (n = 84; n = 70) were carried out using two age groups (18–30; 65+). Volunteers rated individual perception and liking of products, and salivary flow rates (mL/min) were measured. Unstimulated salivary flow rates were significantly lower (p < 0.05) in older adults, although this was not found to influence product perception. Protein fortification of cakes and biscuits significantly increased (p < 0.05) perceived mouthdrying, hardness and “off” flavours, and significantly reduced (p < 0.05) melting rate, moistness and liking compared with the control versions. There is a clear need to address negative sensory attributes associated with protein fortification of cakes and biscuits to ensure product suitability for older adults

Investigation of milk proteins binding to the oral mucosa

High protein dairy beverages are considered to be mouth drying. The drying sensation may be due to the product protein content; however the mechanism of this mouth drying is uncertain. This study investigated the potential adhesion of milk proteins to porcine oral mucosal tissues and their resistance to wash out with simulated saliva was monitored using fluorescence microscopy. Cadein was found to be more adhesive to porcine mucosa then lactogloubulin. Some investigation into the reason for this difference in mucoadhesion was conducted by thiol-content analysis, rheology and zeta-potential measurements. The higher viscosity of casein solution and smaller zeta-potential is believed to be responsible for its better retention on mucosal surfaces. These findings suggest that casein and whey protein are both capable of binding and eliciting mouth drying in high protein dairy beverages

The effect of macro and micro-nutrient fortification of biscuits on their sensory properties and on hedonic liking of older people

BACKGROUND: Under-nutrition in older adults is widespread. Oral nutritional supplement beverages (ONS) are prescribed, yet consumption by older people is often insufficient. A variety of supplement formats may improve nutrient intake. This study developed protein and micro-nutrient fortified biscuits and evaluated their sensory attributes and liking by older people. Two micro-nutrient strategies were taken, to match typical ONS and to customise to the needs of older people. RESULTS: Oat biscuits and gluten-free biscuits developed contained over 12% protein and over 460 kcal 100 g-1 . Two small (40 g) biscuits developed to match ONS provided approximately 40% of an ONS portion of micro-nutrients and 60% of macro-nutrients; however, the portion size was considered realistic whereas the average ONS portion (200 mL) is excessive. Biscuits developed to the needs of older adults provided, on average, 18% of the reference nutrient intake of targeted micro-nutrients. Sensory characteristics were similar between biscuits with and without micro-nutrient fortification, leading to no differences in liking. Fortified oat biscuits were less liked than commercial oat biscuits, partly attributed to flavour imparted by whey protein fortification. CONCLUSION: Macro- and micro-nutrient fortification of biscuits could provide an alternative fortified snack to help alleviate malnutrition in older adults

Opportunistic assessment of hearing in elderly inpatients

Objective: To determine the prevalence of occult hearing loss in elderly inpatients, to evaluate feasibility of opportunistic hearing screening and to determine subsequent provision of hearing aids. Materials and methods: Subjects (>65 years) were recruited from five elderly care wards. Hearing loss was detected by a ward-based hearing screen comprising patient-reported assessment of hearing disability and a whisper test. Subjects failing the whisper test or reporting hearing difficulties were offered formal audiological assessment. Results: Screening was performed on 51 patients aged between 70 and 95 years. Of the patients, 21 (41%) reported hearing loss and 16 (31%) failed the whisper test. A total of 37 patients (73%) were referred for audiological assessment with 17 (33%) found to have aidable hearing loss and 11 were fitted with hearing aids (22%). Discussion: This study highlights the high prevalence of occult hearing loss in elderly inpatients. Easy two-step screening can accurately identify patients with undiagnosed deafness resulting in significant proportions receiving hearing aids

An investigation of the influence of age and saliva flow on the oral retention of whey protein and its potential effect on the perception and acceptance of whey protein beverages

Protein fortified products are regularly recommended to older adults to improve nutritional status and limit sarcopenia. However protein fortification can elicit negative sensory attributes such as mouthdrying. Sensitivity to mouthdrying can increase with age, yet the influence of saliva flow and mucoadhesion remain uncertain. Here two studies tested different whey protein beverages (WPB); 22 healthy younger volunteers completed a pilot and 84 healthy volunteers from two age groups (18–30; 65+) completed the main study. In both studies salivary flow rates (mL/min) were measured and saliva samples were collected at time intervals post beverage consumption to measure mucoadhesion to the oral cavity, where protein concentration was analysed by Bradford Assay. Volunteers rated perception and acceptability of WPBs in the main study. WPB consumption resulted in significantly increased protein concentration (p < 0.0001) in saliva samples compared with a control whey permeate beverage. Older adults had significantly lower unstimulated saliva flow (p = 0.003) and significantly increased protein concentration (p = 0.02) in saliva samples, compared with younger adults. Heating of WPB significantly (p < 0.05) increased mouthdrying and thickness perception and reduced sweetness compared with unheated WPB. Mucoadhesion is concluded to be a true phenomenon in WPBs and increases with age

Ageing and taste

Taste perception has been studied frequently in young and older adult groups. This paper systematically reviews these studies to determine the effect of ageing on taste perception and establish the reported extent of sensory decline. Five databases were searched from 1900 to April 2012. Articles relating to healthy ageing in human subjects were included, reviewed and rated (Downs and Black scoring system). Sixty-nine studies investigated the effect of ageing on taste perception; forty examined detection thresholds of which twenty-three provided sufficient data for meta-analysis, eighteen reported identification thresholds and twenty-five considered supra-threshold intensity perception. Researchers investigating detection thresholds considered between one and thirteen taste compounds per paper. Overall, the consensus was that taste detection thresholds increased with age (Hedges' g = 0·91, P < 0·001), across all taste modalities. Identification thresholds were reported to be higher for older adults in seventeen out of eighteen studies. Sixteen out of twenty-five studies reported perception of taste intensity at supra-threshold levels to be significantly lower for older adults. However, six out of nine studies concerning sucrose found perceived intensity of sweet taste not to diminish with age. The findings of this systematic review suggest taste perception declines during the healthy ageing process, although the extent of decline varies between studies. Overall, the studies reviewed had low Downs and Black scores (mean 16 (SD 2)) highlighting the need for more robust large scale and longitudinal studies monitoring the impact of ageing on the sensory system, and how this influences the perception of foods and beverages

Effect of Patient Age on Management Decisions in Breast Cancer: Consensus from a National Consultation

This qualitative study investigated attitudes, perceptions, and practices of breast cancer specialists with reference to the effect of patient age on management decisions in breast cancer, and attempted to identify national consensus on this issue

Novel flavours paired with glutamate condition increased intake in older adults in the absence of changes in liking

Previous research on the repeat exposure to a novel flavour combined with monosodium glutamate (MSG) has shown an increase in liking and consumption for the particular flavour. The aim of the current work was to investigate whether this could also be observed in the case of older people, since they are most affected by undernutrition in the developed world and ways to increase consumption of food are of significant importance for this particular age group. For this study, 40 older adults (age 65-88) repeatedly consumed potato soup with two novel flavours (lemongrass and cumin) which were either with or without a high level of MSG (5%w/w). A randomized single blind within-subject design was implemented, where each participant was exposed to both soup flavours three times over 6 days, with one of the soup flavours containing MSG. After three repeat exposures, consumption increased significantly for the soups where the flavours had contained MSG during the repeated exposure (mean weight consumed increased from 123 to 164 g, p=0.017), implying that glutamate conditioned for increased wanting and consumption, despite the fact that the liking for the soup had not increased

Cost-Effectiveness Modeling of Surgery Plus Adjuvant Endocrine Therapy Versus Primary Endocrine Therapy Alone in UK Women Aged 70 and Over With Early Breast Cancer

Objectives: Approximately 20% of UK women aged 70+ with early breast cancer receive primary endocrine therapy (PET) instead of surgery. PET reduces surgical morbidity but with some survival decrement. To complement and utilize a treatment dependent prognostic model, we investigated the cost-effectiveness of surgery plus adjuvant therapies versus PET for women with varying health and fitness, identifying subgroups for which each treatment is cost-effective. Methods: Survival outcomes from a statistical model, and published data on recurrence, were combined with data from a large, multicenter, prospective cohort study of over 3400 UK women aged 70+ with early breast cancer and median 52-month follow-up, to populate a probabilistic economic model. This model evaluated the cost-effectiveness of surgery plus adjuvant therapies relative to PET for 24 illustrative subgroups: Age {70, 80, 90} × Nodal status {FALSE (F), TRUE (T)} × Comorbidity score {0, 1, 2, 3+}. Results: For a 70-year-old with no lymph node involvement and no comorbidities (70, F, 0), surgery plus adjuvant therapies was cheaper and more effective than PET. For other subgroups, surgery plus adjuvant therapies was more effective but more expensive. Surgery plus adjuvant therapies was not cost-effective for 4 of the 24 subgroups: (90, F, 2), (90, F, 3), (90, T, 2), (90, T, 3). Conclusion: From a UK perspective, surgery plus adjuvant therapies is clinically effective and cost-effective for most women aged 70+ with early breast cancer. Cost-effectiveness reduces with age and comorbidities, and for women over 90 with multiple comorbidities, there is little cost benefit and a negative impact on quality of life