Assessment of oral health in older adults by non-dental professional caregivers : development and validation of a photograph-supported oral health–related section for the interRAI suite of instruments

Objectives An optimized oral health-related section and a video training were developed and validated for the interRAI suite of instruments. The latter is completed by professional non-dental caregivers and used in more than 40 countries to assess care needs of older adults. Methods The optimized oral health-related section (ohr-interRAI) consists of nine items and a video training that were developed in consecutive phases. To evaluate psychometric properties, a study was conducted in 260 long-term care residents. Each resident was assessed by a dentist and by four caregivers (two who received the video training, two who did not). Results Mean kappa values and percent agreement between caregivers and dentist ranged between kappa = 0.60 (80.2%) for dry mouth and kappa = 0.13 (54.0%) for oral hygiene. The highest inter-caregiver agreement was found for dry mouth with kappa = 0.63 [95% CI: 0.56-0.70] (81.6%), while for the item palate/lips/cheeks only kappa = 0.27 [95% CI: 0.18-0.36] (76.7%) was achieved. Intra-caregiver agreement ranged between kappa = 0.93 [95% CI: 0.79-1.00] (96.4%) for dry mouth and kappa = 0.45 [95% CI: 0.06-0.84] (82.8%) for gums. Logistic regression analysis showed only small differences between caregivers who watched the video training and those who did not. Conclusions Psychometric properties of the optimized ohr-interRAI section were improved compared to previous versions. Nevertheless, particularly the items based on inspection of the mouth require further refinement and caregiver training needs to be improved

Validation and optimization of the oral health-related section of the interRAI suite of assessment instruments

Human lifespan is increasing in all regions of the world. Ideally, these added life years are spent in good health. A healthy mouth, free of infection and with an adequate number of teeth, contributes to well-being and healthy aging. However, oral health is often poor in frail older persons who are not able to perform adequate daily oral care. Access to professional dental services is also challenging for this population which causes that oral health problems are often not detected in time. In professional care settings, oral health assessment by non-dental professional caregivers can help to detect care needs. The interRAI suite of instruments is used internationally to assess care needs and health risks of vulnerable persons. An oral health-related section (ohr-interRAI) is included in the versions used in long-term care and in the home care setting. Ideally, this section detects persons who need assistance with daily oral care or who need to be referred to a dentist. However, the current ohr-interRAI section and related precursor versions fail to achieve this goal. 1. The first part of the PhD explored the underlying reasons for the failure of the current ohr-interRAI section to adequately detect oral care needs. Content validity was evaluated by a group of experts who had a professional background relevant for oral health in care-dependent older individuals. The experts agreed that the ohr-interRAI section was incomplete to assess oral care needs sufficiently. It further became clear that items were lacking in relevance, clarity of wording and feasibility to be completed by non-dental caregivers. Focus group discussions with caregivers revealed that adequate detection of oral health-related care needs was impeded by shortcomings of the ohr-interRAI section itself and by a lack of awareness and training of caregivers. Analysis of available interRAI data from Belgium showed that the prevalence of missing oral health-related information was related to the general health status of the care client. This result confirmed that clear instructions and training are lacking on how to assess oral health. 2. In the second part of the PhD, a new optimized photograph-supported ohr-interRAI section and an associated video training were developed and tested. A preparatory study revealed small differences between dentists and professional non-dental caregivers assessing oral health-related conditions shown on photographs. It was concluded that comments and explanations should complement the photographs to facilitate accurate interpretation by non-dental caregivers. The optimized ohr-interRAI section was developed in consecutive phases. The nine items included self-reported oral health complaints of the client, but inspection of the mouth was also mandatory. Visualizing photographs were selected based on the assessment by a group of experts and dentists. The video training emphasized the relevance of oral health and provided instructions on how to assess oral health with the optimized ohr-interRAI section. A study with 260 nursing home residents showed that psychometric properties of the optimized ohr-interRAI section were improved compared to previous versions. However, caregiver-dentist agreement and agreement among caregivers only ranged between very low and moderate. Small positive effects of the video training were found. Based on these findings, the optimized ohr-interRAI was further modified and refined. 3. In the third part of the PhD, clear and concise practice guidelines for daily oral care were developed for the optimized ohr-interRAI. A modified Delphi study was conducted to complement the available evidence with feedback from international experts. The guidelines are now available to help to improve care when poor oral hygiene is detected with the optimized ohr-interRAI section. In a follow-up research project, the refined version of the optimized ohr-interRAI section will be implemented and its effects will be evaluated internationally.status: publishe

Predictors of patient satisfaction with removable denture renewal: A pilot study

PURPOSE: Conventional removable dentures still play an important role in the treatment of lost teeth. A thorough understanding of the parameters that influence patient satisfaction is useful for deciding whether denture replacement is meaningful. From a clinical perspective, factors that can be measured before starting treatment are relevant. This pilot study investigated whether patient satisfaction after denture renewal was affected by aspects related to the old prostheses, type of jaw, and patient motivation for denture renewal. MATERIALS AND METHODS: Fifty subjects (mean age 68.2 ± 8.4) were provided with 74 removable dentures (partial n = 20, complete n = 54). Satisfaction was assessed before treatment and 3 months after new prosthesis insertion. Total satisfaction 3-month post-insertion (TSP3) merged 6 individual satisfaction items measured after treatment. Change of total satisfaction 3-month post-insertion (CTS3) represented the difference of total satisfaction when old and new prostheses were compared. The effect of the following independent variables was investigated: reason patients requested new dentures (fit, esthetics, broken denture, wear, advice of dentist, extractions), satisfaction with the old prosthesis (general, retention, stability, comfort, pronunciation, chewing, esthetics), and technical quality of the old prostheses as assessed by a dentist (stability, retention, fit, border, wear, esthetics). Gender, age, and a cognitive screening test were included as confounding variables. Mann-Whitney-U tests and linear mixed model analysis were performed. RESULTS: All individual satisfaction items significantly improved with new prostheses for maxillary and mandibular jaws. TSP3 was higher for maxillary prostheses, if retention satisfaction with the old prosthesis was good, and if the dentist assessed the esthetics of the old prosthesis as deficient. CTS3 was associated with male gender, dissatisfaction with chewing before treatment, and dissatisfaction with esthetics before treatment. CONCLUSIONS: This pilot study showed that satisfaction 3 months after new denture insertion was associated with aspects of satisfaction and quality related to the old prosthesis, type of jaw, and gender. These factors may help dentists predict therapeutic benefits when deciding on the need for denture replacement. Further research should be done with a greater number of subjects and should include balanced quantities of the different types of dentures.status: publishe

Impact of Denture Cleaning Method and Overnight Storage Condition on Denture Biofilm Mass and Composition: A Cross-Over Randomized Clinical Trial.

BACKGROUND:Appropriate oral hygiene is required to maintain oral health in denture wearers. This study aims to compare the role of denture cleaning methods in combination with overnight storage conditions on biofilm mass and composition on acrylic removable dentures. METHODS:In a cross-over randomized controlled trial in 13 older people, 4 conditions with 2 different mechanical cleaning methods and 2 overnight storage conditions were considered: (i) brushing and immersion in water without a cleansing tablet, (ii) brushing and immersion in water with a cleansing tablet, (iii) ultrasonic cleaning and immersion in water without a cleansing tablet, and (iv) ultrasonic cleaning and immersion in water with a cleansing tablet. Each test condition was performed for 5 consecutive days, preceded by a 2-days wash-out period. Biofilm samples were taken at baseline (control) and at the end of each test period from a standardized region. Total and individual levels of selected oral bacteria (n = 20), and of Candida albicans were identified using the Polymerase Chain Reaction (PCR) technique. Denture biofilm coverage was scored using an analogue denture plaque score. Paired t-tests and Wilcoxon-signed rank tests were used to compare the test conditions. The level of significance was set at α< 5%. RESULTS:Overnight denture storage in water with a cleansing tablet significantly reduced the total bacterial count (p<0.01). The difference in total bacterial level between the two mechanical cleaning methods was not statistically significant. No significant effect was observed on the amount of Candida albicans nor on the analogue plaque scores. CONCLUSIONS:The use of cleansing tablets during overnight denture storage in addition to mechanical denture cleaning did not affect Candida albicans count, but reduced the total bacterial count on acrylic removable dentures compared to overnight storage in water. This effect was more pronounced when combined with ultrasonic cleaning compared to brushing. TRIAL REGISTRATION:ClinicalTrials.gov NCT02454413

Missing Oral Health-Related Data in the interRAI-HC - Associations with Selected Variables of General Health and the Effect of Multiple Imputation on the Relationship between Oral and General Health.

BACKGROUND:Missing data within the comprehensive geriatric assessment of the interRAI suite of assessment instruments potentially imply the under-detection of conditions that require care as well as the risk of biased statistical results. Impaired oral health in older individuals has to be registered accurately as it causes pain and discomfort and is related to the general health status. OBJECTIVE:This study was based on interRAI-Home Care (HC) baseline data from 7590 subjects (mean age 81.2 years, SD 6.9) in Belgium. It was investigated if missingness of the oral health-related items was associated with selected variables of general health. It was also determined if multiple imputation of missing data affected the associations between oral and general health. MATERIALS AND METHODS:Multivariable logistic regression was used to determine if the prevalence of missingness in the oral health-related variables was associated with activities of daily life (ADLH), cognitive performance (CPS2) and depression (DRS). Associations between oral health and ADLH, CPS2 and DRS were determined, with missing data treated by 1. the complete-case technique and 2. by multiple imputation, and results were compared. RESULTS:The individual oral health-related variables had a similar proportion of missing values, ranging from 16.3% to 17.2%. The prevalence of missing data in all oral health-related variables was significantly associated with symptoms of depression (dental prosthesis use OR 1.66, CI 1.41-1.95; damaged teeth OR 1.74, CI 1.48-2.04; chewing problems OR 1.74, CI 1.47-2.05; dry mouth OR 1.65, CI 1.40-1.94). Missingness in damaged teeth (OR 1.27, CI 1.08-1.48), chewing problems (OR 1.22, CI 1.04-1.44) and dry mouth (OR 1.23, CI 1.05-1.44) occurred more frequently in cognitively impaired subjects. ADLH was not associated with the prevalence of missing data. When comparing the complete-case technique with the multiple imputation approach, nearly identical odds ratios characterized the associations between oral and general health. CONCLUSION:Cognitively impaired and depressive individuals had a higher risk of missing oral health-related information. Associations between oral health and ADLH, CPS2 and DRS were not influenced by multiple imputation of missing data. Further research should concentrate on the mechanisms that mediate the occurrence of missingness to develop preventative strategies

Missing Oral Health-Related Data in the interRAI-HC - Associations with Selected Variables of General Health and the Effect of Multiple Imputation on the Relationship between Oral and General Health

BACKGROUND: Missing data within the comprehensive geriatric assessment of the interRAI suite of assessment instruments potentially imply the under-detection of conditions that require care as well as the risk of biased statistical results. Impaired oral health in older individuals has to be registered accurately as it causes pain and discomfort and is related to the general health status. OBJECTIVE: This study was based on interRAI-Home Care (HC) baseline data from 7590 subjects (mean age 81.2 years, SD 6.9) in Belgium. It was investigated if missingness of the oral health-related items was associated with selected variables of general health. It was also determined if multiple imputation of missing data affected the associations between oral and general health. MATERIALS AND METHODS: Multivariable logistic regression was used to determine if the prevalence of missingness in the oral health-related variables was associated with activities of daily life (ADLH), cognitive performance (CPS2) and depression (DRS). Associations between oral health and ADLH, CPS2 and DRS were determined, with missing data treated by 1. the complete-case technique and 2. by multiple imputation, and results were compared. RESULTS: The individual oral health-related variables had a similar proportion of missing values, ranging from 16.3% to 17.2%. The prevalence of missing data in all oral health-related variables was significantly associated with symptoms of depression (dental prosthesis use OR 1.66, CI 1.41-1.95; damaged teeth OR 1.74, CI 1.48-2.04; chewing problems OR 1.74, CI 1.47-2.05; dry mouth OR 1.65, CI 1.40-1.94). Missingness in damaged teeth (OR 1.27, CI 1.08-1.48), chewing problems (OR 1.22, CI 1.04-1.44) and dry mouth (OR 1.23, CI 1.05-1.44) occurred more frequently in cognitively impaired subjects. ADLH was not associated with the prevalence of missing data. When comparing the complete-case technique with the multiple imputation approach, nearly identical odds ratios characterized the associations between oral and general health. CONCLUSION: Cognitively impaired and depressive individuals had a higher risk of missing oral health-related information. Associations between oral health and ADLH, CPS2 and DRS were not influenced by multiple imputation of missing data. Further research should concentrate on the mechanisms that mediate the occurrence of missingness to develop preventative strategies.status: publishe

Can the interRAI Home Care instrument be applied to the definition criteria of the Global Leadership Initiative on Malnutrition (GLIM)? A longitudinal study

BACKGROUND & AIMS: As malnutrition is an important modifiable risk factor for poor clinical outcomes, it is important to target malnourished older people and older people at risk of malnourishment. The Global Leadership Initiative on Malnutrition (GLIM) recently reached a consensus for a global definition of malnutrition. The primary aim of this study was to apply the interRAI Home Care (interRAI HC) instrument to fit the GLIM definition criteria of malnutrition to the closest. A second goal was to identify potential risk factors associated with malnutrition using this comprehensive assessment and to quantify their association. METHODS: This is a case control study, which retrospectively determines the exposure to the risk of malnutrition and estimates its potential risk factors. The longitudinal data came from a larger study called Protocol 3. Eligibility criteria were a minimum age of 65 years old, a minimum score of 6 on the Edmonton Frail Scale or at least a moderate level of functional impairment measured by a Belgian version of the Katz scale. Older people with an official dementia diagnosis were also eligible. Bivariate analysis was performed and logistic regression models were developed in order to identify significant determinants of malnutrition. RESULTS: The data consisted of 6334 frail older people (mean age: 80.6 ± 6.9, 70.6% female). About 2.4% became malnourished within a follow-up period of one year after baseline. The adjusted logistic regression yielded significant odds ratios for dysphagia (OR 2.2), loss of appetite (OR 1.8), bladder incontinence (OR 1.5) and low fluid intake (OR 1.5). Diabetes (OR 0.5) and visits to the physician (OR 0.5) had both a significant reverse effect. CONCLUSIONS: This study was the first large longitudinal research to explore the risk factors of malnutrition with a comprehensive assessment instrument as the interRAI HC, applying it to the recent GLIM definition criteria. The worldwide use of the interRAI instruments makes these findings relevant for global clinical practice and research. Adapting the interRAI instruments to the GLIM definition improves accurate detection, prevention and early treatment of malnourishment, avoiding further health deterioration in older people.status: Published onlin

Risk Factors for Malnutrition in Older Adults: A Systematic Review of the Literature Based on Longitudinal Data

The present systematic review critically examines the available scientific literature on risk factors for malnutrition in the older population (aged ≥65 y). A systematic search was conducted in MEDLINE, reviewing reference lists from 2000 until March 2015. The 2499 papers identified were subjected to inclusion criteria that evaluated the study quality according to items from validated guidelines. Only papers that provided information on a variable's effect on the development of malnutrition, which requires longitudinal data, were included. A total of 6 longitudinal studies met the inclusion criteria and were included in the systematic review. These studies reported the following significant risk factors for malnutrition: age (OR: 1.038; P = 0.045), frailty in institutionalized persons (β: 0.22; P = 0.036), excessive polypharmacy (β: -0.62; P = 0.001), general health decline including physical function (OR: 1.793; P = 0.008), Parkinson disease (OR: 2.450; P = 0.047), constipation (OR: 2.490; P = 0.015), poor (OR: 3.30; P value not given) or moderate (β: -0.27; P = 0.016) self-reported health status, cognitive decline (OR: 1.844; P = 0.001), dementia (OR: 2.139; P = 0.001), eating dependencies (OR: 2.257; P = 0.001), loss of interest in life (β: -0.58; P = 0.017), poor appetite (β: -1.52; P = 0.000), basal oral dysphagia (OR: 2.72; P = 0.010), signs of impaired efficacy of swallowing (OR: 2.73; P = 0.015), and institutionalization (β: -1.89; P < 0.001). These risk factors for malnutrition in older adults may be considered by health care professionals when developing new integrated assessment instruments to identify older adults' risk of malnutrition and to support the development of preventive and treatment strategies.status: publishe

The oral health‐related section of the interRAI: Evaluation of test content validity by expert rating and assessment of potential reasons for inaccurate assessments based on focus group discussions with caregivers

OBJECTIVES: To explore the failure of the oral health-related section of the interRAI (ohr-interRAI), this study investigated test content validity (A.) and reasons for inaccurate assessments (B.). BACKGROUND: Poor oral health negatively affects quality of life and is associated with a number of systemic diseases. The interRAI instruments, internationally used for geriatric assessment, should accurately detect oral conditions that require care. Previous research showed that the ohr-interRAI and related precursor versions do not achieve this goal. MATERIALS AND METHODS: (A.) A group of 12 experts rated completeness, relevance, clarity of wording and feasibility of the ohr-interRAI. Content validity indices were calculated per item (threshold 0.78). (B.) Focus group discussions with 23 caregivers were organized. A semi-structured question guide made sure that all topics of interest were covered. Qualitative content structuring analysis was applied after transcription. RESULTS: (A.) Experts agreed on the relevance of the items on chewing, pain, gingival inflammation and damaged teeth. They regarded none of the items as worded clearly and only prosthesis use and pain were considered to be assessable by untrained caregivers. All experts agreed that the ohr-interRAI was incomplete. (B.) Focus group discussions revealed that in the care environment oral health had low priority. Aspects related to the ohr-interRAI itself and aspects related to the assessment situation impeded the oral health assessment. The approach of the caregivers to complete the ohr-interRAI was inappropriate to accurately detect oral care needs. CONCLUSIONS: Findings challenge test content validity of the ohr-interRAI and reveal reasons for inaccurate assessments.status: publishe