Long Term Care Dietitians and Oral Health

The elderly are particularly vulnerable when it comes to malnutrition, though it can be difficult to identify individuals who are at the highest risk of poor nutritional status. Though it may seem that weight loss and difficulty eating are part of the normal progression of aging, these often-preventable issues can lead to rapid decline. It is therefore incredibly important to help maximize older individuals’ intake to avoid overall physical decline, and one of the first steps to doing so is by assessing oral health. Aging is accompanied by obvious changes in the body, and the mouth is no exception. Healthcare workers, friends, and family members can play a crucial role when it comes to identifying and addressing oral health issues that might contribute to poor intake and lead to malnutrition.

Research supports the tight link between oral health issues and nutritional status. A meta-analysis of longitudinal studies focusing on the nutritional status of adults 65 years or older revealed that eating-related factors are significantly linked to risk of malnutrition (Favaro-Moreira et al, 2016). The root of this connection is that poor intake can lead to bodily decline and an increase of what is commonly referred to as frailty. The nuance here is that the poor intake itself may be caused by a myriad of factors, including oral health issues, dysphagia, or dementia. The authors of the meta-anlysis did note that improved daily oral hygiene can help minimize this risk of malnutrition, highlighting the importance of comprehensive patient care.

Oral health is perhaps the top overlooked yet prevalent risk factor for malnutrition in the elderly. A recent study found that high-risk elderly individuals-- those who were frail or had more complex medical need-- were also more likely to have oral issues including edentulousness, while those with more remaining teeth tended to have a higher quality of life and better performance on activities of daily living (Hoeksema et. Al, 2017). Studies from dental clinical also support this association, noting that edentulousness is significantly associated with poorer nutritional status than either dentures or partial dentition, though all patients with dental issues were at increased risk of malnutrition (Soini et al, 2016). Though patients who meet malnutrition parameters will often receive detailed interventions, the true heart of the issue is that a large portion of our elderly population are at risk, not only those who have obvious dysphagia or a history of poor intake; any problems with dentition, whether it be complete lack of teeth or partial dentition, are more likely to have poor nutrition leading to a decline in all areas of their daily lives.

For long term care facilities which care specifically for this older population, edentulousness may seem exceedingly normal; a large proportion, often over half of patients in any given center, may be edentulous. Lack of teeth itself does not lead to malnutrition; though it likely will limit the consistency of foods residents can safely or easily consume, they may be able to eat texture-modified soft, chopped, or pureed foods without weight loss. For patients who strongly dislike or reject these foods, which is common especially in confused residents, this texture modification might lead to a major nutritional issue. Some residents may have dentures to address edentulousness, but they are not appropriate in all situations; individuals may be uncomfortable wearing dentures or may have poorly fitting dentures after weight shifts. Those who do have dentures may easily lose or misplace them if confused. Healthcare workers, family, and friends who interact with patients can help to counteract these issues as they arise by being vigilant of where dentures are throughout the day, checking for appropriate fit often (especially after any significant weight changes), and speaking with the resident openly about if they have any discomfort or issues with their dentures.

Similarly, those who work closely with patients during meal time, especially dietitians, nursing assistants, nurses, and food service personnel, can take note of resident complaints and preferences to help ensure that they are receiving foods they are most likely to consume. For example, if a patient has poor dentition and a Speech Language Pathologist recommends only pureed items for safety, that patient may have reject foods that are not commonly pureed, including high-protein items like meat. Serving more commonly pureed items like potatoes, pureed oats, and thicken pureed soups that contain high protein ingredients can help to make their diet more palatable while remaining safe. Offering fortified foods is also a wonderful way to address this by maximizing the calorie and protein content of items served. Food service directors and dietitians can work together to formulate these fortified foods and work them into the menu as either rotating options or daily offerings.

While elderly patients with at least partial dentition can often consume a wider range of food consistencies, such as chopped or soft items, those with all or some natural teeth may still have overall poor oral health. This can lead to dental pain with chewing, cracked teeth which can cause cuts inside the mouth, or temperature sensitivity, all of which may discourage patients from consuming their meals. Those who are present at meal time can be trained and encouraged to recognize patients whose intake has declined and to observe why this may be happening. In alert and oriented patients, these issues can be easily revealed by encouraging staff to have open discussions and asking patients about why they are not eating.

However, dementia or confusion can cloud this issue as residents may not be able to communicate why they are avoiding oral intake. For healthcare workers looking to identifying the root issue and therefore taking the necessary steps towards solving the problem, further steps need to be taken in order to discover any possible oral issues. Oral examinations can be a highly effective intervention when a patient’s intake or weight declines. Incorporating this into policies and procedures can help to make oral examinations more commonplace, so that any patient meeting or approaching malnutrition criteria automatically receives an oral care consult from nursing or an appropriate allied health professional. Providing training to nursing staff so that they feel prepared to identify certain oral issues such as thrush, broken teeth, visual signs of pain when eating, or poorly fitting dentures can help streamline the processes.

The solution starts by discussing oral health as a key part of the comprehensive health of elderly patients or long term care residents. Setting in place routine dental visits can help act as a preventative measure, ensuring that all residents are screened for oral issues by a qualified professional. Alternatively, any resident or patient who meets criteria for malnutrition, exhibits weight loss, has a decline in intake, or shows any visual signs of discomfort or resistance when eating should receive an oral examination as part of the intervention. This is the critical step to highlight any potential oral issues so that the appropriate treatments can be set in place. Incorporating oral health checks, providing in-service trainings for nursing and staff, and observing patients at meal times for any sign of eating issues can all help to protect the most vulnerable elderly and prevent the physical consequences.

RD Nutrition Consultants is a nationwide group of Registered Dietitians who provide professional nutrition consulting services. We are the industry leader in Long Term Care Consultant Dietitians and Nutrition Staffing.

Resources

Favaro-Moreira, NC, Krausch-Hofmann, S, Matthys, C, Vereechen C, Vanhauwaert E, Decleracq A, Bekkering GE, Duyck J. Risk factors for malnutrition in older adults: A systematic review of the literature based on longitudinal data. Advanced Nutrition. 2016 May; 7(3): 507-522. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863272/

Hoeksema AR, Spoorenberg S, Peters LL, Meijer H, Raghoebar GM, Vissink A, Wynia K, Visser A. Elderly with remaining teeth report less frailty and better quality of life than edentulous elderly: a cross-sectional study. Oral Diseases. 2017 May; 23(4):526:536. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28120363.

Soini H, Murrinen S, Routasoalo P, Sandelin E, Savikko N, Suominen M, Ainamo A, Pitkala KH. Oral and nutritional status – is the MNA a useful tool for dental clinics? Journal of Nutrition, Health, & Aging. 2006 Nov-Dec; 10(6):495-499. Available at: https://www.researchgate.net/publication/6617789_Onutritional_status-Is_the_MNA_a_useful_tool_for_dental_clinics