Association between malnutrition, poor general health and oral dryness in hospitalized elderly patients

Age and Ageing, March, 1998 by Valerie Dormenval, Ejvind Budtz-Jorgensen, Philippe Mojon, Andre Bruyere, Charles-Henri Rapin

Introduction

With advancing age the risk of developing malnutrition increases, particularly among institutionalized patients [1]. This may be due to age-associated reductions in food intake combined with the presence of debilitating diseases, social isolation, altered health status, economic limitations and multiple hospital admissions [2, 3]. Saliva plays an essential role in protecting the oral mucosa and the teeth, in taste perception, food-bolus formation, swallowing, communication and digestion. The effect of ageing on saliva flow is unclear and it seems that it is mainly the unstimulated salivary flow rate (USFR) which is affected. This is reduced by a factor of 2-3 in elderly subjects [4, 5] while the paraffin-wax-stimulated salivary flow rate (SSFR) remains constant with age [6, 7]. However, USFR as well as SSFR rates decrease with an increase in number of medications, particular following intake of antihypertensive agents, antidepressant drugs, tranquillizers, sedatives, hypnotics or antipsychotic agents [8]. Furthermore, the degree of hydration is an important factor which regulates salivary flow [9]. Thus, malnutrition and decreased salivary flow might both be associated with medical disorders and their medication.

The purpose of the present study was to examine the relationship between indices of malnutrition, general health (serum albumin concentration), salivary secretion rate and dry mouth feeling in elderly hospitalized patients.

Patients and methods

The study included 99 patients hospitalized for various medical reasons at the University Institute of Geriatrics during two periods (1 August-1 September 1993 and 31 May-18 August 1994). Patients aged 75-95 years were included in the study after a Mini-Mental State Examination (MMSE), comprising an evaluation of the patient's immediate memory, state of orientation and attention [10]. A MMSE score of [is greater than or equal to] 21 (maximum score 30) was required to ensure satisfactory co-operation during the questionnaire and the salivary tests. The study was approved by the local ethical committee.

Information concerning the patients' age, sex, pathologies and numbers and types of current drug prescriptions was obtained from the medical files. Nutritional and medical assessments included body mass index (BMI), mid-arm circumference, triceps skinfold thickness and serum albumin level [11, 12] (Table 1). Mid-arm circumference (lean body mass) was measured in the right arm mid-way between the acromion and the olecranon processes. The following cut-off values according to Fricker et al. [11] and Woo et al. [12] for women (and, in parentheses, for men) at 70 years of age were applied: [is less than] 23.1 cm (23.8cm), severe denutrition; 23.1-25.5 cm (23.8-25.7 cm), intermediate denutrition; 25.6-29.7cm (25.7-28.7cm), moderate denutrition; and [is greater than] 29.7 (28.7 cm), no subnutrition. The triceps skinfold thickness (fat body mass) was measured using a skinfold calliper with a pressure of 10 [g/mm.sup.2] of contact area over its entire operating range. The cut-off values used were: [is less than] 11 mm ([is less than] 5 mm), severe denutrition; 11-14 mm (5-7 mm), intermediate denutrition; 15-21 mm (8-11 mm), moderate denutrition; and [is greater than] 21 mm ([is greater than] 11 mm), no denutrition. For serum albumin and the BMI the cut-off between normal and reduced values was set at [is greater than or equal to] 35 g/1 and [is greater than or equal to] 21, respectively.

Table 1. Anthropometric measures, body mass index and prevalence of malnutrition in 99 hospitalized elderly patients

                          Mean value [  or -] SD

Method                    Men (n = 30)        Women (n = 69)

Arm circumference (cm)    27.3 [  or -] 3.4    27.0 [  or -] 4.7
Triceps skinfold
thickness (cm)             9.4 [  or -] 4.9    12.6 [  or -] 5.2
Body mass index           23.6 [  or -] 3.8    23.2 [  or -] 5.1

                           Degree of malnutrition(a) (prevalence)

Method                     Severe     Intermediate    Moderate

Arm circumference (cm)        37%         10%            34%
Triceps skinfold
thickness (cm)                34%         24%            29%
Body mass index                           35%(b)

(a) Criteria and classification according to Fricker et al.(1991) [11] and Woo et al. (1994) [12].

(b) Body mass index [is less than] 21.

Saliva examinations were performed between 0900 h and 1100 h and the two examinations were carried out on different days. Subjects were asked not to eat or drink for 1 1/2-2 h before the examination, which began with the determination of USFR, after which SSFR was measured [8]. Saliva was collected during 6 min and the patient was asked to spit every 2 min. The average USFR and SSFR was computed from the two samples taken at day 1 and day 2. The cut-offs between normal and reduced USFR and SSFR were set at 0.1 ml/min and 0.5 ml/min, respectively [8]. The patients were asked about feelings of oral dryness such as severity, consequences and need to drink water regularly during the night and day [13].