Oral health care and aspiration pneumonia in frail older people: a systematic literature review

Objective: To systematically review the literature on oral health care interventions in frail older people and the effect on the incidence of aspiration pneumonia. Background: Oral health care seems to play an important role in the prevention of aspiration pneumonia in frail older people. Methods: Pubmed, Web of Science, Cochrane Library, EMBASE and CINAHL were searched for eligible intervention studies. Only publications with regard to hospitalized or institutionalized older people, who were not dependent on mechanical ventilation were eligible. Two authors independently assessed the publications for their methodological quality. Results: Five publications were included and reviewed. Two studies showed that improvement of oral health care diminished the risk of developing aspiration pneumonia and the risk of dying from aspiration pneumonia directly. The three studies remaining showed that adequate oral health care decreased the amount of potential respiratory pathogens and suggested a reduction in the risk of aspiration pneumonia by improving the swallowing reflex and cough reflex sensitivity. Conclusions: According to the results of the current systematic literature review oral health care, consisting of tooth brushing after each meal, cleaning dentures once a day, and professional oral health care once a week, seems the best intervention to reduce the incidence of aspiration pneumonia.     

Bias in the development of health and ecological assessments and potential solutions

The effectiveness and credibility of environmental decisions depend on the information provided by scientific assessments. However, the conflicting assessments provided by government agencies, industries, and environmental advocacy groups suggest that biases occur during assessment processes. Sources of bias include personal bias, regulatory capture, advocacy, reliance on volunteer assessors, biased stakeholder and peer review processes, literature searches, standardization of data, inappropriate standards of proof, misinterpretation, and ambiguity. Assessors can adopt practices to increase objectivity, transparency, and clarity. Decision-makers, managers of assessors, and institutions that commission assessments can adopt other practices that reduce pressures on assessors and reduce opportunities for expression of the personal biases of assessors. Environmental assessment should be recognized as a discipline with its own technical and ethical best practices.     

Specific recommendations (or lack thereof) for older patients with cardiovascular disease in the current European Society of Cardiology guidelines

Due to population ageing, the number of older and frail patients with cardiovascular disease is increasing. In the current guidelines of the European Society of Cardiology specific recommendations for this older population are missing or scarce, probably due to limited evidence concerning diagnosis and treatment of cardiovascular disease in older patients. Moreover, recommendations on shared decision making, palliative care and advanced care planning are also essential in these guidelines. In this article we evaluate the current European of Society of Cardiology guidelines (2013–2020) to determine whether specific recommendations for older patients have been included.

     

Social interactions, body image and oral health among institutionalised frail elders: an unexplored relationship

doi: 10.1111/j.1741‐2358.2011.00523.x Social interactions, body image and oral health among institutionalised frail elders: an unexplored relationship Objectives: This paper draws on theories of ageing, body image and disfigurement, to explore the potential for relationships between oral health, body image and social interactions between institutionalised elders. Background: Social relationships are important at all stages of life. A positive body image increases confidence in social interactions, which contributes substantially to health, well‐being and quality of life. Body image can be negatively impacted by oral conditions, particularly those that are appearance related and do not meet cultural ideals. Results: Typically, the oral health of frail elders in long‐term care facilities is poor, but to what extent poor oral health and dysfunction influence body image, and social behaviours is unclear. Conclusions: We conclude that there is the potential for poor oral health conditions to contribute negatively to the social well‐being in this population, but suggest that it requires further investigation.     

Quality improvement programme to achieve acceptable colonoscopy completion rates: prospective before and after study

Problem A large audit of colonoscopy in the United Kingdom showed that the unadjusted completion rate was 57% when stringent criteria for identifying the caecum were applied. The caecum should be reached 90% of the time. Little information is available on what units or operators need to do to improve to acceptable levels.Design Quality improvement programme using two completed cycles of audit.Setting Endoscopy department in a university linked general hospital in northeast England.Key measures for improvement Colonoscopy completion rate.Strategy for change Two audit cycles were completed between 1999 and 2002. Changes to practice were based on results of audit and took into account the opinions of relevant staff. Lack of time for each colonoscopy, poor bowel preparation, especially in frail patients, and a mismatch between number of colonoscopies done and completion rate for individual operators were responsible for failed colonoscopies. Appropriate changes were made.Effects of change The initial crude colonoscopy completion rate was 60%, improving to 71% after the first round of audit and 88% after the second round, which approximates to the agreed audit standard of 90%. The final adjusted completion rate was 94%.Lessons learnt Achievement of the national targets in a UK general hospital is possible by lengthening appointments, admitting frail patients for bowel preparation to one ward, and allocating colonoscopies to the most successful operators.     

Beyond protocols: improving the reliability of expert-based risk analysis underpinning invasive species policies

Risk assessment tools for listing invasive alien species need to incorporate all available evidence and expertise. Beyond the wealth of protocols developed to date, we argue that the current way of performing risk analysis has several shortcomings. In particular, lack of data on ecological impacts, transparency and repeatability of assessments as well as the incorporation of uncertainty should all be explicitly considered. We recommend improved quality control of risk assessments through formalized peer review with clear feedback between assessors and reviewers. Alternatively, a consensus building process can be applied to better capture opinions of different experts, thereby maximizing the evidential basis. Elaborating on manageability of invasive species is further needed to fully answer all risk analysis requirements. Tackling the issue of invasive species urges better handling of the acquired information on risk and the exploration of improved methods for decision making on biodiversity management. This is crucial for efficient conservation resource allocation and uptake by stakeholders and the public.     

Clinic-based primary care of frail older patients in California.

We surveyed medical directors of primary care clinics in California to learn how those clinics cared for their frail older patients. Of 143 questionnaires sent, 127 (89%) were returned. A median of 30% of all patient encounters were with persons aged 65 or older, and a median of 20% of older patients were considered frail. A total of 20% of the clinics routinely provided house calls to homebound elderly patients. Of clinics involved in training medical students of physicians (teaching clinics), 70% had at least one physician with an interest in geriatrics, compared with 42% of nonteaching clinics (P less than .005). For frail patients, 40% of the clinics routinely performed functional assessment, while 20% routinely did an interdisciplinary evaluation. Continuing education in geriatrics emerged as a significant independent correlate of both functional assessment and interdisciplinary evaluation. Among the 94 clinics with a standard appointment length for the history and physical examination, only 11 (12%) allotted more than 60 minutes for frail patients. The data suggest that certain geriatric approaches are being incorporated into clinic-based primary care in California but do not provide insight into their content or clinical effects.     

The Assessment of Science: The Relative Merits of Post-Publication Review,the Impact Factor,and the Number of Citations

The assessment of scientific publications is an integral part of the scientific process. Here we investigate three methods of assessing the merit of a scientific paper: subjective post-publication peer review, the number of citations gained by a paper, and the impact factor of the journal in which the article was published. We investigate these methods using two datasets in which subjective post-publication assessments of scientific publications have been made by experts. We find that there are moderate, but statistically significant, correlations between assessor scores, when two assessors have rated the same paper, and between assessor score and the number of citations a paper accrues. However, we show that assessor score depends strongly on the journal in which the paper is published, and that assessors tend to over-rate papers published in journals with high impact factors. If we control for this bias, we find that the correlation between assessor scores and between assessor score and the number of citations is weak, suggesting that scientists have little ability to judge either the intrinsic merit of a paper or its likely impact. We also show that the number of citations a paper receives is an extremely error-prone measure of scientific merit. Finally, we argue that the impact factor is likely to be a poor measure of merit, since it depends on subjective assessment. We conclude that the three measures of scientific merit considered here are poor; in particular subjective assessments are an error-prone, biased, and expensive method by which to assess merit. We argue that the impact factor may be the most satisfactory of the methods we have considered, since it is a form of pre-publication review. However, we emphasise that it is likely to be a very error-prone measure of merit that is qualitative, not quantitative.

Author summary

Subjective assessments of the merit and likely impact of scientific publications are routinely made by scientists during their own research, and as part of promotion, appointment, and government committees. Using two large datasets in which scientists have made qualitative assessments of scientific merit, we show that scientists are poor at judging scientific merit and the likely impact of a paper, and that their judgment is strongly influenced by the journal in which the paper is published. We also demonstrate that the number of citations a paper accumulates is a poor measure of merit and we argue that although it is likely to be poor, the impact factor, of the journal in which a paper is published, may be the best measure of scientific merit currently available.     

How repeatable is the Environmental Impact Classification of Alien Taxa (EICAT)? Comparing independent global impact assessments of amphibians

The magnitude of impacts some alien species cause to native environments makes them targets for regulation and management. However, which species to target is not always clear, and comparisons of a wide variety of impacts are necessary. Impact scoring systems can aid management prioritization of alien species. For such tools to be objective, they need to be robust to assessor bias. Here, we assess the newly proposed Environmental Impact Classification for Alien Taxa (EICAT) used for amphibians and test how outcomes differ between assessors. Two independent assessments were made by Kraus (Annual Review of Ecology Evolution and Systematics, 46, 2015, 75‐97) and Kumschick et al. (Neobiota, 33, 2017, 53‐66), including independent literature searches for impact records. Most of the differences between these two classifications can be attributed to different literature search strategies used with only one‐third of the combined number of references shared between both studies. For the commonly assessed species, the classification of maximum impacts for most species is similar between assessors, but there are differences in the more detailed assessments. We clarify one specific issue resulting from different interpretations of EICAT, namely the practical interpretation and assigning of disease impacts in the absence of direct evidence of transmission from alien to native species. The differences between assessments outlined here cannot be attributed to features of the scheme. Reporting bias should be avoided by assessing all alien species rather than only the seemingly high‐impacting ones, which also improves the utility of the data for management and prioritization for future research. Furthermore, assessments of the same taxon by various assessors and a structured review process for assessments, as proposed by Hawkins et al. (Diversity and Distributions, 21, 2015, 1360), can ensure that biases can be avoided and all important literature is included.     

Er is disciplinebreed sprake van relatieve onbevoegdheid en onbekwaamheid op het gebied van kwetsbare ouderen

There is much negative publicity about the health care for the frail elderly especially in nursing homes. However, inscientific research programs the results are also quite disappointing. We see a low percentage (< 50 %) of treatment fidelity in the intervention programs at stake. Research on the education content with respect to the frail elderly showed that this is very poor for every profession.From the perspective of formal education the professionals who provide treatment and care the frail elderly are relatively unqualified and incompetent. Government, health inspection and umbrella organizations should focus on solving this issue instead of enforcing their control mechanisms. Formal education is the hallmark of quality treatment and care especially in case of complex and unpredictable health problems of the frail elderly. If we don’t change our policy and don’t invest in the solution of fundamental educational shortcomings we continue to build on quicksand.     

Evaluating Chemical Interaction Studies for Mixture Risk Assessment

We describe a set of criteria to evaluate the quality of data and interpretations in chemical interaction studies. These criteria reflect the consensus of the literature on interaction analysis developed over decades of research in pharmacology, toxicology, and biometry; address common pitfalls in published interaction studies; and can be easily applied to common methods of interaction analysis. The criteria apply broadly to interaction data for drugs, pesticides, industrial chemicals, food additives, and natural products and are intended to assist risk assessors who must evaluate interaction studies for use in component-based mixture risk assessments. The criteria may also assist researchers interested in conducting interaction studies to inform mixture risk assessment. The criteria are also intended to serve larger scientific goals, including increasing the repeatability of results obtained in chemical interaction studies, enhancing the reliability of conclusions drawn from interaction data, providing greater consistency of interpretations among various analysts, and decreasing uncertainty in using interaction data in risk assessments. We describe the basis for each criterion and demonstrate their utility by using them to evaluate interaction studies from the recent toxicological and pharmacological literature, which serve as examples of different types of data sets that the risk assessor may encounter.     

Rehabilitation of the Aged

The rehabilitation needs and goals of older people differ in many respects from those of the young. In younger individuals a crippling condition may affect an otherwise healthy body, while in an older person it may be superimposed on other pre-existing degenerative diseases. Thus, in older patients the restorative or rehabilitative phase rarely can be separated from the phase of definitive medical treatment.The primary goal of rehabilitation of younger individuals is usually vocational. In the older group this goal or objective is, by and large, secondary. This does not minimize, however, the value of medical and social services in the rehabilitation of older persons. The simple ability to care for his own personal needs can do much to help the elderly disabled patient regain his dignity and self-respect and remove his fears of becoming a burden on his family or society.     

THE DESIGN OF REPLICATED DIFFERENCE TESTS

We show that adding replications in replicated difference tests results in larger power and smaller variance when the number of assessors is fixed. On the other hand, when the number of total assessments is fixed, the power usually decreases and the variability increases whenever replications are considered instead of different assessors. The appropriate numbers of assessor needed to gain the same power and variability, respectively, when replications are used will be given. It is shown that the number of assessors might indeed be reduced, but this has to be paid for by an increasing total number of assessments. We show that two key models, namely the mixture binomial and a corrected version of the Beta-binomial model, are quite similar with respect to the properties of interest. We provide tables from which, according to her/his requirements, the investigator might find an appropriate setting with respect to the number of assessors and replications.     

El anciano en la unidad de geriatría de agudos

Although the implementation of acute geriatric units (AGUs) in general hospitals has a grade A of evidency, in Spain, only 12% of them have this resource. The estimation of geriatric especializad beds for the care of acute frail elderly people is of 2.6/1000 inhabitants older than 75 years. AGUs have demonstrated to reduce the functional loss associated with the hospitalization and to increase the percentage of older people that can return home, without increases in mortality nor costs. In this review we present the characteristics of patients who benefit from AGUs, the services offered, the structure and functioning of the unit, the role of the professionals that work in it and the quality indicators that must be acomplished.     

Recent Advances in Behavioral Research in Geriatric Dentistry1

This paper examines recent studies in behavioral science and health services aspects of geriatric dentistry. With the increased focus on special needs of older patients, researchers have become concerned with psychological and sociocultural factors that influence older people's oral health status, behavior, and attitudes. Studies of dental service utilization patterns among subgroups of the elderly, including those in long-term care settings, will be reviewed. Research on methods to improve oral health care behaviors will be discussed, with their implications for developing oral health promotion and service delivery programs. The special oral health needs of cognitively impaired and frail elderly will be reviewed. Studies of clinical decision-making in geriatric dentistry have been conducted. These studies have revealed significant gaps in dental professionals' knowledge and attention to the special needs of older patients. This and other aspects of behavioral research suggest the need for better methods to disseminate research findings in geriatric dentistry to clinical practice in this field. The presentation will discuss ways of improving dissemination and transfer of research findings to the clinical management of aged patients.     

De lichamelijke en psychische dimensie van kwaliteit van leven van fragiele ouderen

Frail older people have an increased risk of limitations in performing activities of daily living, hospitalization, nursing home admission, and premature death. In this study we determined the difference in experiencing quality of life between frail and non-frail older people. We also investigated the associations between physical, psychological and social components of frailty and the physical and mental dimensions of quality of life. 374 people of 75 years and older filled in a questionnaire, the Senioren Barometer. This questionnaire contained the Tilburg Frailty Indicator (TFI) to assess frailty and the SF-12 for assessing quality of life. The study showed that frail older people on average experience a lower quality of life than non-frail older people. A considerable part of the variance of the physical and mental dimensions of quality of life could be explained by the fifteen components of frailty, after controlling for the background characteristics of the respondents, 33.2% and 36.5%, respectively. The frailty components physical inactivity, physical tiredness, and depressive symptoms were associated with the physical dimension as well as the mental dimension of quality of life. The results confirm the importance of multidimensional assessment of frailty. In addition, they provide a direction to healthcare and welfare professionals in performing interventions with the aim of increasing the quality of life of older people.     

Frail elderly. Identification of a population at risk

In the future the number of frail independently living older people will continue to increase. It is unclear however, which people are meant exactly by those frail elderly. The aim of this article is to discuss the concept of frailty and its adequacy in identifying the frail elderly population. To this end, a literature search has been performed regarding the conceptual and operational definitions of frailty. The results show that frailty often is put on a continuum opposite to vitality. It is emphasised that the process of frailty can be modified or (partly) reversed. Focusing on this reversibility is important because frail elderly have a higher risk for adverse outcomes such as dependence, hospitalization, falls and mortality. After studying the conceptual and operational definitions it is concluded that no actual definition meets the criteria for a successful definition of frailty. Frailty is predominantly defined in terms of physical loss. This may lead to fragmentation of care with lack of an integral approach. In a follow-up study it will be tried to develop consensus on a conceptual and operational definition of frailty.     

Proactieve en gestructureerde zorg voor kwetsbare oudere patiënten in de eerstelijn: Achtergrond, opzet en uitvoering van een screenings- en zorgprogramma

Background

Currently, primary care for the older, vulnerable patient is reactive, fragmented and does not meet patients needs. Given the expected increase of home-dwelling frail elderly people a transition is needed to proactive and integrated care.

Methods

In the described study, we explore two innovative interventions in primary care. First we describe a newly developed screening and monitoring program for frail elderly patients based on routine care information in general practice. Second, we describe a multidisciplinary intervention program by trained nurses for frail elderly patients in general practice. The effectiveness of the interventions is examined in a three-armed, cluster randomized trial, taking place in 58 primary care practices in Utrecht, the Bilt and Maarsenbroek.

Results

Three thousand eight patients are included. Primary outcome measure is the impact of the interventions on the daily activities, measured with the Katz questionnaire. Secondary outcomes measures are the quality of life, mortality, recording in a care or nursing home, visit to an emergency room or outpatient unit, recording in the hospital and volunteer caregivers tax.     

Het verklaren van verschillen in ervaren kwaliteit van leven van kwetsbare ouderen: een ‘mixed-method’ onderzoek

Most research on (multidimensional) frailty focuses on deficits and risks of adverse outcomes. However, frail older people can still report positive outcomes, such as a relatively high QoL. In order to develop more positively oriented prevention strategies, this exploratory study aimed (a) to identify characteristics related to QoL among frail older people; and (b) to explain discrepancies between higher and lower levels of QoL, with a specific focus on strengths frail older people with a higher QoL still may have. Quantitative and qualitative data was gathered by means of semi-structured interviews with Flemish community-dwelling, frail older people with higher (n?=?16) and lower QoL levels (n?=?18). Quantitative analyses showed that frail older people with a higher QoL were older, had lower levels of psychological frailty, and reported higher meaning in life compared to those with a lower QoL. Outcomes of qualitative analysis showed that participants in the high QoL subgroup adapted more effectively to difficulties, had more things in prospect, performed more activities, and were more satisfied with their social network compared to the low QoL subgroup. To conclude, this exploratory study suggests possibilities to promote and improve QoL by strengthening specific resources among frail older people.Please note that an English version of this article has been published in BMC Geriatrics: van der Vorst A, Zijlstra GAR, De Witte N, Vogel RGM, Schols JMGA, Kempen GIJM, D?SCOPE Consortium. Explaining discrepancies in self-reported quality of life in frail older people: a mixed-methods study. BMC Geriatr. 2017;17(1): 251.  https://doi.org/10.1186/s12877-017-0641-y.