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POOR ORAL HEALTH IS A FACTOR THAT ATTENUATES THE EFFECT OF REHABILITATION IN OLDER MALE PATIENTS WITH FRACTURES

 

T. Ogawa, M. Koike, M. Nakahama, S. Kato

 

Chuzan Hospital Clinical Education and Research Center, 6-2-1 Matsumoto, Okinawa city, Okinawa 904-2151, Japan

Corresponding Author: Takahiro Ogawa MD, PhD, Chuzan Hospital Clinical Education and Research Center, 6-2-1 Matsumoto, Okinawa city, Okinawa 904-2151, Japan, Tel: +81-98-982-1346; Fax: +81-98-982-1347, E-mail: ogawa0417takahiro@yahoo.co.jp

J Frailty Aging 2021;in press
Published online December 10, 2021, http://dx.doi.org/10.14283/jfa.2021.54

 


Abstract

Background: Poor oral health can lead to poor general health. We hypothesized that poor oral health might be a factor that attenuates the effect of rehabilitation in older patients with fractures.
Objectives: This study aimed to evaluate the relationship between oral health in elderly patients with fractures and improvement in activities of daily living (ADL) through rehabilitation. In addition, we assessed factors associated with ADL improvement among older patients with fractures.
Methods: This case-control study was conducted at a rehabilitation hospital among 178 men aged ≥65 years who underwent fracture rehabilitation. Patients were divided into two groups based on the oral health assessment tool (OHAT) score on admission (≥4 and <4). Analysis of comparison between the two groups and multivariate linear regression analyses were performed, with respect to functional independence measure (FIM) gain during rehabilitation.
Results: FIM gain was significantly lower in the group with OHAT score ≥4 (26.2±17.5) than that in group with OHAT score <4 (31.1±16.1, p=0.044). There were also significant differences between the two groups in body mass index values, Mini Nutritional Assessment Short Form (MNA-SF) scores, and fracture types. OHAT score on admission was significantly associated with FIM gain during hospitalization (coefficient: 6.350, 95% confidence interval: 1.043-11.658, p=0.019). FIM on admission, Mini-Mental State Examination score, and period of rehabilitation were significantly associated with FIM gain.
Conclusions: We demonstrated that the group with poor oral health had lesser ADL improvement than the group with good oral health. In addition, oral health and period of rehabilitation were independent factors that significantly affected ADL improvements. Older patients with poor oral health should be encouraged to undergo further rehabilitation, and to not refrain from exercise because of old age and fractures.

Key words: Aging, exercise, activities of daily living, periodontitis, frail elderly.


 

 

Introduction

Fractures are a critical problem in older individuals. The incidence of total fragility fractures in the largest five countries of the European Union plus Sweden are estimated to increase from 2.7 million in 2017 to 3.3 million in 2030 (1). Subsequently, older patients may have difficulty building muscles due to reduced physical activity levels. Therefore, activities of daily living (ADL) might not sufficiently improve in older individuals after experiencing fractures. On the other hand, poor oral health is also one of the severe problems. Poor oral health can lead to poor general health. In the past study, the prevalence of periodontitis was 40-57.6% among older people (2). According to some studies, people with periodontitis have risk for hyperglycemia and insulin resistance (3) and there is a relationship between periodontitis and diabetes complications (4). Inflammatory periodontal diseases are also associated with multiple systemic conditions, such as cognitive impairment, cardiovascular disease, respiratory diseases, osteoporosis, and rheumatoid arthritis (5-7). In addition, oral health conditions have been reported to have a direct influence on older people’s quality of life and lifestyle in a previous study (8). Poor oral hygiene may have a negative impact on brain function, cardiovascular function, respiratory function, and motor systems, such as bones and joints, all of which are very important functions and systems during rehabilitation and exercise. Therefore, we hypothesized that poor oral health might be a factor that attenuates the effect of rehabilitation in older patients with fractures. If this association is made clear, it will provide useful information for older people with fracture, who will now see the importance of oral care for multiple systemic conditions improvement as well as additional positive effects of rehabilitation. This study aimed to evaluate the relationship between oral health and ADL improvement by rehabilitation among older patients with fractures. We also assessed factors associated with ADL improvement among them.

 

Methods

Study design, setting, and participants

This case-control study was conducted at Chuzan Hospital in Okinawa City, Japan. Patients in this hospital required rehabilitation for approximately 1-3 hours every day without rest days due to some diseases and trauma. The study period was from October 2018 to September 2020. In this study, the medical doctors decided who required rehabilitation in the hospital. The participants consecutively enrolled in this study were men aged ≥65 years, with fractures, who were admitted to this hospital for fracture rehabilitation. All patients were transferred to this hospital after receiving acute treatment for fractures. All participants were supposed to undergo exercise therapy every day with a therapist, including muscle strength and ADL-based trainings. Rehabilitation was not performed when the patient’s condition might worsen such as when their circulation or respiratory status were unstable. We excluded those patients who had no oral health assessment tool (OHAT) data on admission, who could not undergo bioelectrical impedance analysis (BIA) to accurately measure skeletal muscle mass, such as patients who had cardiac pacemakers or who could not stay sufficiently calm during BIA such as those with dementia or brain dysfunction. We also excluded patients who had no BIA or Mini-Mental State Examination (MMSE) data because they refused examinations or had missing data. In total, 214 consecutive patients with fractures were initially eligible for enrollment in this study, of whom 36 met the exclusion criteria (Figure 1). Of these, three participants had no OHAT data, three had cardiac pacemakers, five participants on admission could not stay calm during BIA or had no BIA data, and 25 participants had no MMSE data. The final analysis included 178 patients.

Figure 1. Flowchart of the study population

OHAT; oral health assessment tool, BIA: bioelectrical impedance analysis; MMSE: Mini-Mental State Examination.

 

Data collection

Patient characteristics on admission, including age, body mass index (BMI), skeletal muscle mass index (SMI), data on functional independence measure (FIM), MMSE, and Mini Nutritional Assessment Short Form (MNA-SF), were collected retrospectively from the clinical database. FIM scores were obtained both on admission and at discharge to get FIM gain data. Data on the types of fractures and OHAT scores on admission were also retrospectively collected from the clinical database. In addition, information regarding the rehabilitation time per day and the length of hospital stay for rehabilitation were obtained from the clinical database. All patients underwent BIA using a segmental multi-frequency bioelectrical impedance analyzer (InBody S10; InBody Japan, Tokyo, Japan). Multifrequency impedance body composition analysis has been shown to correlate well with the results of dual-energy X-ray absorptiometry and has been validated (9-12). For the BIA measurements, patients rested quietly in a neutral supine position for ≥15 min. Skeletal muscle mass was estimated via BIA measurements, and the SMI was calculated as the appendicular skeletal muscle mass divided by the square of height (13). The ability to perform ADL on admission as baseline was evaluated using the FIM (14), a scale containing 18 items (13 items in motor domains and 5 items in cognitive domains). Each item was scored from one (total dependence) to seven (complete independence). The MMSE, introduced in 1975 (15), is a standard tool to evaluate cognitive impairment, and it contains 11 items that assess five areas of cognitive function: orientation, registration, attention and calculation, recall, and language (16). Nutritional status was assessed using the MNA-SF, with scores (range 1-14) ≥12, 8-11, and <8 points defined as a normal nutritional status, at risk of malnutrition, and malnutrition, respectively (17). The OHAT is a reliable and valid screening assessment tool for use in residential care facilities, including those with cognitively impaired residents (18), and its validity and reliability has also been demonstrated (19). The OHAT is one of the most commonly used indicators of oral cavity and is the most complete with regard to their included oral health items (20). This tool comprises eight domains including the lips, tongue, gums and tissues, saliva, natural teeth, dentures, oral cleanliness, and dental pain. They were stratified into three grades (healthy, oral changes, or unhealthy). The scores of the eight domains were summed to create a total score ranging from 0 (healthy) to 16 (unhealthy) (18). In this study, oral health in patients was assessed with OHAT by trained nurses on admission.

Statistical analysis

All continuous variables are presented as mean ± standard deviation, and categorical variables are expressed as number of patients and percentages. Patients were divided into two groups based on OHAT scores on admission: those with OHAT score ≥4 and those with OHAT score <4 on admission; a score <4 out of the maximum OHAT score indicates good oral health (21, 22). Continuous variables were compared between the two groups using the Mann-Whitney U test and Wilcoxon signed-rank test, and residual analysis was conducted after the chi-squared test was performed for categorical variables. Multivariate linear regression analyses were performed to identify the associations with FIM gain. For all comparisons, the level of statistical significance was set at P <0.05. Statistical analyses were performed using IBM SPSS Statistics (version 26.0; IBM, Tokyo, Japan) to analyze all data.

 

Results

Table 1 shows the characteristics of the participants on admission. The mean age, BMI, and SMI were 80.8±8.0 years, 21.4±3.3 kg/m2, and 6.02±0.98 kg/m2, respectively. The mean MMSE, MNA-SF, and OHAT scores on admission were 18.1±7.5, 6.85±2.39, and 2.40±2.21, respectively. The fracture types were hip fracture (58.4%), spine fracture (26.4%), and other fracture (15.2%). FIM was significantly higher at discharge (89.8±26.0) than on admission (60.2±19.2, p<0.001).

Table 1. Patient characteristics on admission

Values are presented as mean ± standard deviation. BMI: body mass index; SMI: skeletal muscle mass index; FIM: functional independence measure; MMSE: Mini-Mental State Examination; MNA-SF: mini nutritional assessment short form, OHAT; oral health assessment tool

 

Table 2 shows the comparison between the two groups with OHAT score ≥4 and OHAT score <4 on admission. BMI values and MNA-SF scores on admission were significantly lower in the group with OHAT score ≥ 4 (20.6±3.4 and 5.74±2.47, respectively) than in the group with OHAT score < 4 (21.8±3.1, p=0.017 and 7.33±2.20, p<0.001, respectively). The FIM gain during rehabilitation was significantly lower in the group with OHAT score ≥4 (26.2±17.5) than in the group with OHAT score <4 (31.1±16.1, p=0.044). The number of patients with spine fracture was significantly higher in the group with OHAT score ≥4 using chi-squared test and subsequential residual analysis. On the other hand, no differences were observed in age, SMI, FIM on admission, MMSE score, period of rehabilitation, and length of hospital stay between the groups.

Table 2. Analysis of variables in both groups with OHAT ≥ 4 and OHAT < 4 on admission

Values are presented as mean ± standard deviations or medians with interquartile ranges; OHAT; oral health assessment tool, BMI: body mass index; SMI: skeletal muscle mass index; FIM: functional independence measure; MMSE: Mini-Mental State Examination, ; MNA-SF: mini nutritional assessment short form

 

Table 3 shows the results of the multivariate linear regression analysis for FIM gain. FIM, MMSE score, OHAT score on admission, and period of rehabilitation were significantly associated with FIM gain ([coefficient, -0.185; 95% confidence interval, -0.363 to -0.006; p=0.043], [coefficient, 0.722; 95% confidence interval: 0.298-1.146, p=0.001], [coefficient, 6.350; 95% confidence interval, 1.043-11.658; p=0.019], and [coefficient, 0.187; 95% confidence interval: 0.089-0.285, p <0.001], respectively). On the other hand, age, BMI, SMI, MNA-SF, fracture type, and length of hospital stay were not significantly associated with FIM gain in the multivariate linear regression analysis.

Table 3. Multivariate linear regression analysis for FIM gain

FIM: functional independence measure; S.E.: standard error; CI: confidence interval; BMI: body mass index; SMI: skeletal muscle mass index; MMSE: Mini-Mental State Examination; MNA-SF; mini nutritional assessment-short form; OHAT; oral health assessment tool; a. Hip fracture coded 1; no hip fracture coded 0. b. Spine fracture coded 1; no spine fracture coded 0; c. Group with OHAT score <4 on admission coded 1; group with OHAT score ≥4 coded 0.

 

Discussion

This study aimed to evaluate the relationship between oral health in men aged ≥65 years with fractures and their ADL improvement by rehabilitation. First, we demonstrated in this study that the group with poor oral health, indicated by OHAT score ≥4, had lesser ADL improvement than the group with good oral health indicated by OHAT score <4. In addition, oral health was an independent factor that significantly affected ADL improvements.
Poor oral health is a severe problem, as it can lead to poor general health. Inflammatory periodontal diseases are associated with multiple systemic conditions such as cognitive impairment, cardiovascular disease, respiratory diseases, osteoporosis, and rheumatoid arthritis (5-7). In addition, oral health were associated with a higher probability of being frail (23) and tooth loss may reduce the capability to chew and consume nutrients, and contributed the development of age-related chronic diseases (24). In this study, these adverse effects due to inflammatory periodontal diseases, frail, and chronic diseases might attenuate the effect of rehabilitation in older patients with fractures. However, several positive effects of exercise have been reported. Increased brain-derived neurotrophic factor serum levels following training suggests that exercise promotes brain health (25, 26). Exercise participation is effective in improving physical activity and cardiac function (27, 28). Skeletal muscle is integral to physical activity, is related to respiratory function (29), and has been identified as the largest endocrine organ that releases myokines, which affect metabolism and health (30). These myokines released from muscle during exercise may also attenuate inflammatory conditions (30). These previous studies indicated that exercise could improve brain function, cardiovascular function, respiratory function, and physical activity, which might be attenuated by poor oral health. In this study, the period of rehabilitation was an independent factor that significantly affected ADL improvements. This result indicated that undergoing further rehabilitation was effective in improving ADL in older patients with poor oral health. Therefore, older patients with poor oral health should be encouraged to undergo further rehabilitation, and to not refrain from exercise because of old age and fractures.
In this study, there were some significant differences between the two groups. The BMI values and MNA-SF scores on admission were significantly lower in the group with poor oral health. These results indicated that poor oral health was associated with poor nutrition. There was also a difference in fracture type between the two groups. The modes of fall may have been different among the patients, such as swaying to the side and falling, or falling on their backside, but the details were unknown. The MMSE score on admission was also a factor that affected patients’ ADL improvements. Although oral hygiene can affect cognitive function (5), there was no difference between the two groups based on oral health, and multivariate linear regression analysis in this study showed that oral health was an independent factor affecting patients’ ADL improvements.
This study had some limitations. First, this study did not focus on the outcomes of long-term rehabilitation. The length of hospital stay during the rehabilitation period was approximately two months in this study; therefore, it is unclear whether oral health affects the effectiveness of long-term rehabilitation. Second, females were excluded from this study. We assumed that there might be possible effects of previous menstrual hormonal changes on their fracture status, cardiovascular, endocrine, and fluid regulation systems. In addition, it was possible that patients’ comorbidities might affect their FIM gain. As inflammatory periodontal diseases were associated with multiple systemic conditions, poor oral health might indirectly influence the improvement of ADL. Furthermore, there might be some biases such as selection bias and information bias because all patients were decided to undertake rehabilitation by the medical doctors in retrospective study. Though randomized control study might be appropriate for eliminating these biases, we were able to obtain as many as 178 patients due to retrospective study.

 

Conclusion

In this study, we demonstrated that the group with poor oral health had lesser ADL improvement than the group with poor oral health. In addition, oral health and period of rehabilitation were independent factors that significantly affected ADL improvements. While poor oral health may attenuate the effect of their rehabilitation, it may be necessary for patients with poor oral health to undergo further rehabilitation for the purpose of ADL improvements and to prevent multiple systemic condition dysfunction.

 

Acknowledgments: We want to acknowledge all the patients who agreed to participate in this study.

Funding: No funding was received for the support of this study.

Ethics declarations: All experimental procedures were performed in accordance with the principles of the Declaration of Helsinki. This study was approved by the institutional review board of the hospital (approval ID: 19-93).

Conflicts of interest: The authors declare that they have no conflicts of interest.

Informed consent: Written informed consent was given by each patient. All participants were provided the opportunity to have their data excluded from the study analysis.

 

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