Theories and significance of oral health in frailty
WE ARE ALL AGING
Clinicians are becoming increasingly interested in the complexity of the mouth in old age as more people are living longer with natural teeth, and there is an appreciation that the mouth and teeth if neglected, can be a serious source of distress and disease. In this chapter, we address the demographics of our changing populations, we highlight how age impacts the mouth and what we think it means to be frail, and finally, we explain how frailty can contribute to and be aggravated by oral diseases, impairments, and disabilities.
The world population is aging as a consequence of longer life expectancy and a decline in fertility, particularly in developed countries, during the latter half of the past century (Fitzpatrick, 2003; United Nations Department of Economic and Social Affairs, 2010). While people in Europe, North America, and Japan are living longer than ever before, a dramatic increase is expected by 2050 in the proportion and total numbers of older people in Latin America, China, and India (Gutman et al., 2000). The current demographic change is a global phenomenon. In 1950, for example, there were about 131 million people on Earth who were 65 years of age or older, whereas by 1995 the number had tripled to about 371 million. Moreover, if the current growth continues until 2025, the number is likely to double, and by 2050 there will be more than 1.4 billion elders around the globe (Fischer and Heilig, 1997).
The United Nations identified the immense significance of these global demographics in Article 2 of the political declarations made at the Second World Assembly on Ageing in 2002 with the statement “that the world is experiencing an unprecedented demographic transformation and that by 2050 the number of persons aged 60 years and over will increase from 600 million to almost 2 billion and that the proportion of persons aged 60 years and over is expected to double from 10 to 21 per cent. The increase will be greatest and most rapid in developing countries where the older population is expected to quadruple during the next 50 years” (United Nations, 2002a). Even more dramatically, we see the rapid growth of the population older than 80 years, who are growing globally at an annual rate of 3.8%, which is currently twice as high as the 1.9% growth of the population over 60 years of age (United Nations, 2002b). These are dramatic changes that will focus attention even more keenly on aging and associated phenomena.
As numbers change, so too will our social networks, our physical functions, and our cognitive agility. The prevalence of chronic disability is noticeable at age 65 years and increases as age increases (Table 1.1).
|Condition||% of age group|
|65–79 years||80+ years|
|High blood pressure||43.2||47.2|
|Alzheimer’s or other dementia||1.1||4.3|
Based on the master file of the Canadian Community Health Survey, Cycle 3.1, and adapted from Denton and Spencer (2010).
Table 1.1 shows data on self-reported health status from elders who are living independently, and undoubtedly, the prevalence of chronic conditions is much higher in the frailer population in nursing homes. The prevalence of dementia, for example, is remarkably low in this noninstitutionalized population. A survey of predominantly Caucasian elders aged 90 years and older in California reported that 45% of women and 28% of men were clinically demented, and the prevalence rates doubled every 5 years for women but not men (Corrada et al., 2008).
THE AGING MOUTH
Normal aging changes the mouth and associated structures in relatively mild ways as physiological capacity is reduced compared with the more extreme reactions precipitated by disease. There is, for instance, age-related loss of mucosal elasticity, submucosal tissue, and tactile sensitivity around the mouth (Landt and Fransson, 1975; Nedelman and Bernick, 1978; Wolff et al., 1991). The sensation of taste also diminishes a little (Easterby-Smith et al., 1994), as does the mass and strength of the jaw muscles (Newton et al., 1993). Within the pulp of vital teeth, there is a decrease in the number of blood vessels and cells and an increase in secondary dentine deposits, all of which compromise a tooth’s capacity to recover from physical trauma and caries (Mandojana et al., 2001). Likewise, cells can lose their ability to proliferate and produce protein as they age. Consequently, we can expect a slight relocation of periodontal attachment and loss of bone support around teeth (Papapanou et al., 1989). The occlusal surfaces of teeth show signs of attrition (Bartlett and Dugmore, 2008), and the curved articulating surfaces of the jaw joints flatten a little as they age (Magnusson et al., 2008). However, it has been challenging to distinguish between the contributions of genes and of the environment to age-related changes because, frequently, the difference between normal “wear and tear” and active disease is obscure.
The balance between health and disease, as between impairment and disability, of the mouth is influenced by interactions of human behavior, the environment, and various diseases such as caries, periodontal disease, trauma and, to a lesser extent, cancer (Gutmann and Gutmann, 1995; Reichart, 2000; Levy et al., 2003; Petersen et al., 2005). Consequently, frail elders today present with repaired or missing teeth because of the ravages of caries over many years (Marcus et al., 1996; Thompson and Kreisel, 1998; Wyatt and MacEntee, 1998; Fure, 2003), and many of them have lost all of their natural teeth (Schoenborn and Heyman, 2009). Problems of the mouth can have a very disturbing affect on nutrition, communications, and social interactions at any age (MacEntee et al., 1997; Moynihan et al., 2000), but as frailty increases, oral neglect can contribute to life-threatening conditions in the respiratory, cardiovascular, and endocrine systems (Bonito, 2002; Awano et al., 2008). Although there is controversy around the strength of the contributions, and awareness of the capacity that elderly people have for coping with adversity (Brondani and MacEntee, 2007), there is little doubt that a neglected mouth can be very challenging to general well-being and quality of life (Gift and Redford, 1992; MacEntee, 2007; Sanders et al., 2009).
THE SILENCE OF THE FRAIL ELDERLY
Frailty complicates the care needed to manage oral diseases, and oral diseases complicate the management of frailty (Satcher, 2000a; Chalmers and Ettinger, 2008). Moreover, the neglect of oral health and acceptance of infectious diseases are complicated even further by elders who are too frail to complain (Satcher, 2000b; Helgeson et al., 2002).
There is much debate about the establishment of a comprehensive definition that describes the characteristics, causes, and management of frailty (Kaethler et al., 2003; Bergman et al., 2007). Helena’s circumstances at age 82 years demonstrate that physical frailty does not necessarily cause social isolation (Box 1.1). Although her upper denture adds a layer of complexity to her health, whether or not she is “frail” and what in fact exacerbates or improves her physical situation is less clear. Is she neglecting her mouth because she is frail? Does her physical disability impede her ability, and therefore her wish, to visit a dentist, or is she so accepting of her mouth and denture problems that she sees no point in visiting a dentist? These are questions that warrant good answers if we are to appreciate fully the role of physical function and oral health in Helena’s life.
Box 1.1 Helena’s frailty.
Helena just had her 82nd birthday. She enjoys reading and the time she can spend in her garden on sunny days. She has not walked for 7 years and gets around in an electric wheelchair. She describes her health overall as “the pits,” with numerous related concerns, including post-polio syndrome, rheumatoid arthritis, heart problems, breathing problems, and seizures. She has been hospitalized several times in the last year. Fortunately, her family is very supportive.
She lives with Joyce, her 50-year-old daughter, and Ken, her 28-year-old grandson. Joyce works as a registered nurse, while Ken quit his job to help out at home where he does a lot of t/>