associations between malnutrition.pdf

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Age and Ageing 1998; 27: 123 -128

Associations between malnutrition,poor general health and oral dryness inhospitalized elderly patientsVALERIE DORMENVAL, EJVIND BUDTZ-JORGENSEN, PHIUPPE MOJON, ANDRE BRUYERE 1,CHARLES-HENRI RAPIN1De partme nt o f Ge rodonto logy and Removable P nosthodontics, University of Geneva, 19 rue Barthelemy-Me nn,CH-1205 Geneva, Switzerland'University Institute of Geriatrics, Geneva, SwitzerlandAddress corresponde nce to: E. Budtz-Jargensen. Fax: (+41 ) 22 78 1 12 97

AbstractObjective: to obtain information about the possible relationship b etwe en symptoms and signs of oral dryness andmalnutrition/poor gen eral health in hospitalized older people .Design: a cross-sectional clinical investigation with measurements of unstimulated salivary flow rates (USFR),stimulated salivary flow rates (SSFR), nutritional status, serum albumin concentration and an evaluation ofsymptoms of oral dryness and loss of appetite by a q uestionnaire.Subjects and methods: a cohort of 99 elderly, non-psychiatric patients hospitalized for medical reasons;collection of demographic and health data from medicalfiles,collection of USFR and SSFR, measurements of bodymass index (BMI), lean body mass, fat body mass, serum albumin con centration; com pletion of a questionn airerelated to sym ptoms of oral dryness and the p atients' app reciation of their nutritional status.Main outcome measures: SSFR and USFR.Results: mean age of the 99 patients was 82.5 4.0 years. Anthropom etric examinations indicated m alnutrition ofsevere or intermediate de gree in about 50% while 46% showed moderately and 40% severely reduce d albumin. Lossof appetite was pre sent in 54% and 51% complained of oral dryness; 17% had an USFR


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V. Dormenval et al .The purpose of the present study was to examinethe relationship between indices of malnutrition,general health (serum albumin concentration), salivarysecretion rate and dry mouth feeling in elderlyhospitalized p atients.

Patients and methodsThe study included 99 patients hospitalized for variousmedical reasons at the U niversity Institute of Ge riatricsduring two periods (1 August-1 September 1993 and31 May-18 August 1994). Patients aged 75-95 yearswere included in the study after a Mini-Mental StateExamination (MMSE), comprising an evaluation of thepatient's immediate memory, state of orientation andattention [10]. A MMSE score of >21 (maximum score30) was required to ensure satisfactory co-operationduring the questionnaire and the salivary tests. Thestudy was approved by the local ethical comm ittee.

Information concerning the patients' age, sex,pathologies and numbers and types of current drugprescriptions was obtained from the medical files.Nutritional and medical assessments included bodymass index (BMI), mid-arm circumference, tricepsskinfold thickness and serum albumin level [11, 12](Table 1). Mid-arm circum ference (lean body mass) wasmeasured in the right arm mid-way between theacromion and the olecranon processes. The followingcut-off values according to Fricker et al. [11] and Wooet al. [12] for wom en (and, in parentheses, for m en) at70 years of age were applied: < 23.1 cm (23 8c m ),severe denutrition; 23.l-25.5cm (23.8-25.7cm), inter-mediate denutri t ion; 25.6-297cm (257-28.7cm),moderate denutrition; and >29.7 (28.7 cm), no subnu tri-tion. The triceps skinfold thickness (fat body m ass) wasmeasured using a skinfold calliper with a pressure of10 g/mm 2 of contact area over its entire operating range.The cut-off values used w ere: 11 mm), no denutrition. For serum albuminand the BMI the cut-off between normal and reducedvalues was set at >3 5 g/1 and ^ 2 1 , respectively.

Saliva examinations were performed betw een 0900 h

and 1100 h and the two examinations were carried outon different days. Subjects w ere asked not to eat or drinkfor \Vi-2h before the examination, which began withthe determination of USFR, after which SSFR wasmeasured [8]. Saliva was collected during 6min andthe patient was asked to spit every 2 min. The averageUSFR and SSFR was computed from the two samplestaken at day 1 and day 2. The cut-offs between normaland reduced USFR and SSFR were set at 0.1 ml/min and0.5ml/min, respectively [8]. The patients were askedabout feelings of oral dryness such as severity, con-sequences and need to drink "water regularly during thenight and day [13].StatisticsThe relationship between variables was assessedwith the Pearson \2 te st- The significance of differ-ences between mean biological measures in twogroups was tested with the Student's /-test when anormal probability p lot indicated a normal d istribution.When the plot indicated a non-parametric distribution,a Mann-Whitney procedure was used. Similarly,correlation was measured with Spearman R or PearsonJ? coefficient depending o n the distribution of the data.Multivariate analysis of variance (MANOVA) was usedto distinguish between two groups using the Hotellingtest. Only normally distributed variables were intro-duced in the model. The significance level was set atP


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Malnutrition, poor general health and oral drynessTable 2. Relationship b etw een mean unstimu lated salivary flow rates (USFR) and complaints of oral dryness in 92hospitalized elderly patients w ho com pleted the salivary test

Dry mouth during dayDifficulty in speakingWater intake >20 times/dayDry mouth complicates denture wearing

With symptom% of patients41123223

USFR/min0.280.300.290.24

Without symptom% of patients USFR/min598 86 87 7

0.470.410.440.36

P0.0030.030.030.03

the patients (Table 1). The serum albumin concentra-tion indicated that only 14% of the patients showedlevels within thenormal range (S 3 5 g/1) whereas 46%showed moderately (30-34g/I) and 40% severely( ^ 3 0 g/1) reduced levels. There was no correlationbetw een age and the various anthropom etric m easuresof nutritional status or serum albumin concentration.App etite, ma lnutrition and serum albuminAmong 53 patients who indicated recent loss ofappetite, a markedly lower serum albumin concentra-tion (F = 0.02) was recorded. In the 35 patients whoreported that loss of appetite had affected their dietover tim e, significantly smaller mid-arm circumference(P = 0.05) and lower BMI (P = 0.05) were observed.Complaints of oral dryness and salivary secretionSignificantly reduced USFR was observed in thepatients showing the following symptoms of oraldryness: dry mouth during day (P = 0.003), difficultyin speaking (P = 0.03), water intake >20 times per day(P 0.03) and dry mouth complicating denture wear-ing (P = 0.03; Table 2). Furthermore, the SSFR wassignificantly reduced in patients showing the followingsymptoms of oral dryness: frequent dry mouth (P


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V. Dormenval et al.Table 4. Relationship between unstimulated salivaryflow rate (USFR) and body mass index among 93elderly patients who comp leted the salivary test

USFR (ml/min)

Total

Body mass index

54(70%)7(44%)61

23 (30% )9 (56% )32

P=0.05.related to oral dryness, 54% indicated that they had lostappetite and 51% complained of oral dryness.There were no correlations between either serumalbumin level or the nutritional status and occurrenceof cardiovascular diseases, cancer, gastrointestinaldiseases or diabetes.Com plaints of oral dryness, loss of appetite andmalnutritionCertain associations were found between symptomsrelated to oral dryness, loss of appetite and poornutritional status. Thus, recent loss of appetite wassignificantly associated with complaints of: dry mouth(P=0.01), dry mouth during night CP=0.03), drymouth when waking up (P = 0.01), dry mouth duringthe day (P = 0.01), dry mouth while eating (P 0.001)and need to keep water near the bed (P=0.03). Theinformation that loss of appetite had affected the dietwas significantly associated with the complaint that itwas difficult to eat dry food (P=0.01). Significantlylower BMI was observed in patients reporting thesymptoms of dry mouth (P 0.05) or dry mouth duringday (P = 0.04). Using a multivariate analysis of variance

BMI, mid-arm circumference and triceps skinfoldthickness were, as a whole, significantly lower inpatients reporting dry mou th during the day (P = 0.05).

DiscussionThe patients selected in the present study wererecently hospitalized elders with a MMSE which madean interview and salivary tests possible. Many recentreports have been published indicating that malnutri-tion is frequent among elderly patients in hospitalsand associated with increased morbidity and mortality[14-16] . This was confirmed in the present study asthere was clinical evidence of protein-energy mal-nutrition in about 50% whereas reduced levels ofserum albumin were observed in 86%. The serumalbumin level may be considered as a marker ofgeneral health or of nutritional state, while the BMIand the an thropometric measures change mo re slowlyover time [17, 18]. This was confirmed in the presentstudy as the serum albumin concentration wassignificantly lower in those reporting recent loss ofappetite. On the other hand, those who reported thatloss of appetite had affected their diet over timeshowed significantly lower arm circumference andBMI.

Xerostomia or dry mouth may develop as a result ofsalivary gland dysfunction due to radiation therapy forhead and neck cancer, pharmacological agents orautoimmune diseases such as Sjogren's syndrome[13]. The clinical manifestations of xerostomia includea dry or burning m outh, difficulty in chew ing, wea ringdentures, swallowing and speaking. Although there isan age-related reduction of USFR rate, this does notcause apparent symptoms of dry mouth and the SSFR(chewing, chemical stimulation) is not affected by age[4-7, 19]. Thus, salivary gland hypofunction and

Table 5. Relationship between unstimulated and stimulated salivary flow rate and anthropometric measures ofmalnutrition in elderly hospitalized patientsNo. (and %) of patients, by measure and degree of malnutritionTriceps skinfold thickness (cm) Arm circumference (cm)Severe Intermediate/better

Unstimulated salivary flow rate (ml/min)>0 .1 20 (28%) 52 (72% )


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Malnu trition , poor general health and oral d ry nessxerostomia in elderly people are most often a symptomof systemic disease or xerogenic medication, not ofageing per se [6, 7, 20]. This was confirmed in thepresent study, as there was no relationship betweenage (within the range 75-95 years) and complaints ofxerostomia or the SSFR and USFR.Reduced USFR and SSFR were observed relativelyfrequently among th e patients and abo ut 50% experi-enced xerostomia. This could be due to the highnumber of medications taken in this group of patientsor intake of drugs with specific xerostomic side effects[13, 21, 22]. We confirmed an association betweennumber of medications and reduced SSFR but noassociation could be found between xerostomicmedication and USFR or SSFR. The finding thatsymptoms of oral dryness were related to reducedUSFR and SSFR is consistent with other studies [8, 23].

Salivary hyposecretion and complaints of oral dry-ness are correlated with the number of systemicdisorders, the duration of the diseases and themedication as well as the number of medications [6,7, 20, 24]. This was confirmed in the present study onhospitalized non-psychiatric patients showing a posi-tive correlation between the serum albumin level andthe SSFR. Also, the number of medications and theSSFR were negatively correlated. Furthermore, wefound an association between malnutrition (low leanbody m ass, fat body mass and BMI) and hy posecretionof saliva and complaints of oral dryness. Theserelationships might be explained in several ways.First, reduced salivary flow rate and feeling of oraldryness could b e side effects of drug intake associatedwith the patie nts' poo r general health status [1 3, 25,26]. Secondly, poor nutritional status and reducedsalivary secretion/feeling of oral dryness could be theconsequences of poor alimentation and insufficientintake of water (dehydration) [1, 8]. Finally, reducedsalivary secretion and feeling of oral dryness couldhave a negative effect on alimentation, appetite andoral comfort. The latter hypothesis has been su ppo rtedby the o bservations that xerostomia affects the abilityto chew and form a food bolus and which leadsto avoidance of certain foods [27] and that foodpreferences are related to the salivary flow rateduring mastication rather than masticatory ability andefficiency [28].

In conclusion, reduced salivary secretion/feeling oforal dryness in elderly hospitalized patients could besigns of poor nutritional or general health status,probably associated with dehydration. To improve thenutritional status and patient comfort, in the long term,improved meal provision and environment, dietarysupplements and regular intake of water could have abeneficial effect [29, 30 ]. It should be recognized,however, that malnutrition and dehydration arecommon symptoms in terminally ill or dying patients[31]- In these patients it is important to relieve thesymptoms of dry mouth by providing them with

regular sips of water, crushed ice to suck and payingmeticulous attention to oral hygiene.

Key points Mouth dryness is an uncomfortable and importantsymptom w hich has many causes and is common indebilitated pa tients. One infivehospitalized elderly patients w ere takingxerostomic drugs. Patients with a dry mouth have reduce d salivaryflow rates. Mouth dryness is associated with inadequatenutrition and poor general health. Reduced salivary secretion and a feeling of oraldryness may have adverse effects on mouthcomfort, appetite and alimentation.

References1. Lipschitz DA. Nutrition and ageing. In: EvansJG, Williams Teds. Oxford Textbook of Geriatric Medicine. Oxford: OxfordUniversity Press, 1992; 6: 11 9-27.2. Rudman D, Feller AG. Protein-caloric under-nutrition inthe nursing home. J Am Geriatr Soc 1989; 37: 1 73 -83 .3 . Payette H. Micronutrient status of the long-term institu-tionalised elderly. Vitamin Inform 1993; 8: 1-2.4. Heft MW, Baum BJ. Unstimulated and stimulated parotidsalivaryflowrate in individuals of different age groups. J DentRes 1984; 63: 1182-5.5. Lopez-Jomet MP, Bermejo-Fenoll A. Is there an age-dependent decrease in resting secretion of saliva of healthypersons? A study of 1493 subjects. Braz Dent J 1994; 5: 93 -8.6. Bertram U. Xerostomia. Acta Odontol Scand 1967; 25(suppl. 9): 1-126.7 . Baum BJ. Research on aging and oral health: an assessmentof current status and future needs. Spec Care Dent 1981; 1:156-65 .8. Sreebny LM, Banoczy J, Baum JL et al. Saliva: its role inhealth and disease. Int Dent J 1992; 42: 291-304.9. Holmes JH. Changes in salivaryflowproduced by changesin fluid and electrolyte balance . In: Sreebny LM, Meyer J eds.Salivary Glands and their Secretions. New York: Macmillan,1964; 177-95.10. Folstein JF, Folstein SE, McHugh PR. Mini-mental s tateapractical method for grading the cognitive state of patientsfor the clinician. J Psych Res 1975; 12: 189-98.1 1 . Flicker J, Gausseres C, Boulier A. Interet clinique desmarqueurs nutritionnels en geriatric Age Nutr 1991; 2: 70- 8 .12. Woo J, Ho SC, Mak YT, Law LK, Ch eung A. N utritionalstatus of elderly patients during recovery from chest infectionand the role of nutritional supplementation assessed by aprospective randomised single-blind trial. Age Ageing 1994;23 : 40- 8 .13 - Sreebny LM, Valdini A. Xerostomia. Part I.Relationship to

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V. Dormenval et al.non-oral symptoms, drug and diseases. Oral Surg Oral MedOral Pathol 1988; 66 : 4 5 1 -8 .14. Czajka-Narin DM, Tsui J, Kohrs MB, Nordstrom JA.Anthropometric indices of a non-institutionalized elderlypopulation. Age Ageing 1991; 2: 95 -1 03 .1 5. Fulop T, Herrmann F, Rapin C-H. Prognostic role ofserum albumin and pre-albumin levels in elderiy patients atadmission to a geriatric hosp ital. Arch Gerontol Geriatr 1991;1 2 : 3 1 -9 .16 . Muhlethaler R, Stuck A, Minder CE, Frey BM. Theprognostic significance of protein-energy malnutrition ingeriatric patients. Age Ageing 1995; 24: 193-7.17 . Rapin C-H, Feuz A, Weil R. La malnutrition proteino-energetique chez le malade age. Rev Ther 1989; 46: 43 -50 .18. Mojon P, Budtz-Jorgensen E, Michel J-P, Limeback H. Oralhealth and history of respiratory tract infection in frailinstitutionalised elders. Gerontology 1997; 14: 9-16.1 9. Tylenda CA, Ship JA, Fox PC, Baum BJ. Evaluation ofsubmandibular salivary gland flow rate in different ages.J Dent Res 1988; 67: 1225-8.20 . Navazesh M, Brightman VJ, Pogoda JM. Relationship ofmedical status, medications and salivary flow rates in adultsof different ages. Oral Surg Oral Med Oral Pathol Oral RadiolEndo 1996; 81 : 1 7 2 -6 .21 . Dormenval V, Budtz-Jorgensen E, Mojon P, Bruyere A,Rapin C-H. Nutrition, general health status and oral healthstatus in hospitalized elders. Gerodontology 1995; 12: 73-80 .22 . Parvinen T. Flow rate, pH and lactobacillus and yeastconc entration s of stimulated w hole saliva in adults. Academicdissertation, Turku, Finland, 1 984.

23 . Kreher JM, Graser GN, Handelman SL. The relationshipof drug use to denture function and saliva flow rate ingeriatric population. J Prosthet Dent 1987; 57: 631-7.24 . Ship JA, Decarlic C, Friedland RP, Baum BJ. Diminishedsubmandibular salivary flow in dementia of the Alzheimertype. J Gerontol 1990; 45: 61 -6 .25- Parvinen T. Stimulated salivary flow rate in relation toage, size and sex. Proc Finn Dent Soc 1 984; 80: 1 27 -3 0.26 . Narhi TO. Prevalence of subjective feeling of dry mouthin the elderiy. J Dent Res 1994; 73: 20-5.27 . Loesche WJ, BrombergJ, Terpenning MS etal Xerostomia,xerogenic medications and food avoidances in selected geriatricgroups. J Am Geriatr Soc 1995; 43 : 401 -7 .28 . Ernest SL Dietary intake, food preferences, stimulatedsalivary flow rate and masticatory ability in older adults withcomplete dentition. Spec Care Dent 1993; 13: 102-6.29 . Elmstahl S, Blabolil U, Fex G, KuUer R, S teen B. Hospitalnutrition in geriatric long-term care medicine. I. Effects of achanged meal environment. Comprehen Gerontol 1987; 1A:29-33 .3 0. Elmstahl S, Steen B. Hospital nutrition in geriatric long-term care medicine, n. Effects of dietary supplements. AgeAgeing 1987; 16: 73 -80 .3 1 . Baines MJ. Symptoms management and palliativecare. In: Evans JG, Williams TF eds. Oxford Textbook ofGeriatric Medicine. Oxford: Oxford University Press, 1992;685-96 .

Received 18 Septembe r 1996

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