Efficacy of a New Post-Mouthwash Intervention (Wiping Plus Oral Nutritional Supplements) for Preventing Aspiration Pneumonia in Elderly People: A Multicenter, Randomized, Comparative Trial.

BACKGROUND/AIMS: Aspiration pneumonia is a common cause of death among the elderly (≥90-year-old) in nursing homes. Studies suggest that its incidence could be reduced by oral care interventions. We aimed to evaluate the efficacy of a new oral care intervention: wiping plus oral nutritional supplements (ONS). METHODS: This prospective observational study was conducted in 252 patients (age 88.0 ± 6.5 years) in 75 nursing homes, rehabilitation hospitals, and other care facilities. Patients were randomly divided into an intervention group (n = 74) and a control group (n = 107), whose members received conventional oral care. Body mass index, activities of daily living (Barthel index), and complete blood count and biochemistry parameters were measured at 2, 4, 6, and 8 months. RESULTS: The cumulative incidence of pneumonia at 8 months tended to be lower in the intervention than in the control group (7.8 vs. 17.7%, p = 0.056) and was significantly lower for men in the intervention group (p = 0.046). CONCLUSIONS: Our new intervention "wiping plus providing ONS" method appears to help prevent aspiration pneumonia, thereby reducing mortality risk. In this study, we disseminate information on how this method is used in Japan.

[Routes of nutrition and types of diet among dependent community-dwelling older care recipients and the relevance to mortality and hospitalization].

AIM: To clarify the routes of nutrition and types of diet and their relevance to the risk of mortality and hospitalization among community-dwelling dependent elderly provided various home care services under the long-term care insurance program. METHODS: The present study consisted of the collection of baseline data of participants in the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE) and data regarding mortality and hospitalization during a three-year follow-up period. The study population consisted of 1,872 subjects, and the baseline data included demographic characteristics, basic activities of daily living (ADLs), comorbidities, nutritional routes and types of diet, which were evaluated by trained visiting nurses. RESULTS: Among the participants, 1,786 were on oral nutrition (solid regular-texture diet: 1,487 (79.5%); modified-texture diet (minced/pureed texture): 299 (16.0%), 82 (4.4%) were on enteral nutrition and four (0.2%) were on parenteral nutrition. During the three-year follow-up period, 453 participants died and 798 participants experienced admission to the hospital (pneumonia-related death and hospitalization: n=103 and 155, respectively). Cox regression models revealed that a modified-texture diet and tube feeding are associated with all-cause mortality and hospitalization. In particular, feeding tube use showed a high risk of pneumonia-related mortality and hospitalization, even after adjusting for potential confounders, including comorbidities and the ADL status.

Accumulation of geriatric conditions is associated with poor nutritional status in dependent older people living in the community and in nursing homes.

AIM: To clarify the association between nutritional status and the prevalence of geriatric conditions in dependent older adults. METHODS: A cross-sectional observational study of dependent older adults aged 65years or older who were living either in the community (n = 511, mean age 81.2years) or in nursing homes (n = 587, mean age 85.2years) was carried out. Data included the participants' demographic characteristics, basic activities of daily living, Charlson Comorbidity Index and the prevalence of eight geriatric conditions (visual impairment, hearing impairment, falls, bladder control problems, cognitive impairment, impaired mobility, swallowing disturbance and loss of appetite). Nutritional status was assessed by the Mini Nutritional Assessment short form (MNA-SF). RESULTS: Of 1098 participants, 21.4% (n = 235) were categorized as "malnourished", according to the MNA-SF classification. Participants in the "malnourished" group had a greater number of geriatric conditions than those in the other two groups. A higher prevalence of all the geriatric conditions except for falls was detected in the group with poorer nutritional status. Multivariate logistic regression analysis showed that malnutrition was associated with the number of geriatric conditions, but not with that of comorbidities, even after controlling for confounders. CONCLUSIONS: Malnutrition was confirmed to have significant associations with geriatric conditions in dependent older adults.

[Factors associated with malnutrition in community-dwelling disabled elderly--the KANAGAWA-AICHI Disabled Elderly Cohort (KAIDEC) Study].

AIM: This study aimed to identify factors associated with malnutrition in community-dwelling disabled elderly. METHODS: A cross-sectional study of baseline data for 1,142 community-dwelling elderly (81.2±8.7 years) from of the KANAGAWA-AICHI Disabled Elderly Cohort (KAIDEC) study was conducted. The data included the participants' demographic characteristics, nutritional status (Mini Nutritional Assessment short-form: MNA-SF), dysphagia status (Dysphagia Severity scale: DSS), comorbidity, basic activities of daily living (bADL), hospitalization with in the past three months and care level according to the Long-Term Care Insurance program. The participants were considered to be in malnutrition or at risk of malnutrition if their MNA-SF score was 0-7 or 8-11, respectively. The chi square test, analysis of variance, Jonckheere-Terpstra trend test and logistic regression analysis were used for the statistical analysis. RESULTS: A total of 16.7% of the participants were classified as having malnutrition. In addition, a higher prevalence of malnutrition was associated with a higher care level in the long-term care insurance program, and malnutrition was associated with a lower bADL score, the presence of dysphagia and dementia and hospitalization with in the past three months. CONCLUSIONS: The present study demonstrated that malnutrition in community-dwelling disabled elderly is associated with a lower bADL score, the presence of dysphagia and dementia and hospitalization with in the past three months.

Relationship between nutrition status and dental occlusion in community-dwelling frail elderly people.

AIM: This study aimed to determine the risk of malnutrition in some communities where the frail elderly receive public long-term care insurance. We also clarified the dental problems in those at risk of malnutrition. METHODS: A total of 716 frail elderly who lived in eight cities in Japan (240 males and 476 females with a mean age of 83.2±8.6 years) were divided into three groups according to Mini Nutritional Assessment short form results: well nourished, at risk of malnutrition and malnourished. They were also divided into three groups in terms of remaining teeth occlusion and denture occlusion: group A, natural dentition with adequate function; group B, partially or fully edentulous, but maintaining functional occlusion with dentures in either or both jaws; and group C, functionally inadequate occlusion with no dentures. The relationship between nutrition status and dental occlusion was evaluated using logistic regression analysis with sex, age, activities of daily living and cognitive function as covariates. RESULTS: The number of participants in each of the groups was as follows: 251 well nourished, 370 at risk of malnutrition and 95 malnourished. When they were divided into just two groups, (i) well nourished and (ii) at risk of malnutrition plus malnourished, in order to study malnutrition risk factors, there were significant relationships between their nutritious status and sex, Barthel index, and occlusion. CONCLUSION: This large-scale cross-sectional survey showed that loss of natural teeth occlusion was a risk factor for malnutrition among community-dwelling frail elderly.

[Place and cause of death in community-dwelling disabled elderly people].

AIM: To examine the place and cause of death in community-dwelling disabled elderly people. METHODS: The baseline data of 1,875 participants and their caregivers in the Nagoya Longitudinal Study for Frail Elderly were used for the analysis. Cox proportional hazard models were used to assess the associations between the variables and the place of death during the 3-year follow-up period. RESULTS: During the observation period of three years, 454 died (hospital death: 347, home death: 107). In total, the rates of pneumonia-, cancer- and heart failure-related death were 22.7%, 14.5%, and 13.2%, respectively. Among the home deaths, 22.4% were age-related deaths and 18.7% were heart failure-related deaths. Females, older, and participants with dementia were more likely to die at home, while those with cancer or a spouse caregiver were more likely to die in the hospital. There were no differences in the levels of caregiver burden or formal service use between the cases of home and hospital death. Multivariate Cox hazard models revealed that home death was associated with an older age and the absence of diabetes mellitus and cancer at baseline. CONCLUSIONS: We demonstrated that death at home among community-dwelling disabled elderly is associated with an older age, and the absence of diabetes mellitus and cancer. Due to the lack of important factors that should be addressed, a further study is required in the future.

Day-care service use is a risk factor for long-term care placement in community-dwelling dependent elderly.

AIMS: To identify predictors of long-term care placement and to examine the effect of day-care service use on long-term care placement over a 36-month follow-up period among community-dwelling dependent elderly. METHODS: This study was a prospective cohort analysis of 1739 community-dwelling elderly and 1442 caregivers registered in the Nagoya Longitudinal Study for Frail Elderly. Data included the clients' demographic characteristics, basic activities of daily living, comorbidities, and use of home care services, including the day-care, visiting nurse, and home-help services, as well as caregivers' demographic characteristics and care burden. Analysis of long-term care placement over 36 month was conducted using Kaplan-Meier curves and multivariate Cox proportional hazards models. RESULTS: Among the 1739 participants, 217 were institutionalized at long-term care facilities during the 36-month follow-up. Multivariate Cox regression models, adjusted for potential confounders, showed that day-care service use was significantly associated with an elevated risk for long-term care placement within the 36-month follow-up period. Participants using a day-care service two or more times/week had significantly higher relative hazard ratios than participants not using such a service. CONCLUSION: The results highlight the need for effective measures to reduce the long-term care placement of day-care service users. Policy makers and practitioners must consider implementing multidimensional support programs to reduce the caregivers' willingness to consider long-term care placement.

[Investigation of whether depressive status contributes to mortality and hospitalization in community-dwelling dependent older people].

AIM: In our aging society, the number of community-dwelling dependent elderly people is increasing. Many studies have shown that depression influences the health of older persons. In the present study, we examined whether depressive status is associated with mortality and hospitalization in community-dwelling dependent older people during a 3-year follow-up period. METHODS: This study was a prospective cohort analysis of 1,409 community-dwelling disabled elderly (489 men, 920 women; average age 80.1, the Nagoya Longitudinal Study for Frail Elderly). Data included demographic characteristics, basic activities of daily living (ADL) scores, comorbidity, and depressive status as assessed by the short version of the Geriatric Depression Scale (GDS-15) at baseline. The participants were considered to have depression or severe depression if their GDS-15 score was 6-10 or above 10, respectively. The Cox proportional hazard model and the Kaplan-Meier method were used to assess any association with depressive status at baseline with mortality or hospitalization during a 3-year period. RESULTS: During a 3-year observation, 284 participants died (53 at home, 231 at hospital), and 576 were admitted to hospitals. Univariate analysis revealed that the depressive status of participants was associated with mortality and hospitalization during a 3-year follow up. However, multivariate models used to adjust for potential confounders including gender, age, ADL status, and comorbidity, did not show any association between depressive status and mortality and hospitalization. CONCLUSIONS: Depressive status among community-dwelling disabled elderly was not associated with mortality or hospitalization in the present series.

Impact of caregiver burden on adverse health outcomes in community-dwelling dependent older care recipients.

OBJECTIVE: To determine whether caregiver burden is associated with subsequent all-cause mortality or hospitalization among dependent community-dwelling older care recipients. METHODS: A prospective cohort study of 1,067 pairs of community-dwelling 65-year-old or older care recipients and their informal caregivers was conducted. The 1,067 pairs completed the baseline assessment including caregiver burden assessed by the Zarit Burden Interview and a 3-year follow-up for all-cause mortality and hospitalization. RESULTS: During the 3-year follow-up, 268 recipients died and 455 were admitted to hospitals. The multivariate Cox proportional hazards model revealed that the recipients with caregivers with a baseline ZBI score in the highest quartile were 1.54 and 1.51 times more likely to show increased risks of all-cause mortality and hospitalization, respectively, in comparison with those with caregivers in the lowest quartile after adjustment for potential confounders. The highest quartile of caregiver burden was associated with all-cause mortality and hospitalization within nonusers of respite services including day-care services, home-help services, and nursing-home respite stay services. No apparent association was observed within the users of these services except for day-care services, for which users showed a statistically significant association between the highest quartile and the risk of hospitalization. CONCLUSIONS: Heavy caregiver burden is associated with mortality and hospitalization among community-dwelling dependent older adults, even after adjusting for potential confounders. The reduction of caregiver burden and improvement of caregiver well-being may not only prevent the deterioration of caregiver health but also reduce adverse health outcomes for care recipients.

Impact of informal care levels on discontinuation of living at home in community-dwelling dependent elderly using various community-based services.

The aim of the study was to examine the effect of informal care levels on overall discontinuation of living at home, all-cause death, hospital admission, and long-term care placement for community-dwelling older people using various community-based services during a 3-year period. Prospective cohort study of 1582 community-dwelling disabled elderly and paired informal caregivers was conducted. Baseline data included the recipients and caregivers' demographic characteristics, comorbidities, informal care levels (sufficient, moderate, and insufficient care), which were evaluated by trained visiting nurses, and the level of formal community-based service use. Among 1582 participants, 97 died at home, 692 were admitted to hospitals, 318 died during their hospital stay, and 117 were institutionalized in long-term care facilities during 3 years of follow-up. A multivariate Cox hazard model demonstrated that when compared with a sufficient informal care level, an insufficient informal care level was associated with overall discontinuation of living at home, all-cause mortality, hospitalization, and institutionalization during 3 years of follow-up (hazard ratio: 1.65, 95% confidence interval: 1.15-2.36; 1.98, 1.17-3.34; 1.56, 1.04-2.35; 2.93, 1.25-6.86, respectively). The results suggested that informal caregiving is an important factor in the prevention of overall discontinuation of living at home in a population of disabled older people.

Information needs and sources of family caregivers of home elderly patients.

Meeting the information needs of family caregivers in a timely and appropriate way is a key concern of home care. The present study aimed to explore the following two areas: (a) the priority information needs and sources of family caregivers of home elderly patients and (b) the differences in information needs according to severity of dementia. The subjects were 475 family caregivers of home elderly patients residing in Nagoya city. Data was collected through questionnaires. Severity of dementia was evaluated according to the criteria of the public long-term care insurance policy (levels 0-5). The top 3 items they perceived as of most concern were dementia, first aid, and available public long-term care insurance services. A few respondents felt the need for information on public long-term care insurance services. Nearly half of the caregivers were interested in food and nutrition. The respondents were more likely to receive information from their care managers or physicians than any other source. Caregivers of elderly dependents with severe dementia reported a greater need for information on the spread of dementia, dementia-specific care, or the negative effects of dementia on family and neighborhood. Our results provide useful information on how family caregivers should be educated.

[Gender difference characteristics in the sociodemographic background of care recipients].

AIM: We compared gender differences in the sociodemographic characteristics of community-dwelling dependent elderly who use various community-based services under long-term care insurance programs, as well as in mortality, hospitalization, and institutionalization during a 3-year follow-up period. METHODS: We conducted a cross-sectional study using the baseline data of 1,875 care recipients from the Nagoya Longitudinal Study for Frail Elderly (NLS-FE), and a prospective study using their 3-year follow-up data. The data, which were collected at the patients' homes or from care-managing center records, included the clients' and caregivers' demographic characteristics, living arrangements, community-based services used, depression as assessed by the Geriatric Depression Scale (GDS-15), a rating for basic activities of daily living (ADL), and comorbidities. The data included, at 3-year follow-up, all-cause mortality, hospitalization, and institutionalization. RESULTS: Among 1,875 care recipients 66.3% were women. They had a higher rate of living alone (26.2% vs 14.6% in men), and a lower rate of receiving care by a spouse (22.1% vs. 73.6% of men). Although there were no differences in ADL levels or GDS-15 scores between genders, a higher Charlson comorbidity index, higher prevalence of cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and cancer were observed in the male care recipients. Kaplan-Meier analysis demonstrated that during the 3-year follow-up, higher mortality, hospitalization, and lower institutionalization rates were observed in men. CONCLUSION: We observed that two thirds of care recipients were women. Compared with male recipients, female recipients were more likely to live alone, and to be cared for by non-spouse caregivers. Lower mortality and hospitalization, but higher institutionalization, were observed in female recipients.

Depressive symptoms of informal caregivers are associated with those of community-dwelling dependent care recipients.

BACKGROUND: The relationship between care recipients' depressive symptoms and those of caregivers remains unknown. We evaluated the association between the depressive status of caregivers and that of community-dwelling disabled care recipients. METHODS: A prospective cohort study of 893 care recipients and paired caregivers was conducted. The care recipients were all eligible for a universal-coverage long-term care insurance program and their ages ranged from 65 to 104 years. They and their paired caregivers (age range 31-90 years) completed the 15-item Geriatric Depression Scale (GDS-15, score range: 0-15) assessment at baseline. The GDS-15 was used to measure the depression of caregivers and recipients with a threshold of <6/6+. The data included each care recipient's demographic characteristics, overall health status, basic activities of daily living, and comorbidities. The data also included the caregiver's demographic characteristics, including the caregiver's relationship to the recipient, and the caregiver's subjective burden as assessed by the Japanese version of the Zarit Burden Interview (ZBI). RESULTS: The mean GDS-15 scores of care recipients and caregivers were 6.7 points and 5.6 points, respectively. There was a positive correlation between the GDS-15 scores of caregivers and care recipients (r = 0.307, p<0.001). Multivariate logistic regression analysis adjusting for potential confounders including ZBI score indicated that the depressive symptoms of caregivers were associated with those whose care recipients were in the groups with moderate and high GDS-15 scores (OR: 1.97, 95% CI: 1.39-2.81, OR: 3.13, 95% CI: 1.87-5.24, respectively). CONCLUSION: Caregivers' depressive symptoms are associated with the depressive mood of the care recipients even after adjusting for confounders including caregiver burden.

Association between masticatory performance and anthropometric measurements and nutritional status in the elderly.

AIM: The association between chewing ability and physical constitution and nutritional status remains uncertain in the elderly. We examined the relationships between chewing ability and anthropometric measurements or nutritional status in the elderly. METHODS: A total of 200 subjects (78 men and 122 women; mean age +/- standard deviation, 76.6 +/- 7.1) were enrolled from geriatric clinical settings. Chewing ability was evaluated by color-changeable chewing gum. Bodyweight, body mass index, mid-upper-arm circumference (MAC), and triceps skinfold, grip strength, serum albumin, physical and cognitive functions, depressive status, and dental status were determined. RESULTS: Correlations were found between chewing ability and bodyweight, MAC, dental status, physical and cognitive functions, and depressive status after adjusting for age and sex. The concentrations of serum albumin were well-correlated with chewing ability and anthropometric measurements. Stepwise linear regression analyses revealed that the masticatory cycle, dental status, bodyweight and MAC are predictors of chewing ability, and that age, chewing ability, grip strength and sex are predictors of serum albumin concentrations. CONCLUSION: Chewing ability is associated with not only oral health status but also the physical constitution of the elderly. In addition, chewing ability may add to the regulation of the nutritional status in the elderly.

The longitudinal change in anthropometric measurements and the association with physical function decline in Japanese community-dwelling frail elderly.

Although anthropometric parameters have been extensively studied regarding their relationship to physical function status, the association between these parameters and the activity of daily living (ADL) function remains controversial. We investigated whether BMI or mid-upper arm circumference (AC) is an indication of variation in the physical functioning of the frail elderly. The present study was a prospective cohort analysis of 543 community-dwelling frail elderly. Data included the participants' demographic characteristics, basic ADL, comorbidity and anthropometric measurements at baseline and at 2-year follow-up. Logistic regression models were used to investigate the association between ADL status and anthropometric measurements during the study period. Among the 543 participants, 418 maintained or improved their ADL status, while 125 showed an ADL decline during the study period. Multivariate logistic regression analysis showed that BMI and AC levels or ADL status at baseline were not independent predictors of the loss of ADL function or the decline in these anthropometric measurements during the study period, respectively. However, the decline in BMI and AC levels and the loss of ADL function were associated with each other during the study period. There is an association between the negative changes in anthropometric measurements during the follow-up period and the decline in ADL function during a 2-year follow-up in community-dwelling frail elderly.

Raised homocysteine and low folate and vitamin B-12 concentrations predict cognitive decline in community-dwelling older Japanese adults.

BACKGROUND & AIMS: Recently, poor cognition and dementia have been associated with elevated homocysteine and low B vitamin concentrations. The aim of this study is to examine the association in community-dwelling older Japanese adults. METHODS: Ninety-nine subjects (71 women and 28 men; mean age 75 years) were eligible for analysis after exclusion of subjects with high serum creatinine concentrations (1.3mg/dl and over) and those taking vitamin supplements. Fasting blood samples were analyzed for plasma total homocysteine, serum folate, and serum vitamin B-12. Global cognitive function was assessed using the Mini-Mental State Examination (MMSE). RESULTS: Multiple regression analysis revealed that homocysteine concentrations were predicted by concentrations of vitamin B-12 (p<0.001), folate (p<0.005), and creatinine (p<0.001) and age (p<0.005). Scores on the MMSE were associated with concentrations of homocysteine, vitamin B-12, and folate. The association between folate or vitamin B-12 concentrations and MMSE scores remained significant after adjusting for homocysteine concentrations. Folate concentrations, but neither homocysteine nor vitamin B-12 concentrations, were significantly associated with serum albumin concentrations. CONCLUSIONS: Reduced folate and vitamin B-12 concentrations were independently associated with cognitive decline. The correlation between folate and albumin concentrations may imply that the reduction of folate in the Japanese older population is due to nutritional deficiency.

Influence of diabetes mellitus on caregiver burden in home care: a report based on the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE).

BACKGROUND: Because little attention has so far been paid to the impact of diabetes mellitus (DM) on caregiver burden in community settings, we sought to confirm the influence of DM on perceived caregiver burden among caregivers providing care to a home elderly person using data from the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE). METHODS: The NLS-FE is a large prospective study of 1875 community-dwelling elderly. A total of 1592 pairs of dependents and caregivers were included in the analysis. The data we used in this study included the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI), characteristics of caregivers and dependents, and caregiving situation. The pairs were sorted into one control and three DM groups: (i) no DM; (ii) DM taking no medications; (iii) DM taking oral medication only; and (iv) DM taking insulin. The differences in dependent and caregiver characteristics among the groups were assessed. RESULTS: Two hundred and twenty-eight dependents from the NLS-FE study had DM. Of these, 25% took no medication to treat it, 55% took oral medications only, and 20% used insulin. No statistical differences were found in age, gender or kinship among caregivers. No differences were found among the DM categories in levels of caregiver burden according to the J-ZBI, before and after adjusting for these baseline variables. CONCLUSIONS: Among the community-dwelling frail elderly, DM is not an independent predictor of caregiver burden.

Association between unmet needs for medication support and all-cause hospitalization in community-dwelling disabled elderly people.

OBJECTIVES: To clarify the association between unmet medication management need and 3-year mortality and hospitalization for community-dwelling older people with various levels of disabilities. DESIGN: Prospective cohort study (the Nagoya Longitudinal Study for Frail Elderly). SETTING: Community-based. PARTICIPANTS: One thousand seven hundred seventy-two community-dwelling elderly subjects (611 men, 1,161 women). MEASUREMENTS: Data included the clients' demographic characteristics, a rating for basic and instrumental activities of daily living (ADLs), number of prescribed medications and physician-diagnosed chronic diseases, medication adherence, ability to manage medication, and presence or absence of medication assistance. Cox proportional hazard models and the Kaplan-Meier method were used to assess the association between the medication management at baseline and mortality or hospitalization during a 3-year period. RESULTS: Of 1,772 participants, 681 reported no difficulty with self-medication management, and 1,091 experienced difficulty with self-medication. Of participants with difficulty with self-medication management, 929 had medication assistance, and 162 did not. During a 3-year follow up, 424 participants died, and 758 were admitted to hospitals. The baseline data demonstrated that participants not receiving medication assistance were younger and had better ADL status and fewer comorbidities. Multivariate Cox regression models adjusting for potential confounders showed that the lack of assistance in those who needed medication assistance was associated with hospitalization but not mortality during the study period. CONCLUSION: In community-dwelling disabled elderly people, lack of medication assistance in those needing medication support was associated with higher risk of hospitalization.