Oral Frailty

The concepts of physical frailty and sarcopenia are now accepted as important geriatric syndromes (1, 2, 3, 4). To enhance the recognition of these syndromes rapid screening tests, i.e., FRAIL and SARC-F, have been developed (5, 6, 7, 8, 9, 10, 11, 12). Recently, it has been suggested that “oral frailty” should be considered a geriatric syndrome and regularly screened for in older persons (13, 14). “Oral frailty” can be defined as difficulty in chewing associated with age related changes in swallowing (presbyphagia) (15, 16). The Eating Assessment Tool — 10 (EAT-10) has been demonstrated to be an excellent screening tool for Oral Frailty (17, 18).

Older persons with sarcopenia have been commonly shown to have swallowing disorders (19, 20, 21). Decreased tongue pressure is common in older persons and is associated with dysphagia and poor nutrition (22, 23, 24). Persons with poor oral health are more likely to have aspiration malnutrition, sarcopenia and physical frailty (25, 26). It needs to be recognized that while sarcopenic dysphagia can cause undernutrition it can also be caused by severe malnutrition such as cachexia (27). Poor grip strength, walking speed and head lifting strength, all of which are indicative of sarcopenia has been associated with dysphagia (28, 29). Similarly tongue strength is associated with grip strength (30). Using ultrasound, older persons with sarcopenic dysphagia had smaller muscle mass (31). Utilizing high resolution manometry sarcopenic patients had lower mesopharyngeal contractility associated with upper esophageal sphincter integrity (32). Cognitive frailty is not uncommon with aging (33, 34) and dementia associated with low calf circumference is associated with poor swallowing function (35). The bi-directional association between sarcopenia and presbyphagia is shown in Figure 1.

Figure 1.

The Causes of “Oral Frailty”

A consensus paper on the diagnosis of dysphagia being related to sarcopenia has been published (36). The criteria required generalized sarcopenia in a person with dysphagia and the demonstration of a decline in oropharyngeal muscle mass. Other causes for sarcopenia need to be excluded.

The treatment of oral frailty requires appropriate treatment for problems with teeth and dentures and treatment of xerostomia if present. In addition, treatment requires caloric support with a supplement containing between 1.0–1.5 g/k/day high quality protein (37). For those with sarcopenia resistance training of the tongue and other oropharyngeal muscles needs to be carried out by a speech therapist (38). In older persons with aspiration pneumonia this rehabilitation needs to be introduced early in hospitalization to reduce mortality (39). Upright positioning in bed and early activity are essential components of the management.

Oral frailty is an important geriatric syndrome (40). Its major causes are poor dental status and sarcopenia. Treatment including resistance exercise of muscles involved in swallowing, needs to be instituted as soon as it is recognized. Screening for oral frailty should include screening with the EAT-10 questionnaire (41) or the D-E-N-T-A-L Questionnaire (Table 1) (42).

Table 1.

D-E-N-T-A-L screening questionnaire (altered slightly from (42)) (3 or more points suggests oral frailty)

Dysphagia (3 points)/Dry mouth (1 point)

Eating difficulty (1 point)

No recent dental care (1 point)

Tooth or mouth pain (2 points)

Alterations or change in food selection (1 point)

Lesions, sores or lumps in mouth (2 points)

Disclosures

The author declares there are no conflicts