Title: The impaCt Of dietary intake and Nutritional status in CarE homes on orAl heaLth: an EviDence synthesis (CONCEALED)
Funder: Public Health Agency, NI

Abstract: A large proportion of older adults who live in care homes suffer from malnutrition (> 25%) due to illness impacting on their appetite and ability to eat, chew or swallow. Many older adults entering care homes suffer from malnutrition having gradually lost their ability to self-care whilst living at home. Malnutrition has significant negative impacts on overall health as well as increasing the likelihood of developing infections, slowing healing and weakening muscles. Malnutrition is also a recognised risk factor for cognitive decline and significantly increases the risk of developing frailty, therefore much attention is paid to preventing and managing malnutrition in care homes. As a result, residents are provided with diets containing large amounts of added sugars in their meals and sugared nutritional supplements to drink. Many also consume medications in sugared solutions, to make them more palatable, and consume large amounts of sweetened drinks daily (including tea, coffee and juices). These nutritional plans are developed to ensure that care home residents consume adequate calories per day to prevent malnutrition. However, these practices are now having devastating impacts on residents’ oral health. Tooth decay (caries) and gum disease (periodontal disease) are becoming significant public health problems in older adults living in care homes. Today, more than half of these residents enter care having at least some of their own natural teeth. This situation highlights a significant shift as previously the majority did not have any natural teeth when entering care homes. Current nutritional practices used to manage malnutrition are now directly contributing to dental disease in care home residents as a consequence of the amount and frequency of sugars consumed. _x000D_ _x000D_ Caries leads to pain, discomfort and negatively impacts on oral function (chewing, eating, speaking, social interaction) and overall quality of life. This condition can result in emergency hospital care (A&E) or treatment under General anaesthetic to remove decayed teeth. Whilst caries and periodontal disease are preventable, little attention has been paid to examining the causative role of dietary intake on oral health within older adults in care homes._x000D_ _x000D_ To address this situation, we will:_x000D_ 1. Examine the existing scientific evidence to gather data on the role of dietary intake on dental disease in older people in care homes _x000D_ 2. Examine existing guidelines issued to care homes around dietary intake to determine if prevention of dental disease is included as a consideration _x000D_ 3. Discuss dietary intake and its role in dental disease with a range of stakeholders. We will ask care home staff to discuss how decisions are made about food and drink provided to residents (including financial factors) and if oral health is considered within these decisions. We will speak directly with older adults and family members to hear their views. _x000D_ _x000D_ We will then work with the group of stakeholders to provide positive recommendations to improve dietary intake, for older adults in care homes, which do not actively contribute to the development of oral disease. These recommendations will retain effectiveness in terms of preventing malnutrition and will be shared with patient groups, care homes and policymakers to ensure appropriate change is implemented. This work will benefit older adults living in care homes by helping to prevent future dental disease and further tooth loss.

Lay abstract: Background_x000D_ Care home residents are provided with diets rich in complex carbohydrates, including sugars, plus additional sugared medications and oral nutritional supplements to increase caloric intake and prevent malnutrition. However, this creates a significant problem for oral health as the causal link between sugar intake and dental caries is well established. Subsequently, the oral health of care home residents is significantly worse than their community living peers, with a very high prevalence of preventible dental disease. Currently little attention is paid to oral health prevention including critically examining the role of dietary intake and nutritional status on oral health in this population. _x000D_ _x000D_ Methods_x000D_ Three work streams (WS) are proposed:_x000D_ WS1 - Review of the scientific literature and current nutritional guidelines_x000D_ A systematic review will be conducted based on the focused question: In older patients living in care homes, what is the impact of dietary intake and nutritional status on oral health? This systematic review will be conducted and reported according to PRISMA guidelines. Studies will be included if participants are aged 60 years or over, dentate and reside in a care home. Studies which include information reporting on both dietary intake and nutritional status, and oral health outcomes will be included. The following will be searched: MEDLINE, CINAHL, Web of Science, EMBASE, WHO International Clinical Trials Registry Platform, UK Clinical Trials Gateway and ClinicalTrials.gov. A scoping review of UK dietary guidelines and policy documents provided to care homes will be completed. Documents from UK government organisations, charities and professional bodies will be considered. We will include documents that provide dietary/nutritional advice or recommendations which optimize dietary intake and nutritional status and include reference to oral health of older adults living in care homes. A narrative synthesis of all guidelines and recommendations will be undertaken. _x000D_ WS2-Qualitative interviews with key stakeholders_x000D_ Semi-structured interviews will be informed by a topic guide developed from WS1 evidence. We will recruit care home residents and family members, care home staff, healthcare professionals, researchers and experts. The semi structured interviews will explore the influences and drivers of dietary intake and nutritional status amongst older adults in care homes and the impact of dietary intake and nutritional status, on oral health amongst older adults in care homes. _x000D_ WS3-Synthesis of evidence and production of recommendations_x000D_ An online workshop will created with the research team and the key stakeholders. The workshop will include a presentation of findings from WS1 and WS2, discussion and a voting/ranking activity, where stakeholders prioritise recommendations by importance using the GRADE scale. The outcome of the workshop will be to reach consensus among the stakeholders on a series of recommendations to ensure that oral health is considered within dietary guidelines for older patients within care homes. _x000D_ _x000D_ Anticipated impact _x000D_ The research team will utilise existing networks to ensure that the outcomes of CONCEALED are widely disseminated to national and international academics, clinicians, patient groups and policymakers. We will work with dental policymakers, including NICE, to embed these recommedations within future policies developed for care homes.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: ORAL AND GASTROINTESTINAL