Older individuals face various health risks, any of which may occur at different stages of life. These risks include conditions such as metabolic symptoms, other chronic diseases, dementia, and depression. Additionally, there is a risk of declining hearing, mobility, oral function, malnutrition, and frailty, ultimately increasing the risk of mortality. The goal is to delay disability by using effective assessment tools for early screening, diagnosis, and treatment before these issues arise, thus reducing future societal costs. Internationally, tools such as ICOPE are used for regular assessment and monitoring, a practice also followed in Taiwan. According to the World Health Organization's (WHO) Integrated ICOPE guidelines, Taiwan promotes functional assessments for older persons, aiming to identify risk factors for disability early. These assessments cover six aspects: cognitive function, mobility, nutrition, vision, hearing, and depression. Mobility, cognition, and vision abnormalities are more prevalent, accounting for 7.6%, 4.1%, and 3.3% of total service recipients, respectively. However, nutritional risk, which can lead to frailty, remains another concern.
Malnutrition may also be associated with other risk factors. For instance, malnutrition-induced frailty can lead to mobility impairment, which, in turn, may result in subsequent loss of social life, causing depression. Furthermore, prolonged bed rest due to frailty can lead to cognitive dysfunction and other significant late-stage manifestations. These factors might indirectly minimize the identification of malnutrition issues. Therefore, there is hope in research to identify the correlation between these factors and develop screening tools for early nutritional risk assessment.
In the community integrated screening program conducted by the Health Bureau of Tainan City, a variety of assessment tools are utilized, including nutritional (MNA-SF), frailty (SOF), psychological (AD8, GDS-15), physiological (grip strength, three highs, exercise volume), difficulty in chewing (chewing scale), and difficulty swallowing (EAT-10) tools. These are employed to investigate whether related oral functional assessment scales can effectively predict nutritional and frailty risks, serving as early assessment tools for risk factors to delay disability and mortality risks.
The results showed that the chewing scale can be directly applied in community screening as an effective tool to assess nutritional risk, while the nutritional scale (MNA-SF) and swallowing scale (EAT-10) can be applied in the community to assess frailty risk. This result is consistent with the study by Yoshida M.27 As age increases, decreased tongue pressure leads to subsequent swallowing difficulties and affects eating, which can lead to future malnutrition issues, increasing the risk of frailty and potentially increasing the risk of death.28–29 According to this analysis, the overall performance of the AUC is acceptable, and it is suggested that in the future, the chewing scale, swallowing scale, and MNA-SF could be used for preliminary screening in the community to detect early cases of malnutrition or frailty. This would facilitate subsequent interventions such as health education, nutritional counseling, or denture restoration treatment to improve oral function, effectively address chewing and swallowing issues, and avoid subsequent problems such as malnutrition, frailty, and ADL (activities of daily living) functional loss, achieving the goal of preventing and delaying disability.
Other research results show similar findings. Older individuals with missing teeth have limited chewing ability, which restricts food choices and can lead to malnutrition. Local governments provide denture subsidies in hopes of restoring oral function in older persons, which may improve their chewing and swallowing function, thereby altering nutritional status. Restoring bite function enhances food intake, improves nutrient absorption, and enhances activities of daily living (ADL) function.28,30 However, further monitoring and observation are needed to assess its effectiveness.31–34 Additionally, reducing the occurrence of frailty and the potential development of sarcopenia can also reduce the risk of subsequent mortality.35–37
The research results also indicate that depression in older persons is another significant factor. This study suggested that combining the Geriatric Depression Scale (GDS-15) with cases of chewing and swallowing difficulties can enhance the predictive power for nutritional and frailty risks. This approach could offer greater benefits for detecting community risk cases and facilitate the early identification of older persons at risk of depression.
In this study, the assessment of chewing and swallowing difficulties was not accompanied by RSST testing, which resulted in a lack of objective assessment tools. However, this approach is challenging to implement in community screening. Therefore, it is recommended that in the second phase of community integrated screening activities, during the review of reports and abnormal referral services, RSST assessment should be conducted for patients with swallowing difficulties, which can provide another objective assessment, enhance overall predictive power, and facilitate subsequent referral services for individuals.38–39
In this survey, cases with a history of the three highs (hypertension, hyperlipidemia, and diabetes) were also recorded. The research results indicate that patients with a history of the three highs have a lower nutritional risk than those without a history. Whether this is due to regular medical treatment, medication, or the use of nutritional supplements warrants further investigation.
Multiple scales were used for assessment in this study. However, the inability to obtain a definitive diagnosis of frailty may introduce bias, which is a major limitation.