Ed i to r ia l

Nutrition, poverty and quality of life for the older adult

Over the past 20 years, research has been directed

at focusing on people’s own perceptions using

instruments to evaluate the impact of oral condi-

tions on quality of life. The concepts of health and

quality of life are elusive and abstract and while we

all know intuitively what they mean, they are

difficult to define. It is further complicated by the

abundance of terms used to describe health and its

constituent aspects, which are often ambiguous, ill-

defined and/or interchanged on a regular basis.

However, this has resulted in a change in our

thinking about what constitutes health and the

strategies necessary to produce it. For older adults

the Oral Health Impact profile (OHIP) and the

General Oral Health Assessment Index have been

used and have shown that the functional, social

and psychological impacts of oral conditions are

associated with an overall sense of well-being and

general health. Research by Gerdin and co-work-

ers, published in this issue, looked at the impact of

dry mouth conditions on oral health-related qual-

ity of life and they find that objective and subject-

ive dry mouth conditions constitute important

public health issues in frail old people. Other papers

cover related topics such as health issues associated

with tooth loss, the wearing of partial or complete

dentures and dietary intake which are more

directed towards obtaining information from the

patient’s perspective, which can be quite different

from those of the clinician carrying out the

assessment. It is interesting to note that the initial

decision that a denture would be needed was

generally difficult to accept and some of the prob-

lems experienced had not been previously dis-

cussed with the dentist.

A recent UK Government report, The Diet and

Nutritional Survey of People Aged 65 years and Over,

showed that generally older people were

adequately nourished. However, on further inves-

tigation the results showed that 60% of men and

women living in the community were overweight,

those living in residential or nursing homes were

more likely to be underweight (one in six), defici-

ent in folate (vitamin B9) or anaemic. They also

identified three particular groups who were more

likely to experience nutritional difficulties: not

surprisingly these are people on low incomes

(which includes many older adults), people living

in institutions and those without their own teeth.

They also state that the key nutritional issue for

frail older people, whether living in residential care

or in their own homes, is maintaining adequate

energy and nutrient intakes. It is suggested that

possible reasons for malnutrition in residential or

nursing homes include an underlying disease or

illness, loneliness or depression, monotonous me-

nus, unfamiliar foods, inappropriate textures and

inflexible meal times. Also mentioned are a lack of

snacks and nourishing drinks, no choice of portion

size, insufficient staff to help with feeding, with no

monitoring of food intake or weight loss. Much of

the food provided tends to be dull and bland, with a

reliance on convenience meals and a general lack

of fresh foods such as vegetables and fruit.

Improvements could be made by providing more

energy-rich foods, and alcohol in small amounts

can actually stimulate the appetite. Many elderly

people suffer from constipation and bowel prob-

lems because of reduced intestinal motility and this

can be helped with increased fibre intake from

cereals, fruit and vegetables. However, the key is an

adequate intake of fluid, which should amount to

six to eight glasses per day. Unfortunately there are

a small number of elderly who become obese and

this greatly increases the risk of diabetes, breathing

difficulties and reduced physical activity. With

these individuals, the diet has to be carefully

modified to reduce the level of sugars and fat, but

to increase the level of fruit and vegetables as well

as promotion of exercise. Difficulties can also arise

from inadequate prostheses, soft tissue lesions,

retained teeth that are painful or very mobile or

where there is a lack of saliva because of medica-

tion or treatment for systemic disease. All of these

can be addressed with varying degrees of success,

but in many instances a simple assessment of the

oral cavity does not occur, let alone an inspection

by a member of the dental team.

The Institute of Fiscal Studies has just produced a

report with the news that at least 10% of 50-year

olds today can expect to live in poverty after

retirement as many overestimated the amount of

income they would have in retirement let alone

considering retirement at an earlier age. Previously

the Pensions Commission had said that 38–43%

would struggle to make ends meet in retirement.

These are at odds with other studies that had

investigated the so called ‘pensions time bomb’ and

proposed that the next generation of pensioners

would have sufficient finance to support them-

selves. Much of this arises from the fact that many

people are overly optimistic about future invest-

� 2005 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2005; 22: 185–186 185

ment returns from the stock market or because

they intend to significantly increase their contri-

butions to their private pensions later in life. The

report also found that there was substantial

inequality in pension wealth. The 10% in the

wealthiest families have at least £1 million (1.5

million Euros) of family wealth, while the poorest

10% have <£110 000 (160 000 Euros). One of the

key concerns is that although these issues are

causing concern, those younger than 50 are saving

even less than their seniors.

In the United States, similar issues arise, with

24% of those aged 60 years and over living in

poverty, with elderly single women being at

greatest risk for obvious reasons. In a study, Pov-

erty Among Seniors published this year, nearly 47%

of people over 65 years were living in poverty if

social security payments were excluded. The per-

centage fell to 8.7% once government support was

taken into account lifting 13 million seniors above

the poverty line. However, as the number of older

people increases – it has been calculated that

America’s over 65 s will rise by 130% – the ability

of various bodies to maintain this level of fiscal

support may be reduced. A similar situation is

apparent in Canada where the poverty rate in the

elderly was reported as high as 19%. A very

extensive investigation into relative poverty rates

has been carried out by the Luxembourg Income

Study group, which compared rates of the total

population, children and the elderly in 30 devel-

oped countries. They were able to show that from

the mid-1980s to 2000, the relative poverty rates

for the elderly had fallen in the majority of

countries, but in a large minority the situation had

deteriorated, with a figure as high as 54% being

identified. This study clearly identifies that poverty

is still a major problem to be addressed in the

developed world as well as in developing and

underdeveloped countries. In Spain it has been

calculated that its population will have the highest

average age in the world by 2050 and currently

the government and local authorities fund 60% of

the cost of public residential care. However as the

numbers of elderly increases and with the increase

in life expectancy, funding becomes increasingly

difficult, with people expected to pay more

towards the cost of their care. Unfortunately many

are not in a position to do so and therefore

younger members of the population or other

members of the family are expected to make a

greater contribution.

Finally, in a recent study from the Medical

Research Council in the UK, it was found that

being richer and healthier provided no protection

against developing dementia. Researchers studied

13 000 people over 65 years from areas which had

different risks of cardiovascular disease. They found

that those in affluent areas, where there was better

health and longer life expectancy, were no less at

risk of developing senile dementia. They also

observed that, unlike other studies, the risk of

dementia did not tail off as a person got well into

there 80s. The incidence was one in 70 for indi-

viduals aged 70–79 years, but this increased dra-

matically to one in 15 for those over 85 years. It

was suggested that the problem of dementia was

more urgent than had previously been thought,

particularly as the relative cost of caring for these

individuals was significantly more than for stroke,

heart disease and cancer put together. The likeli-

hood was that dementia sufferers and their carers

were going to experience significant reductions in

their quality of life if extra funds were not made

available to provide special gadgets to protect

dementia sufferers, respite services for carers and

help with handling their finances.

‘‘In a country well governed, poverty is something to

be ashamed of. In a country badly governed, wealth

is something to be ashamed of.’’

Confucius (551–479 BC)

James P. Newton

Editor

� 2005 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2005; 22: 185–186

186 Editorial