An Exploratory Study of the Overall Systemic and Oral Health Status in Older Patients with Alzheimer's Disease
Received: 10-Feb-2023 / Manuscript No. JADP-22-89274 / Editor assigned: 13-Feb-2023 / PreQC No. JADP-22-89274 (PQ) / Reviewed: 27-Feb-2023 / QC No. JADP-22-89274 / Revised: 06-Mar-2023 / Manuscript No. JADP-22-89274 (R) / Published Date: 13-Mar-2023 DOI: 10.4172/2161-0460.100564.
Abstract
Background: An exploratory study of the overall health conditions and physicochemical properties of saliva were performed in older patients with Alzheimer´s Disease (AD) who reside at long-term nursing homes. We also investigate sleep quality, functional capacity during the abilities of Activities of Daily Living (ADL), and mobility of these individuals.
Methods: We examine thirty-nine older adults with AD who resided at long-term private nursing homes. Oral and systemic health status was identified from medical-dental examinations and medical record database. Salivary parameters, including salivary flow rate, pH value, buffering capacity, and salivary cortisol levels (morning), were analyzed. Risk for Obstructive Sleep Apnea (OSA) and functional capacity during the Activities of Daily Living (ADL) were also assessed through specific questionnaires. An exploratory analysis was done, using descriptive and inferential statistics.
Results: The most of older patients were dentulous, showing residual dental root, periodontal diseases, and carie. The polypharmaceuticals did not substantially interfere on saliva production. No significant alterations in salivary flow and buffering capacity were detected. Risk of psychological-physical stress identified from salivary cortisol was controlled by medicines.
Conclusion: All older patients with high risk of OSA had cardiocirculatory disorders; additionally, the total and severe dependencies in ADL and mobility was strongly evidenced in institutionalized older patients with AD.
Keywords: Alzheimer disease; Oral health; Saliva; Sleep wake disorders; Obstructive sleep apnea
Introduction
Alzheimer ’s Disease (AD) is the most common type of pre-senile and senile dementia in older people, accounts for 50–75% of dementia cases. This neurodegenerative disorder is characterized by irreversible and progressive cognitive dysfunction, memory decline, disturbances of mood, and inability to recognize common objects, family members or friends (visual agnosia), to comprehend or formulate language (aphasia). These facts lead to loss of autonomy, daily functional impairment with associated severe neuropsychological symptoms (e.g., personality changes, delirium, and depression), immobility, severe weakness, and inanition [1-4].
Monitoring efforts to maintain the satisfactory general and oral health in these individuals have been still insufficient and limiting due to the shortage of specialized health professionals in service units, especially in nursing homes. Additionally, this disease becomes a significant financial burden on society, besides causing physical and psychological stress, social isolation, and financial difficulty to the family members. This dementia is considered a critical public health problem due to its high prevalence in worldwide [5]. Reports that the total healthcare costs for the treatment of AD have been estimated at $305 billion, increasing with to more than $1 trillion as the population ages [6].
The main neuropathological hallmarks of AD consist of extracellular fibrillar deposition of abundant Amyloid-β peptide (Aβ) senile plaques, neuropil threads (axonal and dendritic segments containing aggregated and hyperphosphorylated tau), and neurofibrillary helical tangles containing intraneuronal aggregates of hyperphosphorylated or misfolded tau proteins in brain regions. These lesions damage the central nervous system, causing neuronal death by apoptosis or necrosis by altering the plasticity of neurons and losses of neuropil and synaptic activities [2,3,6,8]. Likely, these alterations play a critical role in the cognitive impairment of this disease.
Various risk factors have been implicated in its pathogenesis, such as: Age, genetic factors (e.g.; mutations of the genes amyloid precursor protein, presenile 1 and 2, apolipoprotein E, and others), traumatic brain injury, associated co-morbidities (i.e.; cardiovascular diseases, congestive heart failure, obesity, hypercholesterolemia, immune system dysfunction, poorly controlled diabetes mellitus, and others), psychiatric factors (e.g.; depression, early stress), environmental factors (e.g.; exposure to metals as aluminium, copper, zinc; deficiencies of vitamin and calcium), mitochondrial dysfunction causing decline in cerebral metabolic rate, sedentary lifestyles (e.g.; alcohol use; lack of exercise and cognitive activity), and infections associated with gramnegative, anaerobic bacteria and viruses. [1-3,8].
Among the oral clinical manifestations in AD, some authors reported caries and periodontal disease, candidiasis, and hyposalivation. This last condition may provide irritation and inflammation of the oral mucosa or pathogen oral infections, besides dysarthria, dysgeusia, and dysphagia [1,3,9]. Furthermore, the salivary cortisol levels can identify psychological and physical stress, become a good biomarker to determine the real emotional conditions of older patients with AD, particularly the long-term nursing home residents [10]. It is still noteworthy that patients with DA and severe dysphagia are susceptible to develop aspiration pneumonia. According to Sato et al. (2014), the mortality from pneumonia is high and accounts for 70% of the causes of AD [10]. Given that, the use of assistive technologies in oral selfcare practices and routine exploratory clinical investigations must be recommended in health services to establish an appropriate planning and treatment, as well as to promote a better quality of life of this population [11].
Focusing in one of the sleep breathing disorders, the Obstructive Sleep Apnea (OSA) is one of the comorbidities that may aggravate the signs and symptoms of this neurodegenerative disease, increasing morbidity and mortality rates among people with AD [12]. The OSA causes a decrease of intracellular supply of O2, resulting in cellular hypoxia episodes and long-term tissue damages [10]. This fact can enhance the severity of AD and the intensity of preexistent comorbidities.
As AD progresses in severity, much effort has been devoted in mitigating the appearance of new comorbidities and improving the functional capacity during the Activities of Daily Living (ADL) through medical and dental approaches together, main at nursing homes.
Before outlining appropriate strategic plans for systemic and oral health care for institutionalized older patients with AD, it is important that the multi-professionals know the impact of this disease and its comorbidities on the patients’ daily living and understand its medical and dental implications. Certainly, these approaches could attenuate the enormous burden on society and public health due to the high costs associated with care and treatment of these dementia. Therefore, we perform an exploratory study of the overall health conditions and the physicochemical properties of saliva in institutionalized older patients with Alzheimer´s disease. We also investigate sleep quality, functional capacity during the abilities of ADL, and mobility of these individuals who reside at long-term nursing homes.
Methods
This study characterized the overall health conditions of institutionalized older patients with AD in the following aspects: Systemic disorders or diseases, pharmacological groups used by patients, general oral health, salivary parameter, sleep quality, functional capacity during the activities of daily living, and mobility. This investigation was approved by the Ethics Committees on Human Research of the Institute of Science and Technology of the São Paulo State University, IST-UNESP (CEPh/CAAE process number 82559818.3.0000.0077) and the Informed Consent Form (ICF) was signed by a legally responsible person.
Subjects
Thirty-nine older adults with Alzheimer Disease (AD), with agerange from 62 to 100 years old, were invited to participate in this study. These subjects showed varying degree of dementia and resided at long-term private nursing homes. The inclusion criteria were older patients who were diagnosed with AD, stages from mild to severe, by a neurologist using the International Classification of Diseases (ICD-10), Diagnostic and Statistical Manual of Mental Disorders (DSM-V), Mini- Mental State Examination (MMSE), and Clinical Dementia Rating scale (CDR). The exclusion criteria were when these residents refused to participate of the study or his/her legally responsible caregivers did not accept to sign the informed consent form (Figure 1).
Figure 1: Flowchart of study protocol.
Protocol of study
To understand the proposal methods, a flow diagram was done in order to illustrate the design of this exploratory study, investigating the overall health conditions, the salivary parameters, and the sleep quality in institutionalized older patients with AD.
Overall health conditions
The analysis of systemic health status was performed on each older patient with AD. Systemic disorders/diseases and pharmacological groups were identified from the medical record database and the information was only collected after ethical approval. In study, a novel protocol of screening intrabuccal clinical exam was created to verify the oral health status where the proposed indicators were number of teeth, Caries (Ca), Residual Dental Roots (RR), Periodontal Diseases (PD), total edentulous older patients, and older patients with needs of Oral Prosthetic Rehabilitation (OPR).
Analysis of saliva parameters
All subject´s preparation and salivary testing were accomplished from the methodology of Liu, et al [9]. Where were determined salivary flow rate (SFR; mL/min), pH value, buffering capacity (BC, pH value), and morning salivary cortisol levels (SC-AM, μg/dL) (Figure 2).
Figure 2: Protocol of saliva testing. Note: SFR: Salivary Flow Rate; BC: Buffering Capacity; SC-AM: morning salivary cortisol; (*) and (**): Recommended by the Salimetrics’ manufacturer.
Questionnaires application
The sleep quality was investigated through the application of the Epworth Sleepiness Scale (ESS) and STOP-BANG questionnaires, identifying subjective daytime levels of sleepiness and risk for Obstructive Sleep Apnea (OSA), respectively. These two methods were used in the studies [13-15]. The measure of independence in basic activities of daily living (BADL) and mobility were evaluated using the Modified Barthel Index (MBI), being in accordance with the studies [16,17]. These questionnaires were answered by caregivers and/or health professionals from nursing homes.
Statistical analysis
The results of oral and systemic health status, physicochemical properties of saliva, sleep quality, functional capacity in BADL, dependence degrees, and mobility in older patients with AD were submitted to an exploratory analysis. The descriptive statistics consisted of mean and standard deviation of these data. The inferential statistic was used to estimate the Confidence Interval (CI) for prevalence in the following aspects: Edentulous older patients, older patients with needs of oral prosthetic rehabilitation, older patients with excessive daytime sleepiness, and older patients with risk for OSA. Another inferential statistic was to compare the means between the sexes, using the t-Student test of independent samples in each one of the four variables in analysis. The level of significance was set at p ≤ 0.05.
Results
Overall health status
The Tables 1 and 2 refer all systemic disorders/diseases and pharmacological groups found in older patients with AD. The demographic data showed 35.90% (14/39) older men with 68 to 94 (79.29 ± 8.39) years old and 64.10% (25/39) older women with 65 to 100 (83.24 ± 9.51) years old. Concerning the age ranges, we found the following data: 12.82% (5/39) to 60-70 years old, 28.20% (11/39) to 71- 80 years old, 33.34% (13/39) to 81-90 years old, and 25.64% (10/39) were 91-100 years old (Tables 1 and 2).
| Systemic disorders or diseases | Pharmacological groups | ||
|---|---|---|---|
| Mental disorders (MD) | Neurocognitive disorder | 1.1 Alzheimer's disease (AD) | 1.1.1 N-methyl-D-aspartate (NMDA) receptor antagonist (memantine); (A) |
| 1.1.2 Acetyl-cholinesterase inhibitors. AChEIs (donepezil. galantamine and rivastigmine); (B) | |||
| Other mental disorders (oMD) | 1.2 Anxiety and mood disorders | 1.2.1 Anxiolytic. anticonvulsant. psychotropic (benzodiazepines; valproic acid); (C) | |
| 1.3 Depression | 1.3.1 Antidepressants (tricyclic antidepressants; selective serotonin reuptake inhibitors); (D) | ||
| 1.4 Convulsive seizures | 1.4.1 Barbiturates; (E) | ||
| 1.5 Psychotic disorders (delusions and/or delirium) | 1.5.1 Antipsychotics; (F) | ||
| Sleep disorders (SD) | 2.1 Insomnia | 2.1.1 Sleep inducer. (G) | |
| Cardiocirculatory disorders (CcD) | 3.1 Coronary artery disease; Stroke; Thromboembolism | 3.1.1 Antithrombotics (antiplatelet agents; anticoagulants - coagulation cascade); (H) | |
| 3.2 Cardiac arrhythmia | 3.2.1 Antiarrhythmics; (I) | ||
| 3.3 Systemic Arterial Hypertension (SAH); Congestive Heart Failure (H) | 3.3.1 Antihypertensive (angiotensin-II receptor antagonists; calcium channels blocker; beta-1 selective blocker; angiotensin-converting enzyme inhibitors); (J) | ||
| 3.4 Edema and SAH | 3.4.1 Diuretics; (L) | ||
| 3.5 Chronic vascular diseases (varicose veins) | 3.5.1 Venoactive; (M) | ||
| 3.6 Hyperlipidemia | 3.6.1 Antilipemic; (N) | ||
| Endocrine disorders (ED) | 4.1 Diabetes mellitus - Type 2 | 4.1.1 Antidiabetics; (O) | |
| 4.2 Hyperlipidemia | 4.2.1 Thyroid hormone; (P) | ||
| Rheumatic diseases (RD) | 5.1 Inflammatory rheumatic disease (Gout) | 5.1.1 Anti-hyperuricemic; antigotous; (Q) | |
| Neoplasias (N) | 6.1 Post-treatment of breast carcinoma | 6.1.1 Antineoplastic; (R) | |
| Non-neoplastic proliferative lesions (nNPL) | 7.1 Benign prostatic hyperplasia | 7.1.1 Selective adrenergic alpha-1-blocker; (S) | |
| Gastrointestinal disorder (GD) | 8.1 Gastric reflux; Gastritis; and Esophagitis | 8.1.1 H2 receptor antagonists; hydrogen-potassium pump inhibitor; (T) | |
Note: These findings were obtained from of the medical record database of the health section at nursing homes.
Table 1: Overview of systemic disorders or diseases and pharmacological groups found in institutionalized older patients with AD (n=39).
| Gender | S. no | Age (years) | MD | SD | CcD | ED | RD | N | nNPL | GD | S Medicines per subjects | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| AD | oMD | |||||||||||||||||||||
| A | B | C | D | E | F | G | H | I | J | L | M | N | O | P | Q | R | S | T | ||||
| Men | 1 | 88 | 1 | 2 | 1 | 1 | 5 | |||||||||||||||
| 2 | 85 | 1 | 1 | 1 | 1 | 1 | 5 | |||||||||||||||
| 3 | 68 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | |||||||||||||
| 4 | 68 | 1 | 1 | 2 | 1 | 1 | 1 | 7 | ||||||||||||||
| 5 | 68 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 8 | ||||||||||||
| 6 | 82 | 1 | 1 | 1 | 1 | 2 | 1 | 7 | ||||||||||||||
| 7 | 83 | 1 | 1 | 1 | 2 | 1 | 1 | 1 | 8 | |||||||||||||
| 8 | 74 | 1 | 1 | 2 | 1 | 5 | ||||||||||||||||
| 9 | 94 | 1 | 1 | 1 | 1 | 4 | ||||||||||||||||
| 10 | 76 | 1 | 1 | |||||||||||||||||||
| 11 | 89 | 1 | 1 | 1 | 3 | |||||||||||||||||
| 12 | 73 | 1 | 2 | 2 | 1 | 1 | 1 | 8 | ||||||||||||||
| 13 | 83 | 1 | 2 | 1 | 1 | 1 | 6 | |||||||||||||||
| 14 | 79 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 8 | ||||||||||||
| Women | 1 | 84 | 1 | 1 | 1 | 1 | 4 | |||||||||||||||
| 2 | 84 | 1 | 1 | 1 | 1 | 2 | 1 | 1 | 1 | 9 | ||||||||||||
| 3 | 76 | 1 | 1 | 2 | 1 | 1 | 6 | |||||||||||||||
| 4 | 100 | 0 | ||||||||||||||||||||
| 5 | 82 | 1 | 1 | 1 | 1 | 1 | 1 | 6 | ||||||||||||||
| 6 | 67 | 1 | 1 | 2 | ||||||||||||||||||
| 7 | 78 | 1 | 1 | 1 | 1 | 4 | ||||||||||||||||
| 8 | 91 | 1 | 1 | 2 | ||||||||||||||||||
| 9 | 90 | 1 | 1 | 2 | 1 | 1 | 6 | |||||||||||||||
| 10 | 83 | 1 | 1 | 1 | 3 | |||||||||||||||||
| 11 | 93 | 1 | 1 | 2 | ||||||||||||||||||
| 12 | 90 | 1 | 1 | |||||||||||||||||||
| 13 | 62 | 1 | 1 | 2 | ||||||||||||||||||
| 14 | 77 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 8 | ||||||||||||
| 15 | 93 | 1 | 1 | 2 | ||||||||||||||||||
| 16 | 78 | 1 | 1 | 2 | 4 | |||||||||||||||||
| 17 | 89 | 1 | 1 | 2 | 1 | 1 | 6 | |||||||||||||||
| 18 | 76 | 1 | 1 | 1 | 3 | |||||||||||||||||
| 19 | 94 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 7 | |||||||||||||
| 20 | 82 | 1 | 1 | 1 | 3 | |||||||||||||||||
| 21 | 91 | 1 | 1 | 1 | 1 | 1 | 1 | 6 | ||||||||||||||
| 22 | 81 | 1 | 1 | 2 | ||||||||||||||||||
| 23 | 73 | 1 | 2 | 1 | 1 | 5 | ||||||||||||||||
| 24 | 71 | 1 | 2 | 3 | 1 | 1 | 8 | |||||||||||||||
| 25 | 96 | 1 | 1 | |||||||||||||||||||
| ∑Medicines | 16 | 19 | 8 | 16 | 2 | 24 | 12 | 2 | 29 | 6 | 5 | 9 | 9 | 11 | ||||||||
| 2 | 63 | 20 | 1 | 1 | 3 | 9 | ||||||||||||||||
Note: These findings were obtained from of the medical record database of the health section at nursing-homes. AD: Alzheimer Disease; MD: mental disorders; oMD: other Mental Disorders; SD: Sleep Disorders; CcD: Cardiocirculatory Disorders; ED: Endocrine Disorders; RD: Rheumatic disease; N: Neoplasia; nNPL: non-Neoplastic Proliferative Lesion; GD. Gastrointestinal Disorders.
Table 2: Primary and secondary systemic disorders/diseases related to the pharmacological groups found in each older patient with AD. according to the sex.
We consider AD as a primary systemic disorder/disease; whereas, the other comorbidities were identified as secondary systemic disorders/diseases. Our results showed as comorbidities: Other Mental Disorder (oMD; 82.05%; 32/39), cardiocirculatory disorder (69.23%; 27/39), endocrine disorder (43.59%; 17/39), gastrointestinal disorder (23.07%; 9/39), non-neoplastic proliferative lesion (7.69%; 3/39), sleep disorder (5.12%; 2/39), rheumatic disease (2.56%; 1/39), and neoplasia (2.56%; 1/39). The mean of secondary comorbidities (n=8) was of 2.36 (± 1.22) per subject with AD, being 3 (± 0.96) and 2 (± 1.22) in men and in women, respectively. There was a statistically significant difference between the sexes (t=2.63; gl=37; p=0.012 <0.05).
About the pharmacological therapies taken by the older patients (n=39), the types of drugs more used to treat the main systemic disorders or diseases were: 35 specific drugs to AD (28 patients); 29 antihypertensives (21 patients), 12 antithrombotic agent (10 patients), and 9 antilipemic agent (9 patients) to cardiocirculatory diseases; 24 antipsychotics (20 patients), 16 antidepressants (14 patients) and 8 benzodiazepines/valproic acid (7 patients) to oMD; and 9 antidiabetics drugs (9 patients) and 11 thyroid hormone (11 patients) to endocrine disorders. The mean of used drugs was of 4.72 (± 2.49) per patient, being 5.86 (± 2.14) in men and 4.08 (± 2.48) in women. There was a statistically significant difference between the sexes (t=2.25; gl=37; p=0.030 <0.05). In this study, the prevalence of polypharmacy (use of 5 or more medications) was of 53.85% (21/39 patients).
In the intrabuccal assessment, 17.94% (7/39) subjects showed satisfactory oral health, with any need of dental clinical procedures. Regarding the number of teeth, 22 subjects with AD had teeth, showing an average of 9.23 (± 9.83) teeth/subject. The mean of teeth/subject were 9.93 (± 11.17) and 8.84 (± 9.22) in men and in women, respectively. No statistically significant difference was found between the sexes (t=0.33; gl=37; p=0.745>0.05).
About oral lesions, 36.36% (8/22), 50% (11/22), and 50% (11/22) patients had caries, residual dental roots, and PD, respectively. Moreover, 17 subjects were full edentulous in the upper and lower arch, showing a prevalence of 43.59% [CI: (95%): 27.81 to 60.38%]. Among them, 23.52% edentulous patients (4/17; older men: patients 5, 12, and 13; older women: patient 19) had appropriate total dental prosthesis (denture) in the upper and/or lower arches; therefore, no further oral rehabilitation procedures were recommended. Finally, 48.72% (19/39) older patients [IC (95%): 32.42% a 65.21%] needed oral rehabilitation, especially dental prosthesis (Table 3).
| Gender | Patients | Age (years) | Number of teeth | Dentate older patients | total edentulous older patients | Older patients with needs of OPR | ||
|---|---|---|---|---|---|---|---|---|
| Ca | RR | PD | ||||||
| Men | 1 | 88 | 21 | 🞻 | 🞻 | |||
| 2 | 85 | 0 | ● | ■ | ||||
| 3 | 68 | 23 | 🞻 | 🞻 | ||||
| 4 | 68 | 20 | 🞻 | 🞻 | 🞻 | |||
| 5 | 68 | 0 | ● | |||||
| 6 | 82 | 23 | 🞻 | 🞻 | ■ | |||
| 7 | 83 | 16 | 🞻 | |||||
| 8 | 74 | 0 | ● | ■ | ||||
| 9 | 94 | 8 | ■ | |||||
| 10 | 76 | 0 | ● | ■ | ||||
| 11 | 89 | 0 | ● | ■ | ||||
| 12 | 73 | 0 | ● | |||||
| 13 | 83 | 0 | ● | |||||
| 14 | 79 | 28 | ||||||
| Women | 1 | 84 | 11 | 🞻 | ||||
| 2 | 84 | 21 | 🞻 | 🞻 | ||||
| 3 | 76 | 0 | ● | ■ | ||||
| 4 | 100 | 18 | 🞻 | 🞻 | 🞻 | |||
| 5 | 82 | 8 | 🞻 | 🞻 | ■ | |||
| 6 | 67 | 19 | 🞻 | |||||
| 7 | 78 | 11 | 🞻 | |||||
| 8 | 91 | 7 | 🞻 | 🞻 | 🞻 | ■ | ||
| 9 | 90 | 0 | ● | ■ | ||||
| 10 | 83 | 0 | ● | ■ | ||||
| 11 | 93 | 0 | ● | ■ | ||||
| 12 | 90 | 0 | ● | ■ | ||||
| 13 | 62 | 3 | 🞻 | ■ | ||||
| 14 | 77 | 22 | 🞻 | 🞻 | ||||
| 15 | 93 | 0 | ● | ■ | ||||
| 16 | 78 | 27 | ||||||
| 17 | 89 | 0 | ● | ■ | ||||
| 18 | 76 | 13 | ■ | |||||
| 19 | 94 | 0 | ● | |||||
| 20 | 82 | 0 | ● | ■ | ||||
| 21 | 91 | 9 | 🞻 | |||||
| 22 | 81 | 8 | ||||||
| 23 | 73 | 20 | 🞻 | 🞻 | ||||
| 24 | 71 | 24 | 🞻 | |||||
| 25 | 96 | 0 | ● | ■ | ||||
Note: Ca: caries; RR: Residual dental roots; PD: Periodontal Diseases; OPR: Oral Prosthetic Rehabilitation; (á) Presence of Ca. RR and PD; empty space: Absence of oral lesions; dentate older patients and no needs of OPR; (●) total edentulous older patients; (■) needs of OPR.
Table 3: Overall oral health status in older patients with AD. according to the sex.
Salivary parameters
We evaluated salivary flow rate (SFR; mL/min) in 37 patients; and pH value, Buffering Capacity (BC, pH value), and morning salivary cortisol (SC-AM; μg/dL) in 34 patients. Two patients were excluded by death and insufficient collection of saliva samples to analysis because of hyposalivation associated with highly viscous saliva. The SFR testing showed 25 (67,56%), 7 (18.91%), and 5 (13.51%) patients with normal flow, reduced flow, and hyposalivation, respectively. The mean of SFR per individual was of 0.45 mL/min (± 0.43). Regarding the sexes, the mean of SFR was of 0.52 mL/ min (± 0.39) in men and 0.42 mL/min (± 0.51) in women, with no statistically significant difference (t=0.67; gl=35; p=0.550>0.05).
Regarding the salivary pH, 25 (64.10%) and 9 (23.08%) patients showed normal and high values, respectively; and the mean was of 7.36 (± 0.58). The BC testing showed 19 (55.88%) patients with normal values, 10 (29.41%) patients with limit value, and 5 (14.70%) patients with low values. The mean of BC was of 5.92 (± 1.28) in men and 5.11 (± 0.76) in women (t=0.50; gl=31; p=0.622>0.05). Thus, no significant difference was found between the sexes.
The SC-AM testing showed 32 patients with normal levels and 2 patients with low and high levels. The mean of SC-AM level was of 0.41 μg / dL (± 0.16) per individual, being 0.38 μg/dL (± 0.18) in men and 0.42 μg/dL (± 0.16) in women. No statistical difference was found between the sexes (t=0.68; gl=32; p=0.504>0.05) (Table 4).
| Gender | Patients | Age (year) | SFR | pH value | BC | SC-AM | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Men | 1 | 88 | 0.580 | N | 7.971 | 🠅 | 6.633 | N | 0.411 | N |
| 2 | 85 | 1.000 | N | 7.490 | N | 4.890 | ▲ | 0.331 | N | |
| 3 | 68 | 2.000 | N | 8.339 | 🠅 | 6.760 | N | 0.617 | N | |
| 4 | 68 | 0.300 | N | 7.794 | N | 6.877 | N | 0.213 | N | |
| 5 | 68 | (†) | (†) | (†) | (†) | |||||
| 6 | 82 | 0.290 | N | 8.600 | 🠅 | 5.622 | N | 0.622 | N | |
| 7 | 83 | 0.280 | N | 7.345 | N | 4.992 | ▲ | 0.190 | N | |
| 8 | 74 | 0.340 | N | 7.395 | N | 6.144 | N | 0.583 | N | |
| 9 | 94 | 0.240 | 🠇 | 7.325 | N | 6.010 | N | 0.270 | N | |
| 10 | 76 | 0.380 | N | 7.614 | N | 3.323 | 🠇 | 0.440 | N | |
| 11 | 89 | 0.270 | N | 7.823 | 🠅 | 4.151 | ▲ | 0.087 | 🠇 | |
| 12 | 73 | 0.260 | N | 7.022 | N | 3.100 | 🠇 | 0.254 | N | |
| 13 | 83 | (🞵🞵) | (🞵🞵) | (🞵🞵) | (🞵🞵) | |||||
| 14 | 79 | 0.300 | N | 6.788 | N | 5.000 | ▲ | 0.568 | N | |
| Women | 1 | 84 | 0.300 | N | 7.300 | N | 4.972 | ▲ | 0.435 | N |
| 2 | 84 | 0.300 | N | 6.740 | N | 3.567 | 🠇 | 0.430 | N | |
| 3 | 76 | 0.320 | N | 7.396 | N | 4.436 | ▲ | 0.352 | N | |
| 4 | 100 | 0.180 | 🠇 | 6.650 | N | 3.765 | 🠇 | 0.862 | 🠅 | |
| 5 | 82 | 0.220 | 🠇 | 7.714 | N | 5.786 | N | 0.350 | N | |
| 6 | 67 | 0.060 | ● | (🞵) | (🞵) | (🞵) | ||||
| 7 | 78 | 1.640 | N | 7.931 | 🠅 | 5.614 | N | 0.352 | N | |
| 8 | 91 | 0.440 | N | 6.491 | N | 6.012 | N | 0.224 | N | |
| 9 | 90 | 0.080 | ● | (🞵) | (🞵) | (🞵) | ||||
| 10 | 83 | 0.190 | 🠇 | 6.854 | N | 5.955 | N | 0.529 | N | |
| 11 | 93 | 0.760 | N | 7.935 | 🠅 | 5.857 | N | 0.278 | N | |
| 12 | 90 | 0.380 | N | 7.081 | N | 3.707 | 🠇 | 0.325 | N | |
| 13 | 62 | 0.230 | 🠇 | 6.129 | N | 4.636 | ▲ | 0.393 | N | |
| 14 | 77 | 0.200 | ” | 7.508 | N | 4.976 | ▲ | 0.361 | N | |
| 15 | 93 | 0.260 | N | 6.445 | N | 4.474 | ▲ | 0.240 | N | |
| 16 | 78 | 1.100 | N | 7.593 | N | 6.165 | N | 0.622 | N | |
| 17 | 89 | 0.250 | N | 8.091 | 🠅 | 5.805 | N | 0.550 | N | |
| 18 | 76 | 0.060 | ● | (🞵) | (🞵) | (🞵) | ||||
| 19 | 94 | 0.230 | 🠇 | 7.820 | 🠅 | 5.346 | N | 0.501 | N | |
| 20 | 82 | 0.620 | N | 7.125 | N | 5.273 | N | 0.218 | N | |
| 21 | 91 | 1.200 | N | 7.876 | 🠅 | 4.862 | ▲ | 0.631 | N | |
| 22 | 81 | 0.600 | N | 6.901 | N | 5.161 | N | 0.377 | N | |
| 23 | 73 | 0.060 | ● | 6.742 | N | 5.630 | N | 0.552 | N | |
| 24 | 71 | 0.090 | ● | 6.732 | N | 5.380 | N | 0.394 | N | |
| 25 | 96 | 0.620 | N | 7.721 | N | 5.146 | N | 0.319 | N | |
Note: SFR: Salivary Flow Rate; BC: Buffering Capacity; SC-AM: morning Salivary Cortisol; (N): Normal values or levels; (🠇 ): Reduced or low value; (▲): Limit value; (🠅): High value; (●): Hyposalivation; (†): Death; (🞵) Insufficient saliva sample; (🞵🞵) difficulty to collect saliva because of its high viscosity and hyposalivation; SFR (mL/min): Normal flow (≥ 0.3), reduces or low flow (>0.1;<0.3), and hyposalivation/xerostomia condition (≤ 0.1); pH value: Normal value (N;5.3 to 7.8), low value (<5.3), and high value (>7.8); BC: Normal value (5.1 to 7.0), limit value (4.0 to 5.0), and low value (< 4.0); and SC-AM (above 50 years old): Normal level range for men (0.112 a 0.812), low level for men (<1.112), and high level for men (>0.812); and normal level range for women (0.149 a 0.739), low level for women (<1.149), and high level for women (>0.739).
Table 4: Results of the saliva testing in subjects with AD. according to the sex.
Questionnaire applications
The results of sleep quality, functional capacity to daily personal self-cares and mobility are demonstrated (Tables 5 and 6).
| Patients | Ages (year) | ESS | STOP-BANG | |||
|---|---|---|---|---|---|---|
| Scores ∑1-8 | Scores ∑1-8 | |||||
| Men | 1 | 88 | 7 | 3 | 🞻 | |
| 2 | 85 | 24 | 🞻 | 5 | 🞻 | |
| 3 | 68 | 24 | 🞻 | 5 | 🞻 | |
| 4 | 68 | 11 | 🞻 | 4 | 🞻 | |
| 5 | 68 | 8 | 4 | 🞻 | ||
| 6 | 82 | 24 | 🞻 | 5 | 🞻 | |
| 7 | 83 | 21 | 🞻 | 4 | 🞻 | |
| 8 | 74 | 24 | 🞻 | 4 | 🞻 | |
| 9 | 94 | 5 | 5 | 🞻 | ||
| 10 | 76 | 18 | 🞻 | 2 | ||
| 11 | 89 | 24 | 🞻 | 5 | 🞻 | |
| 12 | 73 | 5 | 5 | 🞻 | ||
| 13 | 83 | 3 | 2 | |||
| 14 | 79 | 18 | 🞻 | 5 | 🞻 | |
| Women | 1 | 84 | 5 | 1 | ||
| 2 | 84 | 17 | 🞻 | 2 | ||
| 3 | 76 | 16 | 🞻 | 1 | ||
| 4 | 100 | 24 | 🞻 | 1 | ||
| 5 | 82 | 13 | 🞻 | 2 | ||
| 6 | 67 | 24 | 🞻 | 3 | 🞻 | |
| 7 | 78 | 5 | 3 | 🞻 | ||
| 8 | 91 | 18 | 🞻 | 2 | ||
| 9 | 90 | 8 | 2 | |||
| 10 | 83 | 3 | 1 | |||
| 11 | 93 | 5 | 2 | |||
| 12 | 90 | 7 | 2 | |||
| 13 | 65 | 19 | 🞻 | 1 | ||
| 14 | 77 | 3 | 1 | |||
| 15 | 93 | 14 | 🞻 | 2 | ||
| 16 | 78 | 6 | 4 | 🞻 | ||
| 17 | 89 | 20 | 🞻 | 2 | ||
| 18 | 76 | 7 | 2 | |||
| 19 | 94 | 8 | 2 | |||
| 20 | 82 | 15 | 🞻 | 1 | ||
| 21 | 91 | 23 | 🞻 | 3 | 🞻 | |
| 22 | 81 | 2 | 1 | |||
| 23 | 73 | 6 | 2 | |||
| 24 | 71 | 11 | 🞻 | 2 | ||
| 25 | 96 | 6 | 2 | |||
Note: (🞻) Risk; (empty space) no risk; ESS: Epworth Sleepiness Scale. value ≥ 10 (excessive and disordered daytime sleepiness and high risk for OSA: Obstructive Sleep Apnea; STOP-BANG: Valor ≥ 3 (great risk for OSA).
Table 5: Results of the sleep quality in older patients with AD, according to the sex.
| Patients | Age (years) | Score of items | ∑1-10 Scores | Level of dependence in BADL | Mobility | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |||||||
| Men | 1 | 88 | 8 | 4 | 8 | 4 | 10 | 8 | 5 | 15 | 5 | 15 | 82 | 🞻🞻 | ⃝ | |
| 2 | 85 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 🞻🞻🞻🞻 | ● | ||
| 3 | 68 | 5 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 5 | 🞻🞻🞻🞻 | ● | ||
| 4 | 68 | 2 | 1 | 2 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 5 | 🞻🞻🞻🞻 | ● | ||
| 5 | 68 | 10 | 3 | 8 | 3 | 8 | 5 | 5 | 3 | 2 | 8 | 55 | 🞻🞻🞻 | ⃤ | ||
| 6 | 82 | 0 | 0 | 0 | ||||||||||||
