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A. Piau1,2,3, E. Campo2,3, B. Vellas1,4, F. Nourhashemi1,4


1. CHU de Toulouse, Gerontopôle, UPS, F-31400 Toulouse, France; 2. CNRS, LAAS, F-31400 Toulouse, France; 3. Univ de Toulouse, UT2J, LAAS, F-31100 Toulouse, France; 4. INSERM, UMR 1027, UPS, F-31400 Toulouse, France

Corresponding Author: A Piau, CHU de Toulouse, Gérontopole, Toulouse, France, piau.a@chu-toulouse.fr



Background: Medical imaging (e.g. PET-scan) and interventional (e.g. robotic surgery) technologies seem- to better fit the actual technological progress than do technologies for aging. The commercial market of aging care remains subdued since the introduction of low-technology devices decades ago (e.g. walker). Revisiting the evaluation and development methods of technologies to support healthy aging could help spread innovative technologies in this field. Methods and findings: In literature, a number of publications have been identified that addresses issues about technological devices that target the different needs of the older person. Nevertheless, a successful evaluation and development often remains unmet. This deficiency arises to a large extent from the confrontation of two worlds: that of technology which is not yet well versed in the field of healthy aging intervention, and the medical world which mainly uses the linear pharmaceutical drug development model. Many methods propose to tackle the global multidimensional evaluation of health technologies. However, they do not address the sequencing of the whole development and evaluation processes. In the present paper, we present a framework to help tackle the complexity of healthy aging technologies assessment and development. Conclusion: The evaluation and development methods usually adopted for healthy aging technologies are not appropriate and that all the collaborative multidisciplinary processes have to be revised.

Key words: Frailty, geriatrics, methodology, assessment, technologies.



Although the adoption of technologies by older persons is still at an early stage, it provides great expectations. Technologies could promote healthy aging (1), independent living, comfort and safety no matter where the persons live. In nursing homes, technologies are potentially able to improve health care efficiency and quality, and also to protect resident privacy. They also potentially bypass the financial, geographical and organizational barriers restricting access to specific services (2). However, a number of obstacles appear to limit their dissemination (3), in surprising proportions. Several reasons can be reported. They include: the lack of objective assessment of these solutions, – inadequate plan for implementing them into practice and, in most cases, no real proof of efficacy is observed. Revisiting the evaluation and development methods could help spread innovative technologies in this field.

The most documented studies are focused on telemedicine, telehealth and concern chronic illnesses (….). Limited evidence is available on the specific application of technologies dedicated to safety, autonomy or dependency prevention (4). Studies performed in this field rarely meet the usual standards of publications on health (4-8)  Many of the trials carried out are too small and the endpoints are often inconsistent. To a large extent, this could arise from the confrontation of two different worlds: that of technology and its business community, which are not yet well versed in the field of health intervention, and that of the medical world, which mainly uses the linear pharmaceutical drug development model (9, 10).
Many authors call for trials which go beyond evaluation of clinical effectiveness (12-15). The point that these methods have in common is that they stress the multidimensional and iterative aspects of the assessement, the need of combining quantitative and qualitative criteria, and the importance of taking into account the setting in which the technology is implemented. Nevertheless, they do not address the sequencing of the development and evaluation processes. Law and Wason suggest adaptive approaches to trial design in telehealth studies (15), in which new decisions can be made about the design or progress of the trial, once the trial is already underway.
In the present brief commented review of literature, we propose a framework to help tackle the complexity of aging technologies development and assessment.


Framework design

Issues to be taken into account

Technical aspects are not only a matter of facing pure technological locks. Information feedback from medical, economic and ethical dimensions must be taken into account at each stage. This is particularly true for the man-machine interface where the end user’s feedback is of primary importance. The medical dimension of evaluation concentrates on the efficacy and security of the technology on the subject. However, it also takes into account its value for public health, which concerns economic and societal dimensions. The difference between efficacy in a controlled context and efficacy in a real context, or effectiveness, seems to provide a greater impact – for technology, since it is highly dependent on the context in which it is deployed. The societal dimension assesses the global effect on society. Evaluation does not only concern a technical device but also its impact on overall management, as part of patient care. If alerts are automatically triggered from a technological device, the common global medical procedure should be well-known and practical implications should be assessed for all those who participate. Early involvement of all stakeholders is required to ensure technology implementation. To a very large extent, the legal and ethical dimensions cross other dimensions also, in particular medical (e.g. deontology) and societal (e.g. basic rights and responsibilities). As soon as the project specifications are decided, advice could be sought from a specialist on these issues and on the possible societal impact of technology. So, before designing a longitudinal evaluation, there is a preliminary question: does the use of the tool respect a legal framework (e.g. biomedical laws), or an ethical framework (e.g. ethics committee)? Should the device of interest be considered as a medical device? Is it necessary to perform the living lab evaluation in an accredited medical research environment? Furthermore, if technology generally carries low intrinsic medical risks, its use may lead to ethical consequences, e.g. geolocation in the case of a 3G-technology device. The economic dimension is a major asset in a highly restrictive economic environment. One of the barriers in implementing technology may be the lack of clear information as to who pays what and for whom.

Phases of development and evaluation

The process of technological development follows a series of phases that is less linear in comparison to that of drug development (see Box 1). We can distinguish a first phase, which corresponds to the phase of specifications. After the identification of a medical need (e.g. promoting healthy aging to prevent disability), the requirements are designed: identification of medical indicators (e.g. gait speed, weight), description of technological tools (e.g. gyroscope), and set up of a preliminary economic model. To better promote future implementation, this phase must involve all those involved in the evaluation, including end users. This could be considered as similar to the preclinical phase in the pharmaceutical process. The second phase corresponds to the technical “lab tests” of the initial solutions proposed. It validates the technical compliance of each “technological brick” in the laboratory with volunteer end users. This phase can be compared to phase I in drug development. The non-technical aspects will remain (Is the solution’s cost economically acceptable?  Are indicators of future adherence reported?). At the end of this phase, a first prototype is available. During the third phase, the prototype may be evaluated in a “living lab”, validating clinical and technical feasibility according to the various medical scenarios established. The environment as well as the end user’s attitude is new variables. Acceptability assessment allows iterative modifications before a wider dissemination. A comparison could be made here with phase II in drug development. A more extensive phase could be carried out. It would then   match the phase III of drug development. This step could include technology distribution on a larger scale within a real-life context, thus enabling to evaluate the medical and social services rendered and the overall economic impact. All the variables are taken into account: the material and organizational context, the disability or the disease. A real appraisal can be made of the actual uses of the device. This evaluation is rarely carried out for reasons relevant to cost and time. Lastly, on the model of the “residual risk” evaluation that is carried out in post-marketing studies associated with a pharmacovigilance study, a final phase could be designed. It would use “observer” devices to follow-up the technology application in “real life” as part of observational studies. At each phase, information and feedback loops can be applied to modify the technology, the organization, or even the target of the application. This would be impossible in drug development, where per-protocol changes are prohibited for methodological reasons. Table 1 presents relationships between development phases and evaluation dimensions.


Table 1 Relationships between development phases and evaluation dimensions

Table 1
Relationships between development phases and evaluation dimensions


Box 1

Characteristics of health technologies as compared to drug development

–    Technology evaluation is multidimensional and therefore multidisciplinary;
–    As technology implies a change in overall strategy, rather than the introduction of a new tool, outcomes are reported to be more dependent to the technology’s implementation context;
–    Technology evaluation is non-linear, more iterative, flexible, pragmatic;
–    Feedback loops are more effective in technology evaluation;
–    So-called positivist quantitative research strategies need to be combined with constructivist qualitative strategies for technology evaluation;
–    Less time is available for technology evaluation because of the rapidly changing market.



The evaluation and development methods usually adopted for aging technologies are not appropriate and the all-collaborative multidisciplinary processes have to be revised. Through this multidisciplinary and iterative approach, industrial partners can now be accompanied to develop relevant technologies in the field of healthy aging. It should be beneficial when setting up regional scalable platforms to develop and assess new devices both by academic and private partners. An example of this kind of platform is deployed by the Oregon Center for Aging and Technology at Oregon University. Today, the Toulouse Gérontopôle aims to achieve this approach in cooperation with industrial partners for the benefit of the aging population.


Author Contributions:  A.P. and E.C. were involved in the writing of the manuscript’s first draft and in the review of the subsequent drafts. B.V. and F.N. were involved in the conception of the article and reviewed the manuscript.

Sponsor’s Role: no funding sources.

Disclosure statement: No potential conflicts of interest were disclosed.



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M. Cafaro Gellar, D. Alter


New York City College of Technology, City University of New York, USA

Corresponding Author: Michelle Cafaro Gellar, 300 Jay St, Pearl 505, Brooklyn, NY 11209 USA, mgellar@citytech.cuny.edu


Objective: There are many factors that can affect appetite in the older adult. Physiological factors affecting appetite can include cardiovascular disease, pulmonary disease, renal disease, mental health issues, zoloft online and even side effects of medications. Decreased ability to ambulate due to joint issues or pain can also negatively impact an older adult’s appetite. But perhaps one significant factor that is commonly overlooked is the ill fitting partial or complete denture. According to the American Dental Association, there are approximately 57% of people ages 65 to 74 wearing some form of denture. Due to this large number of denture wearers, it becomes imperative that health care providers learn to incorporate an oral assessment into their plan of care each time an older adult patient is examined. This assessment can assist providers to identify and differentiate unintentional weight loss and loss of appetite as being either part of a disease process or as a symptom of denture issues. Only then can the overall health of the elderly be holistically viewed and treated. The aim of this paper is to provide a summary of published data expressing the nutritional issues that occur in the elderly due to either being edentulous or from wearing improperly fitting dentures.

Key words: Elderly, dentures, nutrition, assessment.



As the baby boomers of this nation and the American population on a whole are aging, certain significance must be applied to evaluating and ensuring proper nutrition and overall physical and mental health. According to the United States Census, there are over 44.7 million adults over the age of 65 as of 2013 (1). The general health of the elderly is negatively impacted by poor nutrition. As a person ages, the body’s ability to regulate many functions may become impaired (2). Appetite is controlled by several areas in the body: the gastrointestinal system, the brain, and hormones (3). There is a clear relationship between metabolism and appetite. When a person’s metabolism is affected, their appetite is also affected. Due to the inability to move easily, joint pain, or other disease processes, the elderly tend to be less active then when they were younger. This can lead to decreased energy needs which then leads to loss of appetite or anorexia. Any illness can cause a loss of appetite; however, there is not always a definitive cause of anorexia in the elderly, and it may indeed be the first symptom of an undiagnosed illness. Since loss of appetite can cause unintentional weight loss and malnutrition, it is imperative that this symptom not be dismissed as simply a normal part of the aging process. Loss of appetite and malnutrition can also be caused by cancers, cardiovascular disease, pulmonary disease, neurological disease, liver disease, renal failure, and even side effects of medications (3). Mental health issues such as depression, dementia, anxiety and grief may also lead to malnutrition. Factors such as decreased sense of taste, smell and sight dull with age and can also cause a loss of appetite. Additionally, nutritional status impacts on the development of the teeth and an individual’s resistance to many oral conditions, including periodontal diseases and oral cancer (4). In light of this knowledge, it now becomes imperative that health care providers establish whether the loss of appetite in an elderly individual is due to a physiological reason, a mental health issue, or a complication of ill fitting dentures.

Denture Use

It is well established that a good diet is essential for the development and maintenance of healthy teeth, but healthy teeth are important in enabling the consumption of a varied and healthy diet throughout the life cycle (4). The necessities of dental clients, in particular geriatric dental clients, have steadily increased and dental services involving the number of individuals needing complete dentures is on the rise. It is estimated that a person reaching 65 will live an additional 17.8 years. A census collected by the American Dental Association has established that nearly 57% of people ages 65-74 are wearing some form of denture, either partial or complete (5). As per Douglass, there are currently over 32 million people in the United States wearing partial or complete dentures (5). According to a study performed in 2013 by iData Research Inc., there were 2,822,589 complete dentures and 3,722,183 partial dentures fabricated for American patients, totaling 6,544,772; this reflects an increase of 3.5% from the previous year (6). Ensuring the validity and proper use of the dental prosthesis or appliance is of paramount importance for the individual’s overall health.

Multiple reasons may affect an individual’s aptitude in wearing their dental prosthesis. One attribute is the minimization of taste and texture sensation due to covering of palate (7). More significantly, many denture wearers develop painful sores because of ill fitting dental prostheses. Complete and partial dentures must go through a regimented dental protocol to ensure appropriate fit from the onset both in the clinical setting as well as in the laboratory. A poorly fabricated denture could cause harm and discontent for the individual which can potentially lead to cessation of use of the appliance (8). Approximately 33% of denture wearers have reported their dentures as poor fitting and those individuals were more likely to remove or disuse their dentures while eating (9). Furthermore, a responsible regiment of dental services must be engaged. Adults who wear dentures are required to see a dentist at the minimum of once a year for functioning dentures and more frequently for those with a newer dental prosthesis. The dentures should be removed daily for proper hygiene and to allow the gums to rest. Avoiding these measures would lead to movement in the oral cavity and ultimately deem the dental prosthesis to be cymbalta crazy meds ill fitting (7). Those individuals with ill fitting dentures self-reported a significantly lower use of professional dental services, higher degree of oral function limitations, and significantly increased levels of poor health and depression (8).


The Mini-Nutritional Assessment is one tool that is utilized internationally in various healthcare settings to perform a quick yet valid assessment of the nutritional status in the elderly (10). This tool identifies at-risk individuals as well as those who already suffer from malnutrition. Additionally, nutritional status may be measured by Body Mass Index (BMI), serum albumin levels, and self-report of appetite and weight loss. In a study performed by Sheiham and Steele, et. al, the likelihood of older adults having a BMI within the normal range of 20-25 was increased in those who had more than 20 natural teeth. Conversely, adults over 65 years of age who have few natural teeth or no teeth at all were found to be at a greater risk of being underweight due to functional issues leading to inadequate dietary intake, and yet also at a greater risk of being obese due to poor quality of diet (11, 12).

Inspection of the oral cavity can provide information regarding dryness of the oral mucosa which can indicate if the individual is experiencing decreased saliva, and can also alert the healthcare provider to evidence of poor oral hygiene. However, while only a small number of the denture wearers studied by Donini reported that decreased saliva caused discomfort while wearing dentures, approximately 30% of all 65 year olds have been found to have decreased saliva, or xerostomia (13). Xerostomia can lead to problems with chewing and swallowing; therefore, when coupled with poor oral hygiene, xerostomia can lead to changes in dietary intake which can cause malnutrition and involuntary weight loss among frail elderly adults. The ability to chew and digest food may be impaired in the elderly either by the loss of teeth or due to the use of dentures. Impaired dietary intakes were partly associated with poor fitting dentures, lack of teeth or lack of saliva (14). Reduced mastication ability may also lead to a change in the types of foods eaten due to a change in the ability to break down the food or the individual’s perception that such changes are necessary.

Nutrient Intake

The elderly need to eat a variety of nutrient dense foods which can be found in detail on MyPlate (15). This includes a variety of fresh or frozen vegetables, fruit, whole grains, cymbalta dosage lean protein and adequate water intake. An increase in calcium and vitamin D are needed to maintain bone health as people age, and fiber should be increased as well since peristalsis can slow during the aging process. However, edentulous older adults were found to consume less food energy and significantly less protein, intrinsic and milk sugars, non-starch polysaccharide (fibre), calcium, non-haem iron, niacin and vitamin C than dentate people (14). A Tufts University study of older adults found that full or partial denture wearers had diets considerably lower in 19 different nutrients as compared to adults without missing teeth (7). Many of the nutrients missing are found in hard to chew foods such as stringy meats, some vegetables and fruits such as carrots and apples, as well as nuts. Diets high in fat and low in fiber by edentulous individuals could be due to reduced mastication ability in those wearing full replacement dentures (16). Individuals with coexisting health issues or disabilities may be more vulnerable to reduced nutrient intake (14). Another factor affecting nutrition in adults is food preference, which is usually dictated by socio-cultural background as well as economic status, educational level and dwelling type. When individuals cannot prepare meals for themselves, they usually do not have control over the choice of foods included in their diet. This is also true for older adults who reside in various types of institutions. These factors need to be further studied in relation to the cause of malnutrition in the elderly since better fitting appliances or replacement of ill fitting appliances may not make a difference in nutritional intake. Therefore, involuntary weight loss may be caused by a conscious change in dietary intake and food avoidances as opposed to changes in mastication from dentures.


Older Americans who currently have poor oral health have been disadvantaged by not having fluoridated water and oral hygiene products containing fluoride in their younger years. The risk for poor oral health also increases among those who are socio-economically disadvantaged, those who live in rural areas, lack dental insurance, are disabled, homebound, or institutionalized (8). About 25% of those 40.3 million older adults no longer have any natural teeth (1). One reason why the elderly do not pursue dental care is related to lack of dental insurance. Adults over the age of 65 who qualify for Medicare are provided with medical coverage but without dental coverage for any type of oral care (8). Older adults who qualify for Medicaid from the federal government will have dental coverage but reimbursements are low and therefore providers may be more difficult to find. Access to oral health care is one of the greatest disparities in the United States today based on ethnicity and socio-economic status. As a result, the treatment, management, and prevention of oral diseases in the elderly will improve not only the conditions of their mouths, but also their overall health and well-being (17). Research has proven that dental disease can contribute to morbidity and mortality in older adults as well as a decreased quality of life in this population.

Poor oral health may also lead to social isolation due to embarrassment from odor and appearance. Although oral co-morbidities are common in older adults, their association with medical and functional status is often neglected during the geriatric assessment (8). Geriatricians and family practitioners need to start performing an oral evaluation in addition to their standard assessments when the patient is an older adult, as suggested in Table 1. Adults with full dentures need to continue with their scheduled oral assessments as well. Dentures may need alterations over time, and can cause abrasions and edema of the gums. Difficulties in chewing, discomforts with dentures as well as ill fitting dentures of poor quality are common in old age. These complications may ultimately lead the individual wearing the appliances to drastically decrease or alter their oral intake due to pain or discomfort. However, there does seem to be a level of functional discomfort that denture-wearers seem to be willing to cope with, according to Altenhoevel, et al. (18) Attention to the oral cavity may improve the quality of life for the older adult and decrease the risk for other comorbidities while preventing the individual from being at risk for poor diet and nutritional insufficiencies. Proper fitting dental prostheses produced from quality materials is of equal importance for the older adult’s overall quality of life.

Table 1 Suggested guidelines for healthcare providers



Dietary intervention and advice for dental health should be focused on health promotion and should follow the guidelines for general health (19). It should be based on each individual patient’s dietary capabilities and include the consumption of a variety of healthy foods. Health care professionals need to remain consistent in the advice they provide to clients regarding dietary intake. Oral health should not be viewed as separate from general health. Dietary advice that protects against major health conditions can also lead to dental health. Maintaining natural dentition can ensure adequate masticatory function, which can lead to the ingestion of necessary nutrients in the older adult. While dental function is not the only factor influencing food choice, the value of good teeth for enabling the consumption of a varied diet for enjoyment of food and food-related quality of life is an important consideration for nutrition and dental health professionals (4).

Ethical Standards: Neither author has any conflict of interest with review and summation of the information gathered.

Conflicts of Interest: The authors declare that there are no conflicts of interest.



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