J. Dent. 1992;
199
20: 199-201
Assessment of elderly people on entry to residential homes and continuing care arrangements Gillian Hoad-Reddick Unit of Prosthodontics,
Department
of Restorative
Dentistry,
University
Dental Hospital
of Manchester,
UK
ABSTRACT Increasing numbers of elderly people are entering private residential homes in the UK. Results of surveys show poor oral health in this group. A survey was therefore conducted of 50 residential homes (housing 1337 residents) to determine assessment on entry and continuing care provision. In 38 per cent of homes no written notes were made of the initial assessment. Topics of dental interests were infrequently assessed on entry (only 16 per cent of carers examined the oral cavity, 52 per cent assessed the subject’s ability to care for their dentures). Medical topics (mobility, incontinence, eyesight, etc.) were all assessed in more than 80 per cent of subjects. Suggestions are made for utilization of an easy assessment questionnaire and improved denture naming arrangements. The importance of regular check-ups, education and publicity fo; tlhis group is
stressed. KEY WORDS: J. Dent. 1992;
Gerodontology, 20:
199-201
Continuing (Received
care, Residential 26 November
homes
1991;
accepted
10 December
1991
1
Correspondence should be addressed to: Mrs G. Hoad-Reddick, Lecturer in Restorative Dentistry, Department of Restorative Dentistry, Unit of Prosthodontics, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester Ml 5 6FH. UK.
INTRODUCTION As the proportion of elderly people in society increases, the number of private residential establishments catering for their needs is also increasing. In the last 5 years in the UK there has been a change in the pattern of residential care for the elderly. In the 1970s and early 1980s there were few private residential homes providing care for the elderly and many run by the social services. The government now encourages care in the community so many of the social service homes have closed and many private homes have recently opened. Any home caring for more than three people is obliged to register with a central agency - by August 1990, 3300 private homes had registered with the Registered Nursing Home Association (private communication). Many surveys of the elderly have highlighted oral health problems (Ritchie, 1973; Grabowski and Bertram. 1975; Fiske et al., 1990). Particular problems related to elderly residents in long-stay care were found to be dirty dentures, lost dentures and high levels of oral pathology @ 1992 Butterworth-Heinemann 0300-5712/92/040199-03
Ltd.
(Gerrish et al., 1971; Manderson Hoad-Reddick et al., 1987b).
AIMS
and
Ettinger,
1975;
AND OBJECTIVES
A survey was therefore organized to discover the level of assessment of elderly people on their entry to residential care and to compare any dental assessment with other general medical assessment. The regularity of visits by a dentist to the homes was compared to those made by other members of the caring professions. It was hoped that if great differences in initial assessment or in follow-up visits between dentistry and other caring professions were found, this could be used as a basis to influence future care provision for this important social group.
METHOD During
June and July 1990, 50 old people’s homes
were
200
J. Dent.
1992;
20:
No. 4
Table 1. The study population for assessment of elderly on their entry to residential establishments Birkenhead Total no. of homes Type of home (no.) Social service Private Age range (yr) Total no. of residents M:F
therapist, social physiotherapist.
worker,
pharmacist,
psychologist
and
Manchester
25
RESULTS
25
5 20 50-I 01 656 1 :4.9
6 19 55-l 03 681 1 : 5.2
visited in Birkenhead, Merseyside and in South Manchester. Birkenhead is a town situated in the Merseyside Health Authority; the South Manchester Homes are all situated in the city of Manchester, part of the North Western Health Authority. Twenty-five residential establishments were selected from each area at random either from the yellow pages of the telephone directory or from a list of homes provided by the social services department (Table I). One research worker visited each home and interviewed either the owner or the senior care staff member on duty. The type of care establishment (whether it was a social service centre or private establishment), number of residents, age range and sex ratio was noted. Information was sought, on the initial assessment on entry of an elderly person to the home: whether a proforma (printed form) was used to note details of the initial assessment: and also which of the following criteria were included in the assessment: mobility, eyesight, speech, hearing, incontinence, nutritional state, skin condition/pressure areas, sleep patterns, ability to dress and feed themselves unaided, ability to clean their own teeth and/or dentures and condition of the mouth, teeth or dentures (whether painful areas in the mouth were looked at, or teeth and dentures checked). Note was made of whether carers had identification marks placed on their client’s dentures as a routine measure. The regularity of visits by different carers was noted (per week, fortnight, month, 3 or 6 monthly or per year). Details were taken of the regularity of the visits or whether the caring group was called only if needed, or not at all. Groups investigated were: chiropodist, dentist, dietitian, doctor, hairdresser, occupational therapist, speech
The study population is shown in Table I. It can be seen that by visiting 50 residential homes, information on 1337 elderly people could be sought. The age range was from 50 to 103 years and the ratio of men : women 1 : 5. Of the 50 homes, 11 were run by social services. The smallest home housed four residents and the largest had 53 residents. Twenty-two homes held less than 20 residents and five less than ten. Only live homes housed 50 or more elderly people. Analysis of the type of assessment carried out on entry showed that 62 per cent of the homes used a written proforma to record data about their residents. Fig. I shows the data investigated by carers on the initial assessment of the elderly to a residential establishment. It can be seen that mobility (96 per cent) and incontinence (94 per cent) were the most assessed topics and that eyesight, hearing, speech, nutritional state and skin condition, sleep patterns and ability to dress or feed themselves were all similarly frequently assessed (78-88 per cent). However, topics of dental/oral interest were infrequently assessed - only 52 per cent of carers assessed the ability of subjects to care for their own teeth or dentures, only 38 per cent of carers made any assessment of teeth or dentures, and only 16 per cent attempted to examine the oral cavity. In only 14 per cent of the homes investigated were dentures routinely provided with identification marks. In the Birkenhead group all the named dentures were in social service-run homes, whereas in the South Manchester group the named dentures were found in the privately run group of homes. The regularity of visits by outside caring agencies to old people’s homes is shown in Fig. 2. Doctors visited 52 per cent of the homes on a regular basis and were readily on call to a further 34 per cent. In contrast, dentists regularly visited only 16 per cent of homes and were on call if needed at 70 per cent. Hairdressers, pharmacists and chiropodists were the most regular attenders at homes, whereas dentists, physiotherapists and occupational I
Doctor Chiropodits
Mobility
Eyesight Speech
I
Social worker Hairdresser
Hearing incontinence Skin condition Sleep patterns Ability to dress Ability to feed Ability to clean teeth Painful areas in mth Exam. teeth/dentures
~
Physiotherapist Occupation th. Speech th. Dentist Psychologist Pharmacist Dietitian 0
20
40
60
80
100
120
Fig. 7. Criteria assessed by carers when elderly initially enter residential care. ?? , %.
0
20
._~_IlL 40
60
80
___L__ 100
120
Fig. 2. Regularity of visits by outside agencies to residential establishments. W, % regular visits; 8, % on call.
Hoad-Reddick: Care arrangements
therapists (14-16 per cent) and psychologists (6 per cent) and speech therapists (2 per cent) were the least likely to attend. No correlation could be found between the size of the home and use of a proforma or regularity of visits to the home by any of the caring agencies.
DISCUSSION These results show clearly that there is little investigation of dental status when people enter residential accommodation. dentures are not routinely marked and dentists make few regular routine visits to elderly people’s homes. This is in spite of an awareness by the profession (Christensen. 1977; Spratley, 1977) that dentures need regular checks and elderly people should have regular oral health examinations (Hoad-Reddick et al., 1987a). The fact that only 16 per cent of homes have regular visits from a dentist and 70 per cent of the homes state that they would call a dentist if one were needed, should not be looked on as reassuring. It cannot be assumed that carers will be able to assess when a dentist is needed, since an earlier survey by the author (Hoad-Reddick, 1985) found 30.5 per cent of elderly residents in old people’s homes had some form of oral pathology, 72.2 per cent needed new dentures and 73.8 per cent had dirty dentures. These results are in line with those of other researchers (Manderson and Ettinger. 197.5; Davidson, 1979). The lack of interest in dental topics was evident in several comments during the survey: ‘dentures don’t need examining anyway’, ‘we don’t bother with minor details’! The dental profession must renew its efforts to promote dental health for this group. Community dental officers and local general practitioners should maintain regular contacts with all residents of long-stay institutions. The need for regular oral health check-ups - at least every 18 months - should be publicized widely. Gerrish et al. suggested in 1971 that dental hygienists could be used to give advice on both oral and denture hygiene. It has been shown elsewhere (Hoad-Reddick, 1991) that carers can assess the need of elderly people on their entry to residential homes by asking four simple questions: 1. Do you think you need any dental treatment? 2. Do you have any problems when eating? 3. How old are your present dentures or when did you last visit a dentist? 4. Do you have any painful areas in your mouth? The need thus assessed by carers is closer to need assessed by the dentist than to the need perceived by the subjects. The simplicity of this form of assessment should be widely publicized so that it is routinely included in entry assessment to long-term care. In the Birkenhead group all the named dentures were in
in residential homes
201
the social service-run homes: this probably relates to the activity and interest of the community dental services. In the South Manchester group the named dentures were in the privately run group of homes evidencing the importance of an interested dentist or aware home owner. In view of the awareness by the profession of the advantages of identification marks (Heath, 1987). unmarked dentures must be provided with some means of identification either by the carer or by a visiting dentist. Publicity about ease of marking systems and their importance must improve. The dental profession should be seen to take the lead in providing improved care for this disadvantaged group. Education through the media, interested groups and at local levels should be improved. The profession ought to provide the impetus and climate for change.
References Christensen J. (1977) Oral health status of 65-74 year old Danes: a preliminary report of the replication of WHO’s international collaborative study in Denmark. J. Dent. Res. 56, (Special No. C 1977). 149-153. Davidson P. N. (1979) Survey of the dental state and needs of a group of elderly army pensioners in England. Community Dent. Oral Epidemiol. 7, 311-314. Fiske J., Davis D. M.. Watson R. M. et al. (1990) Complete Denture Status in an Elderly Population. Paper presented to the European Prosthodontic Association 14th Annual Conference, Amsterdam. Gerrish J. S.. Yardley A., Stafford G. D. et al. (1971) A dental survey of people living in residential homes for the elderly in Cardiff. Dent. Pratt Dent. Rec. 22, 433-435. Grabowski M. and Bertram V. (1975) Oral health status and the need of dental treatment in the elderly Danish population. Community Dent. Oral Epidemiof. 3, 108-l 14. Heath J. R. (1987) Denture identification - a simple approach. J. Oral Rehabil. 14, 147-163. Hoad-Reddick G. (1985) A Survey into the Dental Health of the Elderly with Special Reference to their Treatment Needs. MSc Thesis, University of Manchester. Hoad-Reddick G. (1991) A study to determine oral health needs of institutionalised elderly patients by non-dental health care workers. Community Dent. Oral Epidemiol. 19, 233-236. Hoad-Reddick G.. Grant A. A and Griffiths C. S. (1987a) The search for an indicator of need for denture replacement in an edentulous elderly population. Gerodontics 3, 223-226. Hoad-Reddick G., Grant A. A. and Griftiths C. S. (1987b) The dental health of an elderly population in North West England: results of survey undertaken in the Halton Health Authority. J. Dent. 15, 139-146. Manderson R. D. and Ettinger R. L. (1975) Dental status of the institutionalised elderly population of Edinburgh. Community Dent. Oral Epidemiol. 3, 100-107. Ritchie G. M. (1973) Some dental findings in a survey of geriatric patients. .I. Dent 1, 106-l 12. Spratley M. H. (1977) An estimation of the demand for prosthetic dentistry in the year 2000. Aust. Dent. J. 22, 17-19.
199
20: 199-201
Assessment of elderly people on entry to residential homes and continuing care arrangements Gillian Hoad-Reddick Unit of Prosthodontics,
Department
of Restorative
Dentistry,
University
Dental Hospital
of Manchester,
UK
ABSTRACT Increasing numbers of elderly people are entering private residential homes in the UK. Results of surveys show poor oral health in this group. A survey was therefore conducted of 50 residential homes (housing 1337 residents) to determine assessment on entry and continuing care provision. In 38 per cent of homes no written notes were made of the initial assessment. Topics of dental interests were infrequently assessed on entry (only 16 per cent of carers examined the oral cavity, 52 per cent assessed the subject’s ability to care for their dentures). Medical topics (mobility, incontinence, eyesight, etc.) were all assessed in more than 80 per cent of subjects. Suggestions are made for utilization of an easy assessment questionnaire and improved denture naming arrangements. The importance of regular check-ups, education and publicity fo; tlhis group is
stressed. KEY WORDS: J. Dent. 1992;
Gerodontology, 20:
199-201
Continuing (Received
care, Residential 26 November
homes
1991;
accepted
10 December
1991
1
Correspondence should be addressed to: Mrs G. Hoad-Reddick, Lecturer in Restorative Dentistry, Department of Restorative Dentistry, Unit of Prosthodontics, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester Ml 5 6FH. UK.
INTRODUCTION As the proportion of elderly people in society increases, the number of private residential establishments catering for their needs is also increasing. In the last 5 years in the UK there has been a change in the pattern of residential care for the elderly. In the 1970s and early 1980s there were few private residential homes providing care for the elderly and many run by the social services. The government now encourages care in the community so many of the social service homes have closed and many private homes have recently opened. Any home caring for more than three people is obliged to register with a central agency - by August 1990, 3300 private homes had registered with the Registered Nursing Home Association (private communication). Many surveys of the elderly have highlighted oral health problems (Ritchie, 1973; Grabowski and Bertram. 1975; Fiske et al., 1990). Particular problems related to elderly residents in long-stay care were found to be dirty dentures, lost dentures and high levels of oral pathology @ 1992 Butterworth-Heinemann 0300-5712/92/040199-03
Ltd.
(Gerrish et al., 1971; Manderson Hoad-Reddick et al., 1987b).
AIMS
and
Ettinger,
1975;
AND OBJECTIVES
A survey was therefore organized to discover the level of assessment of elderly people on their entry to residential care and to compare any dental assessment with other general medical assessment. The regularity of visits by a dentist to the homes was compared to those made by other members of the caring professions. It was hoped that if great differences in initial assessment or in follow-up visits between dentistry and other caring professions were found, this could be used as a basis to influence future care provision for this important social group.
METHOD During
June and July 1990, 50 old people’s homes
were
200
J. Dent.
1992;
20:
No. 4
Table 1. The study population for assessment of elderly on their entry to residential establishments Birkenhead Total no. of homes Type of home (no.) Social service Private Age range (yr) Total no. of residents M:F
therapist, social physiotherapist.
worker,
pharmacist,
psychologist
and
Manchester
25
RESULTS
25
5 20 50-I 01 656 1 :4.9
6 19 55-l 03 681 1 : 5.2
visited in Birkenhead, Merseyside and in South Manchester. Birkenhead is a town situated in the Merseyside Health Authority; the South Manchester Homes are all situated in the city of Manchester, part of the North Western Health Authority. Twenty-five residential establishments were selected from each area at random either from the yellow pages of the telephone directory or from a list of homes provided by the social services department (Table I). One research worker visited each home and interviewed either the owner or the senior care staff member on duty. The type of care establishment (whether it was a social service centre or private establishment), number of residents, age range and sex ratio was noted. Information was sought, on the initial assessment on entry of an elderly person to the home: whether a proforma (printed form) was used to note details of the initial assessment: and also which of the following criteria were included in the assessment: mobility, eyesight, speech, hearing, incontinence, nutritional state, skin condition/pressure areas, sleep patterns, ability to dress and feed themselves unaided, ability to clean their own teeth and/or dentures and condition of the mouth, teeth or dentures (whether painful areas in the mouth were looked at, or teeth and dentures checked). Note was made of whether carers had identification marks placed on their client’s dentures as a routine measure. The regularity of visits by different carers was noted (per week, fortnight, month, 3 or 6 monthly or per year). Details were taken of the regularity of the visits or whether the caring group was called only if needed, or not at all. Groups investigated were: chiropodist, dentist, dietitian, doctor, hairdresser, occupational therapist, speech
The study population is shown in Table I. It can be seen that by visiting 50 residential homes, information on 1337 elderly people could be sought. The age range was from 50 to 103 years and the ratio of men : women 1 : 5. Of the 50 homes, 11 were run by social services. The smallest home housed four residents and the largest had 53 residents. Twenty-two homes held less than 20 residents and five less than ten. Only live homes housed 50 or more elderly people. Analysis of the type of assessment carried out on entry showed that 62 per cent of the homes used a written proforma to record data about their residents. Fig. I shows the data investigated by carers on the initial assessment of the elderly to a residential establishment. It can be seen that mobility (96 per cent) and incontinence (94 per cent) were the most assessed topics and that eyesight, hearing, speech, nutritional state and skin condition, sleep patterns and ability to dress or feed themselves were all similarly frequently assessed (78-88 per cent). However, topics of dental/oral interest were infrequently assessed - only 52 per cent of carers assessed the ability of subjects to care for their own teeth or dentures, only 38 per cent of carers made any assessment of teeth or dentures, and only 16 per cent attempted to examine the oral cavity. In only 14 per cent of the homes investigated were dentures routinely provided with identification marks. In the Birkenhead group all the named dentures were in social service-run homes, whereas in the South Manchester group the named dentures were found in the privately run group of homes. The regularity of visits by outside caring agencies to old people’s homes is shown in Fig. 2. Doctors visited 52 per cent of the homes on a regular basis and were readily on call to a further 34 per cent. In contrast, dentists regularly visited only 16 per cent of homes and were on call if needed at 70 per cent. Hairdressers, pharmacists and chiropodists were the most regular attenders at homes, whereas dentists, physiotherapists and occupational I
Doctor Chiropodits
Mobility
Eyesight Speech
I
Social worker Hairdresser
Hearing incontinence Skin condition Sleep patterns Ability to dress Ability to feed Ability to clean teeth Painful areas in mth Exam. teeth/dentures
~
Physiotherapist Occupation th. Speech th. Dentist Psychologist Pharmacist Dietitian 0
20
40
60
80
100
120
Fig. 7. Criteria assessed by carers when elderly initially enter residential care. ?? , %.
0
20
._~_IlL 40
60
80
___L__ 100
120
Fig. 2. Regularity of visits by outside agencies to residential establishments. W, % regular visits; 8, % on call.
Hoad-Reddick: Care arrangements
therapists (14-16 per cent) and psychologists (6 per cent) and speech therapists (2 per cent) were the least likely to attend. No correlation could be found between the size of the home and use of a proforma or regularity of visits to the home by any of the caring agencies.
DISCUSSION These results show clearly that there is little investigation of dental status when people enter residential accommodation. dentures are not routinely marked and dentists make few regular routine visits to elderly people’s homes. This is in spite of an awareness by the profession (Christensen. 1977; Spratley, 1977) that dentures need regular checks and elderly people should have regular oral health examinations (Hoad-Reddick et al., 1987a). The fact that only 16 per cent of homes have regular visits from a dentist and 70 per cent of the homes state that they would call a dentist if one were needed, should not be looked on as reassuring. It cannot be assumed that carers will be able to assess when a dentist is needed, since an earlier survey by the author (Hoad-Reddick, 1985) found 30.5 per cent of elderly residents in old people’s homes had some form of oral pathology, 72.2 per cent needed new dentures and 73.8 per cent had dirty dentures. These results are in line with those of other researchers (Manderson and Ettinger. 197.5; Davidson, 1979). The lack of interest in dental topics was evident in several comments during the survey: ‘dentures don’t need examining anyway’, ‘we don’t bother with minor details’! The dental profession must renew its efforts to promote dental health for this group. Community dental officers and local general practitioners should maintain regular contacts with all residents of long-stay institutions. The need for regular oral health check-ups - at least every 18 months - should be publicized widely. Gerrish et al. suggested in 1971 that dental hygienists could be used to give advice on both oral and denture hygiene. It has been shown elsewhere (Hoad-Reddick, 1991) that carers can assess the need of elderly people on their entry to residential homes by asking four simple questions: 1. Do you think you need any dental treatment? 2. Do you have any problems when eating? 3. How old are your present dentures or when did you last visit a dentist? 4. Do you have any painful areas in your mouth? The need thus assessed by carers is closer to need assessed by the dentist than to the need perceived by the subjects. The simplicity of this form of assessment should be widely publicized so that it is routinely included in entry assessment to long-term care. In the Birkenhead group all the named dentures were in
in residential homes
201
the social service-run homes: this probably relates to the activity and interest of the community dental services. In the South Manchester group the named dentures were in the privately run group of homes evidencing the importance of an interested dentist or aware home owner. In view of the awareness by the profession of the advantages of identification marks (Heath, 1987). unmarked dentures must be provided with some means of identification either by the carer or by a visiting dentist. Publicity about ease of marking systems and their importance must improve. The dental profession should be seen to take the lead in providing improved care for this disadvantaged group. Education through the media, interested groups and at local levels should be improved. The profession ought to provide the impetus and climate for change.
References Christensen J. (1977) Oral health status of 65-74 year old Danes: a preliminary report of the replication of WHO’s international collaborative study in Denmark. J. Dent. Res. 56, (Special No. C 1977). 149-153. Davidson P. N. (1979) Survey of the dental state and needs of a group of elderly army pensioners in England. Community Dent. Oral Epidemiol. 7, 311-314. Fiske J., Davis D. M.. Watson R. M. et al. (1990) Complete Denture Status in an Elderly Population. Paper presented to the European Prosthodontic Association 14th Annual Conference, Amsterdam. Gerrish J. S.. Yardley A., Stafford G. D. et al. (1971) A dental survey of people living in residential homes for the elderly in Cardiff. Dent. Pratt Dent. Rec. 22, 433-435. Grabowski M. and Bertram V. (1975) Oral health status and the need of dental treatment in the elderly Danish population. Community Dent. Oral Epidemiof. 3, 108-l 14. Heath J. R. (1987) Denture identification - a simple approach. J. Oral Rehabil. 14, 147-163. Hoad-Reddick G. (1985) A Survey into the Dental Health of the Elderly with Special Reference to their Treatment Needs. MSc Thesis, University of Manchester. Hoad-Reddick G. (1991) A study to determine oral health needs of institutionalised elderly patients by non-dental health care workers. Community Dent. Oral Epidemiol. 19, 233-236. Hoad-Reddick G.. Grant A. A and Griffiths C. S. (1987a) The search for an indicator of need for denture replacement in an edentulous elderly population. Gerodontics 3, 223-226. Hoad-Reddick G., Grant A. A. and Griftiths C. S. (1987b) The dental health of an elderly population in North West England: results of survey undertaken in the Halton Health Authority. J. Dent. 15, 139-146. Manderson R. D. and Ettinger R. L. (1975) Dental status of the institutionalised elderly population of Edinburgh. Community Dent. Oral Epidemiol. 3, 100-107. Ritchie G. M. (1973) Some dental findings in a survey of geriatric patients. .I. Dent 1, 106-l 12. Spratley M. H. (1977) An estimation of the demand for prosthetic dentistry in the year 2000. Aust. Dent. J. 22, 17-19.
