Accepted Manuscript Elder’s Oral Health Crisis Janet A. Yellowitz, DMD, MPH PII:

S1532-3382(14)00075-X

DOI:

10.1016/j.jebdp.2014.04.011

Reference:

YMED 962

To appear in:

The Journal of Evidence-Based Dental Practice

Please cite this article as: Yellowitz JA, Elder’s Oral Health Crisis, The Journal of Evidence-Based Dental Practice (2014), doi: 10.1016/j.jebdp.2014.04.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Elder’s Oral Health Crisis

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Janet A. Yellowitz, DMD, MPH

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ABSTRACT

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Declarative Title:

Dentistry must prepare to meet the challenges of providing oral health services to the increasing numbers of medically compromised and cognitively impaired older adults whose care is often complicated by functional, behavioral, and situational factors.

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Background

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With the unprecedented aging of the population, oral health care providers will be treating a greater number of older adults than in the past. There will also be a larger frail and vulnerable cohort with physical and/or cognitive conditions, disabilities and limited financial resources. The elderly suffer disproportionately from oral disease and limited access to oral health care. Many older adults are either unwilling or unable to receive routine care, putting them at greater risk for general and oral complications. Some present with extensive oral disease, the cumulative effects of disease throughout their lifetime, an even more complicated situation when frail elders are homebound or in long-term care institutions. To care optimally for this aging cohort, oral health professionals need to be knowledgeable about the many conditions, disabilities and age-related changes associated with aging.

Methods

Literature review and discussion of the key research studies describing demographic and societal changes leading to the current multifactorial oral healthcare crisis impacting older adults. The authors draw upon the evidence and their experience in geriatric patient care 1

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to provide information relevant to today’s oral healthcare practitioners treating older adults.

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Conclusion Oral health services are an essential component of primary geriatric healthcare. The growing population of older and impaired adults requires practitioners who are sensitive to the myriad of functional, behavioral and situational factors that impact this aged cohort. Adequate access to quality oral healthcare for the aged is a salient public health issue that will require political and psychobiomedical

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interprofessional collaboration to adequately address.

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SORT Score-C LOE Score-3

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Introduction:

Never before has the population of the United States included so many people aged 65. Today this group accounts for 13% of the total population, and will increase to 20% in 2030, when the last of the baby boomer cohort (born between 1946–1964) reach age 65. (See Figure 1)

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Consequently, future elders will likely be living with more chronic diseases and disabilities for longer periods of time than previous older aged cohorts. These conditions will impact their

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ability to care for themselves, access professional health care and maintain their quality of life. By 2030, this age cohort will encompass 88.5 million Americans. What awaits elderly people facing major health challenges? Many ‘old-old’ adults suffer multiple medical conditions, disabilities and/or cognitive impairment, presenting challenges for health care, social services, and family members. In addition, an aging population delivers its own harsh economic realities; for many people, retirement is an elusive dream, while for others, working longer is a financial necessity.

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To effectively care for older adults, healthcare professionals must be able to separate stereotypical aging images from reality and integrate current knowledge with the emerging

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science of disease presentation and management.

Elders Oral Healthcare Crisis:

There is a growing oral health care crisis for older adults. This crisis is multifactorial, involving the rapid growth of the aging population, the role of health care, knowledge, opinions, and

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practices of providers and the public, and the general health conditions associated with aging. Although often portrayed as a single cohort, older adults are a diverse population, spanning 35

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plus years.

Typically identified as the population over 65 years of age, older adults display great variability in their physical, functional and cognitive health as well as their health needs and expectations. The elderly cohort is heterogeneous in that many older adults are not able or willing to receive routine preventive care due to health conditions, disabilities, access issues, limited financial resources, and/or their belief that they do not need care or that it has no value to them. Other elders are more functional, and independent, have more teeth, and more are financially secure

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than in the past. It remains unknown how many older adults will demand oral healthcare as part of their overall health strategies.1

Compared to those 85 years and older, individuals from 65 to 74 years of age have better

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general and oral health, have maintained more teeth and have a more preventive attitude toward health care. This pattern will likely continue in the future, when those 65-74 years of age

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will be over 85.

There is also a significant difference in health beliefs and attitudes between those in the 65-74 age cohort and those 85 years and older.2 Many of the older cohort were raised during the Depression and viewed health and dental care more as a luxury than a preventive routine. For many, dental care was primarily utilized to relieve pain and discomfort. Although future elders have been reported to be more preventive oriented, the data does not extend to oral health care.3 The future elders/baby boomers are, and will continue to be, better educated, have more discretionary income and dental insurance at some time during their lifetime. Many will have more teeth, have received extensive care, be more demanding for treatment options, and yet know little about age-related changes and how their oral health needs change as they age. 3

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Some of the most challenging situations will occur with those 75 years and older as they are most likely to present with significant health conditions, cognitive concerns and financial limitations Providing oral health services to medically compromised and cognitively impaired older adults

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can present unique challenges. Frail and vulnerable older adults are at increased risk for oral disease and often present with extensive oral health needs, complicated by medical, functional, behavioral and situational factors. Frail refers to individuals with limited functional ability and being at an elevated risk for adverse outcomes. Although there is no clear consensus of the

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definition of frail, the most frequently used definition is based on the nutritional status, energy, physical activity, mobility and strength.4 Individuals with diminished cognitive capacity are often unable to identify pain, provide good daily care or advocate for themselves. Frail and vulnerable

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adults are further challenged by having a lack of mobility, financial resources and or access to a healthcare provider willing to provide services. These vulnerabilities become the responsibility of family members, caregivers, guardians and health professionals to advocate for adequate oral health care.5 Another component of this crisis is the caregivers ‘lack of awareness’ of the importance of oral health.

Frailty complicates the care needed to manage oral diseases and oral diseases complicate the

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management of frailty.6 Many health care providers are hesitant to care for frail and vulnerable elders. This hesitancy is often due to lack of education, training and/or comfort 7. Dental insurance facilitates the receipt of routine preventive care for many, yet often when the

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insurance benefit is terminated, so is care. Access issues include factors previously identified such as lack of or minimal dental insurance coverage, financial constraints and lack of perceived need; additional barriers are difficulty in traveling to and from the dental office, being

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homebound or institutionalized.

Oral health status:

Tooth loss increases, not because of age, but as a result of oral diseases. More of today’s older adults are retaining their natural teeth, with fewer experiencing total tooth loss. In 2010, onequarter (24.3%) of non-institutionalized adults 65 years of age and older were edentulous compared to 33 percent in 1993.8, The oral health status of older adults is diverse, on a continuum ranging from a complete dentition with little to no disease, to extensive caries, 4

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periodontal disease and/or edentulism. Restorative status is also variable since some have teeth replaced with implants and some with removable prosthetics (dentures), while others remain edentulous with no replacements. Each of these can impact social functioning and

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nutritional status and consequently, overall wellness.

Health and well-being:

By most standards, the health of the elderly has improved over the past 3 decades. Advances in

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treating acute diseases and chronic conditions has increased the prevalence of disabilities in this aging cohort,9 and the use of assistive devices has allowed many to remain ambulatory.

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The morbidity and mortality that used to define 70 years, now occurs at age 80, and the morbidity and mortality that used to prevail at 80 now appears at age 90.10 Having health profiles that resemble individuals 7-9 years younger allows people to postpone disability and lead healthy, independent lives far longer than previous generations.11 However, as the elderly in United States increase in number and percentage, there will be an ever-increasing vulnerable or frail aged cohort, who have physical and/or cognitive conditions and disabilities, limited

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financial resources and cannot readily access health care.

There is an increase in disability as a result of age-related conditions and diseases. Recent research suggests that while disability among the oldest Americans (80+) has been declining

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since the 1980’s, disability trends among those 50– 64 years have not declined and as such, do not bode well for the future.12

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The vast majority of those aged 65 years and older have one or more chronic conditions.13 In those 70 – 80 years of age, close to 75% have at least one chronic disease, with close to 50% having 2 or more. (See Figure 2) The prevalence of chronic conditions and diseases increases with age. The most common chronic conditions in older adults include hypertension, arthritis and heart disease (see chart). Among the most common conditions, heart disease, stroke, cancer and diabetes are the most costly health conditions. Six of the seven leading causes of death among older adults are chronic diseases which negatively affect one’s quality of life. 14 Between 1980 and 2011, the percentage of people diagnosed with diabetes increased 140% (9.1% to 21.8%) for those aged 65 to 74 years and 125% (8.9% to 20.0%) for those aged 75 5

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years and older.15 More than 90% of persons with diabetes have 1 or more comorbid chronic conditions. 16 Recent statistics reporting the prevalence of diabetes among people aged 75

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and older is 20% and over 21% for those aged 65-74.

Physiologic age-related changes

Independent of disease, age-related physiologic changes are typically most evident in those aged 85 years and older.17 With increasing age, organ systems become progressively less able

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to maintain homeostasis under stressful conditions. As changes are subtle and develop slowly, clinicians are often challenged to differentiate age-related change and pathology.

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Many age-related changes occur in the cardiovascular system. A decline in cardiac reserve occurs in normal aging, but may not become evident until the individual is physically or physiologically stressed.18 Baroreceptor function, which regulates blood pressure, is impaired with age, particularly with change in position. Postural hypotension with orthostatic symptoms may follow, especially after prolonged bedrest, dehydration or cardiovascular drug use, causing dizziness and fall potential.19

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The aging immune system is compromised by concomitant medical conditions making older adults with chronic diseases, more susceptible to infections. Immunosenescence, or immunologic aging, is a primary cause for autoimmunity problems and increased infectious disease susceptibility, morbidity and mortality with advanced age. This qualitative and

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quantitative change in immune response that characterizes immunesenescence is often recognized by an atypical presentation of infection in the elderly. This is particularly important since infections are usually more frequent and prolonged in older adults. Other factors that

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contribute to the predisposition of the elderly to infection, in addition to impaired immune function, include age-related anatomic and functional changes, environmental conditions and degree of exposure to infections.20

Age-related oral changes Many age-related physiologic changes occur in the oral cavity. The oral structures, lips, oral mucosa, tongue and bone, age as does the rest of the body. Although salivary flow in healthy (unmedicated) older adults remains stable,21 many of the medications taken by older adults 6

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have the potential to reduce salivary flow. Hyposalivation and xerostomia can occur as the result of 1 medication but is more likely to occur with the intake of more than 4 daily prescription medications.22 Although only 6-10% of the population at large experience xerostomia, for those over 80 years old the likelihood of xerostomia increases to 40%.23 Patients with hyposalivation

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and/or xerostomia need to be informed of the many potential consequences of having a dry mouth as well as strategies to modify this condition. Although sipping water is a well-recognized approach to reducing the symptoms of hyposalivation many older adults are hesitant to comply due to a decreased sense of thirst.24

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Although the etiology is unknown, oral stereognosis, or the ability to identify and manipulate objects and textures in the mouth, may be compromised in older adults, denture wearers and those experiencing xerostomia.25 This age-related change most likely accounts for the food

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retention and pocketing commonly seen in older adults.

Due to a variety of age-related factors, older adults experience less dental pain than younger people. Many older adults are predisposed to poor oral health because they seek care only when they are in pain or discomfort. In addition to calcification of the canals, the decreased sensation is the result of long term heavy occlusal forces, caries, restorative care and trauma. These conditions precipitate the development of secondary dentin that subsequently invades

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and decreases the size and volume of pulp chambers and canals. The high prevalence of periodontal disease in older adults results from a variety of factors, including a lifetime loss of attachment, exposed interproximal concavities and root surfaces,

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poor oral hygiene, and limited oral care services. No specific systemic disease or condition has been shown to increase the risk of susceptibility to periodontal disease in the absence of dental plaque. However, certain systemic conditions and diseases are risk factors that may increase

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susceptibility to periodontal diseases by either modifying or increasing the host response to bacteria and inflammation. Examples of these are obesity, osteoporosis, and diabetes mellitus.26. (See Hein, Batista, Obesity and Cumulative Inflammatory Burden: A Valuable Risk Assessment Parameter in Caring for Dental Patients, AND Genco and Genco, Control of Common Risk Factors in a Dental Setting: A New Strategy for Interprofessional Management of Periodontal and Associated Systemic Diseases, this publication)

The connection between diabetes and periodontal disease is considered a bidirectional relationship, with periodontal disease considered a complication of uncontrolled diabetes.(See 7

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Genco and Genco, Control of Common Risk Factors in a Dental Setting: A New Strategy for

Interprofessional Management of Periodontal and Associated Systemic Diseases, this publication) Diabetics with uncontrolled or poorly controlled blood glucose levels have an

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increased risk for acute periodontal abscesses, more extensive attachment loss, and a greater risk of bone loss. Uncontrolled diabetics also have a poorer response to non-surgical and surgical periodontal therapy, more rapid recurrence of deep periodontal pockets, and a less

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favorable long-term response to treatment.27 There may be a link between skeletal osteoporosis and alveolar bone loss, 28 with studies reporting a correlation between mandibular bone and

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hipbone mineral density. Osteoporosis doesn't initiate tissue destruction; it may however exacerbate the bone resorption seen in periodontitis.29 Medication-related issues

As a result of chronic conditions and diseases, older adults take multiple medications, often prescribed by multiple health providers. In general, older adults are more likely to have an

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adverse drug reaction, medication adherence issues, and/or a medication error.30 Due to an age-related reduced ability to metabolize and excrete medications (pharmacokinetics)31 and a change in sensitivity to medication, older adults taking multiple medications are at increased risk for an adverse drug reaction32 (See Spolarich, Risk Management for Reducing Oral Adverse

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Drug Events, this publication) Since medications can change frequently, it is critical that healthcare providers update medications at every visit, as well as being aware of over the counter and herbal medicaments that people often take but do not consider a medication, or do

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not think it could possibly interact with medications or foods. Since many age-related physiologic changes affect medication pharmacokinetics and pharmacodynamics, medication dosing needs to be modified for older adults. Although exact dosing guidelines for older adults have not been established, this should be considered. Lexicomp ® publishes an on-line and hard version of The Geriatric Dosage handbook which includes clinical recommendations and monitoring guidelines. Most medications prescribed by dental professionals do not require a geriatric modification; however, understanding the need for geriatric dosing can be helpful in discerning patients’ possible adverse reactions to medications.

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A number of mobile health software applications are available for use by healthcare professionals to assess medication dosing. Two software examples are Epocrates and Lexicomp. These applications provide instant web-based access to a database for pertinent drug information, adverse side effects, and drug interactions. A drug information handbook and

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online version of Lexicomp is available specifically for dentistry. (See Spolarich, Risk Management for Reducing Oral Adverse Drug Events, this publication)

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Age-related Sensory changes

Age-related sensory changes can impact the quality of life of older adults. With a decline in vision and auditory capacity, seniors are at an increased risk for falls, depression and social

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isolation. Vision changes and hearing loss can affect almost every social interaction an elder has, including with healthcare providers. Between 1996–2006, sensory impairments were identified as a significant issue for older adults, with 1 of 6 having impaired vision and one out of four having impaired hearing.33 Vision and hearing impairments increase with age, often doubling in those 80 years and older compared to those 70-79 years. (Figure 3) Addressing these issues through practice strategies and design modifications will enable health care

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settings to provide a user-friendly and safe environment that allows patients to maintain their independence and self-esteem.34 In addition, when recognized, individuals with these changes should be referred to the appropriate healthcare provider.

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VISION:

After age 40, age-related visual changes are almost universal, with a decline in the normal functions of the eyes and an increase in eye disorders. The prevalence of visual impairment

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increases with age, with more than 90% of older adults reporting wearing eyeglasses35 The primary causes of visual impairment include: presbyopia, cataracts, macular degeneration, glaucoma and diabetic retinopathy.36 Several health conditions, such as diabetes and hypertension, commonly found in older adults, predispose to visual impairment. Since the incidence of vision loss increases with age, healthcare providers must accommodate to visual impairments. Due to age-related changes of the eyes, attention to environmental conditions in a health facility, such as having adequate lighting, eliminating glare from a shiny floor and using color contrast are significant issues to address for improved visual functioning and comfort of older adults.37 9

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Adequate vision is needed when patients are completing health history forms, reading medication labels, completing consent forms and navigating streets, stairs and curbs to arrive at the dental setting. Additionally, ineffective plaque biofilm removal can provide clues regarding possible vision issues, although motivation and skill must also be assessed. Ultimately, a

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change in vision can result in a loss of independence, difficulty reading and increase risk of falls. The environment for older adults in healthcare facilities can be improved by the use of uniform lighting, reading glasses available for patients to borrow, spot lighting to assist elders reading in waiting area, contrast paint on door knobs and floor trim and sans serif large font print on

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documents.

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HEARING:

Approximately 1 in 3 people between the ages of 65 and 74 has some degree of hearing loss and nearly half of those older than 75 have difficulty hearing which can have serious consequences when not recognized or managed.38, 39 With increasing age, the ability to hear high frequency sounds Is compromised. Presbycusis, or age-related hearing loss, is one of the most common chronic conditions among older adults, predisposing to a diminished quality of

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life, increased risk for social isolation, depression, and a decline in physical functioning.40 (Pratt) Presbycusis is typically sensorineural, involving the structures in the inner ear or cochlea and/or the auditory pathways in the brain. Many older adults who deny hearing loss may appear withdrawn and/or depressed, common consequences of hearing loss. Of those over 65 years hearing loss.41

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old with moderate to profound hearing loss, only 20 percent perceive themselves as having

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Although volume is often perceived to be the concern of older adults with hearing loss, the hallmark of age-related hearing loss is that speech is perceived as unclear, due to sound and word discrimination. For many, hearing aids can alleviate hearing impairment, however some elders are resistant as a stigma of ‘old’ is often associated with wearing a hearing aid. To facilitate communication, the patient with hearing loss can be queried during the medical history review as to their preferred communication style, such as lip reading, note writing, or using hearing aid. Background noise, often common in a dental setting, can complicate listening for many adults and becomes far more problematic for those with a hearing impairment. Reducing office music, staff chatter, running water and other equipment whenever

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possible will improve communication. Enunciating slowly and clearly in a low frequency and slightly louder than usual improves clarity and allows more time for the hearing impaired person

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to process the information.

Cognitive changes associated with aging

Older adults exhibit a wide variety of cognitive abilities ranging from cognition similar to that of younger people, to mild impairment to clinical dementia. Some people live to extreme old age

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without severe memory loss, although memory loss has been attributed to the aging process. Changes in brain structure and function are age-related events, and many factors influence memory and cognitive ability.42 Due to their enormous impact on individuals, families, the health

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care system and society as a whole, cognitive impairments present a major health issue in the US.

Identifying cognitive losses is challenging since dementia can present with a range of impairments, depending upon the disease stage, etiology and range of abilities. Providing healthcare for the cognitively impaired presents a wide range of ethical dilemmas, with decision-

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making competency a critical concern.

Dementia is a generic term used to designate chronically progressive brain disease that impairs intellect and behavior to the point where customary activities of daily living are compromised.

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Dementia is not a specific disease, but rather a description of a clinical state and does not imply causation or prognosis. Alzheimer’s disease is the most common type of dementia, with short

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term memory loss one of its hallmarks signs. Healthcare professionals often mistake early signs of dementia, which are often subtle and nonspecific, for normal aging changes, thus perpetuating the myths and fallacies about aging and dementia. Cognitively impaired patients may appear ‘normal’, especially when limited time is spent in conversation and observation. Once identified, long-term treatment plans need to be discussed with the individual and also possibly the caregiver. The healthcare team is responsible for identifying a realistic treatment plan, taking into account the potential impact of the disease.

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Activities of daily living Activities of daily living (ADLs) is a commonly used indicator of the degree of disability among older individuals. ADLs include bathing, dressing, eating, and getting around the house. Instrumental activities of daily living (IADLs) include preparing meals, shopping, managing

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money, using the telephone, doing housework, and taking medication. When ADL’s and IADL’s are used to measure disability, 28% of community-resident Medicare beneficiaries age 65+ reported difficulty in performing one or more ADL and an additional 12% reported difficulty with one or more IADL. Limitations in activities due to chronic conditions increases with age. As

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older are much higher than those for persons 65-74. 43

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shown in Figure 4, the rate of limitations in activities among noninstitutionalized persons 85 and

Health care professionals

To ensure the provision of quality oral health care for older adults, health care professionals require training in the care of medically complex, cognitively impaired elders. Practitioners must manage age and disease related conditions of the aging population. Issues of general and cognitive health, mobility, sensory changes, access issues, risk assessment, prevention, ability

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for maintenance and appropriate treatment planning must be integrated when planning and implementing care.

Risk assessment tools for oral disease are used by health care providers to identify risk factors

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associated with caries, periodontal disease and oral cancer. (See Hurlbutt, A Best Practice Approach to Caries Management this publication) Although these tools may be useful for most of the population, age-related modifications are needed to ensure their utility amongst frail and

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vulnerable older adults. Recommended modifications would include, but not be limited to: presence of age-related oral and physiologic changes, chronic and disabling conditions, hyposalivation, adverse drug reactions, cognitive conditions and socio-economic concerns. Health care providers need to be prepared to comprehensively treat geriatric patients by paying attention to a variety of parameters. These are provided in Box 1.

Education and Training

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There is an educational crisis in dental and dental hygiene education as it relates to the care of today’s elderly and those in the future. The current level of training in dental and dental hygiene programs addresses a minimal level of competency, with little emphasis on the older adult population categorized as special needs in predoctoral dental accreditation standards. (ADA –

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CODA) Clinical educational experience in geriatric dental care has been reported as the most effective method of increasing provider confidence and willingness in treating older adults44,45; more such rotations are indicated. Many dental professionals feel either inadequately prepared or are unwilling to provide dental care for this population.46 The education of dental

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professionals must change and adapt to meet the unique needs and demands of the vulnerable

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aging population.

Long-Term Care

Only 5% of the population 65 years and older reside in a long-term care facility, where the majority of residents are 85 years and older. (Figure 5 shows Medicaid enrollees in long-term care facilities) Not included in this cohort are the 733,400 (~3% of 65+) people residing in assisted living or residential care facilities47 Unlike most long-term care facilities that are

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regulated by federal and state laws, oversight of assisted living facilities primarily occurs at the state level.

Due to a variety of barriers, obtaining dental care for residents in long-term care facilities can be

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challenging. Oral health programs designed to care for residents in long-term care facilities are challenged with a medically complex, cognitively impaired population. Providing oral health care services in such a facility can be a rewarding and practice building opportunity for oral

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healthcare providers.

Oral healthcare services for the vulnerable older adult need to be available in diverse settings outside the traditional private practice. Now is the time to address the needs of these populations who are unable to access dental care in private offices. Although dental and dental hygiene education historically has been directed towards a career path primarily in the dental office practice, the curriculum must prepare graduates to assume a position in a variety of healthcare settings not limited to office settings.(See Isman and Farrell, Are Dental Hygienists

Prepared to Work in the Changing Public Health Environment?,this publication) However, restrictions vary by state and often limit the opportunities to be employed in settings where the 13

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vulnerable elder population can access dental care; namely in acute or long term care facilities, FQHC’s, nursing homes, or through the use of mobile services. Many states have adopted legislation that improves access to care for the underserved populations by enabling dental providers to work in alternative practice settings through direct access.(See Naughton, Direct

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Access Care: The Impact on Oral Health, in this publication)

Summary

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As a group, the elderly suffer disproportionately from oral disease and lack of access to oral health care. The oral health of the elderly becomes potentially more complicated as they become frail, homebound or institutionalized or when their access to oral health care is limited.

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This situation will continue to be a salient public health issue as the population of older and impaired adults increases in size, and the demand for oral health services grows. One approach to reduce this crisis in the future is to ensure that adults of all ages are informed about the need for oral health care throughout their lifetime. Elders and adults alike need to understand and manage their need for oral care services. Ensuring older adults have access to oral health care

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is critical, as oral health services are an essential component of primary health care.

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1. Kiyak HA., Reichmuth M. Barriers to and Enablers of Older Adults’ Use of Dental Services. JDE 2005; 69( 9): 975-986 2. Ettinger RL. Attitudes and values concerning oral health and utilization of services among the elderly. Int Dent J 1992; 42:373-84. 3. Martin, LG , Freedman, VA , Schoeni, RF , & Andreski, PM: 2009. Health and functioning among baby boomers approaching 60. Journal of Gerontology: Social Sciences, 64B(3), 369–377. 4. Searching for an Operational Definition of Frailty: A Delphi Method Based Consensus Statement. The Frailty Operative Definition-Consensus Conference Project J Gerontol A Biol Sci Med Sci 2013; 68 (1): 62-67. 5. Mouradian, WE. Huebner C, and DePaola D. "Addressing health disparities through dental-medical collaborations, part III: leadership for the public good." JDE. 2004; 68(5): 505-512. 6. Satcher, D. Oral Health in America: A Report of the Surgeon General. Department of Health and Human Services: 2000a; USPHS. www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/sgr/home.html 7. Chávez EM, Subar PE, Miles J, Wong A, Labarre EE, Glassman P. Perceptions of predoctoral dental education and practice patterns in special care dentistry. J Dent Educ 2011;75(6):726–32. 8. Beltrán-Aguilar ED, Barker LK. Canto MT et al., “Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis—United States, 1988–1994 and 1999–2002,” Morbidity and Mortality Weekly Report. Surveillance Summaries, 54, 1–43, 2005. 9. Crimmins E, “Trends in the Health of the Elderly,” Annual Review of Public Health 2004; 25: 79-98 10. Vaupel JW. Biodemography of human ageing Nature. 2010; 464, 536-542 11. Christensen K et al. Exceptional longevity. Proc Natl Acad Sci USA 2008: 105:1327413279 12. Seeman TE et al., “Disability Trends Among Older Americans: National Health and Nutrition Examination Surveys, 1988-1994 and 1999-2004,” American Journal of Public Health. 2010: 100-107. 13. Friedman VA, Martin LG, Schoeni RF. Recent Trends in Disability and Functioning Among Older Adults in the United States. A Systematic Review. JAMA 2002: 288 (24); 3137-3146. 14. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2010: Key Indicators of Well-Being. Washington, DC: US Government Printing Office. July 2010. http://www.agingstats.govDiabetes Statistics. 15. Diabetes Statistics: http://www.cdc.gov/diabetes/statistics/prev/national/figbyage.htm 16. Parekh AK, Barton MB. The Challenge of Multiple Comorbidity for the US Health Care System. JAMA. 2010;303(13):1303-1304. 15

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17. Hall KE. Aging and neural control of the GI tract. II. Neural control of the aging gut: Can an old dog learn new tricks? Amer. Jour. Physio Gastrointestinal and Liver Physio. 2002. 243; G827-G832. http://intl-ajpgi.physiology.org/ 18. Lakatta EG. Cardiovascular aging in health. Clinics in Geri Medicine. 2000;16: 419-443 19. Kenny RA. Syncope. 2003. In Hazzard WR, Blass JP, Halter JB, Ouslander JG & Tinetti ME (Eds) Principles of geriatric medicine and gerontology. NY; 1553-1562. 20. The National Academies. Open Book. The second fifty years: promoting health and preventing disability, 1992 21. Baum, BJ. "Current research on aging and oral health. Special Care in Dentistry. 1981:1 (3): 105-109. 22. Narhi TO, Meurman JH, Ainamo A. Xerostomia and hyposalivation. Causes, consequences and treatment in the elderly. Drugs Aging 1999;15:103-16 23. Dodds MWJ, Johnson DA, Yeh CK. Health benefits of saliva: a review. J Dent 2005;33:223-33. 24. Campbell N, Dehydration: best practice in the care home. Nursing & Residential Care:2012; 14: 21 25. Shay K. Crest Oral Health and the Older Adult. Oral B – Continuing Education Program. www.dentalcare.com/soap/ce_prot/ce8/overview.htm 26. Genco, R. J. and Borgnakke, W. S. (2013), Risk factors for periodontal disease. Periodontology 2000, 62: 59–94. doi: 10.1111/j.1600-0757.2012.00457. 27. Beck JD, Koch GG, Offenbacher S. Incidence of attachment loss over 3 years in older adults – new and progressing lesions. Community Dent Oral Epidemiol. 1995;23(5):291296. 28. Jeffcoat M. The association between osteoporosis and oral bone loss. J Periodontol. 2005;76(11 Suppl):2125-2132 29. Tezal, Mine, et al. "The relationship between bone mineral density and periodontitis in postmenopausal women."J Periodontol 2000;71:1492-1498 30. Zwicker D, Fulmer T. Reducing Adverse Drug Events. 2008. In Capezuti E, Zwicker D, Mezey M, Fulmer T. Evidence-Based Nursing Protocols for Best Practice. Third Edition. Springer Publishing, NY. 257-308. 31. Mangoni AA, Jackson SHD. 2003. Age-related changes in pharmacokinetics and pharmacodynamics: Basic principles and practical applications. British Journal of Clinical Pharmacology, 57(1), 6-14. 32. Hajjar I, Kotchen TA.. Trends in prevalence, awareness, treatment and control of hypertension in the United States, 1998-200. JAMA; 2003:290: 199-206. 33. Dillon CF, Gu Q, Hoffman HJ, Ko CW. Vision, Hearing, Balance and Sensory Impairment in Americans Aged 70 years and over: United States, 1999-2006. NCHS Data Brief. 2010; 31. US Department of Health and Human Services, National Center for Health Statistics. (http://www.cdc.gov/nchs/data/databriefs/db31.htm) 34. Yellowitz JA, Goldblatt R. The Senior Friendly Office. 2014. Chapter 37 In Friedman P. Geriatric Dentistry. Caring for an Aging Population. Wiley and Sons. 35. Campbell V, Crews H, Moriarty D, Zack M & Blackman D. 1999. Surveillance for sensory impairment activity limitation and health-related quality of life among older adults: US. 1993-1997. MMR Surveillance Summaries, 48 (SS08). 131-156. 16

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36. Eye Health Needs of Older Adults. Literature Review. Exerpt from the National Eye Health Education Program Five-Year Agenda. http://www.nei.nih.gov/nehep/research/The_Eye_Health_needs_of_Older_Adults_Literat ure_Review.pdf 37. Orr AL. Issues in Aging and Vision: A Curriculum for University Programs and In-Service Training, American Foundation for the Blind, 1998 38. NIH National Institute on Deafness and Other Communication Disorders (NIDCD) NIH Publication No. 13-4913. November 2013. http://www.nidcd.nih.gov/health/hearing/Pages/older.aspx 39. Walling AD, Dickson GM. Hearing loss in older adults. Am Fam Physician. 2012 Jun 15;85(12):1150-6. 40. Pratt SR, Kuller L, Talbott EO et al. Prevalence of hearing loss in Black and White elders: Results of the Cardiovascular Health Study. J Speech Lang Hear Res. 2009: 52: 973- 989 41. Chou R, Dana T, Bougatsos C, Fleming C, Beil T. Screening adults aged 50 year or older for hearing loss: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;154(5):347-355. 42. Yellowitz, JA. Cognitive function, aging, and ethical decisions: recognizing change. Dent Clin North Am. 2005 Apr;49(2):389-410 43. A Profile of Older Americans: 2012. www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf Administration on Aging, Administration for Community Living, US Department of Health and Human Services 44. Chávez EM, Subar PE, Miles J, Wong A, Labarre EE, Glassman P. Perceptions of predoctoral dental education and practice patterns in special care dentistry. J Dent Educ 2011;75(6):726–32. 45. Nochajski TH, Davis EL, Waldrop DP, Fabiano JA, Goldberg LJ. Dental Students’ Attitudes About Older Adults: Do Type and Amount of Contact Make a Difference? J Dent Educ October 1, 2011 vol. 75 no. 10 1329-1332 46. Levy N, Goldblatt RS, Reisine S. Geriatrics Education in US dental schools: where do we stand, and what improvments should be made? J Dent Educ 2013 77. 10 1270-1285 47. National Center for Assisted Living, Assisted Living State Regulatory Review 2010 –, 2013. http://www.ahcancal.org/ncal/resources/Documents/2013

Box 1-Components of Comprehensive Care for Elders Determine reliability of medical and dental history reports 17

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Ascertain mental status for providing adequate informed consent Assess and manage key risk factors in disease progression Diagnose and treat oral disease, Utilize appropriate and rational treatment modalities Manage behavior appropriately

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Figure 1. Percent of US population in Selected Age Groups, 1970 projected to 2050

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Source: Population Reference Bulletin analysis of data from US Census Bureau. www.Prb.org Vol. 66 (1) February 2011.

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Figure 4. Percent of Persons with Limitations in Activities - Source: A Profile of Older Americans: 2012 Based on online data from the U.S. Census Bureau’s American Community Survey. The Centers for Medicare and Medicaid Services’ Medicare Current Beneficiary Survey. The National Center for Health Statistics, including the NCHS Health Data Interactive data warehouse 21

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Figure 5

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Elder's oral health crisis.

Dentistry must prepare to meet the challenges of providing oral health services to the increasing numbers of medically compromised and cognitively imp...
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