Ethical Issues in Geriatric Dentistry

Ethical issues involved in providing dental care to geriatric patients have generally been ignored in the practice and academic literatures. Elderly patients require special ethical consideration because of increased burden of illness, sensory deficits which may interfere with symptom interpretation and communication, fiscal constraints and ageism among both providers and patients. A taxonomy of ethical issues is provided including issues pertaining to the patient, the family, service providers, and the health care system. Suggestions are made for improving decision making in geriatric dental care.     

Utilisation of dental services in a university hospital palliative and long-term care unit in Geneva

Objectives: Dental care plays an important role in the multidisciplinary approach, which is used in palliative and long‐term care to address the complex needs of terminally ill patients. The aim of this study was to assess the utilisation of dental services in a University Hospital Palliative and Long‐term Care Unit. Material and method: Over an observation period of 13 months, structured questionnaires were filled in after each dental appointment. The survey covered three main topics: the initiation and incentive from the dental consultation, particular difficulties because of the patient’s health or the hospital’s organisation as well as the accomplished treatment. Results: Two hundred and seventy‐five questionnaires from a total of 102 patients were available for analysis. The patients’ median age was 83 years (SD 10.3, range 49–101 years), 63 were female, 39 male. A majority of first appointments were initiated by a physician (n = 49 of 102), mainly because of pain (n = 62 of 275). 10.5% of the appointments were cancelled on the same day. Only one‐fifth of the patients were able to reach the practice on foot. Six used a walking stick and 54 relied on a wheelchair. Eighteen patients needed to be seen in their bed. The most frequently performed procedures were extractions and removal of denture sore spots (n = 67 of 275) followed by the manufacturing of new dentures (n = 38 of 275). In more than 17% of the appointments, no particular treatment was performed. Conclusion: The utilisation of dental services in terminally ill and severely compromised elderly patients shown justifies a dental service in a palliative care or geriatric hospital setting. The particular dental work profile requires a practitioner with empathy and professional experience.     

Care Needs of the Elderly Treated at a Dental School1

Increased longevity and recently intensified emphasis on gerodontology mandate that dental students'exposure to clinical care of the elderly be enhanced. The extent to which individual students can be exposed to geriatric dental care depends on the availability of elderly patients to dental school clinics and the treatment needs of these patients. The purposes of this study were (1) to determine the dental treatment needs of geriatric patients who seek care at a dental school, and (2) to ascertain if differences exist between the needs of older versus relatively young geriatric patients. Data collected on 128 elderly patients during a three month period indicate that 57% of the aged were either edentulous at examination or treatment planned to become edentulous and receive two full dentures. The remaining 43% were treatment planned to remain dentulous and receive therapies other than full upper and lower dentures. More older geriatric patients required full dentures than their younger cohorts. More young elderly required prophylaxes, scalings, root planing therapy, dental restorations, and partial dentures. Additional to their denture requirements, aged patients appear to have sufficient non-prosthetic needs to allow for meaningful gerodontic experience by students.     

Recent Advances in Behavioral Research in Geriatric Dentistry1

This paper examines recent studies in behavioral science and health services aspects of geriatric dentistry. With the increased focus on special needs of older patients, researchers have become concerned with psychological and sociocultural factors that influence older people's oral health status, behavior, and attitudes. Studies of dental service utilization patterns among subgroups of the elderly, including those in long-term care settings, will be reviewed. Research on methods to improve oral health care behaviors will be discussed, with their implications for developing oral health promotion and service delivery programs. The special oral health needs of cognitively impaired and frail elderly will be reviewed. Studies of clinical decision-making in geriatric dentistry have been conducted. These studies have revealed significant gaps in dental professionals' knowledge and attention to the special needs of older patients. This and other aspects of behavioral research suggest the need for better methods to disseminate research findings in geriatric dentistry to clinical practice in this field. The presentation will discuss ways of improving dissemination and transfer of research findings to the clinical management of aged patients.     

Maryland veterans' knowledge of risk factors for and signs of oral cancers and their use of dental services

Objectives : The purpose of this study was to evaluate outpatient veteran'í knowledge about risk factors for and signs of oral cancers, and their utilization of dental services. Design : Patients receiving primary health care services were surveyed during August 1997. Setting : Primary health care services at three medical centres within the VA Maryland Health Care System (VAMHCS). Subjects: A total of 135 outpatient veterans were interviewed. Intervention: Questionnaire administered by trained interviewers. Main outcome measures : Fifteen percent of the sample were eligible for dental care at the VA, while over 40% of those veterans participating in the study were unaware of their VA eligibility for dental services. Fifty six percent of the total sample received dental services from a private dentist, while 13% reported they had no provider of dental care. Of those not eligible for dental care at the VA (n=115), the majority (67%) received dental care from a private dentist. Current use of tobacco and alcohol was reported by 27% of the sample. Nonsmokers were more likely to visit the dentist in the previous year than smokers (OR=2.39, 95%C.I. 1.11,5.12). Although 84% correctly identified tobacco use as a risk factor, only 39% correctly identified regular alcohol use as a risk factor. Conclusions : Veterans at higher risk for oral cancers were less likely to have visited the dentist in the previous year, and, overall, were ill informed and misinformed about these cancers.     

A Geriatric Dental Resident Training Program

The exponential increase in the size of the U.S. population 75 years and older places new demands on the health care delivery system. Primary among these is the need to train professional manpower in the attitudinal, cognitive, and clinical skills essential to the management and treatment of medically compromised and functionally dependent elderly patients. The university-affiliated skilled nursing facility with a rehabilitation-oriented interdisciplinary staff offers an ideal setting for these educational objectives. The rationale, organization, and experience of a unique geriatric/general practice dental resident training program in such a teaching nursing home is delineated in this presentation.     

A 30-year review of a geriatric dentistry teaching programme

doi: 10.1111/j.1741‐2358.2011.00471.x A 30‐year review of a geriatric dentistry teaching programme Objective: To review the development of the Geriatric Dental and Special Needs Education programme at the University of Iowa over the last 30 years. Background: The programme at Iowa evolved from a didactic elective programme taught by a single faculty person to a required didactic and clinical programme, which includes a Special Care Clinic in the dental school and a mobile unit with portable dental equipment which serves ten area nursing homes with comprehensive care. Materials and methods: Changes have been made in the programme over time based on formal and informal feedback from students and graduates, and we have also looked at the impact of the programme on dental services to our target population. Results: The factors influencing the curriculum development are identified and discussed. Conclusion: As no dental schools are the same, some general applications are suggested from the Iowa experience.     

Continuing dental care for Highlands elderly: current practice and attitudes of dental practitioners and home supervisors

Objective : To investigate current practice and attitudes of Highland dentists and home supervisors to continued dental care of elderly residents. Methods : A cross‐sectional questionnaire was designed to survey the current practice and attitudes of Highland dentists and residential care supervisors in their provision of dental care for the elderly at home and in long stay accommodation. Results : The response rate was 94% of dentists and 79% of homes. Despite 86% of dentists providing domiciliary care and 93% of homes transport to a surgery, no more than a quarter of residents had had contact with a dentist in the previous year. The distribution of residents varied with dependant individuals living in nursing units and the least dependant in residential homes. Only 1% of all residents were totally bed bound. Domiciliary patients were less likely to receive continuing care compared with those seen in a surgery and 75% of homes had to initiate dental care. In terms of patient referral, the majority of GDPs would refer uncooperative patients, salaried dentists would refer those with complex medical histories and community dentists would refer those requiring complex treatments. A dental assessment was undertaken in 46% of homes and 81% of these kept a record of dental care. Conclusion : This study highlights the need for a co‐ordinated, seamless continuing dental care service, tailored to the actual needs of the elderly individuals it is designed to serve, particularly in a remote and rural area.     

Undergraduate geriatric education through community service learning

doi: 10.1111/j.1741‐2358.2010.00444.x Undergraduate geriatric education through community service learning Introduction: Despite the exponential growth of the elderly population worldwide, geriatric education has been a formal component of only a few dental schools’ curricula. Objective: To describe the geriatric community service learning (CSL) component of the professionalism and community service (PACS) module, and to explore a CSL project carried out by a group of first year dental students at a long‐term care facility. Methods: A literature review was performed to present and describe the CSL component of the PACS module. Students’ personal reflections were used to illustrate some of the joys and challenges of experiencing a long‐term care facility environment. Results: The newly developed PACS module combines community service learning with the long‐term care experience. Students develop, apply and evaluate an educational health promotion activity in a long‐term care facility. Conclusions: The PACS module has encouraged students to acquire comprehensive knowledge and awareness of the needs and dynamics of a long‐term care as they collaboratively interacted with personnel from the facility to develop their projects. The authors would like to engage other schools in discussing the need to integrate community‐based geriatric education into their dental curricula.     

An Introduction to a Symposium in Geriatric Dentistry: Issues in Gerontology

The papers in this collection address geriatric dentistry at a time when society is rapidly becoming older. More than ever before, all dental care providers must understand the special needs of elderly patients and the unique biological features of the aged person that affect the diagnosis and prognosis of oral pathology. Attitudes about aging in the elderly must be discussed within the context of the health care setting so we can address the needs for social change, particularly in the dental and medical professions. This symposium brings together a series of papers on topics that are being researched in geriatric dentistry. The topics are diverse, including methods to finance dental care, psychiatric considerations, temporomandibular joint dysfunction, prosthodontics, artificial saliva and nutritional factors, immunology and the new frontiers in dental science, periodontal disease and oral cancer. And as an epilogue to our theme, a dentist with a primarily geriatric practice reflects on the difficulties and the rewards of the elderly patient. Improving the quality of life is the goal of aging research and to investigate aging legitimately we must ask in a systematic manner, what is aging? In this introduction, we discuss briefly the several theories of aging that are guiding research efforts.     

Geriatría transversal. Un reto asistencial para el siglo xxi

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients’ risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term “Cross-speciality Geriatrics” is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.     

New structures in geriatric care: the geriatric home consultation by a nurse practitioner

The growing number of elderly and chronically ill people causes an increasing demand for care. New patterns in care for geriatric patients are required, to guarantee geriatric care in the future. In the Transmural Model for Geriatric Care, the geriatric nurse practitioner participates in geriatric home consultation. The geriatric nurse practitioner makes the home visits of the geriatrician. First experiences with home consultation by geriatric nurse practitioner are positive. The input of the geriatric nurse practitioner in home consultation has two goals: care substitution and improvement of quality of care. Substitution of care enlarges the possibilities of the geriatrician, which are limited now, because of the enormous demand for geriatric care. The specific tasks of the geriatric nurse practitioner are functional assessment and care coordination.     

Eerste ervaringen met patiënt gerapporteerde uitkomstmaten in de geriatrie

Background

There are difficulties in expressing the value of geriatric care in outcome measures such as recovery or mortality rates. Rather, the goal of geriatric care is to maintain quality of life and functionality. As such, patient reported outcome measures (PROMs) may be more effective in measuring the value healthcare creates in geriatric patients. In 2015 the Dutch Geriatrics Society asked their Committee Quality of Care Measurement to select a suitable PROM for the purpose of measuring the outcomes of geriatric hospital care.

Methods/results

The goal of this PROM is to measure outcomes of an hospital admission in the perspective of the elderly patient who was admitted to a geriatric ward. A group of caregivers in geriatric care identified four possible PROMs in the literature and based on selection criteria the TOPICS-MDS was chosen as most suitable. To increase the feasibility of implementation in daily practice, an item reduction study was performed and this resulted in a short form: TOPICS-SF. Two pilot studies in three hospitals took place on a geriatric ward. A response of 62% was observed during the first pilot with TOPICS-MDS and a response of 37% was observed during the second pilot with TOPICS-SF. The Katz-15 improved during hospital stay and during one month at home after discharge.

Conclusion

The TOPICS-SF has been selected as PROM for the older patient receiving geriatric care and is feasible in practice. More research in different settings and with different moments of measurements is needed to evaluate the responsiveness of TOPICS-SF and the conditions for feasible implementation in daily practice.

     

Dental Care for the Elderly

The geriatric population in many parts of the United States is underserved by dentistry. Socioeconomic problems, difficult access to dental facilities, and confusion about the need for dental care often prevent the elderly from seeking dental service. Because dental diseases are not life threatening or outwardly disabling, administrators of institutions for the elderly and health legislators place a low priority on dental care for the elderly. These factors working in concert with the insidious, progressive, and cummulative nature of denture diseases contribute to the poor dental health experienced by some segments of the geriatric population. Dentistry has the manpower and the technology to improve the oral health of the elderly, but society must be made aware of the importance of dental health in the total health of elderly persons in order that dentistry be given a chance to achieve that goal.     

The Yad Sarah geriatric dental clinic, a different model

Introduction: There are not sufficient dental services for elderly people around the world. Yad Sarah is an Israel‐wide network of volunteers aiding sick, elderly, isolated and housebound people with an array of services aimed at making home care possible. It provides medical and social services to more than 380 000 elderly persons per year and in addition, lends medical equipment free of charge, has day rehabilitation centres, legal aid council for seniors, provides transportation for the disabled, meal deliveries and geriatric dental services. Materials and methods: The latter are equipped with five dental units (one mobile unit) and a dental laboratory. During the 5 years from 2000 to 2004 the dental services provided dental care for 3890 elderly patients with the main clinic located in Jerusalem. Patients pay an average of 70% of the cost price of their dental care, with the difference being subsidised by Yad Sarah. Of the 515 patients who applied for treatment in 2004, 54% possessed natural teeth in both jaws, 28% were fully edentulous, 12% were edentulous in the maxilla and 6% were edentulous in the mandible. Females applied for dental treatment more often than the male population. Older patients (75–101 years old) required oral care at their homes or at old age residences, more frequently than the younger age groups (60–74 years old). Conclusion: Dental treatment was administered by 70 volunteer dental surgeons, two certified dental hygienists and dental hygienist students. The clinical staff was provided with a comprehensive in‐service training in geriatric dentistry during the 3‐year service learning period. A survey in 2004 showed that 83% of the selected patients were satisfied, compared with 14% who were not. The reasons for satisfaction were, mainly, the personal relationship with the attending staff (41%) and the professional ability of the dental team (46%).     

Access to National Programs and Needs for Continuing Education1

This paper describes the American Dental Association's ongoing efforts aimed at improving access to comprehensive dental care for special population groups. Primary attention is directed to the elderly population, a major priority of the Association's Access Program. In addition to highlighting the basic components of the Access Program, a review of some of the barriers affecting utilization of dental care by the elderly and programs designed to eliminate those barriers is provided. Finally, the author offers some thoughts regarding the need for appropriate continuing education activities directed to the general dentist on the topic of geriatric dentistry.     

Oral disease experience of older adults seeking oral health services

doi:10.1111/j.1741‐2358.2009.00311.x
Oral disease experience of older adults seeking oral health services Objective: The objective of this investigation was to describe the dental disease (dental caries and alveolar bone loss) experience in a sample of community‐dwelling older adults who regularly utilize dental services in New York City. Background: Public financing for dental care directed at older adults in the United States is minimal. Improved preventive methods, primarily the use of fluorides, have resulted in declines in tooth loss, and concomitant increase in risk for dental diseases among older adults. While the oral disease burden in institutionalized elderly and those unable to access services is well‐documented, the dental care needs of older adults who access dental services are not well documented. Materials and Methods: Radiographic and record review were used to determine prevalence of dental caries, alveolar bone loss, frequency of service utilization, and medical status in this cross‐sectional investigation of a sample of older adults (N = 200) using dental services at Columbia University College of Dental Medicine. Results: Only 9% of the sample was completely edentulous, the mean DMFT was 19.9 and mean alveolar bone loss was 3.6 mm. Missing and Decayed Teeth accounted for 57.8% and 6.5% of the total caries burden respectively. Missing Teeth and alveolar bone loss increased with increasing age, but there was no increase in Decayed Teeth. Conclusions: While access to and utilization of dental services may result in improved tooth retention, older adults who use dental services continue to have dental care needs, especially periodontal care needs.