Informing the debate on oral health care for older people: a qualitative study of older people’s views on oral health and oral health care

doi: 10.1111/j.1741‐2358.2009.00274.x
Informing the debate on oral health care for older people: a qualitative study of older people’s views on oral health and oral health care Background: Older people represent a growing and diverse section of the population. As age increases, people are more likely to experience health and mobility problems and be at higher risk of developing oral disease. Nevertheless, few older people utilise primary oral healthcare services. It is therefore important to understand the value older people place on oral health and dental services to inform providers and planners of oral health care. This research was conducted as part of a study to identify potential ways of minimising barriers to oral health care in older people. Objectives: To explore perceptions of oral health and oral healthcare services amongst older people living in a socially deprived inner city area and how these are related to service utilisation. Methods: A qualitative approach was utilised to explore the range of issues related to older people’s perceptions of oral health and their views on health care. This involved a combination of focus groups and semi‐structured individual interviews with older people and their carers. Data analysis was conducted using the Framework approach. Results:

• ? Response: Thirty‐nine older people and/or their carers participated in focus groups.
• ? Oral health perception: Oral health was associated with the presence of natural teeth, the absence of pain, practical/social functioning, preferably supported by positive assessment by a dentist.
• ? Oral health life‐course: Older people have a long and complex dental history. Past negative experiences with oral health care, especially in childhood, strongly influenced present attitudes towards dentistry and dental personnel.
• ? Citizenship and right to health care: There was a strong perception that, as ‘British citizens’, older people should have a right to free health care and that the National Health Service (NHS) should support them in this phase of their life.

Conclusions: The oral health life‐course of older people is an important influence on their perceptions of oral health and dental attendance. They consider oral health of importance and place great emphasis on their citizenship and rights of access to state funded oral health care. This raises important issues for the funding and delivery of NHS oral health care for older people.     

The Dark at the Bottom of the Stairs: Performance and Participation of Hospitalized Older People

Like all social actors, older people draw on cultural meanings to perform identity. However, when advanced aging brings loss of status as full persons, particularly when it is associated with sickness and dependency, older people can be deemed unsuitable for active medical treatment and care. In addition, loss of status may make it difficult for older people to influence how they and their needs and wants are identified, and how their future life (or death) is conceived. This article discusses how some older people who are admitted to hospital as acute medical emergencies participate in staff's discursive practices to establish a positive clinical identity. By lying low and effacing their distinctiveness as individuals and as social beings, some older people are able to maintain their inclusion in positive medical categories. The article argues that older people are committed to their inclusion in the medical domain because their association with positive medical categories helps them keep at bay the inchoate, the dark at the bottom of the stairs.     

Opening the black box: an encounter in the corridors of health services research.

Health services research has become more prominent as a result of the NHS reforms. Both providers and purchasers want to know exactly where the money is spent and how it could be used more effectively. How best to obtain information about health services is the subject of some debate within and between disciplines engaged in such research. Because of their training doctors are often sceptical of anything other than formal clinical trials and research which produces statistical data. Some sociologists argue that another way to find out what is actually happening in the NHS is to observe people at work and talk to them. This article debates these differing views of research methods. For effective research both quantitative and qualitative approaches need to be used.     

Medical Tourism: A Cost or Benefit to the NHS?

‘Medical Tourism’ – the phenomenon of people travelling abroad to access medical treatment - has received increasing attention in academic and popular media. This paper reports findings from a study examining effect of inbound and outbound medical tourism on the UK NHS, by estimating volume of medical tourism and associated costs and benefits. A mixed methods study it includes analysis of the UK International Passenger Survey (IPS); interviews with 77 returning UK medical tourists, 63 policymakers, NHS managers and medical tourism industry actors policymakers, and a review of published literature. These informed costing of three types of treatments for which patients commonly travel abroad: fertility treatment, cosmetic and bariatric surgery. Costing of inbound tourism relied on data obtained through 28 Freedom-of-Information requests to NHS Foundation Trusts. Findings demonstrate that contrary to some popular media reports, far from being a net importer of patients, the UK is now a clear net exporter of medical travellers. In 2010, an estimated 63,000 UK residents travelled for treatment, while around 52,000 patients sought treatment in the UK. Inbound medical tourists treated as private patients within NHS facilities may be especially profitable when compared to UK private patients, yielding close to a quarter of revenue from only 7% of volume in the data examined. Costs arise where patients travel abroad and return with complications. Analysis also indicates possible savings especially in future health care and social costs averted. These are likely to be specific to procedures and conditions treated. UK medical tourism is a growing phenomenon that presents risks and opportunities to the NHS. To fully understand its implications and guide policy on issues such as NHS global activities and patient safety will require investment in further research and monitoring. Results point to likely impact of medical tourism in other universal public health systems.     

DOES JUSTICE REQUIRE THAT WE BE AGEIST?

This paper restates some of the principal arguments against an automatic preference for the young as advocated by Kappel and Sandøe, arguments many of which have been extant for over a decade but which Kappel and Sandøe largely ignore. It then goes on to demonstrate that Kappel and Sandøe's "indifference test" fails to do the work required of it because it can be met by unacceptable conceptions of justice. The paper develops a number of new arguments against what I have called "ageist" preferences for the young or for those with long life expectancy. Finally I show that Kappel and Sandøe must believe that murdering older people is less morally wrong than murdering the young and that people relying on arguments such as theirs will have to accept the moral respectability of killing the innocent in order to maximise units of lifetime.     

Utility of ADL index for partially dependent older people: discriminating the functional level of an older population

In the present study, the ADL index for the partially dependent older people (Demura et al., 1999) was applied to 218 bedridden (BED), 466 partially dependent (PD) and 245 independent living (IL) people in older groups. The purposes of this study were to clarify the meaning of the evaluation of this index and to examine how ADL items are useful in determining each older group. It is suggested that a perfect score with our ADL index means independent living level, and a score of zero means bedridden level. The results of discriminant analysis indicated that four items with low-difficulty, such as "eating," "going to the toilet," "tossing about in bed" and "writing," are useful in determining if the PD is becoming bedridden. While five items with high-difficulty, such as "putting on slacks," "putting on trousers," "standing up from a sitting posture," "going up stairs" and "washing the whole body," are useful in determining if the PD is becoming independent living. Furthermore, it is inferred that the possibility of falling into a bedridden situation increases when the total score is 5 or less, while the functional level is close to independent living when the total score is 13 or more. These findings make clear the meaning of the evaluation of our ADL index. Furthermore, the functional level of older population may be screened using evaluation of total and item scores of this ADL index.     

Responsibilities in elderly care: Mr Powell's narrative of duty and relations

In Western countries a considerable number of older people move to a residential home when their health declines. Institutionalization often results in increased dependence, inactivity and loss of identity or self-worth (dignity). This raises the moral question as to how older, institutionalized people can remain autonomous as far as continuing to live in line with their own values is concerned. Following Walker's meta-ethical framework on the assignment of responsibilities, we suggest that instead of directing all older people towards more autonomy in terms of independence, professional caregivers should listen to the life narrative of older people and attempt to find out how their personal identity, relations and values in life can be continued in the new setting. If mutual normative expectations between caregivers and older people are not carefully negotiated, it creates tension. This tension is illustrated by the narrative of Mr Powell, a retired successful public servant now living in a residential home. The narrative describes his current life, his need for help, his independent frame of mind, and his encounters with institutional and professional policies. Mr Powell sees himself as a man who has always cared for himself and others, and who still feels that he has to fulfil certain duties in life. Mr Powell's story shows that he is not always understood well by caregivers who respond from a one-sided view of autonomy as independence. This leads to misunderstanding and an underestimation of his need to be noticed and involved in the residential community.     

Financial Strain, Religious Involvement, and Life Satisfaction Among Older Mexican Americans

The purpose of this study is to see if financial strain affects the religious involvement and life satisfaction of older Mexican Americans. In the process, an effort was made to explore the factors that promote financial strain in this ethnic group, including immigration status and English language use. The data come from a nationwide survey of older Mexican Americans. Support was found for the following core relationships in the study model: (1) older adults who were born in Mexico will have less schooling; (2) less education will be associated with less frequent use of English; (3) less frequent use of English will be associated with greater financial strain; (4) greater financial strain leads to less formal involvement in the church; (5) older people who are less involved in the church will have a diminished sense of religious meaning; and (6) older adults with a lower sense of religious meaning will be less satisfied with life.     

Inequity of access to investigation and effect on clinical outcomes: prognostic study of coronary angiography for suspected stable angina pectoris

Objectives To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates.Design Multicentre cohort with five year follow-up.Setting Six ambulatory care clinics in England.Participants 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method.Main outcome measures Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events.Results In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event.Conclusions At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.     

The effect of demographic characteristics on self-medication patterns: a cross-sectional nationwide study from Slovenia

Self-medication is defined as the use of medicines without medical supervision to treat one's own ailment. It is apart of a help-seeking behaviour that depends on socio-cultural and personal factors, which is why people react to the illness differently and also take different measures to cope with it. The aim of this study was to explore the Slovenian citizens' attitudes towards self-medication. The study included a random sample of 1,000 Slovenian inhabitants, stratified to all Slovenian regions. This was a postal survey. Participants were mailed a self-administered questionnaire about attitudes towards self-treatment. In the statistical analysis we used independent t-test and chi2-test. We received 410 responses (41.0% response rate). In the past year, 389 (94.9%) respondents practiced self-medication. Most respondents (209, 52.1%) supported and used it in everyday life. The majority of the respondents (274, 77.2%) practiced self-medication when symptoms emerged. When symptoms lasted for one week or less, 210 (56.5%) of the respondents practising self-medication visited their doctor. The respondents agreed mostly with the statement that their doctor had a positive relationship towards self-medication. Younger people were more confident about the absolute safety of self-medication whereas older people were more certain that they could practice it no matter what disease they might have. As self-medication is very common among Slovenian population and various demographic factors affect the opinions about it and the reasons for its use and also a doctor-patients communication about it, it is important that doctors, especially those in primary health care settings always ask about its use. This is of a particular importance when dealing with older and retired patients, which are more likely to suffer from more chronic diseases and use alternative medicine, which is a common part of self-medication. Also, it is important to educate young people about possible unsafe practice of self-medication.     

OxDONS syndrome: the inevitable disease of the NHS reforms.

The financial demise of Oxford''s department of neurosurgery (OxDONS) was precipitated by the financial rules of the reformed NHS. In particular it was produced by the failure of "resources to follow patients"; the requirement that "prices have to follow costs"; and the use of private income for revenue expenditure, not capital expenditure. This process will eventually affect all hospital departments, but it affected the unit in Oxford sooner as it started as "efficient"--that is, underresourced--and has depended on income from extracontractual referrals and private work. Current NHS accounting rules act as a disincentive to private income being generated in NHS hospitals, and consultants should be aware of this.     

Elderly and humor: a review

Ageing can be associated with physical, cognitive and/or social loss. Most older people, however, cope well with this loss, perhaps by using humour. In this review the research findings concerning humour were collected. Twenty six relevant publications were found. The sense of humour does not seem to be greater in older than in younger adults. There are no indications that humour appreciation or production is associated with longevity. In older people there is a correlation between humour on the one hand and well-being and morale on the other. It has not been proven, however, that the use of humour by the elderly people has a favourable influence on their health. In health care for older people humour is sometimes used as a therapy. Scientific evidence of any positive effects of humour on mental health was not found. It is perhaps better for caretakers to show appreciation for the humour of older people than to make jokes about older people oneself.     

Onderwijs in het Nationaal Programma Ouderenzorg

The Netherlands Organisation of Health Research and Development started in 2008 the Dutch National Care for the Elderly Programme (in Dutch abbreviated as NPO) with the aim to improve the quality of life for the frail older people through better quality of care (health, social, community) which is tailored to the needs and wants of older people. The delivery of good care is related with competent professional behaviour which is inextricably linked to the education of professionals. This article presents an overview of 32 educational programmes developed within the NPO. Within the NPO different educational programmes were developed on relevant themes to improve elderly care. However, the programmes focused mainly on professionals in health care, especially those working in primary care. For nurses and nursing assistants and more or less for physicians also different educational programmes were developed. Educational programmes for paramedics or professionals working in social care, housing or in the municipalities were scarce. This is also the case for specific themes in elderly care like loneliness or (domestic) violence. Moreover, none of the experiments focused on older people or informal care givers. Although 22 of the 32 projects developed educational programmes for different groups, multi – or interdisciplinary education is rare in these programmes. Based on the overview we advise the development of more educational programmes on: target groups which were less or not addressed in the NPO, like professionals in social care and paramedics; multi- or interdisciplinary collaboration; and themes, like loneliness in older people and elder abuse.     

Biomechanics for inclusive urban design: Effects of tactile paving on older adults' gait when crossing the street

In light of our ageing population it is important that the urban environment is easily accessible and hence supports older adults' independence. Tactile 'blister' paving was originally designed to provide guidance for visually impaired people at pedestrian crossings. However, as research links irregular surfaces to falls in older adults, such paving may have an adverse effect on older people. We investigated the effects of tactile paving on older adults' gait in a scenario closely resembling crossing the street. Gait analysis of 32 healthy older adults showed that tactile, as compared to smooth, paving increases the variability in timing of foot placement by 20%, thereby indicating a disturbance of the rhythmic gait pattern. Moreover, toe clearance during the swing phase increased by 7% on tactile paving, and the ability to stop upon cue from the traffic light was compromised. These results need to be viewed under the consideration of limitations associated with laboratory studies and real world analysis is needed to fully understand their implications for urban design.     

Impact of a COPD Discharge Care Bundle on Readmissions following Admission with Acute Exacerbation: Interrupted Time Series Analysis

ObjectivesWe evaluated the impact of a COPD discharge care bundle on readmission rates following hospitalisation with an acute exacerbation.DesignInterrupted time series analysis, comparing readmission rates for COPD exacerbations at nine trusts that introduced the bundle, to two comparison groups; (1) other NHS trusts in London and (2) all other NHS trusts in England. Care bundles were implemented at different times for different NHS trusts, ranging from October 2009 to April 2011.SettingNine NHS acute trusts in the London, England.ParticipantsPatients aged 45 years and older admitted to an NHS acute hospital in England for acute exacerbation of COPD. Data come from Hospital Episode Statistics, April 2002 to March 2012.ResultsIn hospitals introducing the bundle readmission rates were rising before implementation and falling afterwards (e.g. readmissions within 28 days +2.13% per annum (pa) pre and -5.32% pa post (p for difference in trends = 0.012)). Following implementation, readmission rates within 7 and 28 day were falling faster than among other trusts in London, although this was not statistically significant (e.g. readmissions within 28 days -4.6% pa vs. -3.2% pa, p = 0.44). Comparisons with a national control group were similar.ConclusionsThe COPD discharge care bundle appeared to be associated with a reduction in readmission rate among hospitals using it. The significance of this is unclear because of changes to background trends in London and nationally.     

The environment of ageing.

The issue of housing and the wider environment for an ageing population is one where there are many unanswered questions. In this paper a number of key issues are discussed and for each of these the focus is on three aspects. These are the current situation, its reasonableness and what research is needed in order to make decisions about policy and practice. The first three issues relate to the profile of older people themselves and the importance of home to them. The changing profile of older people is not just about an ageing population but also about the growing prominence of those with dementia, women, people from black and ethnic minority groups and one person households, yet little is known about the type of housing which should be provided. Of equal concern is the widening gap between those with a high standard of living (including housing) and those with a low standard of living. The importance of home to older people means that research must focus on how people can be enabled to remain there, and also on the costs, financial and otherwise, to carers and to society. The next three issues relate to the type of housing older people live in and moves in later life. The startling change in the tenure pattern with a growth of owner occupation brings problems as does the decline in social housing. The advantages and disadvantages of the different types of housing--mainstream and specialized--for older people are relatively well known. However the balance between the two needs more research as does that on retirement communities. While it is well known that there are peaks of migration in old age and that moves are often made in haste, little is known about the process of decision making. The final two topics concern links between housing and other aspects of older people''s lives. On health more research is needed on temperature, mortality and morbidity, homelessness and accidents and especially on links between services. These topics have implications for planning and design. The emphasis should be on a multidisciplinary approach using a variety of quantitative and qualitative techniques with an emphasis on dissemination.     

Implications for health services.

Health services for older people in the NHS have developed pragmatically, and reflect the nature of disease in later life and the need to agree objectives of care with patients. Although services are likely to be able to cope with the immediate future, the growth of the elderly population anticipated from 2030 calls for long-term planning and research. The issue of funding requires immediate political thought and action. Scientifically the focus needs to be on maximizing the efficiency of services by health services research and reducing the incidence of disability in later life through research on its biological and social determinants. Senescence is a progressive loss of adaptability due to an interaction between intrinsic (genetic) processes with extrinsic factors in environment and lifestyle. There are grounds for postulating that a policy of postponement of the onset of disability, by modifications of lifestyle and environment, could reduce the average duration of disability before death. The new political structures of Europe offer under exploited-unexploited opportunities for the necessary research.     

Contribution of circadian physiology and sleep homeostasis to age-related changes in human sleep

The circadian pacemaker and sleep homeostasis play pivotal roles in vigilance state control. It has been hypothesized that age-related changes in the human circadian pacemaker, as well as sleep homeostatic mechanisms, contribute to the hallmarks of age-related changes in sleep, that is, earlier wake time and reduced sleep consolidation. Assessments of circadian parameters in healthy young (∼20-30 years old) and older people (∼65-75 years old)—in the absence of the confounding effects of sleep, changes in posture, and light exposure—have demonstrated that an earlier wake time in older people is accompanied by about a 1h advance of the rhythms of core body temperature and melatonin. In addition, older people wake up at an earlier circadian phase of the body temperature and plasma melatonin rhythm. The amplitude of the endogenous circadian component of the core body temperature rhythm assessed during constant routine and forced desynchrony protocols is reduced by 20-30% in older people. Recent assessments of the intrinsic period of the human circadian pacemaker in the absence of the confounding effects of light revealed no age-related reduction of this parameter in both sighted and blind individuals. Wake maintenance and sleep initiation are not markedly affected by age except that sleep latencies are longer in older people when sleep initiation is attempted in the early morning. In contrast, major age-related reductions in the consolidation and duration of sleep occur at all circadian phases. Sleep of older people is particularly disrupted when scheduled on the rising limb of the temperature rhythm, indicating that the sleep of older people is more susceptible to arousal signals genernpated by the circadian pacemaker. Sleep-homeostatic mechanisms, as assayed by the sleep-deprivation-induced increase of EEG slow-wave activity (SWA), are operative in older people, although during both baseline sleep and recovery sleep SWA in older people remains at lower levels. The internal circadian phase advance of awakening, as well as the age-related reduction in sleep consolidation, appears related to an age-related reduction in the promotion of sleep by the circadian pacemaker during the biological night in combination with a reduced homeostatic pressure for sleep. Early morning light exposure associated with this advance of awakening in older people could reinforce the advanced circadian phase. Quantification of the interaction between sleep homeostasis and circadian rhythmicity contributes to understanding age-related changes in sleep timing and quality. (Chronobiology International, 17(3), 285-311, 2000)