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.     

Evaluación pre-post de un programa intergeneracional para mejorar el bienestar en personas mayores y los estereotipos edadistas en alumnos de primaria y secundaria: proyecto CRENCO

ObjectiveThe present study aims to evaluate the effectiveness of the CRENCO project which was carried out during the COVID-19 pandemic including intergenerational activities shared by students from primary and secondary education and users of two centers for older adults and a day hospital in Catalonia. The effectiveness was assessed in terms of well-being in older adults and on negative stereotypes about the elderly in primary and secondary students.MethodsThree interventions were carried out in which 32 older persons (9 users of centers for older adults and 23 of a day hospital), 99 primary students and 56 secondary students participated. Participants answered a questionnaire before and after the interventions. Through multilevel linear models for repeated measures, changes in feelings of loneliness, social support, anxiety and depressive symptoms, self-reported health and health-related quality of life were evaluated in older people. In primary and secondary students, changes in age stereotypes were evaluated.ResultsHealth-related quality of life and self-reported health improved statistically after the interventions in older persons. Users of the day hospital also reported an improvement in social support. Primary school students improved their age stereotypes; no statistically significant changes were detected in secondary students.ConclusionThe results of the present study contribute to underlining the importance of intergenerational programs such as the one proposed by CRENCO, capable of improving well-being and providing a more realistic vision of the older adults. Our results suggest that these programs should be implemented during childhood in order to prevent the proliferation of ageist stereotypes in later life stages.     

Teaching and training in geriatric medicine in the European Union

In 1993 about 20% of the population in the 15 'old' member countries of the European Union (EU) was over 60 years of age and this percentage will increase to more than 25% in 2020. These developments play a key role for the investments in education and training to meet societies needs for health care services. In 2002 about 25% of the medical students in the 'old' EU did not receive any education in geriatric medicine. A question is who will provide the services for older people in related areas, like social care, community care, acute care in the hospitals, long-term care, permanent care and care for psychiatric patients? Geriatric medicine has been recognized as an independent specialty in 8 of the 15 member countries of the 'old' EU. In all EU member states the governments are autonomous regarding all aspects of health care services, including the recognition of specialties and specialist training programmes. A two years training in internal medicine has been recommended in the EU, followed by another four years of training in geriatric medicine. The specialist training has a hospital oriented character, however, it includes also community care and other institutionalised care like nursing homes. The curriculum should contain: biological, social, psychological and medical aspects of common diseases and disturbances in older people. A problem in many EU countries is the shortage of well trained researchers and leading persons for academic positions for geriatric medicine. In a number of countries chairs at the universities remain vacant for long periods of time or even disappear. Good services in the health care for older people need a high quality curriculum and training programme.     

Protecting elderly people: flaws in ageist arguments.

Some form of rationing is necessary in medicine, and to use age as a criterion for rationing seems initially appealing. Many of the criteria currently being used for deciding the distribution of funds depend on subjective judgments. Age, however, is objective and therefore negates the need for value judgments. Justice and fairness, it is sometimes suggested, require that finite resources should be directed at young people, who have not had a chance to live their lives, rather than at elderly people, who have already lived most of theirs. The adoption of ageist policies, however, may not result in the implied savings unless care is also withdrawn. Furthermore, ageist policies, which deny elderly people treatment on the sole grounds of their age, are both unfair and discriminatory and should therefore be resisted.     

Children in an ageing society

This paper explores the implications of demographic aging for children and pediatric practice in the Western society. It focuses on the social class differences in childbearing patterns, specific issues related to disability, and distribution of resources between age groups. Women in the Western world are now having children at an older age than at any time in the past 50 years. Voluntary childlessness or deliberate delay in childbearing is common among highly educated women. This changing pattern in childbearing may increase and polarize health and wealth inequalities. With advancements in neonatal and pediatric care which prolong life expectancy and survival of disabled children, it is projected that there will be an increasing number of very old parents caring for severely disabled offspring. Meanwhile, there are also many children who are carrying considerable burdens of caring for their disabled parents. The community burden of disability will continue to rise. The needs of the elderly population may drain resources from child health services. Despite this demographic pattern, care for the children is still important. Health care authorities must not become contented with the existing pediatric care services just because demographic changes require that the nation should invest more in care of the older population.     

Oral health and access to dental care: a qualitative investigation among older people in the community

doi:10.1111/j.1741‐2358.2009.00320.x
Oral health and access to dental care: a qualitative investigation among older people in the community Objective: The aim of this study was to explore older persons’ beliefs and attitudes towards oral health and access to and use of dental care services. Background: As the proportion of dentate older people increases, the need and demand for dental services will rise (J Public Health Dent, 60, 2000, 276). Design: Focus groups and semi‐structured interviews were used for data collection. Setting and subjects: The study participants included 63 older people in Perth, WA. Results: Five major themes emerged from the interviews – the need for information and knowledge; accessibility of services; cost and affordability of oral care; fear and anxiety regarding dental visits and relationships with dentists. Attitudes and behaviours were slow to change in this group. Conclusion: This investigation provided important perspectives regarding oral health and dental access for older people residing in the community and demonstrated the importance of understanding this group when considering provision and use of services.     

Mental health care for older adults: recent advances and new directions in clinical practice and research

The world''s population is aging, bringing about an ever‐greater burden of mental disorders in older adults. Given multimorbidities, the mental health care of these people and their family caregivers is labor‐intensive. At the same time, ageism is a big problem for older people, with and without mental disorders. Positive elements of aging, such as resilience, wisdom and prosocial behaviors, need to be highlighted and promoted, both to combat stigma and to help protect and improve mental health in older adults. The positive psychiatry of aging is not an oxymoron, but a scientific construct strongly informed by research evidence. We champion a broader concept of geriatric psychiatry – one that encompasses health as well as illness. In the present paper, we address these issues in the context of four disorders that are the greatest source of years lived with disability: neurocognitive disorders, major depression, schizophrenia, and substance use disorders. We emphasize the need for implementation of multidisciplinary team care, with comprehensive assessment, clinical management, intensive outreach, and coordination of mental, physical and social health services. We also underscore the need for further research into moderators and mediators of treatment response variability. Because optimal care of older adults with mental disorders is both patient‐focused and family‐centered, we call for further research into enhancing the well‐being of family caregivers. To optimize both the safety and efficacy of pharmacotherapy, further attention to metabolic, cardiovascular and neurological tolerability is much needed, together with further development and testing of medications that reduce the risk for suicide. At the same time, we also address positive aging and normal cognitive aging, both as an antidote to ageism and as a catalyst for change in the way we think about aging per se and late‐life mental disorders more specifically. It is in this context that we provide directions for future clinical care and research.     

Ecological Aging: The Settings Approach in Aged Living and Care Accommodation

As the proportion of older people increases within populations, financial demands related to the cost of health service delivery threaten global stability. This population trend challenges the traditional approach to health service delivery to older populations. This article presents the Australian context as a case study to argue that the application of a health promoting settings approach to aged care may lead to improved well-being for older people to the extent that the periods of chronic morbidity often associated with aging can be compressed into an ever shorter period of time. Promoting an ecological perspective to aged care suggests that there is no need to manage older people in isolation, as is common practice, but as integral to the way society lives, works, and plays. The article maps parallels between characteristics of health promoting settings such as Health Promoting Schools and the aged living and care industry, arguing that the setting encompassing services for the elderly is a prime location for the establishment of a new health promotion setting. Supporting life opportunities for our aged is central to such an approach. More broadly, an ecological approach orients us toward the connection between environment and health, and encourages increased attention and action within the aged living and care sector on reducing environmental impacts of this growing population. As such, the application of this approach to the aged living and care sector has the potential to reduce the threat that a dependant older population has on global sustainability.     

Health care rationing: the public's debate.

OBJECTIVE--To elicit the views of a large nationally representative sample of adults on priorities for health services. DESIGN--An interview survey based on a random sample of people aged 16 and over in Great Britain taken by the Office of Population Censuses and Surveys. SUBJECTS--The response rate to the survey was 75%, and the total number of adults interviewed was 2005. MAIN OUTCOME MEASURES--A priority ranking exercise of health services supplemented with attitude questions about priorities, who should set priorities, and budget allocation. RESULTS--The results of the main priority ranking exercise of 12 health services showed that the highest priority (rank 1) was accorded to "treatments for children with life threatening illness," the next highest priority (rank 2) was accorded to "special care and pain relief for people who are dying." The lowest priorities (11 and 12) were given to "treatment for infertility" and "treatment for people aged 75 and over with life threatening illness." Most respondents thought that surveys like this one should be used in the planning of health services. CONCLUSIONS--The public prioritise treatments specifically for younger rather than older people. There is some public support for people with self inflicted conditions (for example, through tobacco smoking) receiving lower priority for care, which raises ethical issues.     

A Qualitative Study of Service Provision for Alcohol Related Health Issues in Mid to Later Life

Aims

Epidemiological surveys over the last 20 years show a steady increase in the amount of alcohol consumed by older age groups. Physiological changes and an increased likelihood of health problems and medication use make older people more likely than younger age groups to suffer negative consequences of alcohol consumption, often at lower levels. However, health services targeting excessive drinking tend to be aimed at younger age groups. The aim of this study was to gain an in-depth understanding of experiences of, and attitudes towards, support for alcohol related health issues in people aged 50 and over.

Methods

Qualitative interviews (n = 24, 12 male/12 female, ages 51–90 years) and focus groups (n = 27, 6 male/21 female, ages 50–95 years) were carried out with a purposive sample of participants who consumed alcohol or had been dependent.

Findings

Participants’ alcohol misuse was often covert, isolated and carefully regulated. Participants tended to look first to their General Practitioner for help with alcohol. Detoxification courses had been found effective for dependent participants but only in the short term; rehabilitation facilities were appreciated but seen as difficult to access. Activities, informal groups and drop-in centres were endorsed. It was seen as difficult to secure treatment for alcohol and mental health problems together. Barriers to seeking help included functioning at a high level, concern about losing positive aspects of drinking, perceived stigma, service orientation to younger people, and fatalistic attitudes to help-seeking. Facilitators included concern about risk of fatal illness or pressure from significant people.

Conclusion

Primary care professionals need training on improving the detection and treatment of alcohol problems among older people. There is also a compelling need to ensure that aftercare is in place to prevent relapse. Strong preferences were expressed for support to be provided by those who had experienced alcohol problems themselves.     

The greying of Europe.

About a quarter of the population of Europe is now of pensionable age. Facilities for caring for very old or disabled people differ throughout Europe in scope and means of funding, and the countries of the European Union are far from equity in the status of pensioners. Health expectations have increased in older people--most of the calculated gain in life expectancy is likely to be without disability. Most countries now have specialist geriatric medicine facilities, and international research programmes are under way.     

Age‐related inequalities in health and healthcare: the life stages approach

How should healthcare systems prepare to care for growing numbers and proportions of older people? Older people generally suffer worse health than younger people do. Should societies take steps to reduce age‐related health inequalities? Some express concern that doing so would increase age‐related inequalities in healthcare. This paper addresses this debate by (1) presenting an argument in support of three principles for distributing scarce resources between age groups; (2) framing these principles of age group justice in terms of life stages; and (3) indicating policy implications that merit further attention in light of rapidly aging societies.     

Equity in the NHS. Monitoring and promoting equity in primary and secondary care.

Although need is often assumed to be the most important factor in determining the use of health services, there are many inequities in the provision and use of NHS services in both primary and secondary care. For example, existing data from district child health information services have been combined with census data for small areas to show wide variations in immunisation rates between affluent and deprived areas. Purchasers of health care are already responsible for assessing health needs and evaluating services, and the process of monitoring equity is a logical extension of these activities. Routine data sources used to collect activity data in both primary and secondary care can be used to assess needs for care and monitor how well these needs are met. Purchasers and providers should collaborate to improve the usefulness of these routine data and to develop a framework for monitoring and promoting equity more systematically.     

Reducing inappropriate, anticholinergic and psychotropic drugs among older residents in assisted living facilities: study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: Use of inappropriate drugs is common among institutionalized older people. Rigorous trials investigating the effect of the education of staff in institutionalized settings on the harm related to older people's drug treatment are still scarce. The aim of this trial is to investigate whether training professionals in assisted living facilities reduces the use of inappropriate drugs among residents and has an effect on residents' quality of life and use of health services. Methods and design During years 2011 and 2012, a sample of residents in assisted living facilities in Helsinki (approximately 212) will be recruited, having offered to participate in a trial aiming to reduce their harmful drugs. Their wards will be randomized into two arms: one, those in which staff will be trained in two half-day sessions, including case studies to identify inappropriate, anticholinergic and psychotropic drugs among their residents, and two, a control group with usual care procedures and delayed training. The intervention wards will have an appointed nurse who will be responsible for taking care of the medication of the residents on her ward, and taking any problems to the consulting doctor, who will be responsible for the overall care of the patient. The trial will last for twelve months, the assessment time points will be zero, six and twelve months. The primary outcomes will be the proportion of persons using inappropriate, anticholinergic, or more than two psychotropic drugs, and the change in the mean number of inappropriate, anticholinergic and psychotropic drugs among residents. Secondary endpoints will be, for example, the change in the mean number of drugs, the proportion of residents having significant drug-drug interactions, residents' health-related quality of life (HRQOL) according to the 15D instrument, cognition according to verbal fluency and clock-drawing tests and the use and cost of health services, especially hospitalizations. DISCUSSION: To our knowledge, this is the first large-scale randomized trial exploring whether relatively light intervention, that is, staff training, will have an effect on reducing harmful drugs and improving QOL among institutionalized older people Trial registration ACTRN12611001078943.     

Schistosomiasis-related perceptions, attitudes and treatment-seeking practices in Magu district, Tanzania: public health implications

A study on perceptions, attitudes and treatment-seeking practices related to schistosomiasis was conducted among the Wasukuma in the rural Magu district of Tanzania at the shore of Lake Victoria where Schistosoma haematobium and mansoni infections are endemic. The study applied in-depth interviews, focus group discussions and a questionnaire survey among adults and primary school children. The perceived symptoms and causes were incongruous with the biomedical perspective and a number of respondents found schistosomiasis to be a shameful disease. Lack of diagnostic and curative services at the government health care facilities was common, but there was a willingness from the biomedical health care services to collaborate with the traditional healers. Recommendations to the District Health Management Team were: that collaboration between biomedical and traditional health care providers should be strengthened and that the government facilities' diagnostic and curative capacity with regard to schistosomiasis should be upgraded. Culturally compatible health education programmes should be developed in collaboration with the local community.     

Experiences and perceptions of oral health and oral health care among a sample of older New Zealanders

doi: 10.1111/j.1741‐2358.2010.00402.x Experiences and perceptions of oral health and oral health care among a sample of older New Zealanders Background: Most research on older people’s oral health has been quantitative. A need for more in‐depth understanding of the oral health of that age group has pointed to a need for more qualitative investigations. Objective: To explore experiences and perceptions of oral health and oral health care among an ethnically‐mixed sample of older New Zealanders. Methods: In‐depth interviews were conducted with 24 older people in two communities in New Zealand’s South Island. Thematic analysis of transcribed data was undertaken. Results: Three main themes that emerged were: (1) the processes of negotiating a tension between cost and convenience of access; (2) the experiential constraining of oral health maintenance; and (3) trusting in dental professionals. These serve to organise processes such as normalising, justifying and social comparisons that create an equilibrium or tolerance and acceptance of what might otherwise be considered to be relatively poor oral health. Conclusions: We identified a number of shared experiences which affect older people’s ability to maintain their oral health in the face of material and social barriers to oral health care. Because expectations were generally lower, there was greater concordance between experience and expectation, and people tended to be fairly satisfied with their oral health and the care they had received.     

Assessing oral health promotion determinants in active Greek elderly

doi: 10.1111/j.1741‐2358.2011.00491.x
Assessing oral health promotion determinants in active Greek elderly Objective: To explore older adults’ patterns and risk behaviours to be invoked in the allocation of strategies to promote oral health. Background: Access to dental services is determined by factors that serve as barriers to or enablers of older adults’ behaviour and attitudes towards oral health. Appropriate oral health promotion activities are of particular importance among the elderly in altering oral health behaviour through education, prevention and health protection. Methods: A cross‐sectional study was conducted among 108 dentate elderly subjects. They were attending a University Prosthetic Dentistry Clinic in Greece as patients seeking treatment. Participants underwent a clinical examination and an interview. Results: Data extracted revealed that cost and no disease awareness were the most frequently mentioned barriers to regular dental visits. Most of the participants presented low level of income and education and reduced presence of adverse dental health symptoms compared with the actual oral health status. Besides some predisposing factors, enabling and need variables significantly affected access to dental care services, participants’ number of remaining teeth and as a consequence oral health status. Conclusion: Profiling older adults’ demographics, economic, social and cultural status and their attitudes and beliefs could further contribute in developing universal activities and strategies for oral health promotion so as ageing challenges are favoured.     

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.