Not surprisingly, elderly patients balk at being categorized into the stereotypes associated with old age. Take a fresh, individual look at each older adult who sits in your chair and tailor your services around their needs. Much of your success depends on just getting to know them better.
Ulana Kostiw Cirincione, RDH, MPH
One of the first steps in successfully incorporating geriatric patients into your daily routine is to be armed with knowledge about older adults. New scientific information about the elderly continues to be made available. Research in the area of Alzheimer`s disease, for example, is frequently reported on, and dental hygienists must keep abreast of these findings. Any additional data that can be brought into assessment, planning, or decision-making aids us in better caring for our patients.
Consider your educational experiences in geriatric dentistry. Did you have didactic training which dealt specifically with older adults? Did your training include experiences in settings such as nursing homes? Were you exposed to both well-elderly and the frail?
In the last ten years, more educational programs have included geriatrics in the curricula. At the University of Illinois College of Dentistry, dental students are exposed to "standardized patients." These people are trained to serve as simulated "real" patients. Given a variety of cases, students learn techniques in managing geriatric patients.
For veteran practitioners, prior hands-on experience is valuable, but it may be necessary to upgrade your background on numerous topics related to geriatrics. A continuing education course, a home study program, review of articles, or even a return for formal training may boost your expertise and confidence in treating elderly patients.
What is your attitude about the elderly?
Another important step in your approach to elderly patients is a self-examination of your attitudes regarding this population group. What have been your own personal experiences? Does your family include many seniors? Are you a caregiver for grandparents or parents? Your personal experiences will definitely influence your attitude toward elderly patients.
One dental hygienist, who practiced for 15 years, grew up surrounded by an extended family which included many seniors. During her high school years, she worked as a nurse`s aid in a nursing home. After marriage, the responsibility of caring for her spouses` parents rested with her as well as caring for three young children. She sees this exposure as a benefit for her professional career. "My whole life has been focused on older people. I really understand their problems, their needs, and feel that I can deal with anything in the dental office." After some time, this informal expertise prompted her to pursue an advanced degree in the gerontology field.
It is easy to stereotype older adults. The tendency is probably linked to our lack of understanding about the heterogeneity of the elderly. By assuming most seniors are the same, we tend to generalize their personal characteristics. For example, dental hygienists may limit their oral hygiene message to older adults, excluding a new brushing technique or oral hygiene product because of the assumption that older adults are inflexible and will not accept change easily. Our "ageist" beliefs and attitudes must be changed before we can effectively treat the elderly.
Along with a self-assessment of knowledge level, attitudes, and stereotyping, hygienists must consider their own communication skills. Interaction with the older adult may require a modification due to physical and psychological changes. Interviews may need to be conducted at a slower pace.
Besides dealing with seniors, hygienists may also come in contact with professionals from other disciplines who care for the older patient. You may be part of an informal interdisciplinary team, including, for example, a physician, pharmacist, home health nurse, and social worker. Determination of an older patient`s health history may include consultation with these professionals. So an ability to converse fluently and effectively about your senior patients is critical to the provision of comprehensive care.
Preparing for the population shift
Some estimates indicate that as many as 75 percent of all patients in the dental office are in the older adult category. In the future, we can expect an increase in the number and type of elderly. Because of the decline in birth rate, replacement in the population is slowing. The percentage of elderly in the total population is increasing due to greater life expectancy. The possibility of pushing back retirement age also means more productive, active older adults in society.
Demographic changes indicate a significant rise in those 85 years and older - many of whom have the greatest needs. Women will continue to outnumber men. Most individuals do not live in nursing homes or other institutional settings, as many of us assume. Instead, they reside in their own homes in the community. These shifts in the population will impact the way we practice. It will require that we "adapt to a growing base of elderly patients."
To understand older adults, it is important to focus on physical, social, psychological, and economic factors rather than chronological age. There is as much diversity in those 65-85 years in age as in a group of people between 25-45 years. Ettinger groups the elderly into age categories where he considers their life experiences, previous dental care, and their needs and demands.
Those in the oldest group (85-years plus) did not have the benefit of extensive dental care for much of their lives. Many are edentulous and have a great need for dental care. The "new elderly" (older than 75 years) were better educated and present with a mix of dental care needs. Those born during the Depression (65 to 74 years-old) were exposed to "modern dentistry," but many of these individuals did not reap the benefits. The "boomers" (under age 64) grew up with prevention, were more educated, and have a high expectation for dental services. Each group includes a heterogeneous mix of older adults who each present with their own special needs.
In a recent article about longevity, experts attribute long life - that beyond 90 years - to general health. Individuals without a major illness seem to live longer, even if they did not always follow the ideal preventive behaviors. A better way to categorize the elderly is by functional status:
* Healthy elderly (functionally independent).
* Partially incapacitated elderly (may be frail or need assistance with certain activities).
* Institutionalized/dependent elderly (need other people for basic living assistance, such as with bathing, eating, and dressing).
Assessment of functional status, sometimes referred to as ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living), is accomplished by a series of questions aimed at determining the level at which elderly people can care for their own needs. The addition of a basic question on grooming (which would refer to brushing teeth) aids the hygienist in evaluating the patient and improved dental services.
Gently collecting data about elderly patients
The initial patient assessment is a primary step in rendering care. Older adults coming to the practice for the first time, for example, may need assistance in completing a medical history form. The type on the form should be large enough to read easily. Questions on the history form must also be relevant to seniors - for example, "Have you had a fall recently?" The question is not routinely included in a medical history, but answers may provide information about dizziness, stroke, or hypertension.
Occasionally, the medical history has to be obtained from a caretaker or family member. All questions should first be directed to the older patient. They must not be overlooked during history taking.
Patients who are in progress with dental treatment still require frequent updates with their histories. Even during a short period of time, the health status of a senior can drastically change. Given greater longevity, seniors present with many chronic conditions. These multiple changes may present as atypical diseases or they may be under-reported by the patient.
Serious illnesses may exist, yet an older person may not have definitive symptoms. We need to differentiate between age-related changes vs. disease-related changes. Some of the most common conditions the elderly face are arthritis, heart disease, stroke, hypertension, cancer, Parkinson`s disease, Alzheimer`s disease, and depression. Prosthetic heart valves and joint replacements are commonly found conditions in older adults that require premedication. Sensory changes are expected alterations which vary among the elderly.
A vital component of the medical history is determining if medication is being used. Every older adult is probably taking at least one prescribed medication. When combined with over-the-counter drugs, the result is a potential overuse of multiple medications. Although prescription medications are dispensed by doctors, their actual use by older adults may vary. Errors in drug use can be indirect - too many prescriptions, confusing drug regimes written by multiple providers, or uncertainty about the purpose of the drug.
Prescription bottle caps, although adjusted for safety reasons, may still be too difficult to maneuver for older people. Some elderly are also purposefully non-compliant. They may start or stop taking medication at their own discretion. Many will use a variety of over-the-counter products - cold remedies, sleep aids, anti-inflammatory agents - without knowledge of the side effects of, or interaction with, prescription drugs.
Because drug effects - absorption, distribution, metabolism, and excretion - vary so much in the elderly, a consultation with the physician may be necessary before initiating dental services. Reviewing drug categories which cause xerostomia is an important task for the dental hygienist to do periodically. Many of the drugs are most often prescribed to older adults - anti-hypertensives, diurectics, anti-anxiety agents, and anti-depressants.
Finding out how they live
Updating the medical history along with current medication is invaluable. But factors such as emotional health, social life, and economic concerns shed light on other aspects of the older person`s background. Some older adults may still be living with a spouse. They may have grown children and grandchildren. Their social support assists them in having a fulfilling life.
Others, though, may be living alone, caring for their own needs with little help. A visit to the dental office is a welcome opportunity for interacting with others. The dentist, hygienist, assistant, and receptionist are viewed as a "sounding board" - someone who will listen to personal problems which are not dental.
Elder abuse and neglect, although difficult to determine, has been identified as a problem among institutionalized elderly and among seniors living in the community. The health care professionals` ethical responsibility include assessment and intervention. Frequently, older persons are abused by spouses and their adult children or by caregivers. Suspicious signs can range from emotional changes to physical evidence of injury. Oral-facial trauma must be further investigated.
The financial status of the older patient may dictate treatment options. Many on fixed incomes will be reluctant to come in for frequent visits even if, in the long run, prevention will result in cost-savings.
Therefore, obtaining additional background information will give a more "comprehensive" perspective about your older patients. The information will help you decide on the best care for them.
Oral hygiene for the elderly
With the increased retention of the dentition in older adults, teeth are at greater risk for recurrent decay, root caries, and periodontal diseases. Patients may have secondary caries along with extensive restorative work which they may have assumed would never again require treatment. Recession coupled with poor home care and a cariogenic diet increase the probability of caries along the cementoenamel junction.
Advanced age is a risk factor for periodontal disease only when associated with inadequate plaque control, smoking, lack of dental care, or other factors. Oral conditions such as stomatitis, candidiasis, angular cheilitis, alveolar root resorption are just a few of the findings in the elderly dentition. The presence of dental prostheses may exacerbate some oral pathologies. Oral cancer rates are highest in older adults, especially those engaged in high-risk behaviors.
Keeping in mind the oral conditions in some aging patients, the dental hygienist must identify present and past diseases, as well as determine the patient`s self-perceptions about oral health status. It is also critical to consider findings on functional status and quality of life.
Determination of their ability for self-care requires questioning patients about brushing habits, use of dentifrices, rinses, and care of prostheses. Modifications of oral hygiene aids or instructions to a family member or caretaker are options for those older adults presenting with special needs.
Our health education message should begin with the focus on freedom from pain, enjoyment of eating, fresh breath, and a normal appearance. Prevention strategies should be geared to plaque removal, tongue brushing, use of fluorides and chlorhexidene gluconate rinses, and routine professional care. Proper care of dentures and partials must be included in our message to the edentulous and partially dentate patient.
It is within our purview to incorporate smoking cessation in our treatment plans. Older adults can be taught the steps in an oral self-examination for the detection of suspicious findings which may be indicative of oral cancer.
An inviting place for the elderly
Most importantly, the dental hygienist has to avoid the stereotypical attitude which believes the older adult is unwilling to change an oral hygiene regimen. Introduction of a new brushing technique or a new oral rinse will be accepted by older patients if presented to them in a logical and direct manner. A good way to clarify and reinforce recommendations is by providing written instructions. Specify the brand and company names of an oral hygiene product. Concrete suggestions aid older adults troubled by memory loss. If the suggestions are written legibly and in large print, older people with vision problems will be helped.
One advantage of seniors is their availability for appointments during "non-prime" times - the hours most desired by the employed or by families with children. Morning hours are ideal for seniors. Appointments scheduled after the rush hour are easier on elderly drivers. Some feel more relaxed about coming to the office during daylight hours. People with arthritis, or others with mobility problems, appreciate the extra time to finish morning routines and to prepare for the appointment. Schedules should also coincide with medication regimens - people with diabetes, for example.
It is important to be sensitive to older adults and not assume that everyone will be flexible to the dental office`s schedule. Many adults older than age 65 may still be employed (even on a part-time basis), serve as volunteers in the community, or attend community or social activities.
Besides scheduling, office location, travel time, convenient parking, and transportation are concerns for many older patients. Once in the dental environment, the office must be safe and accessible. Stable chairs with arm rests for support allow for easy movement. Rugs or other obstacles to maneuvering should be eliminated. For those who are wheelchair bound or use walkers, entryways should be accessible as dictated by legislation. Restrooms and other facilities must also accommodate these individuals.
Comfort in the dental chair is an important consideration. Keeping the appointment short and not prolonging the visit will be appreciated by your patients. On occasion, the elderly present with osteoarthritis or kyphosis, and the addition of pillows around the dental chair will provide support.
A standing position, although tiresome for the hygienist, may be necessary for patients with respiratory or cardiac conditions who cannot easily recline. Alternative positioning may actually be a positive change of pace for the hygienist. Caution should be exercised when the older patient gets out of the dental chair. A rapid change from a supine to an upright position can result in postural hypotension.
The adjustments made for treating older adults may lead to concern that the added time results in a decrease in productivity. By establishing a preventive program with emphasis on frequent recalls and self-care, the patient flow can be improved and will result in healthier, more satisfied patients. Older adults appreciate the extra attention and time given to them. In the long term, the initial investment of time may reveal an increase in referrals.
Older adults will continue to represent a major segment of your practice. Before treatment begins, the dental hygienist must recognize the heterogeneity within this group of patients. Personal biases and stereotypes must be put aside, and a confident and knowledgeable approach must be adopted in the management of older patients. All aspects, from initial assessment to final treatment, require consideration of the special needs of these individuals. The end result will be a satisfied clinician and patient.
Ulana Kostiw Cirincione, RDH, MPH, is an associate professor at Northwestern University Dental School.
How functional is your elderly patient?
When determining Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs), consider asking older adults the questions below. The information can help in the evaluation of needed dental services for a patient.
- dress yourself
- bathe yourself
- use the toilet unaided?
- use the telephone?
- get out of bed/chair unaided?
- take own medications?
- manage your money?
- shop alone?
- buy and prepare meals?
- maintain continence?
- clean your house?
- travel to your appointments?
The very different lives of Mrs. Mixler and Mr. Gozier
Miriam Mixler is a 76-year-old female. She has been married for 45 years and has one son and three granddaughters living in a neighboring state. Mrs. Mixler is a retired schoolteacher. She divides her time between New York (her home) in the summers and Miami in the winter. She leads an active social life, volunteers at a local hospital, and has no financial constraints.
Her general health is very good, except for a minor problem with a cardiac arrhythmia for which she takes Digoxin (Lanoxin). Every few months she sees her cardiologist and has a blood draw to check her medication level.
In the dental office, Mrs. Mixler presents with 24 teeth - fixed bridges to replace missing molars. Her gingiva appears healthy with some recession around anterior teeth. Pocketing and bleeding upon probing are minimal. Oral hygiene is good with calculus limited to mandibular anterior teeth and plaque present along crown margins. Decalcification is evident along cervical areas on teeth #22-#27.
Mrs. Mixler does not have limitations with mobility, finances, social support, or activities of daily living. Management of Mrs. Mixler includes:
1.) Maintaining a recall program for her while she is at home and recommending a referral office while in Florida.
2.) Reviewing medical history, medication regimen, taking vital signs, noting changes in health.
3.) Checking pocket depths and gingival bleeding.
4.) Providing prophylaxis and fluoride treatment.
5.) Reinforcing current home care regimen and adding a home fluoride product for daily use.
This case presents someone in the category of "well-elderly." Few modifications are required for this individual, but a continued preventive program with proper follow-up.
Albert Gozier is an 80-year-old, widowed male living alone in a retirement facility. Along with housing, he uses some of the other available services - housecleaning and grocery delivery. His niece brings him to some of his dental appointments when possible. But she cannot always free herself from work.
Mr. Gozier has Parkinson`s disease, as well as a history that includes cardiac bypass surgery five years ago, prostrate problems, bilateral cataracts, and depression. His medications include Sinemet, Cardura, Xanax - all of which he takes sporadically. He is beginning to experience difficulty walking without assistance, and this lack of self-sufficiency is making him more depressed.
In the dental office, Mr. Gozier presents with a full upper denture and lower fixed partial denture. Teeth #21-27 are present with Class II mobility on #24-25. Plaque, calculus, and stain are heavy on all remaining teeth and are evident on his removable appliances. Mr. Gozier admits he is neglecting his home care because it is "harder" for him to brush.
Given Mr. Gozier`s medical history and concerns, the following adjustments in treatment are required by:
1.) Obtaining a resource (such as a medical car) for travel to his dental appointments when his niece is unavailable.
2.) Checking with his physician to determine the stage of his Parkinson`s disease and checking for prescribed medications.
3.) Encouraging him to take his medications as prescribed.
4.) Reviewing care of dentures, suggesting a powered brush for easier toothbrushing, recommending chlorhexidine gluconate.
5.) Providing scaling and root planing on remaining teeth.
6.) Motivating him to maintain self-sufficiency.
Mr. Gozier`s case presents some of the situations encountered by frail older adults. Although there is only a four-year difference in age between the individual in Case 1 and this patient, their differences are significant and predominately based on health status and its management.