The special needs of elderly patients
The older patients we encounter nowadays differ from those in the past. We are living longer and healthier lives thanks to medical technology (US Census Bureau, 2005), improved care and nutrition, biomedical research leading to new treatments, and onset of chronic diseases at greater ages (Sahyoun et al, 2001).
For example, the senior population in the United States in 2000 was 35 million, which will double to 72 million by 2030 with 20% of individuals over 65 years of age (US Census Bureau, 2005).
fter 2030, the oldest group (85 and over) is expected to grow rapidly to 9.6 million due to the baby boomer generation and double by 2050 to 20.9 million. Centenarians (100 and over) in 2000 were over 50,000, with 80% of those being women. World-wide, seniors in 2000 were 420 million or 7% of the population in developed countries. By 2030, numbers will increase to over 974 million (US Census Bureau, 2005).
The internet, newspaper articles, print adverts and television commercials are all mechanisms available to help make consumers more aware of both their medical and dental needs.
As baby boomers begin entering the senior age bracket, we will continue to see oral health needs expand. According to the US Census Bureau (2005): ‘The future older population is likely to be better educated than the current population, especially when baby boomers reach 65. Their increased levels of education may accompany better health, higher incomes and more wealth, and consequently higher standards of living in retirement.’ (US Census Bureau, 2005).
Nonetheless, patients still have special needs to be met. No matter the age, every person is unique and needs to be looked at individually. People are increasing their life expectancies and living more healthily, however issues will always arise, causing problems of the past to surface but at older ages.
Those at the younger end of the senior spectrum may have special needs due to a lack of previous dental care or physical limitations, and that will not change. Individuals needing a modification of dental treatment due to social, psychological, physical or medical conditions are to be classified as ‘special needs’, as proposed by Glassman and Miller in 1988.
Wray and Brookes (2002) defined special needs as ‘the specialty of dentistry concerned with the oral healthcare of patients with special needs for whatever reason, including those who are physically or mentally challenged.’
Special needs and special care is now linked with the oral health of individuals who are affected by medical, intellectual, physical, and/or psychiatric disorders. Further, we now know poor oral health may impact general health (Victorian Government Department of Human Services, 2002).
Physical disabilities/special needs
Disability can strike at any age. With increased life expectancy and the rise in chronic diseases, one must look at the activities of daily living (bathing, brushing teeth, eating, dressing, toileting, and transferring from chair to bed or vice versa) (Lawton MP, Brody EM, 1969; Katz SJ, Stroud M, 1989).
Common problems include:
• Dexterity (arthritis, stroke, neuralgias, etc)
• Decreased visibility (cataracts, retinal obstruction, macular degeneration, presbyopia and normal ageing process)
• Mental capacities (dementia, stroke, Alzheimer’s, etc)
• Physical disabilities (presbycusis, trauma, biological, hormonal)
• Illnesses (acute or chronic).
When considering special needs, problems may overlap as a result of numerous conditions. In the US, statistics for disabilities for Americans 65 and older was 39%, while 57% of those aged 85 and over were found to have disabilities (US Census Bureau, 2005). Therefore, hygienists must be able to recognise the five areas – physical, mental, social, medical and oral health – for older, special needs patients.
For the purpose of discussion, geriatric populations may be split into two segments:
1. Non-institutionalised patients
2. Institutionalised (nursing homes, rehabilitation and care centres, etc) patients.
The leading chronic conditions of non-institutionalised individuals are arthritis, hearing impairments, heart disease and hypertension, while the most prevalent conditions in institutionalised patients are arthritis, heart disease, mental disorders and paralysis.
The severity of the condition will impact upon home oral care and the treatment needed. Other factors to consider are whether the patient has natural teeth, crowns, bridges, implants, partials, and/or dentures.
Special needs are applicable to everyone. It is important for your elderly patients that you continue educating and motivating them regarding home oral care. Prevention is a key factor for their health; it has been documented that the mouth may be the inlet for other systemic problems (heart disease, decubitus ulcers, infections, transmittable diseases, etc.) when periodontal disease is prevalent in the oral cavity, with organisms travelling via the blood vessels and causing problems to develop. Patients need to maintain their teeth and tissues for the benefit of their health and longer lifespan. Various conditions to monitor are:
• Dental caries (especially root caries)
• Gingival recession
• Periodontal disease
• Tooth fractures
• Weight changes
• Oral lesions (cancerous and non-cancerous)
As a result of the general physiology of ageing, older patients may present with numerous conditions evident in their oral cavity, causing a ‘snowball’ effect that results in a combined medical and dental problem.
Treating the patient should always be the main focus and common courtesy should be maintained at all times. Assess your patient’s motor/dexterity, visual and hearing abilities, and mental status.
This will help to determine how you should approach their oral healthcare education. Even at an advanced age, education is always a valuable tool because the oral environment is ever changing.
Areas for oral health concern in the elderly include: cavities/tooth decay, gum disease (gingivitis/periodontal), xerostomia, dentures/partials, dental implants, oral cancer, and home care (Geriatric Oral Health, 2009).
As one can see, these problems are not new but will continue to surface, albeit at an older age.
Having knowledge of normal and abnormal conditions in the elderly will help you to understand the needs of older adults.
Hygienists must grasp the numerous systemic manifestations. The appearance of a condition is just one aspect to consider – it could result in increased severity of a pre-existing problem, a longer duration of illness or cause slower healing. For example, one important consideration is that a decreased metabolism rate affects how medications are excreted from the body. This could cause serious problems with local anaesthesia. In addition, when ageing skin becomes thin, dry and wrinkled, the reduction in elasticity causes a delay in healing and limits the reparative conditions of the tissues.
According to the 2005 US Census Bureau, older people tend to suffer from sensory impairments, with changes in vision and hearing possibly resulting in functional independence loss and a higher risk of fall injuries, social isolation and depression.
Thirty-seven per cent of older men and women have a hearing impairment, while 30% of older individuals are visually impaired due to cataracts, glaucoma, diabetic retinopathy, or macular degeneration (US Census Bureau, 2005; Nussbaum NJ, 1999). These impairments create a difficulty in patients’ perception of how their oral health is faring.
Additional concerns for the elderly include the musculoskeletal changes caused by osteoporosis, osteoarthritis, and a loss of muscle function and tone. Again, the impact of bone loss may cause a chain reaction to result. For example: tooth mobility Ë extractions Ë loss of mastication Ë loss of nutrition Ë disorientation (from lack of nutrition).
Common chronic conditions to consider include arthritis, cardiovascular disease, diabetes and high blood pressure. Knowing your patient will help guide you through their specific needs.
Two particular areas to observe in the older patient are soft tissues and hard tissues.
Soft tissue observations include capillary fragility or hyperkeratosis of the oral mucosa. Older patients may also note reduced taste due to changes on their tongue taste buds. This may cause the individual’s appetite to become suppressed, causing a dietary deficiency. The signs of oral cancer should also be checked, especially with seniors noted as having higher cancer rates.
Hard tissues need to be observed for abrasions, attrition and root caries. Other concerns include darkening of the tooth structure, pulp sensitivity and a decrease in the vitality of teeth, causing brittleness and breakage.
Non-institutionalised individuals residing in their own homes are generally healthier and better able to care for their own dental needs. These individuals may have some medical problems but are still able to manoeuvre on their own.
A typical example of a general impairment is hearing loss – in 2001, approximately one-third of people age 70 or over had hearing difficulties, while almost half were hearing impaired over 85 (Desai M et al, 2001). In 2002, approximately one in five aged 70 or over had dual sensory impairments (Brennan M, 2002). As age increases, impairments also tend to increase.
Once an elderly individual needs greater assistance with their physical functions, it often becomes necessary to enter a nursing home or rehabilitative type of facility.
Oral care needs must still be met in such establishments. Nurses must become involved and document the oral care needs of each patient, and develop and modify effective care plans (Geriatric Oral Health, 2005).
Care may be diversified due to the patient’s physical condition but still needs to address mouth cleanliness, moisturising, being pain-free and infection-free, and maintaining mastication.
Reviewing the patient’s physical limitations will challenge both the nurse and patient. For example, if an individual has had a stroke, rehabilitative services may be required for speech and mobility, and dieticians need to be involved in a plan alongside the normal daily brushing, flossing and rinses. Needs arising from their medication must also be considered, because it may cause xerostomia, leading to a series of associated problems such as halitosis, brittle teeth or rampant decay at the cemento-enamel junction or interproximals, etc.
Patients undergoing cancer treatment will generally need extra care due to the related side effects. When head or neck cancer treatment is ongoing, salivary glands will be impacted, causing a dysfunction that results in xerostomia. Cancer patients should be educated in the use of products containing xylitol, which reduce or inhibit Streptococcus mutans and increase the flow of saliva.
A barrier to nursing care when it comes to oral health is the lack of knowledge, education, skills and motivation of staff members. Often it is the certified nursing assistant who is instructed to provide such a service. As a result, oral health may not be a high priority on their list of activities to perform.
Some final considerations
Older patients need to be given sufficient time and guidance during their appointments. Most seniors are fully competent but may need extra time to process their thoughts. Staff should provide written and verbal suggestions to summarise the patient’s needs. A plan of action needs to be developed to benefit each individual by providing the newest information or technologies to enhance your patient’s care.
Special needs will continue to grow due to the increasing numbers and ageing population. We must begin now to prepare for our changing society.
Brennan M (2002) When vision and hearing fail: dual sensory impairment among older adults. Aging Trends 2, National Center for Health Statistics
Desai M, Pratt LA, Lentzner H, Robinson KN (2001) Trends in vision and hearing among older Americans. Aging Trends 2, National Center for Health Statistics
Geriatric Oral Health: the missing link to comprehensive care (2009) Available at: http://
www.geriatricoralhealth.org. Accessed 13 August 2009
Glassman P, Miller CE (1988) Improving oral health for people with special needs through community-based dental care delivery systems. J Calif Dent Assoc 26(5): 404-9
Katz SJ, Stroud M (1989) Functional assessment in geriatrics: a review of progress and directions. J Amer Ger Soc 37: 267-271
Lawton MP, Brody EM (1969) Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist 9: 179-186
Nussbaum NJ (1999) Aging and sensory senescence. Southern Medical Journal 92(3): 267-275
Sahyoun NR, Lentzner H, Hoyert D, Robinson KN (2001) Trends in causes of death among the elderly. Aging Trends 1. National Center for Health Statistics
US Census Bureau (2005) Population Reports: 65+. Available at: www.census.gov/prod/2006pubs/p23-209.pdf. Accessed 3 August 2009
Victorian Government Department of Human Services (2002) Improved oral health for older people. Special needs dentistry – geriatric dentistry action plan. Available at: www.dhs.vic.gov.au/rrhacs/primaryhealth.htm (0740702). Accessed 3 August 2009
Wray D, Brookes V (2002) Special needs dentistry diploma of the Royal College of Surgeons of Edinburgh. J Disabil Oral Health. Available at: www.resed.ac.uk/content/facults/dental/Dental%20E/. Accessed 3 August 2009